Collection and analysis of data on the use of restraint and decisions concerning open-area seclusion in adult mental health care in 2012

Abstract

The Regional Centre for Research and Education in Forensic Psychiatry for the South-Eastern Norway Regional Health Authority was commissioned by the Directorate of Health to examine the use of restraint and open-area seclusion in adult mental health care in 2012. This report follows up a similar mapping in 2009. Given the lack of an electronic reporting system that ensures complete sets of data on administrative decisions on restraint and open-area seclusion, it was necessary to use a manual whereby anonymised copies were submitted of all handwritten records of the use of restraint and open-area seclusion from 2012. The data were then coded in a specially designed database before being transferred to SPSS for statistical analysis.

Full text

The South-Eastern Norway Regional Health Authority
Collection and analysis of data on the use of
restraint and decisions concerning open-area
seclusion in adult mental health care in 2012
Maria Knutzen, Stål Bjørkly, Martin Bjørnstad, Astrid Furre, Leiv Sandvik
Centre for Research and Education in Forensic Psychiatry,
Oslo University Hospital, Norway
Oslo University Hospital
Ullevål
Project report 2016-2

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ISBN 978-82-473-0041-1
post.kps@ous-hf.no
tel. (+47) 22 02 92 20
P. O. Box 4956 Nydalen, NO-0424 Oslo
Office address: Building 7, Gaustad, Sognsvannsveien 21,
NO-0320 Oslo

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Table of Contents
Foreword .................................................................................................................................... 5
Summary .................................................................................................................................... 6
Findings .................................................................................................................................. 6
Recommendations .................................................................................................................. 7
1 Introduction ............................................................................................................................. 8
Legal authority ....................................................................................................................... 9
1.2 Mandate .......................................................................................................................... 11
2 Research into the use of coercion in adult mental health care .............................................. 13
2.1 A brief summary of the key elements from the research status described in the previous
report (Bjørkly et al., 2011) .................................................................................................. 13
2.2 Main findings from a literature review of international publications dealing with the use
of restraint and seclusion in the period 2011–2014 .............................................................. 14
2.3 An overview of recent Norwegian and Nordic research publications and official reports
dealing with the use of restraint and seclusion ..................................................................... 14
2.3 Main findings from the previous report (Bjørkly et al., 2011) ....................................... 16
3 Method .................................................................................................................................. 17
3.1 Mapping procedure ........................................................................................................ 17
Preparation of a national overview of psychiatric health care for adults 2012 ................ 17
Establishing points of contact in wards issuing administrative decisions and informing
them about the method of collecting and transmitting data ............................................. 18
Reception, registration and scanning of incoming data ................................................... 18
Creating databases and coding of data ............................................................................. 19
Scanning handwritten records of the use of restraint and open-area seclusion in
connection with coding administrative decisions ............................................................. 20
Data analysis .................................................................................................................... 21
Statistical method ............................................................................................................. 22
4 Results ................................................................................................................................... 23
Table 4.1: Patients with decisions on restraint/open-area seclusion, by gender and
number of decisions, 2009 and 2012 ................................................................................ 23
Figure 4.1: Total number of patients with decisions on restraint/open-area seclusion, by
decision type, 2009 and 2012 ........................................................................................... 23
Figure 4.2: Number of patients with decisions on coercive measures/open-area seclusion,
by gender and decision type, 2009 and 2012 ................................................................... 24
Figure 4.3: Patients’ first decisions on restraint/open-area seclusion, by decision type,
2009 and 2012 .................................................................................................................. 25
Figure 4.4: The total number of decisions on restraint/open-area seclusion, by decision
type, 2009 and 2012 ......................................................................................................... 26
Table 4.2: Patients with decisions on mechanical restraint, by gender and number of
decisions, 2009 and 2012 ................................................................................................. 26
Table 4.3: Duration of decisions on mechanical restraint, 2009 and 2012 ...................... 27
Table 4.4: Patients with decisions on pharmacological restraint, by gender and number of
decisions, 2009 and 2012 ................................................................................................. 27
Table 4.5: Patients with decisions on isolation, by gender and number of decisions, 2009
and 2012 ........................................................................................................................... 28
Table 4.6: Duration of decisions on isolation, 2009 and 2012 ......................................... 28
Table 4.7: Patients with decisions on physical restraint, by gender and number of
decisions, 2009 and 2012 ................................................................................................. 29
Table 4.8: Duration of decisions on physical restraint, 2009 and 2012 ........................... 29

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Table 4.9: Patients with decisions on open-area seclusion, by gender and number of
decisions, 2009 and 2012 ................................................................................................. 30
Table 4.10: Duration of decisions on open-area seclusion, 2009 and 2012 ..................... 30
Table 4.11: Index for adjusted average number of patients with decisions, 2009 and
2012, by ward code (average and standard deviation) ..................................................... 31
Table 4.12: Index for adjusted average number of decisions in 2009 and 2012, by ward
code (average and standard deviation for each ward type) .............................................. 32
Table 4.13: Number of decisions on restraint/open-area seclusion, by ward code and
decision type, 2009 and 2012 ........................................................................................... 33
Table 4.14: Patients with decisions on restraint/open-area seclusion, by ward code, 2009
and 2012 ........................................................................................................................... 34
Table 4.15: Decisions on restraint/open-area seclusion, by ward code, 2009 and 2012 .. 35
Table 4.16: Duration of decisions on restraint (isolation, physical and mechanical
restraint), by ward code, 2009 and 2012 .......................................................................... 36
5 Conclusions, main findings, limitations and recommendations ............................................ 37
5.1 Main findings in 2012 .................................................................................................... 37
5.2 Methodological challenges and limitations for deductions and conclusions ................. 38
Reliable and valid annual overviews of reported use of restraint and open-area seclusion
.......................................................................................................................................... 38
Comparing the use of coercion between health thrusts/institutions ................................. 38
Organisational-level analysis ........................................................................................... 39
Data quality ...................................................................................................................... 39
What the mapping of decisions on restraint and open-area seclusion does not tell us..... 40
List of references ...................................................................................................................... 43
Annexes
Annex 1 Ward coding system ……...……………………………………………………..46
Annex 2 Basic data for the number of decisions concerning restraint and open-area
seclusion, and numbers of patients with decisions in 2012, by health trust/institution…..47
Annex 3 Letter to the health trusts...…………………………………………....………....48
Annex 4 Letter to clinic managements ……………………………………….…………50
Annex 5 Letter to ward points of contact ……………………………………………..52
Annex 6 Ward details …………………………………………….………………55
Annex 7 Records of the use of restraint and open-area seclusion – examples of
documentation of decisions………………………………………………………………56

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Foreword
This report presents the results obtained from the mapping and analysis of administrative
decisions on restraint and open-area seclusion in adult mental health care in 2012. This is the
second time the Regional Centre for Research and Education in Forensic Psychiatry and
Psychology for the South-Eastern Norway Regional Health Authority conducts this
assignment on commission from the Norwegian Directorate of Health. The first time,
corresponding data from 2009 were used, and the same method has been applied for both
assignments.
The lack of an electronic reporting system that ensured complete sets of data on decisions on
restraint and open-area seclusion rendered it necessary to use an alternative, highly resource-
intensive manual method.
We would therefore like to thank the staff at all the health trusts and institutions in adult
mental health care who undertook the demanding task of anonymising, copying and
submitting to us all handwritten records of the use of restraint and open-area seclusion from
2012.
We would also like to thank all our project team members for assisting in the laborious work
of coding all the data from records of the use of restraint and open-area seclusion into
electronic databases and transferring the data to SPSS files for analysis.
Oslo, December 17 2014
Maria Knutzen
Project Manager

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Summary
The Regional Centre for Research and Education in Forensic Psychiatry for the South-Eastern
Norway Regional Health Authority was commissioned by the Directorate of Health to
examine the use of restraint and open-area seclusion in adult mental health care in 2012. This
report follows up a similar mapping in 2009. Given the lack of an electronic reporting system
that ensures complete sets of data on administrative decisions on restraint and open-area
seclusion, it was necessary to use a manual whereby anonymised copies were submitted of all
handwritten records of the use of restraint and open-area seclusion from 2012. The data were
then coded in a specially designed database before being transferred to SPSS for statistical
analysis.
Findings
Patients
In 2012, administrative decisions on the use of restraint and open-area seclusion were issued
for 2,602 patients receiving adult mental health care in Norway. This represented an increase
in the number of patients of 7% from the 2009 mapping (n=170). Changes in the numbers of
patients who received decisions on the different types of restraint and open-area seclusion
between 2009 and 2012 were as follows:
 Mechanical restraints: an increase of 3.7% (n=42), from 1,107 to 1,065 patients.
 Pharmacological restraint: a decrease of 0.4% (n=3), from 712 to 709 patients.
 Isolation: an increase of 26.3% (n=30), from 114 to 144 patients.
 Physical restraint: an increase of 30.5% (n=175), from 574 to 749 patients.
 Open-area seclusion: an increase of 13% (n= 211), from 1,406 to 1,617 patients.
Gender
The group of patients with most decisions (20+) comprised more women than men. The
duration of decisions on mechanical restraints was longer for men than for women.
Decisions
A total of 11,535 administrative decisions on the use of restraint and open-area seclusion were
issued in 2012. This represented an increase of 5.4% (n= 596) from 2009 when 10,939
decisions were reported. The following changes from 2009 to 2012 were found in the number
of decisions concerning the different forms of restraint and open-area seclusion:
 Mechanical restraint: a decrease of 586 (13.2%) decisions, from 4,426 to 3,840.
 Pharmacological restraint: a decrease of 390 (20.8%) decisions, from 1,875 to 1,485.
 Isolation: an increase of 302 (112%) decisions, from 269 to 571.
 Physical restraint : an increase of 617 (36.7%) decisions, from 1,680 to 2,297.
 Open-area seclusion: an increase of 629 (23.3%) decisions, from 2,689 to 3,318.
Duration of decisions
The following changes were found in the median duration of decisions on restraint and open-
area seclusion from 2009 to 2012:
 Mechanical restraint: a decrease from 3.25 hours in 2009 to 2.9 hours in 2012.
 Isolation: an increase from 0.53 hours to 1 hour.
 Physical restraint : an unchanged median period of duration of 0.17 hours.

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 Open-area seclusion: an increase from 139.5 hours to 335.9 hours.
Ward type (ward code)
In 2012, acute psychiatric wards accounted for 74% of all patients who received decisions on
restraint and open-area seclusion (70% in 2009), and 59% of all decisions (60% in 2009). The
increase in the number of patients with decisions in acute psychiatric wards was significant.
Health trusts/institutions
The total number of patients with decisions on restraint and open-area seclusion, and the
number of decisions varied between health trusts/institutions. Because this study did not
control for factors that might explain these differences, we cannot draw any conclusions
regarding the reasons for them.
Recommendations
Based on the experiences gained from this mapping, we make the following
recommendations:
 That an electronic documentation system that will ensure reporting of complete data
on restraint and open-area seclusion should be developed and implemented.
 In future mappings of the use of restraint and open-area seclusion, that reported data
should be analysed in relation to relevant background data from the health trusts and
institutions (such as the number of patients treated, the number of admissions, the size
of catchment area). This will make it possible to compare differences in the use of
restraint between institutions and health trusts.
To ensure sound reporting practices, further requirements are recommended for certain
aspects of documentation on the use of physical restraint and open-area seclusion:
 That details be given on the position in which the patient is held during
implementation of the decision (for example: prone position, supine position on the
floor, arms held, seated on bed), number of staff participate (and their gender, where
applicable) and in what way (how personnel use their bodies during implementation).
 That documentation of open-area seclusion decisions shows how decisions are
implemented and what this entails for the patient.
To ensure a common documentation practice, it is recommended that:
 Clarification is reached on how long holding can last before a decision authorising
physical restraint must be made.
 The use of mechanical restraint and physical restraint during the implementation of
involuntary treatment either with medication or nutrition are deemed to be coercive
measures, and that decisions must be entered in records of the use of restraint (Page
64 of the annotated edition of the Mental Health Care Act and the Mental Health Care
Regulations).

