Result Articles

Result Article: 2018

Tingleff, EB., Hounsgaard, L., Bradley, SK., Gildberg, FA. 2018. Forensic psychiatric patients’ perceptions of situations associated with mechanical restraint: a qualitative interview study. International Journal of Mental Health Nursing. doi: 10.1111/inm.12549 Article, peer review. Status: Published!



To reduce the use and duration of mechanical restraint in forensic settings and ensure evidence-based patient care, we need more knowledge about patients’ subjective experiences and perceptions. The aim was to investigate forensic psychiatric patients’ perceptions of situations associated with the use of mechanical restraint and what they perceive as factors impacting the use and duration of mechanical restraint. Twenty participants were interviewed. Four themes were identified through a thematic analysis: ‘overt protest reactions’, ‘silent protest reactions’, ‘illness-related behaviour’, and ‘genuinely calm’, which together characterize patients’ perceptions of their ways of acting and reacting during mechanical restraint episodes. These themes are linked together in two patterns in the process of mechanical restraint: ‘pattern of protest’ and ‘pattern of illness’. Further research is needed to illuminate the associations between patients’ perceptions of being subjected to mechanical restraint and ways of acting and reacting through the process of mechanical restraint.


Sørensen, T., Tingleff, EB., Gildberg, FA. 2018. Feeling safe and taking on responsibilities: Newly graduated nurses’ perceptions and evaluations of their transition into a forensic mental health inpatient setting. Journal of Forensic Nursing. 10.1097/JFN.0000000000000190 Article, peer review. Status: Published.

Forensic mental health care is faced with serious problems in the recruitment and retention of newly graduated nurses (NGNs). Research intoNGNs’ experiences of their transition to and evaluations of transition programs in forensic care is sparse, and more studies are called for. This study aimed to investigate the characteristics of NGNs’ experiences and perceptions of their transition into a forensic setting and their evaluations of the introduction period. Three focus group interviews were carried out, involving 13 NGNs, lasting 79.68 minutes on average. They were analyzed using thematic analysis. Results show twomain themes: “feeling safe” and “taking on responsibilities.” If NGNs felt overburdened with clinical responsibilities during their transition, their feeling of safety reduced. The converse also applied; theThe safer they felt, the greater clinical responsibility they felt capable of handling. The more difficult the NGNs perceived the informal transition, the more unsafe they felt, and the more negatively they perceived the responsibilities placed upon them. Tailored programs designed to support both the informal and formal transitions are recommended, along with preceptorship, theoretical training, and role-based support, such as a shift manager, along with early introduction to conflict management and security measures.

Result Article: 2017

Nielsen, L.D., Beck, P., Hounsgaard, L., Gildberg, F.A. 2017. Mechanical Restraint – Confounders, Risk, Alliance Score: Testing the clinical validity of a new risk assessment instrument. Nordic Journal Of Psychiatry.2017, pp.1-7 online. DOI:10.1080/08039488.2017.1318949 Research: Article, Peer reviewed. Status: Published.

Background: Unstructured risk assessment, as well as confounders (underlying reasons for the patient’s risk behaviour and alliance), risk behaviour, and parameters of alliance, have been identified as factors that prolong the duration of mechanical restraint among forensic mental health inpatients. Aim: To clinically validate a new, structured short-term risk assessment instrument called the Mechanical Restraint–Confounders, Risk, Alliance Score (MR-CRAS), with the intended purpose of supporting the clinicians’ observation and assessment of the patient’s readiness to be released from mechanical restraint. Methods: The content and layout of MR-CRAS and its user manual were evaluated using face validation by forensic mental health clinicians, content validation by an expert panel, and pilot testing within two, closed forensic mental health inpatient units. Results: The three sub-scales (Confounders, Risk, and a parameter of Alliance) showed excellent content validity. The clinical validations also showed that MR-CRAS was perceived and experienced as a comprehensible, relevant, comprehensive, and useable risk assessment instrument. Conclusions: MR-CRAS contains 18 clinically valid items, and the instrument can be used to support the clinical decision-making regarding the possibility of releasing the patient from mechanical restraint. Implications: The present three studies have clinically validated a short MR-CRAS scale that is currently being psychometrically tested in a larger study.


Result Article: 2016


Nielsen, L.D., Gildberg, F.A., Dalsgaard, J.L., Munksgaard, G., Beck, P., Hounsgaard, L. 2016. Forensic mental health clinician´s experiences with and assessment of alliance regarding the patient´s readiness to be released from mechanical restraint. International Journal of Mental Health Nursing. doi: 10.1111/inm.12300 Research: Article, Peer reviewed. Status: Published.

