An Evidence-Based Educational Intervention for Reducing Coercive Measures in Psychiatric Hospitals: A Randomized Clinical Trial

Abstract

Importance: Investing in health care staffs' education can change the scope of action and improve care. The effectiveness of staff education remains inconclusive.

Objective: To examine whether an evidence-based educational intervention for nurses decreases the use of seclusion rooms in psychiatric hospitals compared with usual practice.

Design, setting, and participants: In this pragmatic, 2-arm parallel, stratified cluster randomized clinical trial, 28 wards in 15 psychiatric hospitals in Finland were screened for eligibility and randomly allocated (1:1). Nurses joined on either intervention (n = 13) or usual practice (n = 15) wards. The intervention was performed from May 1, 2016, to October 31, 2017. The follow-up data for January 1 to December 31, 2017, were collected from hospital registers in 2018. Data analysis was performed October 27, 2021.

Interventions: Evidence-based education delivered during 18 months, including 8 months of active education, followed by a 10-month maintenance period.

Main outcomes and measures: The primary outcome was the occurrence of patient seclusion (events per total number of patients).

Results: Of 28 psychiatric hospital wards screened (437 beds and 648 nurses), 27 wards completed the study. A total of 8349 patients were receiving care in the study wards, with 53% male patients and a mean (SD) age of 40.6 (5.7) years. The overall number of seclusions was 1209 (14.5%) in 2015 and 1349 (16.5%) in 2017. In the intervention group, the occurrence rate of seclusion at the ward level decreased by 5.3% from 629 seclusions among 4163 patients (15.1%) to 585 seclusions among 4089 patients (14.3%) compared with a 34.7% increase from 580 seclusions among 4186 patients (13.9%) to 764 seclusions among 4092 patients (18.7%) in the usual practice group. The adjusted rate ratio was 0.86 (95% CI, 0.40-1.82) in 2015 and 0.66 (95% CI, 0.31-1.41) in 2017 (P = .003). However, the number of forced injections increased in the intervention group from 317 events among 4163 patients (7.6%) in 2015 to 486 events among 4089 patients (11.9%) in 2017 compared with an increase in the usual practice group from 414 events among 4186 patients (9.9%) in 2015 to 481 events among 4092 patients (11.8%) in 2017. Seven adverse events were reported.

Conclusions and relevance: In this randomized clinical trial, the educational intervention had a limited effect on the change of occurrence rate of patient seclusion, whereas the use of forced injections increased. More studies are needed to better understand the reasons for these findings.

Trial registration: ClinicalTrials.gov Identifier: NCT02724748.

Conflict of interest statement

Conflict of Interest Disclosures: Dr Välimäki reported being employed by University of Turku, Turku University Hospital, and serving as a board member for the Academy of Finland outside the submitted work. Dr Lantta reported receiving grants from the Academy of Finland and Turku University Hospital at the time the study was conducted and personal grants from the Academy of Finland, the TYKS Foundation, the Finnish Work Environment Fund, and the Finnish Nursing Education Foundation outside the submitted work. No other disclosures were reported.

Figures

Figure 1.. Timeline of Intervention and Outcome Data Collection

Figure 2.. Trial Flow Diagram

aThe survey was conducted on the ward level.