STRATEGIES FOR HANDLING AGGRESSIVE INCIDENTS IN NORWAY by Roger Almvik

There is no national strategy for the management of violent incidents. Generally they are based on local hospital policies and management strategies. However, all these local policies and strategies are based on the Mental Health Act of 1961 (a new law proposal will exist probably next year). Therefore, we can conclude that there is a national strategy for how to formulate and shape strategies for the handling of violence. Furthermore, some regulations in the Mental Health Act consider the strategies: with coercion in the law being defined as seclusion and mechanical restraints.

Seclusion

Seclusion is only allowed in rooms at the minimum size of 8 sq metres. Patients should not be secluded for more than 2 hours alone; and a maximum of 4 hours if staff are present in the seclusion room. No patient under the age of 14 can stay secluded without staff in the same room. Seclusion is only rarely in use in Norway.

Mechanical restraints

These are, according to the law, legal mechanical restraints in use in hospitals in Norway:

• Belts (in general)
• Belts for bed purpose
• Hand and foot-belts
• Straight jacket (Not in use in today's hospitals).

The use of seclusion and mechanical restraints is allowed in hospital settings only. A doctor shall decree all use of restraints, though ward staff can initiate such treatment in an emergency situation; and then immediately contact the doctor on duty. As a general rule the use of any form of restraint should last as short as possible, and never more than 8 hours without attempting to "release" the patient. My personal experience is that usually mechanical restraints are used in emergencies and only for a short time.

When in use - patients in e.g. belts should always have at least one of the staff nearby and of course never be left alone without supervision what so ever. In practice this means that on acute and forensic/secure units there is a room designed for using belts (bed purpose) and that at least one of the staff has physical contact with the restrained patient or will be situated by the bedside. All use of restraints is reported in a Coercion Record frequently seen by the Control Commission.

As in most countries, I guess, for handling violent patients a strategy for preventing such behaviour is of great importance. So also in Norway. In general, one might say that using restraints of any kind is the last solution to any behavioural problem or symptoms displayed by patients. I will, therefore, put forward a strategy for handling violent patients which, in my experience, is as much in use in Norway, as probably beside medication, the most common strategy for handling violence in all types of psychiatric hospitals/wards.

Open Area Seclusion

As mentioned earlier (see above) seclusion rooms, as known in for example the UK, are not in use in Norway. But what is often in use is what we call "open area seclusion". An important component of the milieu treatment of violent patients. Some type of open area seclusion facilities and procedures are present at most hospitals, at least those including an acute/admission ward; and/or secure units. Open area seclusion means that the patient is placed in a separate lockable area together with two or more staff. Note that the patient is never isolated alone in a single locked seclusion room. This seclusion area usually consists of several rooms and is best described as a miniature ward, rather than a simple seclusion or isolation room.

Moreover, the period of seclusion in an area, like the one described above, is used therapeutically to help the patient to improve interpersonal communication and problem-solving skills. Hence, the patient is not brought to the seclusion area solely for destimulation and calming down, but also to help the patient to achieve reality orientation and to improve social skills. In short, the goal of this concept is to help the patient realistically view the situation and their own behaviour, and to help them establish alternative and more acceptable behaviours.

Unfortunately, far too often one can see that the use of seclusion is based on administrative sanction and/or for purely safety reasons. Forgetting/leaving out the therapeutic advantages. These therapeutic advantages are as follows:

• Containment of assaultive and disruptive behaviour
• Stimulus reduction
• Reality orientation
• Behaviour responsibility
• Problem solving

Behavioural Indications for seclusion

• Aggressive behaviour to others
• Self-mutilation and/or suicidal behaviour
• Self-initiated seclusion (rarely)
• Disruptive and/or psychotic behaviour that do not represent any danger to self or others. (E.g. continuous boisterous behaviour, lack of impulse control and others that represent a serious threat to the ward atmosphere)

References

Bjørkly, S. (1995). Diagnosis and prediction of intrainstitutional aggressive behaviour in psychotic patients. Department of Clinical Psychology, faculty of Psychology, University of Bergen. Norway.

For further information on this paper please contact the author E-mail Roger Almvik

Return to Forensic Nursing Resource Homepage

© This page was designed by Phil Woods and is copyright of the author

Send mail to Phil Woods