Staff attitudes and use of coercion in acute psychiatric wards in Norway

Background: Previous research on mental health care has shown considerable differences in use of seclusion, restraint and involuntary medication among different wards and geographical areas. This study investigates to what extent use of seclusion, restraint and involuntary medication for involuntary admitted patients in Norwegian acute psychiatric wards is associated with patient, staff and ward characteristics. The study includes data from 32 acute psychiatric wards. Methods: Multilevel logistic regression using Stata was applied with data from 1016 involuntary admitted patients that were linked to data about wards. The sample comprised two hierarchical levels (patients and wards) and the dependent variables had two values (0 = no use and 1 = use). Coercive measures were defined as use of seclusion, restraint and involuntary depot medication during hospitalization. Results: The total number of involuntary admitted patients was 1214 (35% of total sample). The percentage of patients who were exposed to coercive measures ranged from 0-88% across wards. Of the involuntary admitted patients, 424 (35%) had been secluded, 117 (10%) had been restrained and 113 (9%) had received involuntary depot medication at discharge. Data from 1016 patients could be linked in the multilevel analysis. There was a substantial between-ward variance in the use of coercive measures; however, this was influenced to some extent by compositional differences across wards, especially for the use of restraint. Conclusions: The substantial between-ward variance, even when adjusting for patients’ individual psychopathology, indicates that ward factors influence the use of seclusion, restraint and involuntary medication and that some wards have the potential for quality improvement. Hence, interventions to reduce the use of seclusion, restraint and involuntary medication should take into account organizational and environmental factors. Background Use of coercion in treatment is controversial [1-5], and reducing use of coercion in psychiatric services is a priority health political issue in Western countries [6-8]. Too much use of coercion in mental health care may be a threat to the quality of care, as well as to patients’ human rights. It is of crucial importance to develop a better understanding of the processes and factors involved to reduce the use of coercion. There is evi- dence of considerable variation in the extent to which coercive measures are used. This is shown in interna- tional comparative studies [9-11], and among wards and geographical areas in the same country [12-21]. A recent literature review of the incidence of seclusion and restraint comparing data from 12 countries concludes that available data suggest there are major differences among them in the percentage of patients subjected to coercion and the duration of coercive interventions [22]. Several hypotheses are put forward on factors that may explain differences in coercion. These factors can be divided into four groups [23]. The list is not exhaustive and some factors may belong to several categories. * Correspondence: tonje.l. husum@sintef.no SINTEF Health Services Research, PB 124, 0314 Oslo, Norway Husum et al. BMC Health Services Research 2010, 10:89 http://www.biomedcentral. com/1472-6963/10/89 © 2010 Husum et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Structural factors Physical characteristics of ward, size of ward, double or single rooms, crowding and patient turnover [12,13,18,21,24-26]. Staff-related factors Staff/patient ratio, age and sex of staff, experience of staff, proportion of unqualified staff, level of qualifica- tions, de-escalation training, staff turnover, attitudes of staff and administrators [12,13,16,27-39]. Patient-related factors Diagnoses, level of aggression, symptoms, age and sex, ethnicity, time of day, season [12,18,20,21,32,40]. Treatment-related factors Pharmacological treatment, use of psychotherapy, treat- ment by staff including limit setting, activities for patients, ward atmosphere, treatment philosophy and ideology, regulations and guidelines on use of restraint and seclusion, transitions in ward routines [1,12,28,29,34,35,37]. Taken together, the results from studies on differences in the use of coercive measures are not conclusive. Stu- dies tend to be small, and there are few larger compara- tive studies. A key question is whether differences in the use of coercion among wards may be attributed mainly to composite differences in patient characteristics or to contextual effects such as ward culture, organization or staff attitudes. Our study investigates both patient and ward factors as possible predictors of differences in the use of coercion, and it is to our knowledge the first such study using a statistical multilevel approach. The aims of the study are to: (i) investigate frequency and variance in the use of coercive measures in acute psychiatric wards in Norway, and (ii) identify predictors of the use of coercion for involuntary admitted patients, with emphasis on patient, staff and ward characteristics, investigating especially whether mean ward-level staff attitudes to coercion influence the use of coercion. Methods Design and sample The study was part of the Multicenter study of Acute Psychiatry (MAP) in Norway in 2005-2006, which was carried out by an acute mental health services research network as a cross-sectional prospective study [41]. It was possible to link data about wards with data about patients from 32 acute psychiatric wards located in 17 of the 23 acute psychiatric departments across all 5 health regions in Norway. The sample is considered to be representative of Norwegian acute psychiatric wards. Patients were included in the study over a period of 3 months, and data were collected at admission, during hospitalization and at discharge. Data collection was ended after 2 months if the patient had not been dis- charged during that time. Most patients were, however, discharged before this. Very few patients may have had more than one admission in the 3-month inclusion per- iod. At ward level, data were collected on number of beds, staffing, staff characteristics and attitudes towards coercion. The research institute SINTEF Health Research in Norway organized the network and coordi- nated the study with support from the Norwegian Directorate of Health and Social Affairs. The study was approved by the Regional Committee for Ethics in Med- ical Research and by the Privacy Ombudsman on behalf of the Data Inspectorate. The Regional Committee for Ethics in Medial Research approved the study without requiring consent from the patients; thus, data were restricted to chart data only. The sample consisted of 3572 patients and we estimate this to be approximately 95% of patients admitted in the 3-month inclusion per- iod. Of these, 1214 patients were admitted involuntarily. Coercive measures are used almost exclusively with involuntary admitted patients. Hence, voluntary admitted patients were excluded from the multilevel analyses. For the multilevel analysis, it was possible to link data on patients and wards for 1016 involuntary admitted patients. Definition of seclusion, restraint and involuntary medication (dependent variables) Different national legislation and practices in use of coercive measures during treatment are challenges in comparative studies [13,28,42]. Coercive measures dur- ing hospitalization in this study are defined as seclusion, restraint and involuntary medication. Data about coer- cive measures were recorded on registration forms by clinicians and experienced psychiatric nurses in the teams treating patients. This was done at the end of the stay when the treatment and use of coercion throughout the whole stay was known. At discharge, staff recorded whether the patient had been subjected to any of these measures during the admission. Use of coercive mea- sures was recorded only with yes or no and not with number of times or duration. The use of a coercive measure requires specific decisions that are written in patient records. These records were considered to be highly accurate data that did not require additional tests of validity or reliability. Seclusion The practice of seclusion in Norway resembles the con- cepts of “open area seclusion”, “segregation nursing”, “seg- regation area”, “quiet rooms” or “sheltered area” in international literature (28). The word “shielding” has also been used. However, there is some variation in the Husum et al. BMC Health Services Research 2010, 10:89 http://www.biomedcentral. com/1472-6963/10/89 Page 2 of 9