Received: 21 December 2021 | Revised: 16 December 2022 | Accepted: 18 January 2023

DOI: 10.1111/jpm.12907

ORIGINAL ARTICLE

Nurses' perceptions of nurse–­patient communication in

seclusion rooms in psychiatric inpatient care: A focus group
study

Johanna Berg1 | Essi Lipponen2 | Eila Sailas3 | Päivi Soininen3,4 | Jaakko Varpula4 |
Maritta Välimäki4,5 | Mari Lahti1,4

1
Turku University of Applied Sciences,
Turku, Finland Accessible Summary
What is known on the subject?
2
Mente-­palvelut Oy, Lahti, Finland
3
Helsinki University Hospital, Kellokoski • Communication between nurses and patients is essential in mental health nursing.
Hospital, Kellokoski, Finland
4 • Lack of communication during seclusion causes dissatisfaction among patients.
Department of Nursing Science,
University of Turku, Turku, Finland • Coercive practices can cause psychological discomfort for patients and staff
5
Xiangya Nursing School, Central South members.
University, Changsha, China
• Research related to nurses' perceptions of nurse–­patient communication during
Correspondence seclusion events is scant.
Johanna Berg, Joukahaisenkatu 3, 20520
Turku, Finland. • In Finland, the use of coercive practices has been high despite efforts to reduce
Email: [email protected] the need for coercive practices through the National Mental Health Policy since
Funding information 2009.
The Finnish Work Environment Fund, • Nurse–­patient communication is referred to in the Safewards model as one issue
Grant/Award Number: 116181
of delivering high-­quality care.
What this paper adds to existing knowledge?
• Nurses aim to achieve high-­quality communication while treating patients in
seclusion.
• Nurses aim to communicate in a way that is more patient-­centred.
• Various issues affect the quality of communication, such as nurses' professional
behaviour and patients' state of health.
What are the implications for practice?
• Improved communication between nurses and patients will support therapeutic
relationships and could lead to a better quality of care.
• Nurses' enhanced communication may promote the use of noncoercive practices
more frequently in psychiatric settings.
• Improving nurses' communication skills may help support the dignity and auton-
omy of secluded patients, resulting in patient experiences that are more positive
in relation to care offered in seclusion.
• Nurses should be offered opportunities to take part in further training after edu-
cation to enhance communication skills for demanding care situations.
• Further research that incorporates the perspectives of patients and those with
lived experience of mental health problems is needed.

J Psychiatr Ment Health Nurs. 2023;30:781–794. wileyonlinelibrary.com/journal/jpm © 2023 John Wiley & Sons Ltd. | 781
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782 BERG et al.

• Components of evidence-­based Safewards practices, such as using respectful

and individual communication (Soft Words), could be relevant when developing
nurse–­patient communication in seclusion events.
Abstract
Introduction: Communication between nurses and patients is essential in mental
health nursing. In coercive situations (e.g. seclusion), the importance of nurse–­patient
communication is highlighted. However, research related to nurses' perceptions of
nurse–­patient communication during seclusion is scant.
Aim: The aim of this study was to describe nurses' perceptions of nurse–­patient com-
munication during patient seclusion and the ways nurse–­patient communication can
be improved.
Method: A qualitative study design using focus group interviews was adopted. Thirty-­
two nurses working in psychiatric wards were recruited to participate. The data were
analysed using inductive qualitative content analysis.
Results: Nurses aimed to communicate in a patient-­centred way in seclusion events,
and various issues affected the quality of communication. Nurses recognized several
ways to improve communication during seclusion.
Discussion: Treating patients in seclusion rooms presents highly demanding care situ-
ations for nurses. Seclusion events require nurses to have good communication skills
to provide ethically sound care.
Conclusion: Improved nurse–­patient communication may contribute to shorter seclu-
sion times and a higher quality of care. Improving nurses' communication skills may
help support the dignity of the secluded patients. Safewards practices, such as re-
spectful communication and recognizing the effect of non-­verbal behaviour, could be
considered when developing nurse–­patient communication in seclusion events.
Relevance Statement: This study deepens the understanding of nurse–­patient com-
munication during seclusion events from the perspective of nurses. Caring for pa-
tients in seclusion presents challenging situations for nurses and demands that they
have good communication skills. To enhance their communication skills in seclusion
events, nurses require opportunities to take part in further training after education re-
lated to communication skills for demanding care situations. Knowing the appropriate
ways to interact with individual patients during seclusion can help nurses create and
maintain communication with patients. For mental health nursing, nurses' enhanced
communication may promote increased use of noncoercive practices in psychiatric
settings. For patients, improving nurses' communication skills may help support dig-
nity and autonomy during seclusion and shorten the time spent in seclusion, resulting
in a better quality of care and more positive patient experiences related to care of-
fered in seclusion. In this, the perspectives of people with lived experience of mental
health problems should be acknowledged. Components of Safewards practices, such
as using respectful and individual communication and paying attention to one's non-­
verbal communication (Soft Words), could be useful when developing nurse–­patient
communication in seclusion events.