One of the main reasons for prolonged duration of mechanical restraint is patient
behaviour in relation to the clinician-patient alliance. This article reports on the forensic mental
health clinicians experiences of the clinician-patient alliance during mechanical restraint, and their
assessment of parameters of alliance regarding the patient’s readiness to be released from restraint.
We used a qualitative, descriptive approach and conducted focus group interviews with nurses,
nurse assistants and social and healthcare assistants. The results show that a pre-established
personal clinician-patient alliance formed the basis for entering into, and weighing the quality of,
the alliance during mechanical restraint. In consideration of the patient’s psychiatric condition, the
clinicians observed and assessed two quality parameters for the alliance: ‘the patient’s insight into or
understanding of present situation’ (e.g. the reasons for mechanical restraint and the behaviour
required of the patient to discontinue restraint) and ‘the patient’s ability to have good and stable
contact and cooperation with and across clinicians. These assessments were included, as a total
picture of the quality of the alliance with the patient’, in the overall team assessment of the patient’s
readiness to be released from mechanical restraint. The results contribute to inform the development
of a short-term risk assessment instrument, with the aim of reducing the duration of mechanical


Gildberg, F.A., Paaske, K.J., Rasmussen, V.L., Nissen, R.D., Bradley, S.K., Hounsgaard, L. 2016. Humour: Power conveying social structures inside forensic mental health nursing. Journal of Forensic Nursing. Research: Article, peer reviewed. Status: Published

According to research literature, humor inside the staff–patient interaction seems to be significant in the area of forensic mental healthcare. However, existing literature on the subject is limited. Therefore, the aim of this study was to explore the characteristics of the use humor by forensic mental health staff members in interactions with forensic mental health inpatients. The study included 32 forensic mental health staffmembers, used 307 hours of participant observations, 48 informal interviews, and seven formal semistructured interviews. Outcomes identify four themes concerning the conveyance of power to, from, and between forensic mental health staff and patients as they interact: (a) “the informal use: the human-to-human approach,” characterized by an informal use of humor and without any reference tomental health issues; (b) the “formal use of humor: the staff–patient approach,” characterized as formalwith a view on the patient as mentally ill, unable to understand humor, and with the aim of using humor to prevent conflicts or negative behavior; (c) “protest against requested care: the human–patient approach,” characterized by the use of humor as a protest against requested care; and the use of (d) “inadequacy humor: the staff–human approach,” characterized by the use of inadequacy—humor referring to, for example, patients’ physical features. Recommendations and clinical implications are discussed.


Birkeland, S. Gildberg, F.A. 2016 Mental health nursing, mechanical restraint measures and patients’ legal rights. Vol. 2016. No. 10. pp. 8-14. The Open Nursing Journal. Short Communication Article, peer reviewed, Status: Published.

Coercive mechanical restraint (MR) in psychiatry constitutes the perhaps most extensive exception from the common health law requirement for involving patients in health care decisions and achieving their informed consent prior to treatment. Coercive measures and particularly MR seriously collide with patient autonomy principles, pose a particular challenge to psychiatric patients’ legal rights, and put intensified demands on health professional performance. Legal rights principles require rationale for coercive measure use be thoroughly considered and rigorously documented. This article presents an in-principle Danish Psychiatric Complaint Board decision concerning MR use initiated by untrained staff. The case illustrates that, judicially, weight must be put on the patient perspective on course of happenings and especially when health professional documentation is scant, patients’ rights call for taking notice of patient evaluations. Consequently, if it comes out that psychiatric staff failed to pay appropriate consideration for the patient’s mental state, perspective, and expressions, patient response deviations are to be judicially interpreted in this light potentially rendering MR use illegitimated. While specification of law criteria might possibly improve law use and promote patients’ rights, education of psychiatry professionals must address the need for, as far as possible, paying due regard to meeting patient perspectives and participation principles as well as formal law and documentation requirements.


Result Article: 2015
Tingleff, E. B., Dalsgaard, K., Lunding, D. & Gildberg, F. A. 2015 ”Merged into culture”: The experiences of being newly employed nursing staff in adult psychiatry. Vol. 29. No. 3 pp. 11-26 .Klinisk Sygepleje. Research: Article, peer reviewed. Status: Published.