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1 Introduction
Society has an overall responsibility for giving all groups of patients the right treatment at the
right time. This is contingent on the continual updating of information about how different
patient groups are safeguarded and treated. There is broad consensus that all use of restraint in
mental health care raises issues relating to ethics, legality, human rights and treatment.
Politicians and health care bureaucrats have repeatedly stressed the importance of reducing
and quality-assuring the use of restraint in mental health care. In order to form sound opinions
on reducing the use of restraint, one must first obtain reliable information about the existing
quality and the prevalence of the use of restraint. Report No 10 (2012–2013) to the Storting
(Parliament) High Quality – Safe Services gives the following description on page 25: ‘The
lack of basic data makes it challenging to monitor developments in the use of restraint in
mental health care.’ On this basis, the Regional Centre for Research and Education in
Forensic Psychiatry and Psychology for the South-Eastern Norway Regional Health Authority
was commissioned by the Directorate of Health to map the use of restraint and open-area
seclusion in adult mental health care in 2012.
Restraints include: 1. belts, straps and clothing specially designed to prevent injury
(mechanical restraint), 2. pharmacological restraint (short-acting medication), 3. isolation and
4. physical restraint (brief holding). Open-area seclusion is not a form of restraint, but rather a
decision that entails keeping the patient fully or partially separated from other patients and
from personnel not involved in the examination, treatment or care of the patient.
Several official reports have been published over the past 15‒20 years concerning the use of
restraint in mental health care, including Hatling & Krogen (1998) and Høyer & Drange
(1991; 1994). The purpose of many of the reports published since the turn of the millennium
has been to map the annual incidence of the use of coercive measures and, gradually,
seclusion (see Bremnes, Hatling & Bjørngaard, 2008). However, methodology issues
rendered it difficult to make reliable comparisons of the incidence figures in these reports for
the years 2001, 2003, 2005, 2007 and 2009 (see Bjørkly et al., 2011 for further explanation).
One of the objectives for mapping annual incidence as covered by the current report is to
make it comparable with the findings of the previous report (Bjørkly et al., 2011). This means
that we do not give a detailed description of findings from other previous reports. In Chapter 2
Research into the use of restraint in adult mental health care (page 12), we will:
 Give a brief summary of main elements from the research status described in the
previous report (Bjørkly et al., 2011).
 Present the main findings from a literature review of international publications
dealing with the use of restraint and open-area seclusion in the period 2011-2014.
 Provide an overview of Norwegian and Nordic research publications and official
reports dealing with this topic.
 Describe the main findings from the previous report (Bjørkly et al., 2011).

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Legal authority
The Act relating to the Provision and Implementation of Mental Health Care (the Mental
Health Care Act, 1999) and its Regulations govern all use of restraint in mental health care
provision. The use of restraint (Section 4-8) and open-area seclusion (Section 4-3) dealt with
in this report is warranted by Chapter 4 of the Mental Health Care Act and regulated by the
Regulations of 16 December 2011 No 1258 concerning the Provision and Implementation of
Mental Health Care etc. (the Mental Health Care Regulations), Chapter 3 Section 15-30.
Restraint
Institutions must be approved to initiate and implement mental health care. Restraint may also
be used on all admitted patients (voluntarily admitted patients, and patients placed under
compulsory observation or compulsory mental health care).
‘Restraint shall only be used in respect of the patient when this is absolutely necessary
to prevent him or her from injuring himself or herself or others, or to avert significant
damage to buildings, clothing, furniture or other things. Restraint shall only be used
when milder means have proved to be obviously futile or inadequate.’ (the Mental
Health Care Act Section 4-8).
The Act goes on to describe which forms of restraint may be used:
a. Mechanical restraint means belts and straps and clothing specially designed to prevent
injury which hamper the patient’s freedom of movement
‘Letter a): The provision permits the use of mechanical restraints. By this is meant
devices that hamper the patient’s freedom to move his/her arms and/or legs. The list of
the various types of mechanical restraints (belts, straps and clothing specially
designed to prevent injury) provides examples and is therefore not exhaustive.’ (Page
76 of Circular no IS-9/2012, the Mental Health Care Act and the Mental Health Care
Regulations).
b. Isolation. Detention for a short period of time behind a locked or closed door without a
staff member present.
‘Letter b):
The inclusion not only of locked doors but also of “closed” doors means that decisions
shall be made in emergency situations to keep a door between the patient and the staff
closed by physical force, using a door wedge or similar device.’ (Page 76 of Circular
no IS-9/2012, the Mental Health Care Act and the Mental Health Care Regulations).
c. Pharmacological restraint. Single doses of medicines with a short-term effect for the
purpose of calming or anaesthetizing the patient.
‘Letter c):
With respect to medication, justification of use will determine whether or not it is
deemed to be restraint. The use of medication for treatment purposes without the
patient’s consent is regulated by the Mental Health Care Section 4-4. The term “short-
term effect” means that the choice of medication and dosage must be based on the
purpose of relieving acute anxiety. Long-acting medication may therefore not be used.
The use of depot medication will generally not be allowed. When medicating it must
nonetheless be correct to take into account what medication is expected to have a
generally favourable effect on the patient’s condition and it must be accepted that it
may take time for that effect to disappear completely. On this basis, exceptions from the
general rule must be allowed in special circumstances. For example, the use of

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Cisordinol-Acutard must be accepted in cases where the responsible health care
professional deems it likely that the duration of the acute risk prompting the need for
restraint will be approximately the same as the effective time of this preparation
(usually two to three days).’ (page 76 of Circular no IS-9/2012, the Mental Health Care
Act and the Mental Health Care Regulations).
d. Physical restraint. (Briefly holding the patient fast) (Section 4-8).
‘Letter d):
The term “brief” has been added to emphasise that the use of this measure must not be
sustained longer than strictly necessary; cf. Section 4-2.
This provision is not intended to cover any and all measures that involve a patient
being held. It would take quite a lot for the measure to be deemed physical restraint in
the legal sense. The provision only covers measures intended to prevent injury (cf. the
first paragraph). In many situations, holding will be a natural part of patient care
rather than a form of restraint; for example, when health care personnel embrace
patients to reassure and comfort them. To the extent to which the main purpose of a
measure is to provide care and to set boundaries (not to prevent injury), the measure
is minimally intrusive and meets no resistance from the patient, the measure will fall
outside the prevalence of this provision.
If the patient actively resists the measure orally and/or physically, this indicates that
holding shall be deemed restraint in the legal sense. At the same time, a measure may
in itself be so intrusive that it falls under the provision without the patient resisting, for
example if a patient is held fast for a long time in order to prevent self-harm. On the
other hand, situations where holding is less intrusive – for example where a patient is
held by the arm and guided to his/her room without showing resistance – may fall
outside the scope.’
‘Whether or not holding calls for an administrative decision must be determined on
the basis of a concrete evaluation in which the key elements will be the purpose of the
measure, how the patient reacts to the measure, how long it is sustained, and how
intrusive it is.’ (pages 76–77 of Circular no IS-9/2012, the Mental Health Care Act and
the Mental Health Care Regulations).
Responsible decision-maker
‘The decision to use restraint shall as a rule be made by the responsible health care
professional; cf. Section 1-4. The decision to use pharmacological restraint shall be
made by a physician. However, an exception has been made to the general rule (in the
Mental Health Care Regulations Section 25 second paragraph) whereby “the staff
member in charge of the ward” may make decisions on the use of restraint when an
acute situation renders immediate contact with the responsible health care
professional impossible. The exception does not apply to measures concerning
pharmacological restraint. Such decisions shall always be made by a physician.’
(Page 78 of Circular no IS-9/2012, the Mental Health Care Act and the Mental Health
Care Regulations).
Open-area seclusion
Although the use of open-area seclusion has always been widespread in mental health care, it
was not regulated as a coercive measure by law until 1999. «Open-area seclusion means that

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the patient is placed in a segregated (and locked) area together with staff members, but the
patient is never isolated alone in a single locked room for seclusion”(Stål Bjørkly 1995,p148)
and is not deemed to be a form of restraint, but rather a measure that, according to the Mental
Health Care Act, shall be justified by ‘reasons related to his or her treatment or in the
interests of other patients’ (cf. the Mental Health Care Act Section 4-3).
‘If a patient’s mental state or aggressive behavior during a stay in an institution makes
open-area seclusion necessary, the responsible mental health professional may decide that
the patient, for reasons related to his or her treatment or in the interests of other patients,
shall be kept completely or partly segregated from fellow patients and from personnel who
do not take part in the examination, treatment and care of the patient.’ (the Mental Health
Care Act Section 4-3).
Open-area seclusion may not be used against the patient’s will if he or she has been
voluntarily admitted, but it ‘must, however, be practised in such a way that patients under
voluntary mental health care feel they have the possibility to ask to be discharged and leave
the institution.’ (page 133 of Circular no IS-9/2012, the Mental Health Care Act and the
Mental Health Care Regulations).
Open-area seclusion may be used for shorter periods without the need for an administrative
decision. However,
‘An administrative decision shall be made if open-area seclusion is maintained for more
than 24 hours. If the patient is transferred to a closed unit or similar which entails a
significant change in the patient’s surroundings or freedom of movement, an
administrative decision shall be made if open-area seclusion is maintained for more than
12 hours. Decisions regarding open-area seclusion shall be recorded without undue delay.
Decisions may only be made for up to two weeks at a time.’ (the Mental Health Care Act
Section 4-3).
Registration of the use of restraint and open-area seclusion
Wards are required to register information about the use of restraint in records approved by
the Directorate of Health and Social Affairs (Section 10 Registration of the use of restraint,
the Regulations concerning the use of restraint, 2000) (Section 9 of the Regulations
concerning the use of open-area seclusion).
1.2 Mandate
The mandate for the assignment was to map and analyse restraint and open-area seclusion in a
similar way to the assignment from 2009.
‘The mapping shall cover data from 2012 from all inpatient institutions in the mental
health care service dealing with:
 restraint (mechanical restraint, pharmacological restraint, isolation and physical
restraint)
 administrative decisions authorising open-area seclusion for more than 24/12 hours.’
‘Data shall be collected in a way that enables comparison with the results obtained from
the previous mapping. A description shall be given of how the provider will organise the
work to ensure data quality and comparability with previously collected data in terms of
institutional structure and ward structure, completeness and quality of the material, and
classification according to the laws that regulate the use of restraint in mental health
care.’

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The underlying assumption was that the mapping in 2012 should be conducted using the same
method as for the national mapping of restraint and open-area seclusion in 2009 (Bjørkly et
al., 2011), which would provide a reliable basis for comparison (see page 17).
When it comes to operationalising the five measurement ranges – restraint (mechanical
restraints, short-acting medication, isolation and brief holding) and open-area seclusion – we
refer to our own review of the legal authority (see page 9).
‘The tenderer is asked to describe its strategies for ensuring that all wards be included
in the data supplied, and how it envisages dealing with any gaps in the data material.’
In this context, reference is made to the preparation of a national overview of health
trusts/institutions/wards/units in the mental health care service for adults 2012 (see page 17).
‘As part of the work on quality assuring the data, the tenderer shall ensure that all
institutions covered by the mapping receive written feedback on their figures/rates for
relevant variables and on the level of use of the different forms of restraint and open-
area seclusion compared with the national average.’
‘The data analyses shall include:
 The level in 2009 (number of administrative decisions and number of patients).
The rates per 365 bed days for the hospitals, and the duration of restraint and
administrative decisions on open-area seclusion at the national level (i.e. both
hospitals and other institutions), by each individual hospital, broken down by
ward type.’
 Trends from 2009 to 2012 in the use of the different forms of restraint and
open-area seclusion for more than 24/12 hours.