KEYWORDS
communication, nurse, patient, psychiatric care, restraint, seclusion
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BERG et al. 783

1 | I NTRO D U C TI O N management of challenging situations—­including alternative mea-

sures to coercion or therapeutic communication—­can differ. After
Based on the literature, coercive practices, such as seclusion and re- graduation, nurses have the possibility to specialize in mental health
straints, are used when a patient's behaviour compromises the safety and substance abuse care and continue their studies at the graduate
of other patients (Keski-­Valkama et al., 2010), staff or the unit (Meehan level (Salminen et al., 2019), which gives them varied possibilities to
et al., 2004). Coercion is used when less restrictive methods have deepen their professional skills (e.g. nurse–­patient communication)
not been helpful (Gerace & Muir-­Cochrane, 2019; Price et al., 2018). in clinical psychiatric practice.
Seclusion and restraint are used as interventions and are currently In Europe and Finland, the trend of reducing psychiatric beds has
permitted for use in mental health services and other settings to con- been strong and has led to increasing service in outpatient care fa-
trol or manage a person's behaviour, even though coercive practices cilities (Taylor Salisbury et al., 2016; Välimäki et al., 2019). In Finland,
may cause physical harm (Kinner et al., 2017; Varpula et al., 2021) the number of coercive practices has not decreased in the same
and psychological discomfort for patients (Chieze et al., 2019; Kinner manner that psychiatric beds have reduced (Välimäki et al., 2019).
et al., 2017) and staff (Sequeira & Halstead, 2004; VanDerNagel Despite the ideological change in psychiatric care, the use of coer-
et al., 2009). A decades-­long debate on the subject has raised the cive practices has been high in Finland even though the Ministry
claim that coercive practices violate human rights and should no lon- of Social Affairs and Health (2014) launched the National Mental
ger be used (de Bruijn-­Wezeman, 2019; Dyer, 2003; Gooding, 2021; Health Policy in 2009 to reduce the need to use coercive measures
McSherry, 2013; Rodrigues et al., 2020). Furthermore, Sailas and in psychiatric services. A study of coercive practices conducted in 11
Fenton (2000) stated already two decades ago that the use of seclu- European countries and Israel found that forced medication was the
sion should be minimized due to ethical reasons. Respect for basic most used coercive measure (56%), followed by restraint (36%) and
ethical principles of autonomy, dignity, integrity and vulnerability seclusion (8%) (Raboch et al., 2010). In McLaughlin et al. (2016), the
is of high importance in discussions related to seclusion as a care use of seclusion varied from 0% to 30% between studied European
method, which often is pointed to as inhuman and degrading treat- countries. Steinert et al. (2009) showed that 10%–­30% of all patients
ment (Rendtorff, 2002). Besides ethical challenges during seclusion admitted into acute psychiatric wards are exposed to seclusion, re-
event, therapeutic communication between patients and nurses is straint or forced medication in some form. Furthermore, one study
minimal (Lahti et al., 2018). In a recent study by Berg et al. (2022) from Switzerland showed the prevalence of using seclusion and re-
on psychiatric intensive care units, it was found that patients and straint was 6.4% (Lay et al., 2011). In Finland, Välimäki et al. (2019)
nurses highly valued the use of therapeutic communication and en- found that the overall prevalence of coercive treatment among
vironments that promote it. This approach aims to reduce the use inpatients was 9.8%. This includes using seclusion (6.9%) and limb
of seclusion, as patients receive close care and support from staff restraints (3.8%), which are distinct restrictive practices. Thus, co-
(Berg et al., 2022). ercion practices put a high demand on nurses (Jalil et al., 2017). In
According to the European Committee for the Prevention of these situations, the role of nurses is to observe patients and eval-
Torture and Inhuman or Degrading Treatment or Punishment (2017), uate their mental and physical status (Ward & Gwinner, 2015), se-
seclusion refers to a stripped-­down room in which a patient is placed cure patients' basic needs (Björkdal et al., 2010; Salzmann-­Eriksson
alone and is monitored via security cameras by staff or through et al., 2008) and guarantee their safety.
small windows in seclusion room door resulting minimal face-­to-­face Nurse–­patient communication in mental health nursing care is
communication (Lahti et al., 2018). Restraint refers to restraining a essential (Harris & Panozzo, 2019; Priebe & McCabe, 2006; Van
patient chemically, physically or mechanically as a way to immobi- Der Merwe et al., 2013) because it forms the basis of therapeu-
lize him or her. The use of coercive methods is strictly regulated by tic interventions, alleviates patients' feelings of distress (Allikmets
national policies and legislations (McSherry, 2013, 2017). et al., 2020) and is one prerequisite of high-­quality care (Chambers
In Finland, according to the Mental Health Act (1116/1990), co- et al., 2015). Patient-­centred communication includes understand-
ercive measures can be initiated by a physician, and they must pro- ing patients' needs and cultural context to reach a shared under-
ceed in as short a time as possible and must be closely monitored standing of the problems they face and treating patients according
by staff to ensure fulfilment of patients' basic needs (Finlex, 1990). to their values as much as possible (Epstein & Street, 2007). In ad-
In Finland, coercive care in psychiatry includes seclusion, limb re- dition, principles of good professional communication in psychiatry
straints, forced injection and physical restraints. Despite the include actively listening to patients, openness and speaking plainly
demands to decrease the use of coercive measures in Finnish psy- (Naughton, 2018), focusing on the patient's concerns, respect and
chiatry, the overall reduction in the use of these methods has been genuineness with a personal touch (Priebe et al., 2011) and ensuring
small during the last two decades (Välimäki et al., 2019). In Finland, safe treatment (Kanerva et al., 2015).
nursing education is provided in universities of applied sciences at However, communication between nurses and patients is chal-
the bachelor level (210 credits under the European Credit Transfer lenged during coercive practices due to the nature of their proce-
and Accumulation System). In mental health nursing programs, the dures (e.g. a patient being put in a seclusion room alone with limited
number of credits and study contents offered between universi- possibilities for outside contact). Coercion events can also cause a
ties of applied sciences vary. For example, courses related to the breakdown in communication because of the patient's mental state
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784 BERG et al.

