Result Articles

Result article 2019

Frandsen, TF., Gildberg, F., Tingleff, E.B., 2019 Searching for qualitative health research required several databases and alternative search strategies: a study of coverage in bibliographic databases. Journal of Clinical Epidemiology Vol. 114, p118–124. https://doi.org/10.1016/j.jclinepi.2019.06.013 Article, Peer reviewed. Status: Published!

Objective: Retrieving the qualitative literature can be challenging, but the number and specific choice of databases are key factors. The aim of the present study is to provide guidance for the choice of databases for retrieving qualitative health research. Study Design and Setting: Seventy-one qualitative systematic reviews, from the Cochrane Database of Systematic Reviews and JBI database of Systematic Reviews and Implementation Reports, including 927 qualitative studies, were used to analyze the coverage of the qualitative literature in nine bibliographic databases. Results: The results show that 94.4% of the qualitative studies are indexed in at least one database, with a lower coverage for publication types other than journal articles. Maximum recall with two databases is 89.1%, with three databases recall increases to 92% and
maximum recall with four databases is 93.1%. The remaining 6.9% of the publications consists of 1.3% scattered across five databases and 5.6% that are not indexed in any of the nine databases used in this study. Conclusion: Retrieval in one or a few although well selected databases does not provide all the relevant qualitative studies. The remaining studies needs to be located using several other databases and alternative search strategies.  2019 Elsevier Inc. All rights reserved.

Nielsen, L.D., Bech, P., Hounsgaard, L., Gildberg, F.A. 2019.Construct validity of the Mechanical Restraint – Confounders, Risk, Alliance Score (MR-CRAS): a new risk assessment instrument. Nordic Journal Of Psychiatry. doi.org/10.1080/08039488.2019.1634757 Article, Peer reviewed. Status: Published!

Background: A new short-term risk assessment instrument, the Mechanical Restraint – Confounders, Risk, Alliance Score (MR – CRAS) checklist, including three subscales with altogether 18 items, has been developed in close collaboration with forensic mental health nurses, psychiatrists’ etc., and shows evidence of being comprehensible, relevant, comprehensive and easy to use for assessing the patient’s readiness to be released from mechanical restraint.
Aim: The aim of this study was to investigate whether the subscales: confounders, risk and parameters of alliance constituted separate subscales and needed further revisions.
Materials and methods: MR – CRAS was field-study tested among nurses, nurse assistants and social and health care assistants in 13 Danish closed forensic mental health inpatient units, and a Mokken analysis of scalability and a Spearman correlation analysis were performed.
Results: MR – CRAS was completed by clinicians in 143 episodes of mechanical restraint, representing 88 patients, with a mean duration of 63.25 hours. Most patients were younger men, diagnosed within the schizophrenia spectrum. One-third of the patients had repeated mechanical restraint episodes ranging between 2 and 8 episodes. MR – CRAS and especially the parameters of alliance were perceived
as usable for assessment of the patient’s readiness to be released from mechanical restraint. The psychometric analyses showed that the three subscales were unidimensional.
Conclusions: The study shows evidence of the construct validity of MR – CRAS among clinicians at closed forensic mental health inpatient units. MR – CRAS contributes with a common language and structured, systematic and transparent observations and assessments on an hour by hour basis during mechanical restraint

Tingleff, EB, Hounsgaard, L., Bradley, SK., Wilson, R., Gildberg, FA. 2019. A Matter of Trust and Distrust: A qualitative investigation of parent perceptions about the use of mechanical restraint on their adult children in a forensic psychiatric setting. Journal of Forensic Nursing.15/2. Doi: 10.1097/JFN.0000000000000237 Article, Peer reviewed. Status: Published!

Introduction: Increased knowledge about forensic psychiatric patients’ relatives’ perceptions in regard to the use of mechanical restraint (MR) is necessary, if clinical practice is to be improved and to achieve a reduction in the use and frequency of MR. However, a specific knowledge deficit about relatives’ perspectives on the use of
MR limits the evidence base considerably.
Aim: The aimof this study was to investigate the perceptions of MR held by relatives of forensic psychiatric patients’ including factors impacting its use and duration.
Method: Qualitative interviews were conducted with 15 parents of patients within a forensic psychiatry setting and thematically analyzed.
Findings: Two main themes were identified, namely, “care and protection” and “inclusion and involvement,” and one subtheme, “information.” These themes revealed the framework used by parents to construct a sense of “trust or distrust” about the ability of staff to provide adequate and safe care for their adult children in the forensic psychiatric setting.
Conclusion: Some parents in this study considered that forensic psychiatric staff used MR as a necessary protection. However, most parents held strong negative perceptions regarding the use of MR and the quality and safety of care provision. It is apparent that parents in this study believed they should be included and involved in the care in situations associated with the use of MR, because they considered that this could reduce its use. Further research is required to target interventions to reduce the use and duration of MR episodes and to improve clinical practice in forensic psychiatry.

Tingleff, EB., Hounsgaard, L., Bradley, SK., Gildberg, FA. 2019. 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 restraint.

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.