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2 Research into the use of coercion in adult mental health
care
The first descriptions of restraint used on people with mental illness go all the way back to
antiquity (see for example Browne & Tooke, 1992). Already then, seclusion was used and, in
extreme cases, mechanical restraints. The main intention was sensory deprivation in the form
of limited contact with others, and the objective was to avoid deterioration of the person’s
mental state. This closely coincides with today’s justification for using such forms of
intervention. It is also interesting to note that, already then, there was an interest in finding
optimal solutions for interior environments and architectural design.
For the sake of this overview, we have drawn a distinction between research papers in
scientific journals, on the one hand, and books and official reports, on the other. Although we
conducted a literature review, our presentation does not provide an exhaustive list of
publications.
2.1 A brief summary of the key elements from the research status described
in the previous report (Bjørkly et al., 2011)
The presentation of the research status was largely based on a review of recently published
review articles analysing empirical research relevant to the areas of restraint and seclusion.
This limitation was imposed because systematic reviews summarise findings from a large
number of studies and therefore give a more stable and clear overview of the field of research.
Two reviews were conducted.
Hamrin, Iennaco & Olsen (2009) reviewed studies that focused on the effect of ecological
factors on violence, self-harm and other behaviour that legally can invoke the use of restraint
in psychiatric institutions (referred to as ‘aggressive behaviour’ in the study). The main
finding was that ecological factors such as the quality of unit culture and therapeutic
relationships could either increase or reduce the incidence of such behaviour. Good
therapeutic assessment and communication, clear patient engagement, availability,
willingness to cooperate, and facilitation of training and development were the most important
relational qualities among staff for the prevention of aggressive behaviour. The most
important ward culture variables were meaningful activities, a stimulating ward environment,
and good staffing levels.
The literature review in Gaskin, Elsom & Happels (2007) focused on the significance of
service systems for the use of restraint and seclusion. They concluded that improved
leadership, staff educational programmes and the establishment of specialist teams in the
treatment units with expertise in handling escalating situations may reduce the use of restraint.
Three other reviews were limited to the influence of either staff or patient characteristics on
the use of coercion (Flannery, 2007; Gadon, Johnstone & Cooke, 2006; Jansen, Dassen &
Jebbink, 2005). Attention was also drawn to an increase in number of studies that tested
interventions for reducing the use of restraint resulting from prior intervention based on early
recognition of warning signs of escalation towards aggressive behaviour (Abderhalden et al.,
2008; Bjørkly, 2004; Fluttert et al., 2010).

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2.2 Main findings from a literature review of international publications
dealing with the use of restraint and seclusion in the period 2011–2014
This update search was conducted in Medline and PsycINFO, and covered the period from
2011 to August 2014. The goal was not to conduct an in-depth systematic review but rather to
create an updated overview of the most important trends in international research literature
since the publication of our previous report (Bjørkly et al., 2011). We found a total of 61
relevant articles: 25 articles in Medline and 36 articles in PsycINFO. Seven of them were
duplicates. A review of our own article archive produced seven new articles. This made a total
of 61 unique publications. Among these were two review articles, one dealing with the
incidence and risk factors for the use of restraint (Beghi et al., 2013) and one dealing with
staff and patient views of seclusion (van der Merwe, Muir-Cochrane, Jones, Tziggili &
Bowers, 2013). The first review included 49 studies and found that the prevalence of the use
of restraint varied between 3.8% and 20% in the different studies. These figures showed that
the use of restraint had not decreased, despite attempts to reduce it. Nor was any change found
in the characteristics of patients subjected to coercive measures: involuntarily admitted, male,
of foreign origin and diagnosed with schizophrenia, or in the reasons for using restraint:
attempts to escape, aggressive behaviour or the present of male health care personnel in the
units in question (Beghi et al., 2013). After analysing the 39 empirical studies of experiences
of seclusion, van der Merwe et al. (2013) found that patients experience seclusion as a
distinctly negative experience, whereas staff emphasised the therapeutic effect and could not
see how such wards could operate without seclusion. Both parties agreed on the need for
improved staff-patient communication before, during and after seclusion episodes.
Our analyses of the other 59 articles showed that one-third dealt with clinical testing of
interventions to improve or reduce the use of restraint and seclusion. This tendency is now far
clearer than it was in the period prior to our previous report. Around one-quarter of the
publications focused on justifications and/or patient characteristics that triggered the use of
restraint or seclusion. Although many studies show replications of earlier findings, more
recent studies show a growing tendency to stress the significance of active psychotic
symptoms and characteristics of the interaction prior to the use of restraint (see for example
Beghi et al., 2013 above and Simpson et al., 2014). We interpret this to indicate a shift
towards a growing interest in the significance of dynamic and interactional factors in this
context. Publications that focus on patients’ experience also appear to be prominent now, but
relatively speaking, these studies no longer hold the same position in the research literature
that they once did. Other topics that we found in only a few publications were prevalence,
testing of the use of forced medication (involuntary treatment) versus seclusion, and the
physical and mental consequences for patients of restraint and seclusion.
2.3 An overview of recent Norwegian and Nordic research publications and
official reports dealing with the use of restraint and seclusion
Scientific articles concerning the use of restraint in psychiatric institutions for adults in
Norway
For many years, the mapping of restraint and seclusion in Norway has focused on the wide
variations in prevalence between different regional health authorities and health trusts. In
2011, Wynn and colleagues published an article whose main purpose was to examine to what

15
degree acute psychiatric wards in different regions around the country showed the same type
of behaviour and attitudes with respect to the use of restraint (Wynn, Kvalvik & Hynnekleiv,
2011). Staffs on the wards were asked to complete a questionnaire that contained, among
other things, two fictional cases where the staff were asked to suggest the type of intervention.
The results showed no significant differences between staff at individual or group level. Male
staff and unskilled staff tended to choose more restrictive interventions, however.
In 2014, Knutzen and collaborators published an article dealing with the prevalence of the use
of restraint on individual patients in acute psychiatric wards (Knutzen et al., 2014). Around
three-quarters of patients had experienced one to two episodes involving restraint, 15.8% had
experienced three to five such episodes, and 9.1% had experienced six or more episodes. The
latter group was categorised as ‘frequently restrained’ and stood out from the other patients
subjected to coercive measures by being younger, having longer inpatient stays and more
frequent admissions. Eight of the 19 women in the frequently restrained group had a
personality disorder.
In 2010, Husum and colleagues published an article in which she examined the degree to
which the use of different forms of restraint in emergency psychiatric wards in Norway was
associated with patient, staff or ward characteristics (Husum et al., 2010). Of the sample of
patients who were admitted to different acute psychiatric wards, 35% had been committed. Of
this group, 35% had been isolated, 10% had been subjected to mechanical restraints, 9% had
been subjected to involuntary treatment with medication and 9% had been subjected to both
isolation and mechanical restraints. This cross-sectional study showed significant differences
between Norwegian acute psychiatric wards regarding the use of isolation and mechanical and
involuntary treatment with medication. This could not be explained by differences in patient
characteristics. Husum concludes that the ward characteristics may influence the use of
coercive measures, and that future interventions to reduce its use should focus on
organisational and structural factors.
Scientific articles concerning the use of restraint in psychiatric institutions for adults in
Denmark
Bak et al. (2014) published an article in which they presented a study whose purpose was to
identify measures that could prevent the use of mechanical restraint (Bak et al., 2014). Three
preventive factors were significantly associated with a low incidence of mechanical restraints:
retrospective review of episodes with restraints, patient involvement and no crowding in
wards.
Scientific articles concerning the use of restraint in psychiatric institutions for adults in
Finland
Putkonen et al. (2013) published an article dealing with reduced use of isolation and
mechanical restraint on Finnish men suffering from schizophrenia and a history of violent
behaviour (Putkonen et al., 2013). Using a cluster-randomised controlled trial, the study found
that introducing a specific intervention reduced the use of restraint without increasing the
level of violence in the ward.
Attempts that have been made to compare the prevalence of restraint and open-area seclusion
in the Nordic countries have revealed different laws and inadequate registration procedures in
the respective countries.

16
Reports
In 2012, the Norwegian Knowledge Centre for the Health Services published a report titled
Interventions for reducing seclusion and restraint in mental health for adults (Norwegian
Knowledge Centre for the Health Services, Report No 9, 2012). The purpose of the report was
to summarise research on the effect of interventions intended to reduce the use of coercive
measures in mental health care. The following main findings were reported: Crisis plans may
reduce the number of committed patients, but the quality of documentation was low.
Systematic risk assessment of patients admitted to an acute psychiatric ward may reduce the
use of restraint, but the quality of documentation was low. The report concludes that more
research is needed to be able to draw more firm conclusions about the effect of interventions
intended to reduce the use of coercive measures.
2.3 Main findings from the previous report (Bjørkly et al., 2011)
As explained earlier, we did not perform any comparisons with previous studies because the
methodological conditions for making such comparisons were not met.
The report with findings from 2009 covered a total of 10,939 administrative decisions made
concerning the use of restraint and open-area seclusion on 2,432 patients.
1. Pharmacological restraints (short-acting medication): 1,875 decisions involving
712 patients.
2. Mechanical restraint: 4,426 decisions involving 1,065 patients, with an average
(median) duration of 3.25 hours per decision.
3. Isolation: 269 decisions involving 114 patients, with an average duration of 0.53
hours.
4. Physical restraint: 1,680 decisions involving 574 patients, with an average duration
of 0.17 hours.
5. Open-area seclusion: 2,689 decisions involving 1,406 patients, with an average
duration of 139.5 hours.
6. Gender: More decisions authorising the use of mechanical restraint were issued for
women, but the average duration per decision was almost three times longer for men.
7. Ward codes: Acute psychiatric wards accounted for 60% of all decisions, and
together with the forensic units, they accounted for 75% of all decisions on restraint
and open-area seclusion.
8. The health trusts: wide variations in the use of restraint and open-area seclusion.
Because our study did not control for factors that might explain these differences, we
cannot draw any conclusions regarding the reasons for them.
9. Data quality: To ensure that all units issuing administrative decisions submit their
data is time consuming. Different methods of registering the handwritten records
rendered it necessary to develop procedures that ensured consistent coding of the data
collected from the records concerning use of restraint and open-area seclusion.
10. Time factor: Comparison over time is complicated by changes to laws and
corresponding changes to formal routines and procedures in clinical practice regarding
the use of restraint. For example, physical restraint (holding) was introduced as a new
type of restraint on 1 January 2007. Such a change can affect the use and incidence of
other forms of restraint.

17
3 Method
This section presents a review of the method used for mapping.
3.1 Mapping procedure
1. Prepare a national overview of all the health trusts and institutions and clinical wards
and units providing mental health care for adults in 2012.
2. Establish points of contact in wards issuing administrative decisions and inform them
of the method of collecting and transmitting data.
3. Receive, register and scan incoming data.
4. Establish a database and code the data.
5. Quality assures and analyse the data.
6. Prepare a report.
Preparation of a national overview of psychiatric health care for adults 2012
The preparation of a national overview of all the health trusts and institutions with pertaining
clinical wards and units that provide mental health care for adults, and issue decisions on
restraint and seclusion was to form the basis for the mapping of decisions on restraint and
seclusion. The work can be divided into four separate processes. In practice, and for a number
of reasons, there was considerable overlapping between them, partly because it proved time-
consuming to find individuals who possessed the necessary overview of units issuing
decisions on restraint and open-area seclusion.
We used two lists as our starting point:
 The Medlex list (bought from Lex publishing house; helseadresser.no) and
 The Norwegian Patient Registry (NPR) (a list of all wards/units providing mental
health care that have been reported to the NPR by the health trusts; bought from NPR
via helsedirektoratet.no).
We also prepared an internet list based on information from the websites of each health trust,
accessed in June and July 2013. In addition, we used the national overview we had prepared
for the mapping of the 2009 data (Bjørkly et al., 2011).
The clinic management of each health trust received a list of their units and wards for adult
mental health care, based on information obtained from the NPR list of 2012. In addition, the
Medlex list and the internet list were combined into one document and distributed as a
supplementary list. To ensure a complete overview, we asked each health trust to check and,
where necessary, supplement the lists with more units/wards/district psychiatric centres
(DPC) before returning them to us. We also asked for the names of individuals in the wards
who we could contact and who would obtain and transmit data to us. In some cases, it was
necessary to contact a ward, unit or DPC directly via email or phone in order to establish a
point of contact.