or a nurse's interpersonal skills and communicative competence 2 | M E TH O D S

(McCabe & Priebe, 2008). Nurse–­patient communication during se-
clusion events can be defined as an essential element of quality care, 2.1 | Study design
and it includes providing or exchanging information, ideas or feelings
(Xue & Heffernan, 2021). In this study, a qualitative descriptive design was used. The qualita-
Patients are not satisfied with the number of staff visits to se- tive approach was selected because it allows a deeper understanding
clusion rooms or the number of opportunities to have discussions of the phenomenon to be studied (Sandelowski, 2000) and enables
with staff during seclusion (Aguilera-­Serrano et al., 2018; Allikmets descriptions of the lived experiences and gives them significance
et al., 2020; Chien et al., 2005; Iversen et al., 2020; Keski-­Valkama (Grove et al., 2013). Consolidated criteria for reporting qualitative
et al., 2010; Kontio et al., 2012). Nurses' poor communication skills studies were used to guide the reporting of this study (Supplement
during seclusion and restraint practices have also been reported 1; Tong et al., 2007).
(Kontio et al., 2012). The quality of communication between pa-
tients and nurses is important in care situations because it could af-
fect patients' behaviour (Allikmets et al., 2020) or the way patients 2.2 | Setting
perceive their experience of being secluded (Askew et al., 2020;
Tingleff et al., 2017). However, patients may have difficulties in en- The study was conducted in one hospital district in southern Finland
gaging with nurses, especially if they are coerced (Rio et al., 2020). that served approximately 1,000,000 inhabitants at the time. The
Patton (2013) found that nurses might have difficulties in interacting hospital provided care for patients of varying age groups and psychi-
with patients who are not able to communicate or participate in care atric diagnoses. The data were collected on the hospital's six wards,
decisions, and Cleary et al. (1999) found unit layout hampered com- which have separate focuses of care and patient populations: two
munication. Furthermore, the need for enhanced communication acute psychiatric wards, one psychogeriatric ward, one psychosis
between nurses and patients during seclusion or restraint has been ward and two forensic psychiatric wards. The wards were mixed-­sex,
found in several studies (Boumans et al., 2015; Haw et al., 2011; provided care 24 h a day, had 13–­20 beds, were behind locked doors
Kontio et al., 2012; Ntsaba & Havenga, 2007; Steinert et al., 2013). and had altogether approximately 150 nurses. The study wards were
Research related to nurse–­patient communication from recruited with the help of hospital directors. Wards were eligible for
nurses' point of view during seclusion events is scant (McAndrew this study if they had seclusion rooms and the possibility to use a
et al., 2014; Sandhu et al., 2015), which is evident from a database mechanical restraint.
search (PubMed, CINAHL, Medline) covering the previous 10 years
(communication AND nurse AND seclusion). This quick critical re-
view identified only 10 relevant published articles, 9 of which were 2.3 | Participant selection
written in English. Upon closer examination, it was found that none
of the articles described nurses' perceptions related to commu- The nurses were recruited using the purposive sampling method
nication during seclusion events. The focus of the articles varied, (Palinkas et al., 2015), which is a useful approach when participants
including the concept of respect in mental health care (Cutcliffe hold information needed in research (Higginbottom, 2004). Two
& Travale, 2013), nurses' feelings related to restrictive practices researchers (M. L. and J. B.) held separate information sessions on
(Riches et al., 2022), patient perspectives on the seclusion pro- each study ward during the same day. The staff members and ward
cess (Ling et al., 2015; Faschingbauer et al., 2013; Hammervold managers were informed about the study, its purpose, the meaning
et al., 2022), an educational program to reduce seclusion (Boumans of participating in the study, informed consent, implications of the
et al., 2015), nurses' communication skills in de-­escalation situa- study and confidentiality. The voluntariness of participation in the
tions (Ye et al., 2020; Jury et al., 2019) and unit design that improves focus groups was highlighted. After the information sessions, the
safety and staff-­patient encounters (Holmes et al., 2020). ward managers approached the nurses working on these wards and
Patients in acute psychiatric wards lack communication during screened nurses' eligibility to join the study. After nurse managers
challenging events, which might lead to aggressive incidents had recruited participants and informed this to researchers, they en-
(Allikmets et al., 2020). However, little is known about nurses' per- sured a sufficient level of staffing in wards. Inclusion criteria for the
ceptions of nurse–­patient communication in seclusion events. By nurses were (a) experience with seclusion and restraints practices,
exploring nurses' perceptions of communication with patients, their (b) ability to speak and read Finnish and (c) working on the study
communication skills may be improved, leading to more positive ex- ward as a registered nurse or practical nurse. Exclusion criteria were
periences and better therapeutic care for patients, as well as reduc- (a) no experience with seclusion or restraint practices, (b) not fluent
ing the time spent in seclusion rooms. Therefore, in this study, we in the Finnish language, (c) short-­term substitute employment (less
focused on answering two research questions: (a) How do nurses than 3 months) and (d) being a nurse student. Forty nurses were will-
perceive nurse–­patient communication during patient seclusion? (b) ing to take part in the focus group interviews. However, six refused
How can nurse–­patient communication during patient seclusion be before signing the informed consent form, and two were not able to
improved? join the interviews due to responsibilities on the wards.
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BERG et al. 785

