Abstract Deprivation of liberty is always an infringement of a person's constitutional rights. During the past decades, Western countries have focused on their Mental Health legislation, in particular, by making changes concerning involuntary treatment. After all, little is known about the frequency and quality of involuntary treatment, yet this information is needed to modificate the phenomenon. The present thesis is a part of the Nordic study ''Paternalism and Autonomy''. Two Finnish data have been used in this thesis: the register and the interview studies. The material of the register study comprises all admissions to the study hospitals (Tampere, Turku and Oulu) during a six-month period. The material of the interview study comprises the interviews of 50 patients admitted involuntarily and the interviews of the 50 voluntarily admitted patients following each involuntary admission. Both studies used a questionnaire based on previous studies. In Finland the rate of involuntary treatment is high. The motivation for deprivation of liberty is, however, the interest of patients. Deprivation of liberty was predicted by a diagnosis of a psychotic disorder as well as previous involuntary treatment. Harmfulness to others-criterion as the motivation of involuntary treatment was rarely used. In this material, it was never used as the sole motivation of detainment. Agitation/desorientation was the common reason for seclusion/restraint. Actual violence was more frequently the reason for seclusion of female patients whereas threat of violence was the reason for seclusion/restraint of men. There were differencies among the study hospitals concerning the rate of seclusion/restraint: in Oulu mechanical restraint was used more frequently than in other study hospitals. International comparison of deprivation of liberty is difficult because of the differences among countries in legislation and the paucity of the previous studies. Ward culture as well as the methods of registration vary in different countries, and, thus reliable comparison is restricted. The results of the current study confirm the notion that deprivation of liberty is more frequent in Finland that in many other countries. / Tiivistelmä Vapauden rajoittaminen on aina kajoamista ihmisen perustuslailliseen oikeuteen ja siten tahdosta riippumaton hoito psykiatriassa on ongelmallinen alue. Länsimaissa on herätty keskustelemaan tästä aiheesta viime vuosikymmeninä ja tahdosta riippumatonta hoitoa on pyritty vähentämään lainsäädännöllisin keinoin. Jotta tahdosta riippumattoman hoidon ja toimenpiteiden käyttöön voidaan vaikuttaa, tarvitaan vertailukelpoista tietoa sen määrästä ja laadusta. Tämä tutkimus on osa yhteispohjoismaista tutkimushanketta "Paternalism and Autonomy – A Nordic Study on the Use of Coercion in the Mental Health Care System". Tähän väitöskirjaan on käytetty em. tutkimushankkeen kahta suomalaista aineistoa: rekisteritutkimusta ja haastattelututkimusta. Rekisteritutkimukseen kerättiin kaikki 6 kuukauden aikana tutkimussairaaloihin (Tampere, Turku ja Oulu) tulleiden potilaiden tiedot. Haastattelututkimukseen pyydettiin 6 kuukauden aikana 50 tahdosta riippumattomalla lähetteellä tullutta ja heille 50 vapaaehtoisesti tullutta verrokkia. Molemmissa tutkimuksissa käytettiin aiempiin tutkimuksiin pohjautuvia kyselylomakkeita. Rekisteritutkimukseen kerättiin sosiodemografiset taustatiedot, aiempi sairaalahoitohistoria ja ajankohtaisen hoitojakson vapauden rajoittamista koskevat tiedot sekä diagnoosit. Haastattelututkimukseen kerättiin tietoja potilaan kokemuksesta sairaalaantoimittamisesta ja mahdollisuudesta vaikuttaa toteutuvaan hoitoon. Potilaiden psyykkinen tila arvioitiin haastattelututkimusosiossa käyttäen standardoituja psykiatrisia arviointiasteikkoja. Vapauden rajoittaminen psykiatriassa on Suomessa yleistä, tahdosta riippumattoman hoidon osuus on suuri. Vapautta rajoitetaan kuitenkin potilaan etua ajatellen (hoidon tarve ja potilaan vaarallisuus itselle). Psykoosi oli vapauden rajoitusta ennustava tekijä, kuten kuuluukin olla, koska psykoosi on tahdosta riippumattoman hoidon edellytys. Selittäväksi tekijäksi nousi myös aiempi tahdosta riippumaton hoito. Vaarallinen muille-kriteeriä käytettiin harvoin tahdosta riippumattoman hoidon perusteena, tässä aineistossa sitä ei käytetty yksinään sitovassa hoitopäätöksessä