Seclusion “Let’s start opening the doors”
Executive Summary
The use of seclusion and restraint is a common practice within acute mental health settings in New Zealand. Current evidence suggests that seclusion and restraint is used as a safety measure to prevent harm to others and themselves. However, it can often result and cause significant psychological and physical harm to patients and staff. This form of treatment can be detrimental to a patient’s recovery, particularly those who have experienced traumatic life experiences.
Recommendations
1. Workforce development to reduce restraint and seclusion should be developed and implemented and evaluated with involvement of staff and consumers.
2. Implementation of practical prevention methods and ward layouts
Introduction
The issue of seclusion within acute mental health facilities is an interesting issue for me within health care. I have worked in an acute inpatient mental health setting for five years and completed a second year nursing placement in another. While working in these settings I have witnessed many seclusion episodes which have resulted in patients being secluded due to being deemed unsafe and as a result of their unmanageable behaviours. I have constantly reflected upon this issue and have realised what a frightening experience this must be for patients who are also struggling to hold on to reality. I do however support the use of seclusion as a temporary measure in cases where patients present with high risk behaviours and are deemed a danger to themselves and others as safety is paramount. There are, however, strategies and initiatives that can be implemented to reduce and appropriately manage seclusion time within acute inpatient mental health facilities. These strategies have been put into practice internationally and have been found to be successful in decreasing or eradicating the amount of time a patient spends in seclusion and therefore alleviating patient distress through therapeutic activities, promoting recovery based practice and reducing staff distress (Huckshorn, 2004).
What is Seclusion?
The act of seclusion is a form of restraint whereby the patient is held alone and securely in a room where sensory input is minimised and freedom to exit is decided by staff (as cited in Mental Health Commission, 2004). Prior to the commencement of seclusion patients can potentially be put in physical restraint following an aggressive episode or when pose a high risk to themselves or others and are controlled by either physical restraint, or by an object (mechanical restraint) or by limiting their normal access to an environment (environmental restraint) (O’Hagan, 2008). While a patient is in seclusion nursing staff perform routine 10 minute checks on the patient to monitor their general condition, breathing, position, activity and behaviour. Every two hours the nurse must attempt to enter the room to conduct an assessment of the patient’s mental state and physical state as appropriate. These entries require a number of nursing staff depending on the protocols of the service. A psychiatric assessment must be conducted every eight hours (O’Hagan, 2008).
Trauma Informed Care
Trauma-informed care is defined as mental health care that addresses the significant effect that trauma may have on a person’s neurobiology, psychology, social relationships and traumatic experiences and disorders of those who receive mental health services (Champagne & Stromberg, 2004). Addressing the needs of individuals is essential and requires accurate assessment of trauma history that includes identifying risk factors that provoke intense fear responses, which could lead to dangerous behaviours.
Clinical issue
In my clinical experience I feel that these incidents could have been dealt with differently as past traumatic history was not taken into account and the reason to seclude someone was not an optimal choice in my opinion. I believe seclusion is a last resort form of treatment when all other measures have failed. Seclusion is a non therapeutic measure rather than a therapeutic one (Huckshorn, 2004).