18
Establishing points of contact in wards issuing administrative decisions and informing
them about the method of collecting and transmitting data
The points of contact in the wards received overviews by email of the units in their wards that
issued administrative decisions on restraint and open-area seclusion in 2012. They were asked
to complete the list with information about the ward type, occupancy rate per unit, inpatient
care beds per unit and anonymised copies of records of the use of restraint and open-area
seclusion from units that had made such decisions in 2012.
The list below gives a simplified point-by-point presentation of the process of preparing a
national overview. The first three items cover the work involved in preparing a national
overview of all the health trusts and institutions with clinical wards and units providing
mental health care for adults in 2012. Item no 4 describes the final phase in the process: the
reception, registration and scanning of incoming data. This will be elaborated on later.
1. Prepare a national overview of all health trusts/institutions with units approved for the
use of restraint in 2012.
2. The clinic management in each health trust was contacted and received an overview of
their wards issuing administrative decisions on restraint and open-area seclusion. Each
clinic management was then asked to quality assure the overviews they received on
units approved for the use of coercive measures in 2012.
3. Receipt of quality-assured overviews from the clinic management of each health
trust/institution with wards/units approved for the use of restraint and overviews of
each ward, including details regarding the number of beds and occupancy rate. This
information was used to prepare the first draft of the above mentioned national
overview of health trusts and institutions/wards with mental health care wards/units
for adults in 2012.
4. Receive anonymised copies of handwritten records of the use of restraint and open-
area seclusion, code data from these to the access database, systemise the information
received and conclude the work on preparing a national list of health trusts/wards and
units that made administrative decisions on restraint and open-area seclusion in 2012.
Reception, registration and scanning of incoming data
Anonymised copies of the left-hand side of the records of the use of restraint open-area
seclusion were received from all relevant wards with relevant units. Finally, the units/wards
that had submitted these records were registered in a national overview of health
trusts/institutions/wards with adult mental health care units that had made decisions on
restraint and open-area seclusion in 2012. The submitted copies of records and pertinent
forms containing details about the wards were archived in PDF format on a server to which
only project members had access.
The copies of submitted records and pertinent forms containing details about the wards were
numbered and scanned as follows:
 A copy of one page of a record represented data concerning a patient and was assigned
a number (see data collection procedure, Annex 5). Any records containing multiple
pages of data concerning the same patient were stapled together by the ward staff.
These were numbered as follows: the first copy in the pile was assigned number 1, the
next copy number 2, and so on. In cases where multiple decisions had been issued for a
patient, the record sheets were stapled together and each sheet pertaining to a patient
was numbered as follows: first patient: 1.1, 1., second patient: 2.1, 2.2, 2.4, and so on.

19
 The hard copies of the records and forms containing details about the wards were later
used as data sources in connection with the coding of the decisions in the database (see
the section below).
Creating databases and coding of data
The data were coded into the same type of database used for the mapping in 2009. This was
specially designed for registering the data on decisions on restraint and open-area seclusion
included in the mapping.
 The names of all health trusts/institutions/wards were entered into the database
manually. A unique code was assigned to each health trust/institution before the data
were transmitted to the statistics data files (SPSS, version 8.0).
 Text field: the name/number assigned to each unit. Details about each unit were coded
according to the Norwegian Board of Health Supervision’s ward coding system for
psychiatric institutions IK–44/89 (see Annex 1). These codes were used at ward level
because one ward can contain units with different patient categories; for example, one
and the same ward may contain secure units and emergency units.
 ID number per patient: A random number was generated by the database in question.
 ID code for each database: Each copy of the databases had its own ID code: DB1
(database 1), DB2 and so on. This was necessary because data were coded into
multiple copies of the database. The ID number generated by each database for data on
each patient was unique to each database.
 Unique patient ID: A combination of the ID number generated by the database into
which a patient’s data were coded and the ID code of the relevant database (DB1, DB2
etc.).
 Information about decisions on restraint and open-area seclusion: Date/time of when a
decision was implemented and the date/time of when the measure discontinued type of
restraint and patient gender.
 Text field for any comments from coders and/or from those who kept the records.
Coding of units and wards in data files
The data for all decisions/episodes were extracted from the databases and transferred to
statistics program files.
The Norwegian Board of Health Supervision’s ward coding system for psychiatric institutions
(Circular No IK–44/89) was used in both the mapping for 2012 and the mapping for 2009.
The coding system comprises the following ward codes: 61 = acute psychiatric ward,
62 = short-term care ward, 63 = intermediate care ward, 64 = long-term care ward,
65 = rehabilitation ward, 66 = forensic ward, 67 = psychogeriatric ward, 71 = ward for young
schizophrenics (hereinafter referred to as first psychosis ward). In addition, inpatient
institutions in district psychiatric centres (DPCs) were assigned a separate category in the
same way as in the 2009 mapping (DPC inpatient wards = 80), and special care wards (code =
85) such as regional wards for eating disorders (RASP) and wards for people with
development disabilities/autism.
Coding of data from records to database
The project team members worked in pairs: one coder scanned the records and the other
coded them into the database. Each pair of coders had their own copy of the database. Each
time new data were entered, the database was saved with the current date so that the most
recent date showed the most recently updated database. Representatives from the project team

20
were available to the coders at all times during the coding work. To coordinate the coding
work as best as possible, the project team developed a template titled ‘Procedure for coding
data in the database’. In addition, the coders were given an introduction to laws and practical
use of restraint and open-area seclusion. There were also taught key concepts used in the
records.
As the data were coded, the database generated a random number for each patient. This
number was entered on the hard copy of the record along with the coder’s initials. The coder’s
initials and the numerical series of the generated numbers identifying data pertaining to
individual patients were also entered on the form containing ward details in order to facilitate
re-examination. This made it easy to trace the anonymised hard copies of the records of the
use of restraint and open-area seclusion pertaining to each patient.
Scanning handwritten records of the use of restraint and open-area seclusion in
connection with coding administrative decisions
Codeable data
Here, reference is made to examples of how the records of restraint were completed (Annex
7).
 The process of ‘scanning’ the records was time-consuming because they were
handwritten and because practices for keeping the records differed between wards and
within one and the same record or ward. For example, this applied to entering the time
when an administrative decision ceased to apply.
 Different terms are used for restraint: for example, mechanical restraint might be
described as: belt, full restraint using belts, restraint bed, strapping, fully fixated or just
letter a), which refers to ‘a. mechanical restraints’ in the list of different types of
coercive measures entered at the top of the right-hand column in the record (Annex 7).
The documentation of pharmacological restraint intended to have a sedative or
anaesthetic effect was often entered along with the name of the medication, in
accordance with the instructions for the record. Sometimes the name of the medication
was written between documentation of other types of restraint or in the same column as
another decision.
 The restraint records are designed in such a way that details about a patient for whom a
decision on restraint has been issued extend over two pages in the record. The left-hand
side of the record contains data documenting the decisions that are included in the
mapping (see ***Annex 7a, b and c for the restraint records and Annex 7d for open-
area seclusion records. Some data that were not included in the mapping are also
documented; for example adjustments to and changes in the patient’s body position
during the implementation of an administrative decision concerning the use of
mechanical restraint. The time of each change in the patient’s body position must be
recorded continuously, and each change must be recorded on a new line in the records.
One has to read every single line and column in the records in order to find the specific
form of restraint, decision and the time and date when each type of restraint starts and
ends. The information on the right-hand side of the records contains details about who
made the decision and put it into effect, as well as comments from the control
commission. This information was not included in the mapping.
Identifying administrative decisions
Entries in records of the use of restraint and open-area seclusion are made by many different
individuals in the course of a shift or a day. Because of requirements for continuous

21
documentation of restraint used over time (often mechanical), and where changes were made
to the patient’s body position and/or two types of restraint were used simultaneously, it was
difficult to determine when restraint commenced and when it ended. In such cases, the records
had to be scanned horizontally (all columns) and vertically (all lines) because the reporting of
a decision could cover several pages in the records (see Annex 7, examples a and c in the
record).
Period of duration of administrative decisions on restraint and open area seclusion
The registration of the duration of each measure applies to isolation, mechanical restraint,
physical restraint and open-area seclusion. For the database to generate the duration, the time
and date when a measure started and ended were coded in the database. These details proved
not always to be fully documented in the records, however. Annex 7 shows examples of
entering decisions in the restraint and open-area seclusion records.
Data analysis
Reports from the databases were connected so that we would create two types of data files: a
data file where each line contained information about each individual decision, and a patient
file consisting of one line for each patient for whom one or more decisions had been issued.
The patient file summarised the following data on one line per patient: gender, total number
of decision and number of each type of restraint and open-area seclusion, total duration of
each measure, and health trust/ward code.
Overcounting patient numbers
As in the 2009 mapping, we only had access to anonymised data in this study. The method of
data collection entailed the locally responsible point of contact in each ward stapling together
all copies of the record sheets pertaining to each patient, across different wards/units, before
the data were anonymised. This was done to ensure that all decisions were included in the
mapping. Another reason was to reduce the probability of a patient being registered as a new
patient (overcounting) in each unit in the ward in which that patient had been made subject to
restraint and open-area seclusion. To estimate a potential overcount of patients within a health
trust, patients for whom a decision had been issued on the use of restraint and open-area
seclusion across different units/wards were counted in relation to the total number of patients.
This mapping resulted in an estimated overcount of 10%.
Indexes
The occupancy rate is another corrective factor that was included in analyses and
interpretations of incidence and changes over time. Adjusting the use of restraint using the
number of beds gives a relatively unreliable measurement of prevalence. To obtain a more
reliable measurement, we also corrected for the occupancy rate in the units that were
analysed. This provided a more precise estimate of the incidence of restraint and open-area
seclusion. For example: two units with 10 beds each and occupancy rates of 50% and 100%,
respectively, both have 100 registered instances of open-area seclusion. An unadjusted
comparison will show that the incidence rate is the same, but since the respective occupancy
rates were 50% and 100%, the incidence of open-area seclusion per bed in the unit with an
occupancy rate of 50% was twice as high as in the other unit.
In order to be able to compare different types of wards in terms of the frequency of restraint
and open-area seclusion, we calculated indexes for each unit at each psychiatric institution. If
one health trust/institution had multiple units with the same ward category, these units were
treated as one ward category. This means that, in situations like these, we calculated the total

22
number of decisions, the total number of patients with decisions, and the total number of beds
in these units.
Two indexes were used to adjust for occupancy rate: one index for decisions on restraint and
open area seclusion (ITV) and one index for patients subjected to restraint and open-area
seclusion (IP):
ITV = (number of decisions) / (number of beds x occupancy rate / 100)
IP = (number of patients) / (number of beds x occupancy rate / 100)
If the standard deviation for an index within a ward category is greater than the average, this
can be interpreted to mean that the index varies considerably between the wards.
Statistical method
For approximately normally distributed variables, the arithmetic mean was used as the
measure of central tendency, while the median was used for skewed variables. The Mann-
Whitney U test was used to compare two medians. The chi-square test was used to compare
percentages. The statistical analyses were performed with the help of SPSS, version 18.0.