2.4 | Data collection method and data collection reread word by word, highlighting text (words and sentences) that
relates to the research questions and coding the text. Codes are
Data were collected using focus group interviews between 20 then sorted into subcategories and categories. Finally, definitions
September and 13 October 2017 by four researchers (three female of codes, subcategories and categories are developed. Data analy-
and one male) trained to carry out focus groups. Focus groups were sis was first performed by one researcher. First, the data were read
selected as the data collection method because they allow par- through carefully several times to obtain a thorough understanding
ticipants to express their thoughts safely in a homogeneous group, of the information. Second, data were reread word by word, keep-
and each group's dynamics may generate authentic information ing in mind the two research questions that guided the analysis and
(Jayasekara, 2012). A specified interview protocol was prepared to highlighting meaningful units (word and sentences). Third, meaning-
guide the interviews. The focus group interviews were conducted ful units answering the research questions were coded and were
outside the study ward on the hospital's premises to ensure a peace- sorted into subcategories. Fourth, the subcategories were formed
ful place for the discussions. Only the participants and two facili- into categories. While working with the data, we used abstraction
tating researchers were present during the focus group interviews. and interpretation to form subcategories and categories from the
The participants were given oral and written information prior to the data. Then, the data were reanalysed to ensure that the context of
interviews before they signed a written consent form. the categories was accurate (Hsieh & Shannon, 2005). The data were
At the beginning of the interviews, the nurses were asked to give reanalysed as follows: Data were read through once more, and then,
background information (age, gender, education, possible further coding was done first by one researcher (E. L.) and then repeated
education on coercive measures, work experience and current work by two researchers (J. B. and M. L.) to ensure the credibility. The
position). Next, the following questions were asked: (a) What is good quotations, codes, subcategories and categories from the data were
communication between a nurse and a patient in seclusion events? translated from Finnish into English for the reporting of the results.
(b) What is poor communication between a nurse and a patient in
seclusion events? (c) How would you develop the communication
between a nurse and a patient during seclusion events? The ques- 2.6 | Ethical considerations
tions were designed to be open enough for participants to engage
in discussion during the interview. The focus group questions were The study proposal was assessed by the ethical committee, and per-
based on knowledge gaps identified in the literature, with questions mission to conduct the study was granted by the study organizations.
included to explore these gaps. Written informed consent was obtained from the participants to
The literature showed that the themes were essentially related support autonomous decision-­making. The voluntariness of partici-
to the study topic and thus guided the development of the ques- pation was underlined. To ensure confidentiality, participants were
tions (Kvale & Brinkman, 2015; Patton, 2014). In addition, they were encouraged to keep the information they heard during the interview
evaluated by and were discussed with professional experts on the confidential. However, confidentiality and privacy are problematic
research team. The experts had strong clinical and research experi- in focus groups because researchers cannot control the information
ence related to the study topic, and after the discussions, no major participants may discuss outside the group (Sim & Waterfield, 2019).
changes were made to the questions. In addition, the researchers anonymized the collected data to ensure
Altogether, four focus group interviews with 32 nurses were that no identifying information was presented (Grove et al., 2013).
conducted. Each interview was recorded with a digital audio record-
ing device and was transcribed verbatim to facilitate the data anal-
ysis. The interviews lasted between 60 and 180 min (M = 90 min). 3 | R E S U LT S
According to Moser and Korstjens (2018), saturation in qualitative
research is reached when new analytical information no longer arises 3.1 | Demographic characteristics of participants
or when study participants have provided all the information possible
on a phenomenon. Saturation was achieved in our four focus group The mean age of the participants was 39 years, and the sex ratio was
interviews because no new themes emerged in the last interview. 59% female (n = 19) and 41% male (n = 13). Most of the participants
(59%) were registered nurses. The average working experience was
9 years, ranging from 9 months to 36 years (SD = 8.65). More than
2.5 | Data analysis half of the participants (62%) had received further education related
to coercive practices (Table 1).
The data were analysed using Hsieh and Shannon's (2005) conven-
tional approach to content analysis, which is useful when wanting
to describe a phenomenon with limited existing research literature. 3.2 | Summary of results
According to Hsieh and Shannon's conventional approach, data
analysis begins with reading all data several times to obtain a com- The aim of this study was to describe nurses' perceptions of nurse–­
plete understanding of the content and structure. Then, data are patient communication during patient seclusion and explore nurses'
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786 BERG et al.

TA B L E 1 Participant demographics (N = 32).

One important issue is that we can establish contact
Study participants' characteristics N (%) with the patient. Sometimes there is no contact be-
Age (N = 32) tween nurse and patient and no communication.