koskaan. Agitaatio/desorientaatio oli yleisin syy eristämiselle (eristys huoneeseen/leposide-eristys). Miehiä eristettiin hieman yleisemmin kuin naisia ja naisten eristys edellytti ajankohtaisen väkivaltaisuuden, kun miehiä eristettiin uhkaavan väkivallan vuoksi. Väestöön suhteutetut eristysluvut erosivat eri tutkimussairaaloiden välillä: Oulussa leposide-eristettiin muita sairaaloita yleisemmin. Eristystä ennusti parhaiten tutkimussairaala, mutta vapauden rajoituksen runsasta käyttöä ennusti aiempi tahdosta riippumaton hoito sekä ajankohtainen tahdosta riippumaton status. Tahdosta riippumattoman hoidon samoin kuin eristysten yleisyyden kansainvälinen vertailu on hankalaa aiempien tutkimusten vähäisyyden ja eri maiden välisten lainsäädännöllisten erojen vuoksi. Luotettavaa vertailua vaikeuttavat myös erilaiset hoitokäytännöt sekä rekisteröintimenetelmät. Saadut tulokset tukevat käsitystä, että psykiatristen potilaiden vapauden rajoittaminen on Suomessa yleisempää kuin monissa muissa maissa.

In psychiatric settings, the use of seclusion and/or restraints can be emotionally and psychologically traumatizing for patients. Patients often experience these interventions as inhumane and humiliating, and such interventions can have physical and mental adverse effects and in some cases can be fatal. This study examined the role of demographic, clinical, and hospital variables in predicting seclusion and/or restraint episodes in adult psychiatric inpatients. A total of 395 patients were included in the study. Adult psychiatric inpatients previously restrained (n = 91) were compared to psychiatric inpatients never restrained (n = 304). A binary logistic regression research design was used to examine the relationship of demographic variables, clinical variables, and hospital variables on the likelihood of being placed in seclusion or restraints. The results yielded age as a significant predictor for patients being restrained. Also, individuals diagnosed with bipolar disorder were less likely to experience a seclusion and/or restraint event than patients diagnosed with depressive disorder or within the schizophrenia spectrum. In addition, findings suggest that adult psychiatric inpatients that experienced restraint episodes were restrained within the 1st month of admission, during the weekday and during the 1st shift. In summary, given the findings from this study, knowledge of risk factors that precede patient restraint could enhance education and provide staff with information necessary to meet the clinical needs of the psychiatric inpatient population. Research indicates that the use of seclusion and restraint has decreased followed by implementation of educational programs designed to help staff assess patient clinical care needs and develop more therapeutically appropriate alternatives (Bower et al., 2003). By being aware of possible risk factors associated with seclusion and/or restraint, mental health providers can use early intervention and prevention strategies to reduce the use of seclusion and/or restraint. This would provide safer environments for mental health patients receiving treatment.

This research paper examines how an empowerment perspective can provide insight into women’s citizenship in the context of menstrual seclusion. Within the field of development, the goal of many civil society actors is to empower women through their intervention efforts. This objective frequently makes empowerment seem like a straightforward process. However, there are numerous factors to consider when investigating women’s status in the complex environment of menstrual seclusion in Nepal. By incorporating evidence from 17 semi-structured interviews, four documents, and one focus group discussion with intervention actors and women practising menstrual seclusion, this study demonstrates how women can become empowered in this setting. The material is evaluated through a thematic analysis within the empowerment framework and contextualised through feminist theory. The findings indicate that actors solely focus on certain components of empowerment although holistic and context-driven efforts are needed. This research paper concludes that in order to generate development outcomes, empowerment efforts need to target all aspects of women’s participation to have a larger effect on their active citizenship in this setting.