23
4 Results
Table 4.1: Patients with decisions on restraint/open-area seclusion, by gender and
number of decisions, 2009 and 2012
Number of patients
subjected to
restraint/seclusion by
gender
Groups of patients by number of decisions
(percentage)
1
2
3-4
5-9
10-19
20+
Total
2009
male
1200
42,9
21,3
17,3
11,9
4,4
2,2
100
2012
male
1386
43,1
19,6
17,8
11,9
5,1
2,5
100
2009
female
1093
41,4
18,9
18,2
11,0
6,3
4,1
100
2012
female
1195
42,2
19,4
14,6
14,1
5,4
4,4
100
2009
total
2432
42,3
20,3
17,6
11,2
5,5
3,1
100
2012
total
2602
42,7
19,5
16,3
13,0
5,3
3,3
100
2009: Insufficient information about gender: 139 patients
2012: Insufficient information about gender: 21 patients
Of all the patients for whom decisions were issued, patients with only one decision
(authorising either a type of restraint or open-area seclusion) accounted for approximately
42% in both 2009 and 2012. Among the patients with the most decisions (20+), women
accounted for a larger percentage than men in both 2009 and 2012.
Figure 4.1: Total number of patients with decisions on restraint/open-area seclusion, by
decision type, 2009 and 2012
From 2009 to 2012, an overall increase of 455 was found for patients with decisions on the
use of mechanical restraint, pharmacological restraint, isolation, physical restraint or open-
area seclusion. Eighty-five per cent of this increase concerned open-area seclusion (an
Mechanical
restraint
Pharma-
cological
restraint Isolation Physical
restraint Open-area
seclusion
2009 1065 712 114 574 1406
2012 1107 709 144 749 1617
0
200
400
600
800
1000
1200
1400
1600
1800
2009
2012

24
increase of 211 patients) and physical restraint (an increase of 175 patients). The number of
patients with decisions on pharmacological restraint remained unchanged, while the number
of patients with decisions on mechanical restraint and isolation increased by 42 and 30,
respectively.
Figure 4.2: Number of patients with decisions on restraint/open-area seclusion, by
gender and decision type, 2009 and 2012
The number of men with at least one decision concerning restraint (all types) and open-area
seclusion appears to have increased from 2009 to 2012. The number of women with decisions
on isolation, pharmacological restraint and open-area seclusion increased, while the number
of women with decisions on mechanical restraint and pharmacological restraint fell slightly.
Mechanic
al
restraint
Pharma-
cological
restraint Isolation Physical
restraint Open-area
seclusion
male-09 584 335 55 215 713
male-12 675 375 91 331 837
female-09 432 341 44 320 617
female-12 425 325 52 406 767
0
100
200
300
400
500
600
700
800
900
male-09
male-12
female-09
female-12

25
Figure 4.3: Patients’ first decisions on restraint/open-area seclusion, by decision type,
2009 and 2012
To obtain information about the incidence of each type of restraint and open-area seclusion,
each patient’s first episodes in 2009 and 2012, respectively, were analysed. The findings
indicate that a shift took place between 2009 and 2012 from mechanical restraint and
pharmacological restraint to increased use of isolation, physical restraint and open-area
seclusion.
Mechanical
restraint
Pharmacologi
cal
restraint Isolation Physical
restraint Open-area
seclusion
2009 835 286 43 238 1021
2012 633 199 76 404 1284
0
200
400
600
800
1000
1200
1400
2009
2012

26
Figure 4.4: Total number of decisions on restraint/open-area seclusion, by decision type,
2009 and 2012
The total number of decisions authorising the use of mechanical restraint and pharmacological
restraint fell slightly between 2009 and 2012, by 586 and 390, respectively, and the number of
decisions on isolation, physical restraint and open-area seclusion increased. The decrease in
the use of mechanical restraint and pharmacological restraint corresponds to the increase in
the use of physical restraint (by 617 decisions) and isolation (by 302 decisions). Figure 4.4
shows the same trend as the analysis of the patients’ first episodes (see Figure 4.3).
Table 4.2: Patients with decisions on mechanical restraint, by gender and number of
decisions, 2009 and 2012
Number of patients
subjected
to mechanical
restraint
Groups of patients by number of decisions (percentage)
1
2
3-4
5-9
10-19
20+
Total
2009
male
584
61,2
18,7
9,2
7,6
1,6
1,6
100
2012
male
675
60,9
17,3
13,6
5,0
1,9
1,2
100
2009
female
432
48,9
14,9
14,9
11,9
5,1
4,3
100
2012
female
425
56,2
14,1
11,5
9,2
3,8
5,2
100
2009
total
1056
56,8
16,9
11,2
9,1
3,0
2,7
100
2012
total
1107
59,2
16,0
12,8
6,6
2,7
2,7
100
2009: Insufficient information about the gender of 49 patients
2012: Insufficient information about the gender of 7 patients
The majority of patients subjected to mechanical restraint, had one decision in 2009 and one
in 2012. The proportion of women with the most decisions (20+) increased by 21% between
2009 and 2012, while the proportion of men with the most decisions decreased by 25%. In
Mechanical
restraint
Pharma-
cological
restraint Isolation Physical
restraint Open-area
seclusion
2009 4426 1875 269 1680 2689
2012 3840 1485 571 2297 3318
0
500
1000
1500
2000
2500
3000
3500
4000
4500
5000
2009
2012

27
2009, the percentage of women who had experienced 20 or more episodes of mechanical
restraint was double that of men. In 2012, the number of women in this category was four
times that of men.
Table 4.3: Duration of decisions on mechanical restraint, 2009 and 2012
Number of
patients
subjected
to
mechanical
restraint
Number
of
episodes
with
duration
Duration (hour) of decisions with mechanical restraint in 2009 and 2012
(percentage)
0,01-
0,49
0,50-
0,99
1-
1,99
2-
4,99
5-
9,99
10-
19,99
20-
49,99
50-
99,99
100-
408,99
409-
2009
1065
4200
3,0
9,5
21,1
27,5
16,6
14,2
5,3
1,7
0,9
0,2
2012
1107
3682
4,4
11,2
22,6
25,7
14,6
10,6
7,0
2,2
1,4
0,3
2009: Insufficient information about duration of 226 decisions
2012: Insufficient information about duration of 158 decisions
Median duration (hours) of the use of mechanical restraint
Year
Total
Male
Female
2009
3,3
6,0
2,3
2012
2,9
5,3
2,0
In 2012, men were subjected to mechanical restraint over longer periods than women
(median: 5.3 hours for men compared with 2.0 hours for women, Mann-Whitney U test, p
<0.001). The data showed no significant differences between 2009 and 2012 in the duration
broken down by time intervals (hours). Just under 50% of the decisions lasted between one
and five hours.
Table 4.4: Patients with decisions on pharmacological restraint, by gender and number
of decisions, 2009 and 2012
Number of patients
subjected
to pharmacological
restraint
Groups of patients by number of decisions (percentage)
1
2
3-4
5-9
10-19
20+
Total
2009
male
335
54,5
22,2
13,6
8,2
1,1
0,7
100
2012
male
375
66,7
17,9
8,8
5,3
1,3
0
100
2009
female
341
55,4
17,9
13,5
8,7
3,5
1,3
100
2012
female
325
51,7
18,8
17,2
9,8
2,2
0,3
100
2009
total
712
54,6
20,5
13,3
8,5
2,4
1,0
100
2012
total
709
59,7
18,2
12,7
7,5
1,8
0,1
100
2009: Insufficient information about the gender of 36 patients
2012: Insufficient information about the gender of nine patients

28
In 2009 and 2012, the majority of patients only received one decision on pharmacological
restraint. More men than women had only one decision in 2012. Both in 2009 and 2012
overall, a larger proportion of women than men in the groups had ten or more decisions.
Table 4.5: Patients with decisions on isolation, by gender and number of decisions, 2009
and 2012
Number of patients
subjected to
isolation
Groups of patients by number of decisions (percentage)
1
2
3-4
5-9
10-19
20+
Total
2009
male
55
73,9
13
8,7
4,3
0
0
100
2012
male
91
63,7
9,9
11
6,6
6,6
2,2
100
2009
female
44
52,3
31,8
2,3
2,3
11,4
0
100
2012
female
52
61,5
9,6
5,8
9,6
7,7
5,8
100
2009
total
114
60,4
18,8
8,3
8,3
4,2
0
100
2012
total
144
63,2
9,7
9,0
7,6
6,9
3,5
100
2009: Insufficient information about the gender of 15 patients
2012: Insufficient information about the gender of 1 patient
In 2009 and 2012, the majority of patients only received one decision concerning isolation.
The overall increase in the number of patients with decisions on isolation was 26%. The
number of decisions involving men increased by 65%, while the corresponding number for
women was 18%. In 2012, twice the number of patients had one or more decisions on
isolation. Between 2009 and 2012, the percentage of patients with decisions on isolation
lasting more than ten hours increased by 24%.
Table 4.6: Duration of decisions on isolation, 2009 and 2012
Number of
patients
Number
of
decisions
with
duration
Duration (hour) of decisions with isolation in 2009 and 2012 (percentage)
0,01-
0,49
0,50-
0,99
1-
1,99
2-
4,99
5-
9,99
10-
19,99
20-
49,99
50-
99,99
100-
408,99
2009
114
214
36,0
25,2
21,0
11,7
2,8
1,9
0,5
0,5
0,5
2012
144
497
24,9
18,3
25,8
17,5
9,3
2,4
1,6
0
0,2
2009: Insufficient information about duration of 55 decisions on isolation
2012: Insufficient information about duration of 74 decisions on isolation

29
Median Duration (hours) of decisions on isolation
Year
Total
Male
Female
2009
0,5
0,6
0,5
2012
1
0,9
1
In 2009, 82% of decisions lasted less than two hours. In 2012, 67% of decisions lasted less
than two hours. In 2012, women were isolated for significantly longer periods than men
(median: 1.0 hours for women compared with 0.9 hours for women; Mann-Whitney U test, p
<0.003). The greatest increase in patients in terms of duration was found within the 2 to 10-
hour interval.
Table 4.7: Patients with decisions on physical restraint by gender and number of
decisions, 2009 and 2012
Number of patients
subjected
to physical restraint
Groups of patients by number of decisions (percentage)
1
2
3-4
5-9
10-19
20+
Total
2009
male
215
63,1
16,2
10,6
7,8
1,7
0,6
100
2012
male
331
63,1
14,5
11,2
8,8
2,1
0,3
100
2009
female
320
56,7
16,4
11,9
9,6
2,7
2,4
100
2012
female
406
52,2
15,3
13,3
13,3
3,0
3,0
100
2009
total
574
57,6
16,9
11,4
9,3
3,0
1,7
100
2012
total
745
57,3
14,9
12,2
11,1
2,6
1,9
100
2009: Insufficient information about the gender of 39 patients
2012: Insufficient information about the gender of 8 patients
Both in 2009 and 2012, the majority of patients had only received one decision concerning
physical restraint. The group of patients with most decisions (20+) contained significantly
more women than men. Compared with 2009, the number of women in 2012 increased by
25% while the number of men decreased by 50% among patients with 20 or more decisions.
Table 4.8: Duration of decisions on physical restraint, 2009 and 2012
Number of
patients
subjected to
physical
restraint
Number
of
episode
s
with
duration
Duration (hour) of decisions with physical restraint in 2009 and
2012 (percentage)
0,01-
0,49
0,50-
0,99
1-
1,99
2-
4,99
5-
9,99
10-
19,99
20-
49,99
2009
574
1456
83,0
10,2
4,3
1,6
0,5
0,1
0,3
2012
745
1999
83,7
10,7
3,6
1,7
0,3
0
0
2009: Insufficient information about duration of 224 decisions
2012: Insufficient information about duration of 298 decisions