18–­29 8 (25) (Participant 2)

30–­39 9 (28)
Treating patients individually
40–­49 9 (28)
Nurses recognized that successful communication is related to treat-
50+ 6 (19)
ing patients individually. This was acknowledged, for example, by
Gender (N = 32)
considering the gender of the patient. Nurses stated that some pa-
Female 19 (59)
tients communicate better with male nurses and others with female
Male 13 (41) nurses.
Professional background (N = 32)
Mental health nurse 2 (6) When we observe that a patient communicates no-
Practical nurse 11 (35) tably better with female nurses, of course we aim to
Registered nurse 19 (59) take advantage of that in order to establish contact
Further education of coercive measures (N = 29) with the patient.
Yes 18 (62) (Participant 13)

No 11 (38)
Individual treatment of the patients also included acknowledging that
Working experience in psychiatric care (N = 32)
various cultural factors, such as language, habits, practices and man-
Less than 1 year 2 (6)
ners, affect communication, and they are reflected in interactions.
1–­5 years 12 (38)
5–­10 years 7 (22)
If we have patients with a different cultural back-
10–­15 years 4 (12)
ground, then first of all it is important to understand
More than 15 years 7 (22) the language, habits and manners.
(Participant 12)

ideas on ways to improve nurse–­patient communication during Treating patients individually enabled nurses to know the patients.
patient seclusion events. The results show that the main category When a nurse and patient knew each other, it was easier to establish
extracted from the interviews was striving toward patient-­centred contact and a confidential relationship.
communication. This included three categories labelled nurses' ef-
forts to establish communication with the patients, nurses' qualities My own patient was secluded for several days. I cared
related to communication and patients' state of health affecting com- for him intensively. It became easier over the time be-
munication. Moreover, nurses' ideas for ways to improve communi- cause we knew each other better. It really helps when
cation in seclusion events raised two categories: a patient-­centred you know your patient and his habits.
approach and clinical practices in psychiatric wards. The main cate- (Participant 17)
gory as well as other categories and subcategories related to patient-­
centred communication and ideas for ways to improve nurse–­patient Aiming for collaboration
communication in seclusion events are presented in Table 2 in addi- Nurses strived to cooperate with patients. Cooperation was defined
tional details. as interaction in which a nurse and patient understood each other.
Sometimes nurses tested the patients' ability to cooperate.

3.3 | Striving toward patient-­centred Before we enter the seclusion room, we some-
communication times ask the patient who is standing in front of the
door to go and sit on the mattress, and if the pa-
3.3.1 | Nurses' efforts to establish communication tient acts according to our instruction, that is good
with patients co-­operation.
(Participant 3)
Being present and establishing contact with the patient
Nurses considered it essential to establish contact with the patient, Informing the patient
which requires nurses to be genuinely present in the situation. Being Providing the patient with information was important for successful
present and establishing contact were considered preconditions for communication in seclusion. Nurses described that the patient must
high-­quality communication. be informed about various issues happening in the seclusion room,
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BERG et al. 787

TA B L E 2 Nurses' perceptions on nurse–­patient communication in seclusion and ideas for improvement.

Main category Categories Subcategories

Nurses' perceptions on nurse–­patient communication during patient seclusion events

Striving toward patient-­centred Nurses' efforts to establish communication Being present and establishing contact with the
communication with the patients patient
Treating patients individually
Aiming for collaboration
Informing the patient
Nurses' qualities related to communication Recognizing one's opinions
Paying attention to one's expressions and gestures
Being calm and neutral
Communicating in a clear and appropriate way
Patients' state of health affecting Observing the patients' mental health
communication Evaluating patients' mental health
Nurses' ideas for ways to improve nurse–­patient communication in seclusion events
Striving toward patient-­centred Patient-­centred approach Considering patient's needs
communication Recognizing one's attitudes and feelings
Clinical practices in psychiatric wards Improving a ward's physical layout
Planning the communication
Acting as an interpreter

such as the reasons the patient is secluded and information about Being calm and neutral
medication and other health-­related treatments. Nurses aimed to be calm in their behaviour, although sometimes sit-
uations in the seclusion room demanded quick actions. Calm speech
You explain to the patient what is happening and why, and a neutral tone of voice were means to create a tranquil atmos-
and what we are going to do. phere in the seclusion room for patients.
(Participant 25)
When we are entering the seclusion room, we have to
be calm and not fuss around.
3.3.2 | Nurses' qualities related to communication (Participant 24)

Recognizing one's opinions Nurses stated that regardless of the way patients behave, they
Nurses recognized the relevance of their opinions to communication should remain neutral in their behaviour. When patients' behaviour
in seclusion. Personal opinions influenced whether it was possible evokes negative feelings in a nurse, the nurse should remain calm
to achieve a common understanding of the situation. For example, and offer the patient an opportunity to discuss the situation later.
sometimes nurses disagreed with each other on the reasons for se- Nurses stated that they should avoid being provoked by patients'
cluding a patient or the way a patient should be treated during se- behaviour.
clusion. Some nurses felt that they should only communicate about
necessary issues with the patient and not offer any communication It is no use to be horrified or shocked at the situation or
during seclusion. start blaming the patient. It is better to be as neutral as
possible and later discuss the situation with the patient.
Paying attention to one's expressions and gestures (Participant 13)
Nurses observed that expressions and gestures influenced nurse–­
patient communication. They thought that even small gestures Communicating in a clear and appropriate way
could signal a nurse's emotions to the patient and affect the com- Communication in the seclusion room should be as clear and simple as
munication between them. Nurses consciously paid attention to possible. Therefore, nurses felt they should explain issues to patients
the way they physically acted and communicated in the seclusion in a simple, understandable way. However, a patient's mental health
room. status could hinder the patient from understanding what is being said.
In these situations, clear communication is even more important.
If you stand with your hands on your hips or with your
fists clenched, it sends a negative message to the When the patient is confused, it is really important
patient. that the nurse explains clearly and in a simple way.
(Participant 22) (Participant 5)
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788 BERG et al.