Background: Newly qualified nurses experience a stressful transition into mental health nursing, but research shows that transition programs meet many of the challenges. Research on transition into mental health nursing that includes experienced nurses and health care assistants seems sparse. Aim: To investigate how newly employed nursing staff experience the transition and experience and evaluate the introduction to adult psychiatry. Method: 17 participants were interviewed in 3 focus groups. Data was analyzed using thematic analysis within a symbolic interactionism framework. Results: The newly employed experience themselves working in certain ‘culture’ and undergo a ‘transition’ characterized by four themes; ’Formal introduction’, ’Informal introduction’, ’The role’ and ’Working environment’. Conclusion: The newly employed experiences of ‘culture’ are very essential for their experiences of the transition and experiences and evaluations of the introduction. Structured, research-based transition programs are necessary in order for newly employed to achieve a healthy transition into mental health nursing.

Gildberg, FA, Fristed, P, Makransky, G, Moeller, EH, Nielsen, LD, Bradley, SK. 2015 As Time Goes by: Reasons and characteristics of prolonged episodes of mechanical restraint in forensic psychiatry. Vol. 11, No.1, 41-50. Journal of Forensic Nursing. Research: Article, peer reviewed. Status: Published.

Evidence suggests the prevalence and duration of mechanical restraint are particularly high among forensic psychiatric inpatients. However, only sparse knowledge exists regarding the reasons for, and characteristics of, prolonged use of mechanical restraint in forensic psychiatry. This study therefore aimed to investigate prolonged episodes of mechanical restraint on forensic psychiatric inpatients. Documentary data from medical records were thematically analyzed. Results show that the reasons for prolonged episodes of mechanical restraint on forensic psychiatric inpatients can be characterized by multiple factors: “confounding” (behavior associated with psychiatric conditions, substance abuse, medical noncompliance, etc.), “risk” (behavior posing a risk for violence), and “alliance parameters” (qualities of the staff-patient alliance and the patients’ openness to alliance with staff), altogether woven into a mechanical restraint spiral that in itself becomes a reason for prolonged mechanical restraint. The study also shows lack of consistent clinical assessment during periods of restraint. Further investigation is indicated to develop an assessment tool with the capability to reduce time spent in mechanical restraint.

Result article 2013
Gildberg, F.A., Bradley, S.K., & Hounsgaard, L. 2013. Comparing the Obvious: Interactional characteristics of staff in acute mental health nursing and forensic psychiatric nursing Vol 2013, no 12, pp. 205-214. International Journal of Forensic Mental Health. Forskning: Artikel, peer reviewed. Status: Published.

This article reports on and compares two separate studies of the interactional characteristics of forensic mental health staff and acute mental health staff as they interact with inpatients, respectively. Both studies were conducted using participant observation, along with informal and formal interviews. Findings show that both acute and forensic mental health nursing practice is characterized by two overriding themes; ‘trust and relationship-enabling care’ and ‘behavior and perception-corrective care.’ The comparison of the two studies shows no major differences in the characteristics of staff interactions with patients or in the overall meanings ascribed by staff in the different practice settings.

Result Article 2012

Gildberg, F.A., Bradley, S.K., Fristed, P., & Hounsgaard, L. 2012. Reconstructing normality: Characteristics of staff interactions with forensic mental health inpatients. vol. 2012, no.21, pp. 103-113., Int J.Ment.Health Nurs. available from: PM:22321258 Acces

Forensic psychiatry is an area of priority for the Danish Government. As the field expands, this calls for increased knowledge about mental health nursing practice, as this is part of the forensic psychiatry treatment offered. However, only sparse research exists in this area. The aim of this study was to investigate the characteristics of forensic mental health nursing staff interaction with forensic mental health inpatients and to explore how staff give meaning to these interactions. The project included 32 forensic mental health staff members, with over 307 hours of participant observations, 48 informal interviews, and seven semistructured interviews. The findings show that staff interaction is typified by the use of trust and relationship-enabling care, which is characterized by the establishment and maintenance of an informal, trusting relationship through a repeated reconstruction of normality. The intention is to establish a trusting relationship to form behaviour and perceptual-corrective care, which is characterized by staff’s endeavours to change, halt, or support the patient’s behaviour or perception in relation to staff’s perception of normality. The intention is to support and teach the patient normal behaviour by correcting their behaviour, and at the same time, maintaining control and security by staying abreast of potential conflicts.