30
Median duration (hours) of decisions on physical restraint
Year
Total
Male
Female
2009
0,17
0,14
0,17
2012
0,17
0,08
0,17
Both in 2009 and 2012, 83% of decisions authorising physical restraint lasted less than 30
minutes. In 2012, physical restraint lasted longer for women than for men (median: 0.17 hours
for women compared with 0.08 hours for men; Mann-Whitney U test, p < 0.001). A real
decrease in duration was found for men between 2009 and 2012.
Table 4.9: Patients with decisions on open-area seclusion, by gender and number of
decisions, 2009 and 2012
Number of patients
subjected to open-
area seclusion
Groups of patients by number of decisions (percentage)
1
2
3-4
5-9
10-19
20+
Total
Male 2009
715
66,1
17,6
9,7
5,0
1,2
0,5
100
Male 2012
837
63,3
17,1
12,5
5,0
1,2
0,8
100
Female 2009
617
63,7
17,2
12,2
5,0
1,8
0
100
Female 2012
767
60,8
21
11,2
5,2
1,4
0,4
100
Total 2009
1406
65,1
17,3
10,9
5,2
1,4
0,2
100
Total 2012
1617
62,2
18,9
11,9
5,1
1,3
0,6
100
2009: Insufficient information about the gender of 74 patients
2012: Insufficient information about the gender of 13 patients
The number of patients with decisions on open-area seclusion increased by 211 between 2009
and 2012. The percentage breakdown of patients by the number of decisions showed the same
pattern in 2009 and 2012.
Table 4.10: Duration of decisions on open-area seclusion, 2009 and 2012
Number of
patients
Subjected
to open-
area
seclusion
Number
of
decisions
with
duration
Duration (hour) of decisions with open-area seclusion, 2009 and 2012
(percentage)
0,01-
0,49
0,50-
0,99
1-
1,99
2-
4,99
5-
9,99
10-
19,99
20-
49,99
50-
99,99
100-
408,99
409-
2009
1406
634
1,7
4,7
5,2
5,0
2,1
5,5
11,5
10,9
51,1
2,2
2012
1617
2270*
2,1
1,6
1,9
1,6
1,0
2,6
7,5
5,8
74,2
1,7
2009: Insufficient information about duration of 2,055 decisions
2012: Insufficient information about duration of 1,048 decisions

31
Median duration of decisions on open-area seclusion
Year
Total
Male
Female
2009
139,5
96,0
174,95
2012
335,9*
336,0
312,0
The number of decisions stating no duration was halved between 2009 and 2012. The number
of decisions stating a duration more than tripled between 2009 and 2012. In 2012, there was a
notable increase in the number of decisions authorising open-area seclusion lasting more than
100 hours. This is reflected in a notable increase in the median duration between 2009 and
2012. This increase applies to both genders. In 2012, men were subjected to open-area
seclusion for longer periods than women (336 hours for men compared with 312 hours for
women, Mann-Whitney U test, p < 0.001).
Table 4.11: Index for adjusted average number of patients with decisions, 2009 and
2012, by ward code (average and standard deviation)
Ward codes: The Norwegian Board of
Health Supervision´s ward coding system
for psychiatric institutions, Circular No
IK-44/89
2009
2012
Corrected
mean
Standard
deviation
Corrected
mean
Standard
deviation
Acute psychiatric ward (61)
3,53
3,1
3,69
1,98
Short-term care ward (62)
0,76
0,84
0,71
0,71
Intermediate care ward (63)
0,64
0,59
0,59
0,42
Long-term care ward (64)
0,58
0,59
0,27
0,16
Rehabilitation ward (65)
0,62
0,55
0,49
0,31
Forensic ward (66)
0,83
0,34
0,85
0,7
Psychogeriatric ward (67)
0,35
0,25
0,64
0,35
Ward for first-episode psychosis (71)
0,15
0,12
0,49
0,7
District psychiatric centre (DPC) (80)
0,31
0,35
0,51
0,65
Other: Regional ward for eating disorders
(RASP),
Ward for people with development
disabilities/autism (PPU) (85)
1,45
0,93
0,22
0,24
Adjusted for the average number of patients who received decisions in each ward type.
IP Index = (number of patients with decisions) / (number of beds x occupancy rate/100), (the
index is an adjustment for differences between ward types in terms of number of beds and
occupancy rate).
Explanation of results in Table 4.11:
Example: The figure 3.69 (adjusted average) for emergency wards in 2012 means that, on
average, the emergency wards issued decisions for 3.69 patients per occupied bed in 2012.
The most significant changes from 2009 to 2012 occurred in the wards for patients with first-

32
episode psychosis (71) and special care wards (85). These findings are difficult to interpret
because the number of patients in these wards was low. Long-term care wards (64) appear to
show a marked decrease in the number of patients with decisions, while psychogeriatric wards
(67) appear to show a corresponding increase.
Table 4.12: Index for adjusted average number of decisions in 2009 and 2012, by ward
code (average and standard deviation for each ward type)
Ward codes: The Norwegian Board of
Health Supervision´s ward coding system
for psychiatric institutions, Circular No IK-
44/89
ITV-2009
ITV-2012
Corrected
mean
Standard
deviation
Corrected
mean
Standard
deviation
Acute psychiatric ward (61)
13,7
9,9
12,1
5,4
Short-term care ward (62)
3,2
3,8
5,6
2,8
Intermediate care ward (63)
1,9
2,3
5,7
6,7
Long-term care ward (64)
4,5
5,2
2,2
2,4
Rehabilitation ward (65)
2,7
2,7
3,1
3,6
Forensic ward (66)
7,5
7,2
7,6
9,4
Psychogeriatric ward (67)
2,8
6,8
2,8
2,3
Ward for first-episode psychosis (71)
0,2
0,2
2,6
3,1
District psychiatric centre (DPC) (80)
1,0
1,1
1,7
2,3
Other: Regional ward for eating disorders
(RASP),
Ward for people with development
disabilities/autism (PPU). (85)
8,1
3,4
0,6
0,8
The index is an adjustment for differences between ward types in terms of number of beds
and occupancy rate. Based on ITV index = (number of decisions on restraint and open-area
seclusion) / (number of beds x occupancy rate / 100).
Example: The figure 12.1 (adjusted average) for emergency wards in 2012 means that the
emergency wards issued an average of 12.1 decisions per occupied bed in 2012. The most
significant changes in the adjusted average from 2009 to 2012 were found in the ward codes
63, 64, 71 and 85.
Comments on tables 4.11 and 4.12
Comparing the indexes for the number of patients with decisions and the number of
decisions for each ward type provides a clearer picture of the individual wards. Both in 2009
and 2012, the psychogeriatric wards showed an increase in the number of patients with
decisions (index increased from 0.35 to 0.64), while the index for the number of decisions
remained stable at 2.8. In simple terms, this means that once adjustments are made for the
number of beds and occupancy rate, we find that a ward has more patients who received a
decision, but fewer decisions per patient.

33
Table 4.13: Number of decisions on restraint and open-area seclusion, by ward code and
decision type, 2009 and 2012
In 2009, acute psychiatric wards and secure wards accounted for a total of 75.9% of all
decisions. This proportion did not change significantly in 2012 (73.5%).
2009 2012 2009 2012 2009 2012 2009 2012 2009 2012 2009 2012
2890 2340 1272 1111 127 253 778 1251 1523 1860 6590 6826
73 256 24 38 211 51 132 107 167 257 609
1 9 10
141 109 66 43 36 210 101 132 258 130 602 624
373 91 37 840100 44 125 111 639 255
57 144 21 17 11 064 160 96 127 249 448
841 748 139 116 57 46 301 245 377 500 1715 1659
35 87 218 61 18 44 127 112 38 203 436 508
0 9 0 12 00337 746 10 105
13 52 80 45 13 687 157 111 90 304 352
026
13 13
1 2 0 33 0122962 12 100
Ward codes: The Norwegi a n Board of
Health Supervis i on´s ward coding sys tem
for ps ychiatri c ins titutions,
Circular No IK-44/89
1
0
District psychi a tri c centre (DPC) (80)
Ward for fi rst-epis ode psychos i s (71)
Psychogeriatric ward (67)
Total number of deci si ons
4426
3840
1875
1484
Other: Regional ward for eating disorders
(RASP), Ward for people with development
disabil i ties/autis m (PPU) (85)
Substance abuse ward
Missing ward code
Mechanical
restraint
Pharmacological
restraint
Short-term care ward (62)
Acute psychiatric ward (61)
General psychiatric ward (60)
Intermediate care ward (63)
Long-term care ward (64)
Rehabil i tation ward (65)
2
2
18
0
Forensic ward) (66)
11535
Is olation
Physi cal restraint
Open-area
seclusion
Total
571
1680
2297
2689
3318
10939
269
66
24
38
125

34
Table 4.14: Patients with decisions on restraint and open-area seclusion by ward code,
2009 and 2012
Ward codes: The Norwegian
Board of Health Supervision´s
ward coding system for
psychiatric institutions,
Circular No IK-44/89
2009
2012
Number of
patients
n (%)
Average
number of
decisions per
patient
Number of
patients
n (%)
Average
number of
decisions per
patient
Acute psychiatric ward (61)
1707 (70,2)
3,9
P<0.001
1936 (74,4)
3,5
General psychiatric ward (60)
Short-term care ward (62)
Intermediate care ward (63)
241 (9,9)
7,6
P<0.001
144 (5,6)
8,6
Long-term care ward (64)
62 (2,5)
10,3
P<0.001
26 (1,0)
9,8
Rehabilitation ward (65)
60 (2,5)
4,2
P=0.94
65 (2,5)
6,9
Forensic ward) (66)
174 (7,2)
9,9
P=0.55
168 (6,5)
9,8
Psychogeriatric ward (67)
70 (2,9)
6,2
P=0.092
97 (3,7)
5,2
Ward for first-episode
psychosis (71)
7 (0,3)
1,4
P<0.001
37 (1,4)
2,8
District psychiatric centre
(DPC) (80)
85 (3,5)
3,6
P=0.82
88 (3,4)
4
Other: Regional ward for
eating disorders (RASP),
Ward for people with
development
disabilities/autism (PPU) (85)
Substance abuse ward
19 (0,8)
6,6
P=0.098
11 (0,5)
1,3
Missing ward code
7 (0,3)
30 (1,2)
Total number of patients
2432 (100)
2602 (100)
Increase in number of patients from 2009 to 2012 170 (7%)
Overall, the number of patients who received at least one decision on restraint and open-area
seclusion increased by 7% between 2009 and 2012 (n=170). There were significant increases
in the percentage of patients with decisions in acute psychiatric wards (61) between 2009 and
2012 (from 70.2% to 74.4%, chi-square test, p <0.001) and in first-episode psychosis wards
(71) (from 0.3% to 1.4%, chi-square test, p<0.001). There were significant decreases in the
percentage of patients with decisions in general psychiatric wards, intermediate care wards
and short-term care wards (60, 62 and 63, respectively) between 2009 and 2012 (from 9.9% to

35
5.6%, chi-square test, p<0.001) and in long-term care wards (64) (from 2.5% to 1.0%, chi-
square test, p<0.001).
Table 4.15: Decisions on restraint and open-area seclusion, by ward code, 2009 and 2012
Ward codes: The Norwegian Board of Health
Supervision´s ward coding system for psychiatric
institutions, Circular No IK-44/89
2009
2012
Decisions
n (%)
Decisions
n (%)
Acute psychiatric ward (61)
6590 (60,2)
6826 (59,2)
General psychiatric ward (60)
909 (7,8)
10
609 = 1243 (10,8)
624
Short-term care ward (62)
Intermediate care ward (63)
Long-term care ward (64)
639 (5,8)
255 (2,2)
Rehabilitation ward (65)
249 (2,3)
448 (3,9)
Forensic ward) (66)
1715 (15,7)
1659 (14,4)
Psychogeriatric ward (67)
436 (4,0)
508 (4,4)
Ward for first-episode psychosis) (71)
10 (0,1)
105 (0,9)
District psychiatric centre (DPC) (80)
304 (2,8)
352 (3,0)
Other: Regional ward for eating disorders
(RASP),
Ward for people with development
disabilities/autism (PPU) (85)
Substance abuse ward
185 (1,1)
39 (0,3)
Missing ward code
12 (0,1)
100 (0,9)
Total number of decisions
10939 (100)
11535 (100)
Increase in number of decisions from 2009 to
2012
596 (5,4%)
Overall, the number of decisions increased by 5.4% (n= 596) between 2009 and 2012. The
number of decisions decreased in long-term care wards (64), secure wards (66) and special
care wards (85), while the number of decisions increased in acute psychiatric wards (61),
general psychiatric wards (60), short-term care wards (62), intermediate care wards (63),
rehabilitation wards (65), psychogeriatric wards (67), first-episode psychosis wards (71) and
district psychiatric centres (80).

