Lauri Kuosmanen

Patient restrictions: Are there ethical alternatives to seclusion and restraint?

The use of patient restrictions (e.g. involuntary admission, seclusion, restraint) is a complex ethical dilemma in psychiatric care. The present study explored nurses’ (n = 22) and physicians’ (n = 5) perceptions of what actually happens when an aggressive behaviour episode occurs on the ward and what alternatives to seclusion and restraint are actually in use as normal standard practice in acute psychiatric care. The data were collected by focus group interviews and analysed by inductive content analysis. The participants believed that the decision-making process for managing patients’ aggressive behaviour contains some in-built ethical dilemmas. They thought that patients’ subjective perspective received little attention. Nevertheless, the staff proposed and appeared to use a number of alternatives to minimize or replace the use of seclusion and restraint. Medical and nursing staff need to be encouraged and taught to: (1) tune in more deeply to reasons for patients’ aggressive behaviour; and (2) use alternatives to seclusion and restraint in order to humanize patient care to a greater extent.

Patient complaints in Finland 2000–2004: a retrospective register study

Today, monitoring of patient complaints in healthcare services is being used as a tool for quality assurance systems and in the future development of services. This nationwide register study describes the number of all complaints processed, number of complaints between different state provinces, healthcare services and healthcare professionals, and outcomes of complaints in Finland during the period 2000–2004. All complaints processed at the State Provincial Offices and the National Authority for Medicolegal Affairs were analysed by statistical methods. Complaints about mental healthcare were explored in greater detail. The analysis showed that the number of patient complaints increased considerably during the study period. There were changes in the number of complaints between study years in different provinces. Out of different healthcare services, an especially marked increase was seen in private healthcare. Nearly all complaints were lodged against physicians, and over half of the complaints were made because of medical error. In mental health care, patients more often complained about unsatisfactory certificates and statements and the use of compulsory hospital care. An analysis of the outcomes revealed that in mental health care complaints more seldom led to consequences. The results need to be utilised when planning interventions for advanced supervision, prevention of adverse events and patient safety in healthcare, and especially in mental health care. From the patients’ perspective, it is important to create a culture where most problem situations are handled where the treatment was provided, thus avoiding a complex complaints process.

The effectiveness of technology-based patient education on self-reported deprivation of liberty among people with severe mental illness: A randomized controlled trial

Deprivation of liberty (DL) in psychiatric inpatient care is common worldwide. As liberty is a central element of patients’ rights, there is a need to develop most effective methods supporting patients’ personal liberty. The article presents initial results from a study to determine the effectiveness of an information technology (IT)-based patient education programme on patients’ experiences of being deprived of their liberty during their in-hospital stay. An overall sample of 311 patients with schizophrenia spectrum psychosis was randomized into three groups: an intervention group with needs-based computerized patient education, a patient education group with conventional education and a control group with standard care. Data on the general experience of DL were collected at baseline and during the patient discharge process. In general, all patients experienced less DL at the time of their discharge. The change in patients’ experiences of their DL did not differ statistically between the three groups. Male patients in the standard care group were significantly more likely to drop out of the study than female patients. Although technology-based patient education was not found to be superior to other approaches, we did not find any reason to inhibit its utilization in patient care among persons with severe mental health problems. From the healthcare organizations’ perspective, a cost-effectiveness analysis is needed, as the IT education was slightly more time-consuming.

Assessing quality of life in patients with schizophrenia in an acute psychiatric setting: Reliability, validity and feasibility of the EQ-5D and the Q-LES-Q

Background: Quality of life (QoL) is considered an important outcome of treatment in psychiatry. Two QoL instruments, the EuroQoL-5D (EQ-5D) and the Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q), have been increasingly used among patients with schizophrenia. Aims: The aim of this study was to investigate the reliability, validity and feasibility of the EQ-5D and the Q-LES-Q among patients with schizophrenia and related disorders (n = 311) in the most acute stage of their illness. Methods: The study was carried out in nine acute psychiatric wards of two psychiatric hospitals in Finland. The instruments’ internal consistency, construct validity and missing values were evaluated. Results: Our findings show high internal consistency for the Q-LES-Q (Cronbachs alpha 0,89). For the EQ-5D, the Cronbachs alpha value was minimally acceptable (0.63) taking in to consideration the low number of items. Lower overall functioning indicated poorer QoL measured by the EQ-5D (U = 3098, P < 0.001) or the Q-LES-Q (U = 3357, P < 0.001). Missing values in the EQ-5D ranged from 6% to 7% and in the Q-LES-Q from 6% to 31%. Conclusion: Our results suggest that both QoL scales are reasonably reliable, valid and feasible in this patient group. The decision regarding which instrument to use would depend on clinical or research questions. When more detailed information for patients’ satisfaction with QoL is needed then the Q-LES-Q would be a better choice, whereas if the primary interest is to briefly assess patients’ QoL problems related to health status the EQ-5D would be a better choice.

