Seclusion should always be the last resort when it comes to dealing with aggressive episodes involving young offenders with psychiatric disorders, according to staff who took part in a four-country study published in the November issue of the Journal of Psychiatric and Mental Health Nursing.
Researchers led by the Universities of Turku and Tampere, Finland, report that the multi-disciplinary teams they spoke to said that verbal intervention was their first choice. Putting adolescents in a bare, locked room was viewed as the least favoured option in the three countries where seclusion remains legal.
The research team also found that countries with a longer history of treating adolescents in medium to high security units tended to use less physical restraints on fewer occasions.
"Adolescent aggressive behaviour poses a challenge for staff working in forensic units, which cater for 12 to 18 year-olds who have been in trouble with the law, because it occurs so frequently" says lead author Johanna Berg from the Department of Nursing Science at the University of Turku.
"Our study of units in Belgium, Finland, the Netherlands and UK found that while the principles of dealing with aggression were fairly similar, there were some differences in the practical solutions."
The study comprised forensic units ranging from eight to 12 beds, treating young offenders with a range of problems, including: severe mental health disorders, delinquent, violent and non-compliant behaviour and impulse control problems. One unit was established in the 1980s (UK), two in the 1990s (Belgium and the Netherlands) and one in the 2000s (Finland).
The 58 staff, including nurses, doctors, psychologists, social workers, educators, support workers, occupational, art and family therapists and sports instructors, had an average age of 36.
Key findings from the one-to-one interviews included:
- Verbal intervention was the favoured technique and was most effective when it was clear, structured and used in the early stages of aggression. Talking about the incident afterwards was also very important, so that both the adolescent and staff could reflect on why it happened and how it could be prevented in future.
- Staff planned daily routines and worked together so that risks were minimised. Being able to respond quickly and call on colleagues for support, including staff from other units, was vital.
- Isolation techniques ranged from separating the aggressor from other adolescents for five to 15 minutes, to give them a chance to calm down, to seclusion, which was only used when less restrictive interventions had failed. It was not used in Finland, where it is banned by legislation.
- Duveting, where the adolescent is swathed in blankets to prevent violent acts and enable staff to transfer them to the seclusion room was not used in the UK unit. Restraint beds with straps were only used in Finland, for intensive care and for as short a time as possible.
- If medication was needed it was jointly decided between the staff and adolescent, if possible. Forced medication was rarely used and only in major incidents where safety was seriously compromised.
- Key factors that determined the level of response included the level of aggression involved, how well staff knew the individual adolescent's behaviour and what had proved helpful in the past.
- Teamwork was important and all members of the multi-disciplinary team needed to be committed to therapeutic aggression management.
"Staff in all four units displayed high ethical standards when it came to the use of restrictive treatment measures" says Johanna Berg. "They endeavoured to cooperate with the adolescent as long as possible and avoid coercive measures, while still maintaining the safety of others."
The research team have come up with a number of key recommendations for clinical practice as a result of their research:
- Continuous education is necessary to ensure that staff know how to evaluate incidents and implement the safest and most effective practices when intervening in aggressive situations.
- Sufficient resources should be available so that the needs of adolescents can be met without compromising the occupation safety and well-being of the staff that care for them. This will help to retain qualified staff in this challenging working environment.
- Further studies are needed to identify current practices, measure how effective they are and suggest how they could be improved.
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Management of aggressive behaviour among adolescents in forensic units: a four-country perspective. Berg et al. Journal of Psychiatric and Mental Health Nursing. 18, pp776-785. (November 2011). doi: 10.1111/j.1365-2850.2011.01726.x