L’isolement avec ou sans contention (IC) en milieu psychiatrique touche près d’un patient sur quatre au Québec (Dumais, Larue, Drapeau, Ménard, & Giguère-Allard, 2011). Il est pourtant largement documenté que cette pratique porte préjudice aux patients, aux infirmières et à l’organisation (Stewart, Van der Merwe, Bowers, Simpson, & Jones, 2010). Cette mesure posant un problème éthique fait l’objet de politiques visant à la restreindre, voire à l’éliminer. Les études sur l’expérience de l’isolement du patient de même que sur la perception des infirmières identifient le besoin d'un retour sur cet évènement. Plusieurs équipes de chercheurs proposent un retour post-isolement (REPI) intégrant à la fois l’équipe traitante, plus particulièrement les infirmières, et le patient comme intervention afin de diminuer l’incidence de l’IC. Le REPI vise l’échange émotionnel, l’analyse des étapes ayant mené à la prise de décision d’IC et la projection des interventions futures. Le but de cette étude était de développer, implanter et évaluer le REPI auprès des intervenants et des patients d’une unité de soins psychiatriques aigus afin d’améliorer leur expérience de soins. Les questions de recherche étaient : 1) Quel est le contexte d’implantation du REPI? 2) Quels sont les éléments facilitants et les obstacles à l’implantation du REPI selon les patients et les intervenants? 3) Quelle est la perception des patients et des intervenants des modalités et retombées du REPI?; et 4) L’implantation du REPI est-elle associée à une diminution de la prévalence et de la durée des épisodes d’IC? Cette étude de cas instrumentale (Stake, 1995, 2008) était ancrée dans une approche participative. Le cas était celui de l’unité de soins psychiatriques aigus pour premier épisode psychotique où a été implanté le REPI. En premier lieu, le développement du REPI a d’abord fait l’objet d’une documentation du contexte par une immersion dans le milieu (n=56 heures) et des entretiens individuels avec un échantillonnage de convenance (n=3 patients, n=14 intervenants). Un comité d’experts (l’étudiante-chercheuse, six infirmières du milieu et un patient partenaire) a par la suite développé le REPI qui comporte deux volets : avec le patient et en équipe. L’évaluation des retombées a été effectuée par des entretiens individuels (n= 3 patients, n= 12 intervenants) et l’examen de la prévalence et de la durée des IC six mois avant et après l’implantation du REPI. Les données qualitatives ont été examinées selon une analyse thématique (Miles, Huberman, & Saldana, 2014), tandis que les données quantitatives ont fait l’objet de tests descriptifs et non-paramétriques. Les résultats proposent que le contexte d’implantation est défini par des normes implicites et explicites où l’utilisation de l’IC peut générer un cercle vicieux de comportements agressifs nourris par un profond sentiment d’injustice de la part des patients. Ceux-ci ont l’impression qu’ils doivent se conformer aux attentes du personnel et aux règles de l’unité. Les participants ont exprimé le besoin de créer des opportunités pour une communication authentique qui pourrait avoir lieu lors du REPI, bien que sa pratique soit variable d’un intervenant à un autre. Les résultats suggèrent que le principal élément ayant facilité l’implantation du REPI est l’approche participative de l’étude, alors que les obstacles rencontrés relèvent surtout de la complexité de la mise en œuvre du REPI en équipe. Lors du REPI avec le patient, les infirmières ont pu explorer ses sentiments et son point de vue, ce qui a favorisé la reconstruction de la relation thérapeutique. Quant au REPI avec l’équipe de soins, il a été perçu comme une opportunité d’apprentissage, ce qui a permis d’ajuster le plan d’intervention des patients. Suite à l’implantation du REPI, les résultats ont d’ailleurs montré une réduction significative de l’utilisation de l’isolement et du temps passé en isolement. Les résultats de cette thèse soulignent la possibilité d’outrepasser le malaise initial perçu tant par le patient que par l’infirmière en systématisant le REPI. De plus, cette étude met l’accent sur le besoin d’une présence authentique pour atteindre un partage significatif dans la relation thérapeutique, ce qui est la pierre d’assise de la pratique infirmière en santé mentale. Cette étude contribue aux connaissances sur la prévention des comportements agressifs en milieu psychiatrique en documentant le contexte dans lequel se situe l’IC, en proposant un REPI comportant deux volets de REPI et en explorant ses