Evidence for Change
Currently seclusion is a common intervention used within acute mental health units throughout New Zealand. This form of treatment has been considered by patients and their families as aversive and traumatising (Azeem, 2011). Current evidence suggests that nursing a patient who has had previous negative perceptions of seclusion and a traumatic history can cause a range of adverse effects which include
‘physical injury such as bruising, scratching, choking, dehydration and various levels of psychological distress’ (Groves, 2008, p.2). A pilot study conducted in a mental health unit in Queensland, Australia regarding the use of seclusion surveyed individual patients and their responses on their experiences in seclusion. They described the experience as traumatic, some describing their feelings as sorrow, anger and annoyed or trapped and insecure (Roberts & Crompton, 2009). There is little evidence that suggests it is therapeutic and in extreme situations it can cause death (Groves, 2008)
A training package in the United States developed by the (National Association of State Mental Health Program Directors) NASMHPD incorporates a range of best practice methods in reducing seclusion and restraint within mental health facilities (O’Hagan, 2008). This package focuses on six strategies: Leadership toward organisational change, use of data to inform practice, Workforce development, Use of seclusion and restraint prevention tools, full inclusion of consumers and families, making debriefing rigorous (O’Hagan, 2008). This training package works on the public health prevention model that emphasises the following approaches of primary, secondary and tertiary prevention interventions. The primary prevention addresses minimising conflict, analysis of policy and procedures, and individualized risk assessments. Secondary prevention addresses effective use of early interventions to alleviate conflict or aggression when they occur which include de-escalation methods, staff behaviours in conflict situations and comfort rooms. Tertiary prevention addresses effective ways to reduce trauma of those who witness seclusion and restraints, which includes problem solving activities and event debriefings whilst having mandatory involvement of the consumer (Huckshorn, 2004).
Implications for Nursing Practice
In order for nurses to reduce seclusion episodes they need to constantly reflect upon their practice. In using reflective models such as the Gibbs reflective cycle which allows the nurse to challenge their feelings of what happened during the incident and evaluating what happened and develop an action plan with the patient so that if a similar situation arose (Dempsey, Hillege & French, 2009).
Nurses need to be educated and trained in regards to trauma informed care and to integrate this into their nursing practice. The various forms of trauma a patient experiences need to be considered and incorporated these into a client’s plans. Nurses also need to look at least restrictive care practices and methods and to use seclusion as a last resort when all other methods have failed and where evidence and safety guidelines support this. Nurses who require the support of management need to ensure these practices are enforced but nurses should be the driving force of practice and change. They must reflect on their own attitude regarding restraint and seclusion. There is also a need to highlight seclusion as a critical event whereas at present this is not considered critical.
It is important that human resources make available skilled people as a part of the debriefing process. These people must be trained and be available 24 hours a day. Nurses must ensure that if seclusion has occurred documentation is accurate and the reason for secluding someone must be warranted. Staff recruitment is also an important action in workforce development to ensure that there is a high ratio of staff to service users and requires staff to be skilled and mature and with a focus on reduction initiatives in the use of seclusion and creating change within the environment. The environment is a major factor and research suggests that a patient’s level of agitation and aggression will decrease if the environment is not overcrowded and there are adequate places for people to go (Champagne & Stromberg, 2004). Within this environment an emphasis on meaningful activities is needed such as sensory-based approaches, multi-sensory rooms and sensory modulation. According to Dunn (2001) ‘the experience of being human is imbedded in the sensory events of everyday life’ (p. 608). These rooms are on the increase in facilities in the United States and invoke a calming and distracting effect were patients can express themselves through the use of weighted blankets, art work, music or climbing structures (Champagne & Stromberg, 2004).
Nurses also need to be given the tools in the form of medication by clinicians who are confident in their practice and prescribing in order to create a therapeutic calm (Anonymous, personal communication, March 8, 2012). It can be a delicate and careful process but with sound knowledge of medication and the implications surrounding its use so that negative consequences are avoided a therapeutic calm can be achieved. Delirium, for example, is often not recognised and mistaken for mental illness and nurses must be skilled to differentiate the two. Depending on the setting and the volatility of the patient, the entry process into a facility can be the foundation for the relationships that are developed throughout the admission. If seclusion and restraint can be avoided at this initial stage the trust between the nurse and the service user is immediately strengthened. If a seclusion episode occurs that trust must be regained and this can take some time, if ever. It can also lead to the client mistrusting in the giving of vital information leading to an inaccurate assessment of mental state, avoidance and even non-compliance with medication. It would have to be argued strongly that a smooth process into and through the service would shorten the stay for the client.