36
Table 4.16: Duration of decisions on restraint (isolation, physical restraint and
mechanical restraint), by ward code, 2009 and 2012
Ward codes: The Norwegian Board of
Health Supervision´s ward coding system
for psychiatric institutions, Circular No IK-
44/89
2009
2012
Hours (%)
Hours (%)
Acute psychiatric ward (61)
31568 (69,1)
26539 (57,7)
Short-term care ward (62)
1165 (2,6)
1918 (4,1)
Intermediate care ward (63)
2028 (4,4)
Long-term care ward (64)
1720 (3,8)
241 (0,5)
Rehabilitation ward (65)
1102 (2,4)
2077 (4,5)
Forensic ward (66)
9439 (20,7)
12753 (27,7)*
Psychogeriatric ward (67)
383 (0,8)
219 (0,5)
Ward for first-episode psychosis (71)
2 (0)
30 (0,1)
District psychiatric centre (DPC) (80)
71 (0,2)
179 (0,4)
Other: Regional ward for eating disorders
(RASP),
Ward for people with development
disabilities/autism (PPU). (85)
17 (0)
5 (0)
Missing ward code
189 (0,4)
29 (0,1)
Total duration (hours) of decisions
45656 (100)
46012 (100)
*One patient was excluded from this estimate due to the long duration of the decision (8,808 hours)
Overall, the increase in the duration of restraints was 0.7% (n= 356 hours). There was an
overall decrease in duration in three ward types: acute psychiatric wards (61), long-term care
wards (64) and psychogeriatric wards (67). The remaining ward categories showed an
increase is total duration: short-term care wards (62), intermediate care wards (63),
rehabilitation wards (65), forensic wards (66), district psychiatric wards (80) and first-episode
psychosis wards (71).

37
5 Conclusions, main findings, limitations and
recommendations
5.1 Main findings in 2012
(Figures in brackets denote findings from 2009)
1. Total number of decisions: A total of 11,535 administrative decisions (10,939)
concerning the use of restraint and open-area seclusion were issued. This
represents an increase of 5.4% in the number of decisions issued between 2009
and 2012.
2. Total number of patients: Decisions authorising the use of restraint or open-area
seclusion were issued for 2,602 (2,432) patients. This represents an increase of 7%
from 2009.
3. Duration of decisions on restraint: The total duration of decisions on restraints
was 46,012 hours (45,656). This represents an increase in duration of 0.7% from
2009.
4. Pharmacological restraint: A total of 1,485 (1,875) decisions on
pharmacological restraint were issued for 709 (712) patients. This represents a
decrease in the number of decisions of 20.8%, and no change in the number of
patients since 2009.
5. Mechanical restraint: A total of 3,840 (4,426) decisions on mechanical restraint
were issued for 1,107 (1,065) patients, with an average (median) duration of 2.9
(3.3) hours per decision. This represents a decrease of 13.2% in the number of
decisions on mechanical restraint and a 3.9% increase in the number of patients
since 2009.
6. Isolation: 571 (269) decisions on isolation were issued for 144 (114) patients. The
average duration of isolation was 1 (0.5) hours. This represents an increase of
112.3% in the number of decisions on isolation and a 26.3% increase in the
number of patients.
7. Physical restraint: 2,297 (1,680) decisions on physical restraint were issued for
749 (574) patients, with an average duration of 0.17 (0.17) hours. This represents
an increase of 36.7% in the number of decisions on physical restraint and a 30.5%
increase in the number of patients.
8. Open-area seclusion: 3,318 (2,689) decisions were issued for 1,617 (1,406)
patients. This represents an increase of 23.4% in the number of decisions and a
15% increase in the number of patients. The average duration of decisions was
335.9 (139.5) hours. In 2012, it was a significantly higher number of decisions on
open-area seclusion stating a period of duration (31.8% of decisions lacked details
regarding the duration in 2012, compared with 75.4% in 2009).
9. Type of restraint/open-area seclusion: Between 2009 and 2012, we found an
increase in the number of patients who were subjected to restraint (apart from
pharmacological restraint) and open-area seclusion. An analysis of the first
decisions issued for each individual patient (either by type of restraint or open-area
seclusion) in 2009 and in 2012 shows a shift in use from mechanical restraints and
pharmacological restraint to isolation, physical restraint and open-area seclusion.
10. Gender: The number of men increased for all types of restraint and for open-area
seclusion. There was an increase in the number of women with decisions on
isolation, physical restraint and open-area seclusion. Simultaneously, somewhat
fewer women got decisions on mechanical restraint and pharmacological restraint

38
(7 and 16 patients, respectively). Both in 2009 and 2012, there were more women
than men in the category of patients who had more than 20 decision concerning
restraint.
11. Ward codes: The acute psychiatric wards accounted for 59% (60%) of all
decisions on restraint and open-area seclusion, and together with forensic wards,
they accounted for 74% (75%) of all decisions authorising the use of restraint and
open-area seclusion. This represents a significant increase in the percentage of
patients in acute psychiatric wards (p<0.001) with decisions, compared with the
total number of patients with decisions.
12. The health trusts: There are wide variations in the number of patients with
decisions and in decisions on restraint and open-area seclusion. Because our study
did not control for factors that might explain these differences, we cannot draw
any conclusions regarding the reasons for them.
5.2 Methodological challenges and limitations for deductions and
conclusions
Reliable and valid annual overviews of reported use of coercive measures and seclusion
There were considerable methodological challenges associated with obtaining reliable and
valid annual overviews of reported use of restraint and open-area seclusion. The main
challenge was to obtain complete data in the sense that the findings objectively reflected
reality. This required:
 An accurate overview of units, wards, hospitals and health trusts.
 Reliable procedures for ensuring that all units in the overview submitted data or
verified that they did not use restraint or open-area seclusion in the period in question.
 Reliable procedures for processing incoming data:
 Coding of data
 Control of data quality after they were entered in the statistics files (data
cleansing)
 Relevant statistical analyses.
 Empirical verification of the deductions made regarding incidence and trends.
A weakness in one or more of these conditions would reduce the scientific quality in such a
way as to raise justifiable doubts about the validity of the described findings and conclusions.
It is therefore decisive that the methods applied are transparent and accurately described.
Accurate reporting of any inadequate incoming data is particularly important in this context?.
Comparing the use of coercion between health thrusts/institutions
One challenge is associated with which organisational level should be analysed. This is
particularly relevant when comparing different units, wards and hospitals. One condition for
being able to compare units of analysis that are assumed to be similar is that they are in fact
comparable.
Two hospitals of the same size may have different functional areas: while one hospital may
focus on functions and patients where the use of coercive measures is likely, the opposite may
be the case for another hospital. A comparison must necessarily be moderated accordingly.
Moreover, hospitals and wards change function over time. This complicates comparisons
made over time. An increase or decrease in the use of restraint may be explained by one ward
being assigned new functions or being relieved of others. If such changes in areas of

39
responsibility are not taken into account, there is a risk of drawing an incorrect conclusion
that changes in the use of restraint are due to or reflect changes in a unit’s professional profile
or culture. Even within one and the same unit, there may be alternative explanations for a
notable increase or decrease in the use of restraint. In a forensic unit with eight beds, or in an
acute psychiatric unit with 14 beds, one new patient may account for a substantial and
justifiable increase in the use of restraint.
Recommendation: The data reported in future mappings of restraint and open-area
seclusion should be analysed in relation to relevant background data from the health trusts
and institutions (such as the number of patients treated, the number of admissions, and size
of catchment area). Such analyses may render it possible to compare differences in use
between institutions and health trusts.
Organisational-level analysis
The term ‘ward code’ is interpreted in the same way as in the mapping in 2009 with the help
of the Norwegian Board of Health Supervision’s coding system for psychiatric institutions
(Circular No IK–44/89; see Annex 1).
Due to continual structural changes in mental health care services for adults, such
comparisons based on institutional structures and ward structure are complicated. Functions
are moved from one ward or hospital to another, or units are merged with others or change
their function without changing their name, etc. Moreover, new designations have come into
use that creates confusion as to which functions a unit actually has. One such example is the
definition of a former forensic unit (sikkerhetspost) to ‘reinforced rehabilitation unit’
(forsterket rehabiliteringspost) where forensic psychiatric patients are treated alongside other
long-term patients. However, the main problem lies at ward level because over time, a ward
may cover highly diverse types and numbers of units. There are also examples of sharing or
transferring functions between hospitals. This makes comparisons at ward level and hospital
level highly complicated. Performing comparisons at unit level seem to be relatively reliable,
provided that measurements at this level are available and that functions in the unit in
question have not changed since the previous mapping.
It is recommended that the ward coding system for psychiatric institutions be updated
in line with new developments in the organisation of mental health care services, and an
updated, national overview of units/wards approved for the use of restraint should be
created. Such a national overview of health trusts and institutions providing mental health
care for adults with decisions on restraint and open-area seclusion could ensure complete
reporting by all relevant units providing adult mental health care.
Data quality
Overcounting of patients
The same method was used in this mapping of restraint and open-area seclusion as in that
conducted in 2009. This time, a specific control of potential overcounting of patients was
conducted, which estimated 10% of the patients (see page 21). This does not affect the
number of decisions. Whether the estimated 10% overcount of the number of patients applies
to all health trusts depends on organisational conditions such as the length of stay in each
ward (special treatment services) and the progression of the patient flow in each health trust.

40
Documentation of decisions in places other than the prescribed records
It appears that the mapping was not complete because two health trusts used the Distributed
Information Patient System (DIPS) to document the use of open-area seclusion and restraint.
DIPS is part of the electronic patient records and therefore constitutes a data source other than
the restraint records. In one health trust, it involved eight patients with an undetermined
number of decisions on open-area seclusion. In another health trust it involved 39 patients
with 89 decisions (concerning both restraint and open-area seclusion).
It is recommended that an electronic documentation system be developed and implemented.
Preparatory work for such a reorganisation has already been done, and this could form the
basis for further cooperation between IT staff and clinicians (EPJ standard:
Tvangsprotokoller i psykisk helsevern. Kravspesifikasjon og teknisk standard. KITH rapport
02/07) (‘EPR Standard: Use-of-restraint records in mental health care. Requirements
specification and technical standard. Norwegian Centre for Informatics in Health and Social
Care, Report No 02/07’). The development of a common, national electronic patient records
system in this area would produce several results:
 Patients would not be counted multiple times in mappings of the use of
restraint and open-area seclusion.
 Documentation of restraint could be obtained from the same data source.
 Such a system would generate continuous reports to aid day-to-day operations.
 It would provide easier access to control commissions and other supervisory
authorities.
 It would improve data quality and, thereby, research quality.
What the mapping of decisions on restraint and open-area seclusion does not tell us
The mapping and analyses were based on reported information taken from records. While
performing the mapping work, we reflected on the quality of the documentation of decisions
on restraint and open-area seclusion.
The following section outlines some areas that, in our opinion, could be improved. Further
requirements for documentation of certain aspects of coercive measures and open-area
seclusion could provide more detailed information about initiating and implementing restraint
and open-area seclusion.
Distinguishing between decisions and episodes of restraint
An administrative decision concerning the use of restraint must be made by the responsible
health care professional and recorded in a designated document that does not make up part of
the restraint record. The decision is scanned and then stored in the patient’s electronic patient
record (a copy may be entered in the restraint record). Can a decision concerning mechanical
restraints cover multiple episodes? Under this interpretation, a decision concerning restraint
could be interpreted as multiple episodes of restraint in the restraint record. This can be
illustrated as follows: If a decision concerning restraint is made at, for example, 16.00, and
any continuous periods of mechanical restraints are entered in the record (each lasting for a
limited time period and, for example, over a period of some hours ahead in time), these
periods would, under this interpretation, be regarded as episodes of restraint under a decision
concerning restraint.
In the records of restraint, the term vedtak (‘administrative decision’) is used. Therefore, no
distinction was made in this mapping between an episode and a decision, and under this