retombées. Nos résultats soutiennent le potentiel du développement d’une prévention tertiaire qui intègre à la fois la perspective des patients et des intervenants. / In Quebec, seclusion with or without restraint (SR) affects nearly one in four patients in psychiatric wards (Dumais, Larue, Drapeau, Ménard & Giguère-Allard, 2011). It is widely recognized that this practice affects patients, nurses, and organizations (Stewart, Van der Merwe, Bowers, Simpson, & Jones, 2010). Coercive measures pose an ethical dilemma and are the object of policies aimed at reducing or even eliminating their use. Studies on patients’ experience and nurses’ perception of seclusion showed the need for a review of the seclusion event. Several teams of researchers proposed a post-seclusion and-or restraint review (PSRR) involving both the staff and the patient as an intervention to reduce the incidence of SR. It aims at exchanges on emotions, analysis of the steps leading to the decision to use SR, and projection of future interventions. The purpose of this study was to develop, implement, and evaluate a PSRR with patient and staff of an acute psychiatric care unit to improve their care experience. The research questions were: 1) What is the context of implementation of the PSRR? 2) What are the facilitators and barriers to PSRR implementation according to patients and staff? 3) What is the point of view of patients and staff regarding the modalities and impact of PSRR?, and 4) Is PSRR implementation associated with a decreased prevalence of SR and a reduction of hours spent in SR? This instrumental case study (Stake, 1995, 2008) was rooted in a participatory approach. The case was an acute psychiatric care unit specialized in first-episode psychosis. To document the context prior to the implementation of the PSRR, the principal investigator went through a 56-hour immersion on the unit and individually interviewed a convenience sample of staff (n= 14) and patients (n= 3). A committee of experts (the principal investigator, six nurses from the unit and a patient partner) developed the two PSRR tools (one for the patient and one for the staff) that were implemented. To evaluate the impact of the PSRR, patients (n = 3) and staff (n =12) were interviewed and data on the prevalence and duration of SR were collected before (6 months) and after (6 months) the implementation of the PSRR. Qualitative data were subjected to thematic analysis (Miles, Huberman, and Saldana, 2014) and administrative data were analyzed with descriptive and non-parametric statistics. The findings were that, for patients, the context of implementation was defined by implicit and explicit standards. They felt they had to conform to staff expectations and unit’s rules. Patients believed that the use of SR could create a vicious circle of aggressive behaviours fuelled by their profound feeling of injustice regarding SR. Participants’ viewpoint showed the ongoing need to foster opportunities for authentic communication, especially through a PSSR. The practice of PSSR seemed to vary from one staff member to the other. For staff, findings suggested that the main facilitator for the implementation of the PSRR was the study’s participatory approach, while barriers were related to the difficulties in involving all witnesses of the SR witnesses within the staff PSSR. During the PSRR with the patient, nurses felt they could explore patient’s feelings and point of view, which led to the restoration of the therapeutic relationship. The staff PSRR was perceived as a learning opportunity and allowed for adjusting the patient’s treatment plan. There was a significant reduction in the use and the duration of seclusion in comparison with data prior to implementation. The findings highlighted the possibility to overcome the perceived discomfort of all parties regarding SR by systematizing the use of a PSRR with patients and staff. Additionally, the findings emphasized the need for a genuine presence of the nurse to achieve meaningful sharing in the therapeutic relationship, which is the cornerstone of mental health nursing. This study contributed to knowledge on the management of aggressive behaviour in psychiatric settings by shedding light on the context in which SR practices occur, by offering two PSRR tools, and by exploring the impact of their implementation. The results supported the potential of a participatory research approach in which patients and staff perspectives were taken into account to develop alternatives approaches to the use of SR.

