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The Use of Seclusion in the Management of Violence within Psychiatric Settings.

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1 The Use of Seclusion in the Management of Violence within Psychiatric Settings

2 Introduction Aggressive and violent incidents in health care settings are reported to be increasing worldwide. Research suggests that despite attempts to introduce new methods of managing violence and aggression traditional methods such as seclusion, restraints and closed wards still dominate present practice. (Bloor et al, 2004)

3 Introduction Seclusion elicits different views and opinions from healthcare professionals, service users and society at large. Seclusion is very controversial practice as it is in stark contrast with the principle of treating people with mental illness in the least restrictive environment which has been adopted in most developed countries. (Husum et al, 2010; Happell & Koehn, 2010a)

4 Defining Seclusion There is no single agreed definition for the term seclusion but the general consensus is that it involves the placement of a patient alone in a locked room, from which he/she cannot freely exit (Meehan et al, 2000)

5 Defining Seclusion Different definitions over the last three decades may highlight both the positive and negative outlooks on this practice. These include Forcible denial of the company of other people Isolation of client who may be dangerous to self and others Providing a safe environment Confinement (Leopoldt, 1985; De Cangas, 1993; Finke, 2001)

6 Defining Seclusion The ISPN (2001) defined seclusion as an emergency intervention employed as a last effort involving a patient in a room especially designed for the purpose usually because the patient is combatant and dangerous to self and others

7 Indications The basic tenets underlying the use of seclusion include: Containment of violent and aggressive behaviour Prevention of injury Reduction in sensory stimuli Isolation from interpersonal contact Special protection and observation (Martinez et al, 1999; Oberleitner 2000)

8 Concerns and Justification Justification for the use of seclusion in mental health settings continues despite increasing awareness that this intervention has negative consequences for both patients and professionals (Happell & Koehn, 2011) Voices of concern regarding seclusion must be balanced with the realities of managing highly aggressive patients. (Delaney, 2001)

9 Concerns and Justification The ISPN (2001) suggested caution in a blanket endorsement of zero seclusion policies. Serious adverse consequences can be a potential by- product such as insidious escalation in the use of medications. Literature also highlights the impact of seclusion both on patients and staff as well as different views and opinions on this subject

10 Effects on Patients Feelings usually reported by patients regarding their seclusion experience include: Humiliation Fear Loss of control Vulnerability Worthlessness A sense of being punished (Happell & Koehn, 2011; Le Gris et al, 1999; Meehan et al, 2000; Oberleitner, 2000)

11 Effects on Patients Different authors highlighted the fact that seclusion may result in sensory deprivation, restlessness, mood swings, heightened awareness of sounds, difficulty in judging time. Also dysfunctional thought sometimes also involving hallucinatory or delusional experiences. Moreover seclusion is often associated with physical injuries and longer hospital stays (Happell & Koehn, 2011; Le Gris et al, 1999; Meehan et al, 2000; Oberleitner, 2000)

12 Effects on Nurses Literature also outlines the fact that seclusion ay also have negative consequences on nurses. In fact in some studies the practice of seclusion has been associated with higher rates of injuries on staff and higher incidence of burnout. Nurses may also be more at risk for legal liability, and also the fact that seclusion may be detrimental to the therapeutic nurse – patient relationship thus affecting the outcomes of care (Forster, Caveness & Phelps, 1999;Happell & Koehn,2011)

13 Abuse Seclusion may also be used abusively which usually involves: duration of time spent in the single room use of excessive force in secluding a patient overuse of medication while patient is in seclusion non-adherence to policy guidelines and regulations the use of seclusion as punishment (Alty, 1997; LeGris et al, 1999; Savage & Salib,1999)

14 Positive Outlooks It would appear that the benefits of seclusion arise from the belief that : Patients can feel safe from persecutors and external stimuli Is effective in controlling and preventing violence Rather than a final solution seclusion may be viewed as an effective starting point for focused emotional care

15 Positive Outlooks Containment in limiting the environment in which the disturbed patient operates Isolation in providing respite from the pain and difficulties which tax the individual’s coping abilities Providing a relief from stimuli that seem ordinary to others but prove unbearable for those in psychosis (Alty, 1997; Le Gris et al, 1999; Meehan et al, 2000;Happell & Koehn, 2011; Steele, 1993)

16 Considering Perceptions It is important to consider both nurses and patients perceptions in order that a full picture about the practice of seclusion may emerge. Literature outlines the fact that staff and patients tend to have different if not opposing views regarding seclusion (Allen, 2000; Delaney, 2001)

17 Considering Perceptions The split field of perception regarding seclusion consists in that patents more often attribute environmental factors such as noise levels or lack of space which may result in seclusion On the other hand nurses seem to attribute patient’s disposition such adherence to treatment or behavioural aspects such as violence which determine the use of seclusion (Allen, 2000; Delaney, 2001)

18 Violence and Seclusion Work place violence has been actively addressed by a number of disciplines in various work places including retail, public transport, factories etc. Workplace violence refers to a broad range of behaviours including harassment, bullying, verbal abuse and physical violence. Metal health nurse have had a long standing interest in the study and management of violence and aggression. The main focus being the aggressive mental health patient and great efforts were made to develop accurate assessments. (Beech & Bowyer, 2009)