Conclusion
This submission has outlined and highlighted the need to reduce seclusion time and a change in practices by nurses. The literature supported that seclusion is a non-therapeutic practice and confirms the need for staff to focus on the importance of trauma informed care. The National Association of State Mental Health Program Directors training curricula used in the United States incorporates the best practices in the use of seclusion and restraint. I wish to propose that acute mental health facilities in New Zealand adopt this training in their curriculum. The goal of reducing seclusion in acute mental health facilities means that services users can receive treatment in the least restrictive settings, thus reducing negative outcomes for patients and service providers.
Recommendations
1. Workforce development to reduce restraint and seclusion should be developed and implemented and evaluated with involvement of staff and consumers.
Rationale: This will include constant monitoring of restraint and seclusion practices and accurate assessments carried out regarding trauma assessment history. Staff education is essential which involves crisis planning and working out prevention tools with the client to identify emotional triggers and for them to develop an awareness of stressors that could lead to conflict.
2. Implementation of practical prevention methods and ward layouts
Rational: The inclusion of meaningful activities needs to be introduced in acute mental health settings that enhance recovery such as sensory modulation which help patients develop skills and coping methods in dealing with anger.
References
Azeem, M., Aujla, A., Rammerth, M., Binsfeld, G., & Jones, R. (2011). Effectiveness of six core strategies based
on trauma informed care in reducing seclusions and restraints at child and adolescent psychiatric hospital. Journal of Child and Adolescent Psychiatric Nursing. Retrieved from: http://web.ebscohost.com/ehost/pdfviewer/pdfviewer?vid=5&sid=e24ccbbd-36df-4a52-a9af-2b369eb4097e%40sessionmgr104&hid=127
Champagne, T.,& Stromberg, N. (2004). Sensory approaches in inpatient psychiatric settings innovative
alternatives to seclusion & restraint. Journal of Psychosocial Nursing & Mental Health Services, 42(9), 34-44. Retrieved from: http://www.hogg.utexas.edu/uploads/documents/sensory_approaches.pdf
Dempsey, J., French, J., Hillege, S., & Wilson, V. (2009). Thoughtful practice and the process of care. In J.
Dempsey, S. Hillege & J. French (Eds.). Fundamentals of nursing & midwifery (pp. 241-294). Philadelphia, USA: Wolters Kluwer/Lippincott Williams & Wilkins.
Dunn, W. (2001). The sensations of everyday life: Empirical, theoretical, and pragmatic considerations. American
Journal of Occupational Therapy,55(6), 608-620. Retrieved from: http://www.kumc.edu/SAH/pted/nonPT/863non/dunn003.pdf
Groves A. (2008). Policy statement on reducing and where possible eliminating restraint and seclusion in
Queensland mental health services. Queensland Health. Retrieved from: http://www.health.qld.gov.au/mentalhealth/docs/sandrpolicy_081030.pdf
Huckshorn, K. (2004). Reducing seclusion & restraint use in mental health settings core stratergies for prevention.
Retrieved from: http://web.ebscohost.com/ehost/pdfviewer/pdfviewer?vid=8&sid=e24ccbbd-36df-4a52-a9af-2b369eb4097e%40sessionmgr104&hid=127
O’Hagan M., Divis M., & Long, J. (2008). Best practice in the reduction and elimination of seclusion and restraint;
Seclusion: time for a change. Auckland:Te Pou Te Whakaaro Nui: The National Centre of Mental Health Research, Information and Workforce Development. Retrieved from: http://www.maryohagan.com/resources/FINAL-SECLUSION-REDUCTION-BEST-PRACTICE-Research-Report.pdf
Roberts D., Crompton D., Milligan, E., & Groves, A. (2009). Reflections on the use of Seclusion In an Acute
Mental Health Facility. Journal of Psychosocial Nursing, 47(10), 25-30. Retrieved from: http://web.ebscohost.com/ehost/pdfviewer/pdfviewer?vid=9&sid=e24ccbbd-36df-4a52-a9af-2b369eb4097e%40sessionmgr104&hid=127