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Submitted by Jamile Barbosa da Cruz (jamile.cruz@ucsal.br) on 2016-10-25T14:46:21Z No. of bitstreams: 1 Versao Final (111115) 7 para impressão (2).pdf: 1013938 bytes, checksum: 6401e7cf6a19764c7a2f2015f98e8b94 (MD5) / Approved for entry into archive by Maria Emília Carvalho Ribeiro (maria.ribeiro@ucsal.br) on 2016-12-28T20:41:51Z (GMT) No. of bitstreams: 1 Versao Final (111115) 7 para impressão (2).pdf: 1013938 bytes, checksum: 6401e7cf6a19764c7a2f2015f98e8b94 (MD5) / Made available in DSpace on 2016-12-28T20:41:51Z (GMT). No. of bitstreams: 1 Versao Final (111115) 7 para impressão (2).pdf: 1013938 bytes, checksum: 6401e7cf6a19764c7a2f2015f98e8b94 (MD5) Previous issue date: 2015-11-30 / A presente dissertação pretende abarcar criticamente o conceito e aplicação do auxílio-reclusão na sociedade do espetáculo, entendido como alegoria na democracia liberal brasileira, em antinomia com a idéia de justiça e o atual estágio da crise estrutural do capital. Deste modo, a partir da pergunta central: o que é de fato o auxílio reclusão serão apontados quais são os princípios previdenciários norteadores e como se delineia a Previdência Social no Brasil, com destaque para a contextualização histórica, retratando, com especial ênfase, o período compreendido entre a Constituição Federal de 1988 a 2013. A resposta para referida pergunta está muito longe de ser simples, portanto, a abordagem dos meios de comunicação - desde revistas periódicas até as redes sociais, sem olvidar das demais fontes de/para (des) informação – considera os motivos que realmente motivam esses discursos excludentes e que levaram, inclusive, a uma proposta de emenda constitucional, a PEC 304, que retrata exatamente os argumentos lançados, ainda que desprovidos de sustentação teórica e compreensão do fenômeno em apreço. Pretende-se, ainda, desvelar outros fundamentos e motivações que justificam a forma com que esta questão é evidenciada nestas abordagens midiáticas. Um viés a ser desnudado com a pesquisa em voga. Não obstante, insistimos que não parece existir, a principio, uma resposta fácil para esta indagação. A velha dicotomia entre o bem e o mal não pode ser diluída facilmente, ainda mais se as respostas se mostram subservientes à lógica do capital - a mercantilização de todas as esferas da vida. Neste contexto, o papel e o propósito do Estado serão concomitantementes avaliados sob a égide do sujeito ético-moral ser suplantando pelo sujeito mercadoria. / This thesis aims to critically address the concept and implementation of aid-seclusion in the society of the spectacle, with the allegory of the Brazilian liberal democracy in contradiction with the idea of justice and the current stage of capital's structural crisis. However, what is in fact the aid seclusion will be singled out which are the guiding social security principles and how it outlines the Social Security, with special emphasis on the period between the Brazil Federal Constitution of 1988 to 2013 The answer to that question is far from simple, nevertheless, we insist that there seems to be, at first, an easy answer to this question. The old dichotomy between good and evil can not be easily diluted, even if the answers are shown subservient to the logic of capital. In this context, the role and purpose of the State shall be concomitantementes evaluated under the aegis of the ethical-moral subject is supplanting the subject-commodity.