Patient education practices in psychiatric hospital wards: A national survey in Finland

Background: Despite the fact that patients’ receiving of information is one of the fundamental rights of patients, there is still limited information available on how patient education is carried out in psychiatric healthcare organizations. Aims: The aim of this study was to describe patient education practices in adult acute psychiatric hospitals. Methods: A descriptive questionnaire survey was administered in all adult acute psychiatric wards in Finland. Data was analysed using descriptive statistics and qualitative content analysis. Results: A total of 55 head nurses participated in the study (response rate 60%). The content of patient education covered almost all investigated informational areas and patient education was mostly carried out orally and with leaflets. However, patients’ individual needs for certain communication methods were not met. Moreover, staff rarely received adequate on-the-job training. In the study wards, there were only few systematic procedures and instructions regarding patient education. Problems relating to the delivery of patient education were described in four themes: patients’ poor condition, lack of staff resources, discrepancies in procedures and poor operational conditions. Conclusion: Patient education in psychiatric hospitals covers the informational areas investigated. However, there are numerous quality gaps in the realization of patient education in psychiatric hospitals. The results of this study suggest that to ensure patients’ right to receive information, specific guidelines and instructions are needed for psychiatric patients. These guidelines and instructions should thoroughly consider different domains of patient education including content, communication methods, definition of patients individual needs and delivery personnel.

Changes in the clinical features of child and adolescent psychiatric inpatients: a nationwide time-trend study from Finland

Background: Few studies have focused on the recent trends in clinical features child and adolescent inpatient. Aims: This study focuses on the change in the characteristics of child and adolescent psychiatric inpatients in Finland. Methods: The data collection was carried out on selected study days in 2000 and 2011. Questionnaires were sent to the psychiatrists of all child and adolescent wards in Finland. Results: By comparing the data obtained in 2000 (n = 504) and 2011 (n = 412), several changes were found: the percentage of girls in adolescent wards grew and the diagnoses of depression, anxiety disorders, attention deficit hyperactivity disorder and eating disorders increased. In contrast, the diagnoses of psychosis and conduct or oppositional disorders decreased. General functioning was evaluated with the Childreńs Global Assessment Scale (CGAS). There were no changes in the distribution of CGAS scores among child inpatients, whereas among adolescents the share of inpatients with lowest CGAS scores (1–30) increased significantly. The mean length of stay dropped. Conclusions: The growing percentage of girls in adolescent wards is associated with an increase in diagnoses that are more prevalent among girls than boys, namely depression, anxiety, and eating disorders. The changes in the distribution of diagnoses may be due to changes in diagnostic or referral practices, or reflect true changes in the prevalence of disorders among children and adolescents in need of inpatient treatment. The share of adolescent inpatients with the poorest general functioning has increased. The observed shortening in inpatient treatment time seems to be a result of changes in treatment practices.

National time trend changes in psychotropic medication of child and adolescent psychiatric inpatients across Finland

BACKGROUND There have been no comprehensive studies on trends in psychotropic medication use in child and adolescent inpatient settings. The aim of this nationwide study was to report changes in the psychotropic medication given to child and adolescent psychiatric inpatients across Finland and the factors associated with those changes. METHODS We asked the psychiatrist responsible for each inpatient to complete a questionnaire that included questions about the pharmacological treatment and background information. The data were collected on all inpatients on one selected study day in 2000 and 2011. Changes in the use of regular psychotropic medication were studied by comparing the data on 504 patients in 2000 and 412 patients in 2011. RESULTS The study showed that there had been a significant increase in the use of psychotropic medication from 2000 to 2011. According to the multivariate analysis, the increase in psychotropic medication was associated with the study year (in 2000 39%, in 2011 58%), but could not be explained by changes in diagnostic profiles, age distribution, suicidality, violence or the Childrens Global Assessment Scale scores. The use of combined psychotropic medication increased from 9% in 2000 to 25% in 2011. The increase in the use of antipsychotics among child inpatients was particularly noteworthy, with an increase from 10% to 32%. CONCLUSIONS There is a need for evidence-based studies to clarify recommendations for indications and treatment practices when using psychotropic medication in children and adolescents. Cross-cultural studies of the use of psychotropic medication are warranted.

Connectivity to computers and the Internet among patients with schizophrenia spectrum disorders: a cross-sectional study

Purpose Information and communication technologies have been developed for a variety of health care applications and user groups in the field of health care. This study examined the connectivity to computers and the Internet among patients with schizophrenia spectrum disorders (SSDs). Patients and methods A cross-sectional survey design was used to study 311 adults with SSDs from the inpatient units of two psychiatric hospitals in Finland. The data collection lasted for 20 months and was done through patients’ medical records and a self-reported, structured questionnaire. Data analysis included descriptive statistics. Results In total, 297 patients were included in this study (response rate =96%). More than half of them (n=156; 55%) had a computer and less than half of them (n=127; 44%) had the Internet at home. Of those who generally had access to computers and the Internet, more than one-fourth (n=85; 29%) used computers daily, and >30% (n=96; 33%) never accessed the Internet. In total, approximately one-fourth of them (n=134; 25%) learned to use computers, and less than one-third of them (n=143; 31%) were known to use the Internet by themselves. Older people (aged 45–65 years) and those with less years of education (primary school) tended not to use the computers and the Internet at all (P<0.001), and younger people and those with higher education were associated with more active use. Conclusion Patients had quite good access to use computers and the Internet, and they mainly used the Internet to seek information. Social, occupational, and psychological functioning (which were evaluated with Global Assessment of Functioning) were not associated with access to and frequency of computer and the Internet use. The results support the use of computers and the Internet as part of clinical work in mental health care.