41
interpretation, all ‘episodes’ were therefore identified as decisions. However, if the decisions
entered in the patient journals were used as a data source for the use of restraint, such an
interpretation would result in a lower number of decisions on restraint.
The issue of whether a decision in a record is a ‘new period’ or a ‘new episode’ is discussed
on page 78 of the annotated edition of the Mental Health Care Act and the Mental Health Care
Regulations, Circular No IS-9/2012:
‘The fifth paragraph second sentence stipulates that the decision must be recorded
without delay, meaning as soon as possible.
There may have been a question of how frequently decisions should be made if restraint
must be used continuously for a long period, for example two to four times in a 24-hour
period. How frequently decisions on restraint should be made in such situations must be
assessed in each individual case. Elements in such assessments may then be whether it
was a case of a “new period” or whether the restraint was only suddenly terminated in
connection with, for example, a need to use the toilet.’
It is recommended that the relationship between an episode and a decision is clarified, in
order to ensure a common understanding and documentation of decisions authorising the
use of restraint.
How physical restraint is practised
The mandate for mapping restraint was to map the number of decisions and the number of
patients who had been subjected to physical restraint. It was not to collect further details about
how physical restraint was practised. Physical restraint was defined as restraint in 2007, but it
had long been used in many areas of mental health care. It is worth noting that the information
in the records of restraint says nothing about how the decision was initiated and implemented.
The documentation says that a decision was made and initiated (‘holding’, ‘brief holding’).
The documentation provides no details about how physical restraint was implemented in
practice or how many from the staff were involved. Nor does it say anything about whether
consideration was given to which method of implementation would be least intrusive (see
quotation below) or to the gender of the personnel who are to implement the measure. This is
discussed on page 41 of the annotated edition of the Mental Health Care Act and the Mental
Health Care Regulations, Circular No IS-9/2012.
‘The measure must be implemented in the least intrusive manner possible. What is
deemed to be the least intrusive manner must be assessed in each case for each patient?
For example, for some patients, physical restraint should only be carried out by staff of
the same gender as the patient. Likewise, it is conceivable that holding patients who
have been subjected to sexual assault should to be avoided.’
We know from practice and publications that there are many different ways of implementing
the use of physical restraint. Here are some examples:
- the patient is placed in the lateral position, with personnel holding the patient’s arms and
legs.
- the patient is seated on the edge of the bed while personnel sit on either side of the patient
and hold the patient’s arms.
- the patient may be placed face-down on the floor, with two or more personnel lying on
top/holding the patient down. The latter example has proven to pose a high level of risk.
Fatalities have been reported as a result of this type of intervention (Ball, 2005). In a
similar case in Norway, however, the patient survived because the individual concerned
received CPR in time (Nissen et al., 2012).

42
It is recommended that further requirements be developed for documenting the use of
physical restraint so that information is provided about the position in which the patient
should be held during implementation of the decision (for example: prone position, supine
position on the floor, arms held, seated on the bed), how many staff participate (and their
gender, where applicable) and in what way (how personnel use their bodies during the use
of physical restraint).
Stipulating the time aspect of when holding becomes a coercive measure
Experience from practice shows that different understandings prevail of how long holds must
last in order to be deemed a physical restraint requiring an administrative decision. Some
professional communities have stipulated that a hold must last a given number of minutes
before it can be deemed as physical restraint, whereas others deem holding as physical
restraint regardless of duration. These conflicting understandings of when a hold becomes
physical restraint has implications for how physical restraint is documented because the use
of holding in two different wards will be recorded as different numbers of decisions when
restraint are reported.
It is recommended that it be clarified how long holds must last in order to require an
administrative decisions.
Use of restraint in connection with implementing other types of coercive measures
One example is whether different holds should be deemed restraint or should have no
implications for whether or not the use of different holds is documented. It is known that
personnel use different types of holds when administering different types of involuntary
treatment such as force-feeding or forced medication. The question of whether holds are
deemed to be restraint has implications for whether the use of holding is documented.
Different interpretations lead to different reporting practices and potential under-reporting of
the use of physical restraint. This is clarified on page 64 of the annotated edition of the Mental
Health Care Act and the Mental Health Care Regulations (Circular No IS-9/2012), as follows:
‘If, when administering the involuntary treatment, it becomes necessary to exercise coercion
(physical/mechanical restraint), an administrative decision must be made to this effect
(Section 4-8).’ This clarification does not appear to be widely known in clinical practice.
It is recommended that this clarification be made known to the professional communities.
Consequence of measures concerning open-area seclusion
The way decisions authorising open-area seclusion are documented in the open-area seclusion
records provides no details about the content of such measures or about what restrictions they
impose on the patient’s day-to-day life. The documentation contained in the records is sparse,
and the following phrase often appears in the column describing the measure: ‘segregated
unit’. We know from clinical practice that both organisational and architectural conditions in
wards/units can vary considerably. This can apply to conditions such as regulating and
tightening control of the patient’s day-to-day activities, the architectural design of a
segregated unit, the number of patients, the composition of patients or how contact with staff
is organised (how long personnel are present each time).
It is recommended that guidelines be developed for documenting how open-area seclusion
should be implemented so that the decision clearly states what it entails for the patient.

43
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Annex 1
Ward coding system
The Norwegian Board of Health Supervision’s ward coding system for psychiatric
institutions, Circular No IK-44/89
6 Psychiatric wards
60 General psychiatric ward
61 Acute psychiatric ward
62 Short-term care ward
63 Intermediate care ward
64 Long-term care ward
65 Rehabilitation ward
66 Forensic ward
67 Psychogeriatric ward
68 Neurosis ward
69 Local code, where applicable
7 Other psychiatric wards
71 Ward for young schizophrenics (referred to as the ward for first-episode psychosis)
72 Psychosomatic ward
73 Ward for substance abusers (‘Greenhouse’)
74 Local code, where applicable
75 Children and adolescent psychiatric ward
76 Child psychiatric ward
77 Adolescent ward
78 Family ward
79 Psychiatric nursing home
8 Other hospital wards (defined by the Regional Centre for Research and Education in
Forensic Psychiatry and Psychology for the South-Eastern Norway Regional Health
Authority)
80 District psychiatric centre (DPC)
85 Other: Regional ward for eating disorders (RASP), Ward for people with development
disabilities/autism (PPU).

47
Annex 2
Basic data for the number of decisions on coercive measures and seclusion, and the numbers
of patients with decisions in 2012, by health trust/institution
* Under-reporting of 8 patients due to documentation in DIPS
**Under-reported data on 39 patients due to documentation in DIPS
Comments:
If it is to be possible to compare the use of restraint and open-area seclusion between different
health trusts/institutions, they must be comparable. Several conditions make it impossible to
compare the absolute statistics submitted by the health trusts/institutions regarding the
numbers of decisions and the numbers of patients with decisions without making reservations.
Two hospitals of the same size may have different functional areas. While one hospital may
focus on functions and patients where the use of restraint and open-area seclusion is likely,
the opposite may apply to another hospital. A comparison must necessarily be moderated
accordingly. Moreover, hospitals and wards change function over time. This complicates
comparisons made over time. An increase or decrease in the use of restraint and open-area
seclusion can be explained by one ward being assigned new functions or being relieved of
others. If such changes in areas of responsibility are not taken into account, there is a risk of
drawing an incorrect conclusion that changes in the use of restraint and open area seclusion
are due to or reflect changes in a unit’s professional profile or culture. Even within one and
the same unit, there may be alternative explanations for a notable increase or decrease in the
use of restraint and open area seclusion.
Health trust/institution
Number of patients
with decisions
Number of
decisions
Østfold Hospital health trust
137
424
Akershus University Hospital health trust
313
1136
Oslo University Hospital health trust
174
1083
Diakonhjemmet Hospital health trust
85
177
Lovisenberg Diaconal Hospital health trust
150
531
Vestre Viken Hospital health trust
157
745
Telemark Hospital health trust
85
243
Vestfold Hospital health trust
135
401
Innlandet Hospital health trust
200
679
Sørlandet Hospital health trust
111*
380
Stavanger University Hospital health trust
286
2259
Fonna Hospital health trust
111
405
Bergen Hospital health trust
204
1272
Førde Hospital health trust
32
145
Møre and Romsdal Hospital health trust
95
326
Nord-Trøndelag Hospital health trust
42
182
St. Olav’s Hospital health trust
117
620
Nordland Hospital health trust
70
204
University Hospital of Northern Norway health
trust
94* *
309
Other institutions:
Furukollen psychiatric centre
Skjelfoss psychiatric centre
4
14
Total
2602
11535

48
Annex 3

49

50
Annex 4

51

52
Annex 5

53

54

55
Annex 6

56
Annex 7
Duration of two different types of restraints when these are recorded in parallel (same
boot time) in the restraint protocol
There were episodes where physical restraint and isolation or mechanical restraint, were
documented on the same line and column for decisions. Thus, it was not possible to know
when the decision on physical restraint ended and the decision on isolation or mechanical
restraint was initiated. In such cases, the decision on physical restraint was encoded with
missing termination (se example 1a above).
Date
Initia tion,
date, hour
Termination,
date, hour
Patients
"article -status"
(voluntary or
res tra int)
Decisions:
a. Mechani ca l res traint (speci fy type)
b. Isolation
c. Pharmacologica l restra int (drug, dose and administration)
d. Physica l restrai nt
01/10 2012 09.40 am § 3.2
C. Zyprexa inj 10 mg x 1 i.m
D. Physical restrai nt approx. 30 - 35 min all together
01/10 - 12 04.00 pm § 3.2
a. 5 pt. belt bed
d Phys i ca l restraint in bed
02/10 - 12 09.30 pm 09.45 pm § 3.2 4 poi nt fi xa tion - left arm released
02/10 - 12 09.45 pm
3.10 - 12
10:30 am
§ 3.2 3 poi nt fixa tion - ri ght leg released
03.10 - 12 10.30 am § 3.2 released
04.10 - 12
approx.
11.00 am
approx.
01:00 pm
§ 3.3 d) repeated physical restrai nt
27.01-12 10.15 am 3.3 a) Belt bed
27.01-12 01.15 pm > diagonal releas e 01.15 pm
27.01-12
27.01
11:15 am
c) Stesol i d 10 mg I.M
27.01-12 11.15 am c) Haldol 10 mg I.M
27/1-12 02.20 pm
wrong note,
08:25 pm
a) belt
27/1-12 03.45 pm Diagonal release 03.45 pm
27/1-12 10.10 pm Both legs releas ed
27/1-12 10.45 pm Both arms released
27/1-12 11.35 pm Released from belt, stomach
28/1-12 00.20 am 00.20 a m Completely releas ed from belts
27/1-12 08.45 pm c) Stesolid 10 mg I.M
27/1-12 08.45 pm c) Haldol 10 mg I.M
Restraint protocol

57

58
Oslo University Hospital
www.oslo-universitetssykehus.no
Oslo University Hospital consists of the former health trusts Aker University Hospital,
Rikshospitalet University Hospital (incl. the Norwegian Radium Hospital) and Ullevål
University Hospital. Post to the management: Oslo Universitetssykehus HF, P.O. Box 4950
Nydalen, NO–0424 Oslo. Switchboard: 02770. Oslo University Hospital is owned by the
South-Eastern Regional Health Authority (Helse Sør-Øst RHF).