Nurses stated that successful interaction with patient included 3.4 | Nurses' ideas for ways to improve nurse–­
planning ways to communicate before entering the seclusion patient communication in seclusion events
room, which required nurses to agree upon who had the main
responsibility of talking with the patient beforehand. They also Regarding possibilities to develop and improve communication in se-
evaluated ways many nurses would be needed to enter the se- clusion events, nurses recognized two categories: a patient-­centred
clusion room to avoid provocative situations and to ensure clear approach and clinical practices on psychiatric wards.
communication.

We have agreed that one of us [nurses] has the 3.4.1 | Patient-­centred approach
responsibility to speak with the patient and we
also plan how we take our positions in the seclusion Considering patients' needs
room. Nurses wanted to pay more attention to patients during the se-
(Participant 25) clusion event, for example, by responding to patients' needs more
quickly. In addition, nurses stated that they should more carefully
Communication should be appropriate between nurses and pa- consider the way they answer patients' questions.
tients in seclusion events. Appropriate communication was de-
fined as professional communication in which emotions are Patients often wonder why they are secluded and
controlled, and the focus is on the situation at hand and not on when the seclusion will be terminated. It would be
anyone's personal qualities. For nurses, using appropriate language good if we could give them a better answer than just
was self-­evident and they must regulate their language use and saying, ‘Try to behave better’.
keep it suitable. (Participant 2)

Of course, appropriate language; that is self-­evident. Nurses also stated that patients should not be ignored. Communication
(Participant 20) should be related to the patient's issues and condition.

When we are manually holding the patient, it is not

3.3.3 | Patient's state of health affecting right to ignore the patient and talk about something
communication not at all related to the situation at hand.
(Participant 13)
Observing the patient's mental health
Nurses described that the mental condition of a patient could in- More attention should be paid to giving sufficient information to a se-
fluence the nature of nurse–­patient communication in seclusion cluded patient. Patients were often uninformed of the reasons they
events. Nurses experienced that even if they tried their best to com- were secluded or of the kind of treatment that they might be offered
municate with a patient, sometimes the communication failed be- during the seclusion.
cause of the patient's state of mental health. This was often due to
the patient being highly disorientated or aggressive. We could do better in informing the patients—­
informing them of what we are going to do and what
Sometimes communication between us [nurse–­ we have planned. You can never inform too much.
patient] just doesn't work, whatever you are trying (Participant 12)
because of the patient's mental health.
(Participant 1) Recognizing one's attitudes and feelings
Nurses wanted to highlight staff's attitudes and feelings during se-
Evaluating patients' mental health clusion episodes and the various effects they may have on communi-
Nurses used communication as a tool for evaluating patients' mental cation. Recognizing and controlling one's feelings were perceived as
health. In addition, taking care of patients' basic needs, such as giv- important, and nurses felt that their feelings should not affect com-
ing them food, enabled nurses to obtain information on the patients' munication. For example, nurses should not be provoked by patients.
condition. Continuous evaluation of the mental state of patients was
also seen as essential when nurses explored justifications to termi-
nate the seclusion. 3.4.2 | Clinical practices on psychiatric wards

Communication is a good means to evaluate and ob- Improving a ward's physical layout
tain information on patients' wellbeing, it gives valu- The environment of a ward and its physical space should be devel-
able information. oped in a way that could make nurses more easily available for pa-
(Participant 31) tients in the seclusion room.
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BERG et al. 789

