1. Hannele Laaksonen D. Sc., RN Principal Lecturer University of Applied Sciences Health Care and Social Services Finland The violent behaviour of patients as an Ethical Problem

2. Background of the study Violent 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

3. 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

4. Research problem 1. 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

5. 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 disturbances Unit’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

6. Number of cases of violent behaviour and the targets of behaviour %

7. The classification of cases of violent behaviour Classification%f ”Close call” cases71%32 Consequences29%13 Classification of violent behaviour in 2005

8. Cases of Violent behaviour 2005-2007 (in months) f

9. Number of cases according to time of day

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

11. Places where violent behaviour occurs (n=145) Dining room/lounge 25% Own rooms 24% Corridors 16% Toilet 9% Office 2% Unnamed places 24%

12. 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, squeezing Pushing Twisting hands Threatening for example with chair 2005 – 2006 Shouting, threatening, abusive language 75% Beating (fist fight) 78%  fists to the face, arms, back, or chest Gripping, squeezing Pushing Twisting hands Threatening for example with chair 2007 Gripping, squeezing (33%) Hitting (33%) Pushing (14%) Strangulation (5%) Tearing (5%) Distortion (5%) 2007 Gripping, squeezing (33%) Hitting (33%) Pushing (14%) Strangulation (5%) Tearing (5%) Distortion (5%)

13. Consequences of violent behaviour

14. 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

15. Discussion The main aims are to decrease violent behaviour and to prevent incidents from happening in the future Patient perspective: Single rooms are recommended Unit divided into smaller modules No one in extra beds Timing 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

16. …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 patients More education of staff about how to manage violent situations Make procedures about how to act in different violent situations It is always necessary to organize discussion meetings after a violent situation: how we acted and how we should act in the future Work coaching More nurses on evening and night shifts

17. Thank you!