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An evidence-based educational intervention for nurses at psychiatric hospitals had limited effect in curbing the use of coercive measures on patients, such as physical restraints and seclusion rooms, according to a cluster randomized trial in Finland.

From 2015 to 2017, use of seclusion rooms in hospital psychiatric wards dipped from 15.1% to 14.3% in the intervention group compared with an increase from 13.9% to 18.7% in the usual-practice group, reported Maritta Välimäki, PhD, of the University of Turku in Finland, and colleagues in .

Over time, the intervention group achieved a small reduction in seclusion rate, as compared with an increase for the usual-practice group (P=0.003 for interaction).

Conversely, however, the researchers also found a larger increase during the study period in the use of forced injection in the intervention group (from 7.6% in 2015 to 11.9% in 2017) compared with the usual-practice group (9.9% to 11.8%; P<0.001 for interaction), the team said.

Investigators noted an increase in the use of limb restraint per ward in the usual-practice group (from 5.4% to 7.3%) compared with no change in the intervention group (P<0.001).

The findings don't necessarily mean, however, that evidence-based education does not have some promise in reducing coercive measures, said Jacob Ballon, MD, MPH, a clinical professor of psychiatry and behavioral sciences at Stanford University in California, who was not involved with the study.

"This doesn't mean that there are not effective interventions to help minimize seclusion and restraints on an inpatient unit, it's just that this is a very specific finding on a very specific sample that didn't find a difference," he told MedPage Today. "We should still be pursuing methods and strategies for lowering seclusion and restraints."

For their study, the researchers recruited 27 government-funded psychiatric hospitals that included 648 nurses. Of the 8,349 patients, 53% were male, and the mean age was 40.6 years. The intervention used -- VIOLIN (Violence Intervention) -- is an evidence-based training program for nurses designed to reduce coercive practices.

The study looked at a specific educational program for preparing nurses to reduce the use of seclusion rooms, but it was limited in the definitions of coercive measures, Välimäki and co-authors noted. In fact, they said, a similar increase in the use of forced injections was also seen in the national level data in Finland during the study period, which might have been caused by "changes in the reporting system."

There were also questions about whether the use of forced injections were defined as coercive throughout the study, the authors said, adding that facility preference may have played a role in the apparent switch from seclusion rooms to forced injection. "[N]urses might have preferred involuntary medication and replaced seclusion events with forced injections; nurses are eager to switch to less restrictive coercive methods," the researchers wrote.

Ballon said he believes there are many other education-based methods that could offer benefits in reducing use of coercive measures in psychiatric wards. "I think there are effective tactics that can be utilized in inpatients to help with minimizing restraint episodes, so just because this one didn't show that, it doesn't mean it's not a worthwhile goal to pursue," he said.

The researchers noted that unlike in previous studies, they "found only weak evidence that the effect of the evidence-based educational intervention for nurses reduced the occurrence of seclusion events at the hospital level." However, one major difference in the group's study was the use of a tailored educational approach, which "may not be strong enough to show positive effects on a hospital level," the investigators said, adding that they could also not be sure exactly which aspects of the intervention were effective in reducing restriction practices.

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