The physical layout of units could be developed in a during seclusion, which has been described as a high-­stress situ-
way that the seclusion room could be situated near ation for both patients (Kontio et al., 2012; Steinert et al., 2013)
the nurses' office. This would make it easier for nurses and nurses (Moran et al., 2009; VanDerNagel et al., 2009). In ad-
to monitor patients, and nurses would be more quickly dition, the evidence related to this topic is very scant (McAndrew
available for the patient. et al., 2014; Sandhu et al., 2015).
(Participant 23) Nurse–­patient communication in mental health nursing care is
essential, as noted in studies by Harris and Panozzo (2019), Priebe
To maintain their safety, the nurses stated that they occasion- and McCabe (2006), and Van Der Merwe et al. (2013). Even in chal-
ally had to communicate through the seclusion room door. This lenging situations, such as seclusion, communication is the primary
was described as a challenge: How can one be sure that the pa- tool that nurses use to provide care. In our study, nurses also rec-
tient hears what is said and at the same time protect the patient's ognized the importance of continued communication with secluded
privacy? patients, which is consistent with findings from other studies, in-
cluding Chambers et al. (2015) and Van Der Merwe et al. (2013),
When it is not safe to enter the seclusion room, it where nurses expressed a desire for more contact and better com-
would be nice if we wouldn't have to yell through the munication with patients. Furthermore, a recent review by Berg
seclusion room door. The challenge is that everyone et al. (2022) on psychiatric intensive care units found that patients
in the unit knows what is discussed. and nurses valued therapeutic interaction and environments that
(Participant 8) promote communication.
In our study, nurses aimed for patient-­centred communication.
Planning the communication According to Epstein and Street (2007), patient-­centred communi-
Nurses expressed a need to plan the communication between cation involves understanding patients' needs and cultural context,
nurses and patients better in seclusion events. Better planning of and treating patients according to their values as much as possible.
communication could decrease possible misunderstandings and This was also emphasized by nurses in our interviews, who noted
disagreements among nurses and promote systematic communi- that recognizing patients' individual needs and considering factors
cation. Planning communication is particularly important when such as gender and habits are essential when establishing commu-
a patient is restrained with mechanical restraints (e.g. four-­p oint nication. The importance of establishing contact with patients was
belts). highlighted as a prerequisite for good communication, which sup-
ports findings from a previous study by McCabe and Priebe (2008).
When the patient is restrained with mechanical re- The Safewards model also emphasizes the importance of communi-
straints to the bed, it is sometimes difficult to know cation in building a trustworthy relationship between nurse and pa-
how much to communicate with the patient. There is tient by providing methods, such as respectful communication and
disagreement amongst nurses how to act and also in- psychoeducation (Bowers, 2014), that could be applied in seclusion
consistency in practices. events as well.
(Participant 20) In our study, giving patients enough relevant information was
other key determinant to good communication. Studies have shown
Acting as an interpreter that patients want to receive more information about their condi-
Sometimes language barriers exist between patients and staff. tion and to have discussions to help them understand their treat-
Nurses stated that it was challenging to act as an interpreter be- ment when secluded (Allikmets et al., 2020; Boumans et al., 2015;
tween a patient and doctor. A lack of a common language can lead Haw et al., 2011; Iversen et al., 2020; Keski-­Valkama et al., 2010;
to misunderstandings. Kontio et al., 2012). This would give patients a sense of control and
security (Lanthén et al., 2015) and may result reduced time spent in
It would be good if we had a doctor who is able to seclusion room, which should be the preferable trend according to
speak Finnish, because then the patient is also able to literature (Gooding, 2021; Rodrigues et al., 2020). However, in our
understand what is said. study, nurses stated that a patient's poor mental state could ham-
(Participant 29) per the patient's sense of security and control and therefore weaken
nurses' possibilities to establish communication with the patient in
a seclusion room.
4 | DISCUSSION Nurses identified the relevance of their expressions and gestures
and stated that even small gestures or body posture could influence
In this study, we aimed to describe nurses' perceptions of nurse–­ communication. Non-­verbal communication is an essential part of
patient communication and nurses' ideas for improving communi- high-­quality nursing and it should be considered an important as-
cation in seclusion events. To our knowledge, this is the first study pect when professionals meet clients' needs (Hall & Lloyd, 1990).
to describe nurses' perceptions of nurse–­patient communication Literature related to communication (Hall et al., 2019; Jones &
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790 BERG et al.

LeBaron, 2002; Marcinowicz et al., 2010) has shown that most com- facilitates nurses in establishing and maintaining communication
munication is expressed by gestures, facial expressions, body pos- with secluded patients.
ture and tone of voice, which are important to keep in mind while Planning communication between professionals beforehand
establishing communication in seclusion. In our study, professional to communicate with patients better and to avoid misunderstand-
behaviour was described as acting in a calm and neutral manner, ings and disagreements among nurses was mentioned as a way
avoiding provocation by patients' behaviour. The importance of to improve communication. Tran and Johnson (2010) stated that
professional behaviour to communication has been recognized in communication between nurses can be poor, meaning that nurses
previous studies as well (Chien et al., 2005; Harris & Panozzo, 2019; may not communicate with each other and thus might fail to pro-
Lanthén et al., 2015). vide essential observations about the patient. Fluent information
Surprisingly, nurses stated that they sometimes disagreed transfer and an open communication culture in which nurses can
about the reasons a patient was being secluded and the way freely communicate with each other in a timely manner are also
they should communicate with the patient in the seclusion room. matters of patient safety (Kanerva et al., 2015). Recognizing the
The disagreement causes an ethical dilemma, and the phenom- importance of patient-­centred communication in seclusion events
enon has been verified in other studies (Hem et al., 2014; Lind indeed raises the requirement to ensure that nurses could develop
et al., 2004). This variance between nurses may indicate a lack of their skills related to professional communication. In addition,
consistent care practices and weak care culture when treating pa- nurses must have possibilities and enough time to develop an open
tients in seclusion situations, leading to low-­quality patient care. care culture in which communication is recognized as one of the
Aguilera-­S errano et al. (2018) made a similar point: Patients need key determinants to practice nursing care safely in challenging pa-
information, contact, and interaction with nurses, and whether tient situations.
these needs are met influences patients' subjective experiences
of coercion. When nurses have differing views on the reasons
for a patient's seclusion, it could affect the communication in 4.1 | What the study adds to existing evidence
the seclusion room. Nevertheless, during their education, nurses
can train for nurse–­p atient communication in various situations. Our study provides new insights on nurse–­patient communication in
In addition, ethics of communication and respect of the patient seclusion rooms from the perspective of nurses. It adds to the exist-
(Rendtorff, 2002) could be highlighted and be discussed under ing literature on this topic, which is a highly demanding aspect of
professional education, which might contribute to consistent and psychiatric nursing care. The study provides new knowledge about
high-­quality care practices and communication in demanding pa- nurses' perceptions of communication in seclusion rooms, including
tient situations. the qualities that nurses possess related to communication. It also
The nurses gave their ideas for improving communication in se- expands understanding of how to improve nurse–­patient communi-
clusion events. First, they stated that good professional communi- cation in seclusion rooms.
cation should centre more on the patient during seclusion, which
meant that nurses should be aware of their thoughts, attitudes
and feelings and not let them influence communication. Improving 4.2 | Limitations of the study
communication also included providing patients with more infor-
mation. This finding is in line with other studies (Aguilera-­Serrano One limitation of this study is that the recruitment strategy we used,
et al., 2018; Iversen et al., 2020; Kontio et al., 2012) that found pa- which involved recruiting head nurses, may have resulted in a biased
tients were disappointed with the lack of information and wished sample compared to other approaches. Additionally, focus group
to have more interaction with nurses. Second, nurses suggested interviews were conducted in Finnish, and the findings were trans-
improvements for clinical practices of the unit. Being more easily lated to English afterwards. This translation process may have led to
available to the patients was closely related to unit layout. In pre- the loss of some contextual meanings and potentially undermined
vious studies (Cleary et al., 1999; Keski-­Valkama et al., 2010), unit the credibility of the findings (Lincoln & Guba, 1985). The transfer-
layout was found to play a significant role in nurse–­patient commu- ability of the findings to other psychiatric settings is limited, as the
nication. Holmes et al. (2020) conducted a study that highlighted the study focused on nurse–­patient communication in a confined set-
significance of unit layout in psychiatric units and found that reduc- ting, specifically seclusion rooms (Lincoln & Guba, 1985). However,
ing barriers related to the environment and increasing connections the results may be applicable to some extent in similar settings.
between nurses and patients can lead to safer units, support the Another limitation to consider is that focus group interviews as a
dignity of patients and promote a patient-­centred approach. In the data collection method may have limited participants to give their
context of seclusion rooms, this suggests that environmental solu- true perceptions about the topic under discussion when answers
tions should support nurse–­patient communication, such as allowing were given in front of several colleagues listening to one's answers.
patients to contact nurses through an audio monitor. Additionally, Furthermore, seclusion and patient aggressive behaviour might
seclusion rooms should be positioned in the unit in a way that be sensitive topics for some participants and might hinder honest
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BERG et al. 791

