Hannele LaaksonenD. Sc., RN

Principal LecturerUniversity of Applied Sciences

Health Care and Social ServicesFinland

The violent behaviour of patients as an Ethical Problem

Background of the studyViolent behaviour has increased in psychiatric

health care (Needham, ym. 2005; Farrell, ym. 2007; Bonner, ym. 2007; Duffin 2007; Josefsson, ym. 2007)

Patients’ violent behaviour towards each other has been examined little, if at all

Finland was the first in Europe to pass an Act (17.8.1992/785) where it is stated that patients have the right to receive good and quality treatment

In the case of dementia patients, it is very important to safeguard their physical integrity

Purposes of the study 1. to increase knowledge of the incidence of

violence in dementia care, especially mentally and physically violent behaviour between patients

2. to start a dialogue about how to prevent violent behaviour

Research problem1. What kind of violent behaviour has been

reported among patients and nurses at one psychiatric dementia care unit in Finland between 2005 and 2007?

Research method and data collection:Quantitative longitudinal study Document evaluation Violent behaviour documents from 2005-2007 (N=145)Material analysed in autumn 2008

Lehtiharju Hospital a public hospital which serves several

municipalities in Ostrobothnia on the west coast of Finland

three units: psychogeriatric unit, social rehabilitation unit, and day care unit

This study was carried out in the psychogeriatric unit, which has 18 beds

Patients’ diagnoses: About 60% have dementia About 40% have schizophrenia Other diagnoses (with above mentioned) are

mental and distress disturbancesUnit’s degree of use is 99-120%Unit divided into two modules: a smaller one for

dementia patients and a larger one for the rest

Number of cases of violent behaviour and the targets of behaviour

Year 2005 (n=45)

Year 2006 (n=56)

Year 2007 (n=44)

71,1

55,4

75

28,9

44,6

25

Patient as a target of violent behaviour

Nurses as a target of violent behaviour

%

The classification of cases of violent behaviour

Classification

% f

”Close call” cases

71% 32

Consequences 29% 13

Classification of violentbehaviour in 2005

Cases of Violent behaviour 2005-2007 (in months)

0

2

4

6

8

10

12 Year 2005 (n=45) Year 2006 (n=56) Year 2007 (n=44)f

Number of cases according to time of day

What kind of situations lead to violent behaviour? (patient-patient)

2005-2007 (n=91)

%

Beating when someone walked by 19

Patient tried to enter another patient’s room 16

Irritating behaviour of another patient 16

Disagreements between patients 16

Fight about places/chairs at dining room 11

Two patients sitting together 6

Some other unnamed situation 17

Places where violent behaviour occurs (n=145)

Dining room/lounge 25%Own rooms 24%Corridors 16%Toilet 9%Office 2%Unnamed places 24%

Cases of violent behaviour (n= 94, patient-patient)

2005 – 2006 Shouting, threatening, abusive language 75%Beating (fist fight) 78%

fists to the face, arms, back, or chest

Gripping , squeezingPushing Twisting hands Threatening for example

with chair

2007Gripping, squeezing

(33%)Hitting (33%)Pushing (14%)Strangulation (5%)Tearing (5%)Distortion (5%)

Consequences of violent behaviour

2005 – 2007 (n=145) f Erythematus on the skin

8

Swollen lip, earflap 3 Bruises 3 Scratches with blood 3 Nosebleed 2 Cardiac symptoms 1 Patient requires X-ray 1 Total 21

Management of violent situations

Nurses intervene 53%The situation calms down on its own

39%Patient moved by nurses 5%On one occasion, a patient bound with

belt Victim left

Discussion The main aims are to decrease violent behaviour

and to prevent incidents from happening in the future

Patient perspective:Single rooms are recommendedUnit divided into smaller modulesNo one in extra bedsTiming of meals: for example, small groups eat

together and/or some patients eat in their own rooms

Nurses should be present as much as possible

…continued…Environmental perspective :Development of rooms, dining rooms, corridors, living

rooms and other places inside the unit (also furniture)Enough space to walk around the unit: in rooms, corridors

and living rooms

Care perspective:Enough nurses to care for patientsMore education of staff about how to manage violent

situationsMake procedures about how to act in different violent

situationsIt is always necessary to organize discussion meetings

after a violent situation: how we acted and how we should act in the future

Work coachingMore nurses on evening and night shifts

Thank you!