Bakgrund Meticillinresistent Staphyloccus aureus är ett hälsoproblem som har en ökad spridning och är en aktuell hälsofråga som berör sjukvården. Anledningen till den ökade spridningen är bland annat dålig handhygien samt för lite kunskap inom ämnet. En strategi för minskning av spridningen av MRSA är att se till att patienten får eget rum för avskildhet. Sedan är det av vikt att patienter som bär MRSA får förmedla sina tankar och upplevelser för att få sina behov tillgodosedda. Syfte Syftet var att beskriva patienters upplevelse av meticillinresistent staphylococcus aureus på sjukhus. Metod Denna litteraturöversikt har fullföljts av nio kvalitativa vetenskapliga artiklar samt en kvantitativ vetenskaplig artikel. Artiklarna som använts har hämtats från databaserna CINAHL Complete och PubMed och utvärderas i enhet med Fribergs metod. Resultat Resultatet presenteras i två huvudteman: Känslan av att vara MRSA bärare och skam, samt stigma och kontakten med närstående. Upplevelsen av vård för MRSA bärare innebär isolering, förändringar i kontakten med vårdpersonal samt vårdpersonalens otillräckliga kunskaper inom ämnet. Diskussion Litteraturöversiktens resultat diskuteras med hjälp av Katie Erikssons teori som handlar om lidande med tre begrepp i fokus: Sjukdomslidande, Vårdlidande och Livslidande. Det som främst diskuteras är kunskapsbrist, isolering och vårdpersonals bemötande. / Background Methicillin-resistant Staphylococcus aureus (MRSA) is a concern in healthcare as it is becoming more widespread and is a current health issue that is commonly found in healthcare settings. The reason for the increased spread is, among other things, poor hand hygiene and too little knowledge on the subject. One strategy for reducing the spread of MRSA is to ensure that the patient has his or her room for privacy. Furthermore, it is essential that patients who carry MRSA are allowed to convey their thoughts and experiences in order to have their needs met. Aim The aim is to bring out the patient’s feelings about living with MRSA in hospital. Method This literature review has been completed by teen qualitative scientific articles. The articles used have been retrieved from the CINAHL Complete and PubMed databases and are assessed andevaluated following Friberg's method. Results The result depicts two main themes: are divided into subgroups. The feeling of being an MRSA carrier and the feeling of shame. As well as stigma and contact with relatives. The experience of the care of MRSA carriers who have themes: isolation, contact with health professionals and insufficient knowledge of the subject. Conclusion The results of the literature review are discussed on the basis of Katie Eriksson's theory of suffering with the following concepts in focus: disease suffering, care suffering and life suffering. The main findings discussed are lack of knowledge, isolation and the treatment of health care professionals.

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After sixteen intensive months, I quit my employed position as a security guard at a local hospital. By drawing on my autoethnographic experiences in the form of “ethnographic fiction writing”, as well as eight interviews with my former male colleagues, I explore how the guards’ constructions of masculinity intersect with their security assessment and subsequent application of force, chemical incarceration, and other coercive security tactics on involuntarily-committed mental health patients. The narratives are framed by the available literature on gender and masculinity within the security, police, prison and military institutions, as well as the theoretical notions of gendered institutions (Acker), hegemonic masculinity (Connell & Messerschmidt), doing gender (West & Zimmerman), and Dave Holmes’s application of Foucauldian biopolitical power to forensic healthcare settings. These concepts are used in tandem with a creative methodological tool to reveal the “messy”, “bloody” and “gendered” ways in which hospital life unfolds between the guard, the nurse, and the patient prisoner. By escaping more traditional forms of academic writing, I am able to weave raw, sensitive and reflexive thoughts and emotions into the research design and analysis. The analysis is divided into two narratives: “Us” and “Them”. “Us” emphasizes the gendered ways in which the hospital guard learns, reproduces, resists, lives up, or fails to live up to the masculine codes of the profession. Here, the guard must confront cultural demands to demonstrate physical prowess, authority and heroism during a patient battle. “Them” explores how hegemonic masculinity shapes the hierarchical and coercive relations between the guard, the nurse, and the patient, and reinforces psychiatrized discourses that promote punishment, pain, bureaucracy and control. Overall, these findings call for the abolition of physical restraint, chemical incarceration and other coercive security measures within our healthcare institutions, and encourage future research to give voice to the lived experiences of women guards and security management teams.