perceptions (Greenbaum, 2000; Kvale & Brinkman, 2015), hamper- AU T H O R C O N T R I B U T I O N S

ing the credibility of the data (Lincoln & Guba, 1985). All authors meet the authorship criteria set by the International
Committee of Medical Journal Editors. All authors are in agreement
with the submission of this manuscript.
5 | R E LE VA N C E FO R C LI N I C A L PR AC TI C E
AC K N O​W L E​D G E​M E N T S
Patient-­centred communication is an essential part of clinical practice We would like to express our gratitude to the Director of Hyvinkää
during seclusion events. Being present and choosing respectful and Hospital Area, Raija Kontio, for the study organization and all the
individual communication styles may help nurses create and main- nurses who participated in our study. We would like to thank Jaakko
tain therapeutic relationships with patients, and this may shorten Varpula for helping with the data collection. We would also like to
their time spent in seclusion. Nurses' enhanced patient-­centred thank the Finnish Work Environment Fund for funding this study.
communication skills may support the secluded patients' dignity and
autonomy and give them more positive seclusion experiences. In the F U N D I N G I N FO R M AT I O N
future, more research should be done from the perspectives of pa- The Finnish Work Environment Fund funded this study (grant num-
tients and people who have experienced mental health problems. ber 116181, Maritta Välimäki; 116181, Mari Lahti).
Nurses working with secluded patients should have opportunities
to take part in further education related to patient-­centred commu- C O N F L I C T O F I N T E R E S T S TAT E M E N T
nication to improve their clinical skills in these demanding care situ- The authors declare no conflict of interests.
ations. In Finland, further training is offered for registered nurses
working in psychiatric units, with the aim of strengthening their DATA AVA I L A B I L I T Y S TAT E M E N T
professional nursing skills after they have earned their bachelor's Research data are not shared.
degrees. In addition, the nursing team should have sufficient time
for discussion and planning so they can create a consistent care ap- E T H I C S S TAT E M E N T
proach, such as patient-­centred care, for secluded patients, there- The study proposal was evaluated by the Helsinki University
fore promoting high-­quality care in seclusion room situations. Based Hospital Ethical Committee (12/13/03/03/2016). Permission to
on this study, we assert that clinical practice should be developed conduct the study was obtained from the study organizations.
toward noncoercive and more communication-­oriented care. Participants were informed orally and with written text about the
study, and written informed consent was obtained. Participants
were informed about voluntary participation. The research data
6 | CO N C LU S I O N were stored in a secure cloud service with access for the main
researchers only.
This study adds knowledge about the phenomenon of nurse–­patient
communication during seclusion and contributes to the insights on ORCID
how nurses perceive their communication with patients. Nurses' Johanna Berg https://orcid.org/0000-0002-6660-0506
qualities, for example, respectful and calm interactions, and patients' Maritta Välimäki https://orcid.org/0000-0001-7234-2454
mental states can affect the nurses' possibilities for establishing Mari Lahti https://orcid.org/0000-0002-3403-5418
patient-­centred communication during seclusion. Treating patients
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