19 Violence and Seclusion Amongst individuals with major psychiatric disorders dangerous behaviour is often preceded by the rapid escalation of acute symptoms all of which can trigger aggressive behaviour. These include: Paranoia Psychomotor restlessness Agitation Auditory or visual disturbances Disorganised thinking (Knight, 2011; Paterson & Leadbetter, 2004; Van der Nagel et al, 2009)

20 Violence and Seclusion Care providers may not recognise the subtle changes in behaviour or symptoms and are therefore unable to intervene early in the escalation process. Once the symptoms become more obvious, safety of the patient and others in the immediate environment becomes a pressing concern Despite reassurance and redirection from staff, some people’s symptoms continue to escalate and seclusion or restraint become necessary (Knight, 2011)

21 Violence and Seclusion Several authors argued that symptoms and behaviour that lead to seclusion occur in the context of illness and rarely manifest independently. However such symptoms and patterns of escalation have not been fully described in the literature Thus understanding the process and patterns of symptom escalation might allow early effective interventions which are vital in reducing the use of seclusion (Knight, 2011; Paterson & Leadbetter, 2004; Van der Nagel t al, 2009)

22 Violence and Seclusion There are other factors which may be related to the use of seclusion. Vruwink et al (2012) pointed out that determinants of seclusion and violence have in most cases been studied separately. The same authors however argue that in many studies such determinants overlap thus pointing towards a close association between aggressive and violent behaviour and the use of seclusion (El-badri & Mellsop, 2002; Leggett & Silvester, 2003; Mann-Poll et al 2011; Vruwink et al,2012)

23 Other Determinants of Seclusion These include: Gender (male) Age (young) Diagnosis (psychotic, bi-polar, substance intoxication) Involuntary hospitalisation Ethnic minority (Mann-Poll et al 2011; Vruwink et al,2012)

24 Other Determinants of Seclusion Other determinants of seclusion and aggressive behaviour include contextual characteristics. These include: Length of hospitalisation Number of previous hospitalisation Time of day Ward/unit characteristics Work place culture Literature however outlines that differences in the trend on the use of seclusion may vary according to differences in legislation, policy guidelines as well as staff training and alternative measures available (Le Gris et al, 1999; Steinhart et al, 2010; VanDerNagel et al, 2009; Vruwink et al, 2012; Wynn 2002)

25 Reducing the Use of Seclusion Increased concern for Human Rights, increased awareness about the adverse effect of coercive practices such as seclusion and restraint as well as promotion of safe work environments have led to changes in legislation and policies regarding seclusion In most developed and developing countries efforts by governments and interested parties are striving towards reduction and were possible elimination of seclusion in mental health settings. (Beech & Bowyer, 2009; Happell & Harrow, 2010; Happell & Koehn, 2010; Huf et al, 2011; Hyde et al, 2009)

26 Reducing the Use of Seclusion There are several alternative measures to the use of seclusion. These may be other coercive (controversial) measures such as physical or chemical restraints On the other hand there are also other non- coercive measures such as de-escalation techniques. This outlines the importance of staff training and education in the management of violence and the care of the acute mentally ill patient if reduction in the use of seclusion is to occur (Bloor et al, 2004; Hyde et al, 2009; Mann-Poll et al, 2011)

27 Reducing the Use of Seclusion The use of training systems in the management of violence and aggression as well as providing decision frameworks in deciding what options to use during intervention and resolution of an incident is important. Literature outlines the fact that training and education has been associated with positive changes in staff’s attitudes, knowledge and confidence thus leading in the decrease of the use of coercive measures such as seclusion (Beech & Bowyer, 2009; Happell & Koehn, 2010; Huf et al, 2011; Hyde et al, 2009)

28 Training and Education Staff education may include training regarding assessment and intervention in the cycle of aggression, symptom recognition, verbal intervention skills and the critical thinking strategies designed to select the least restrictive intervention best suited to the presenting needs of the patient. Management which over controls, stifles initiative and promotes custodial regimens may hinder staff education thus affecting delivery of care. A leadership style which emphasises shared decision making, recognition of the power already in staff role as well as ownership and accountability for work is related to higher job satisfaction and better care for acutely distressed individuals. (Beech & Bowyer, 2009; Happell & Koehn, 2010; Huf et al, 2011; Hyde et al, 2009)

29 Training and Education Any physical contact skills should only be used as a last resort. Moreover given that there will be inevitable situations were it will be necessary to physically restrain and seclude distressed individuals, ethical behaviour by nurses can only be ensured if they are trained in safe and effective ways of restraining disturbed persons and analyse techniques which they know to be both safe and effective Patients have the right to be cared for in developmentally appropriate ways by competent staff members. This mandates for on going training in both physical and verbal skills in the care of highly disturbed patients. (Bloor et al, 2004; Delaney, 2001; Hyde et al, 2009; Hopton, 1995; Mann-Poll et al, 2011)

30 The Local Perspective To date there is little known about mental health nurses’ views and perceptions on the use of seclusion in Malta. However this issue was addressed in two small scale unpublished dissertations. Using a qualitative approach Gouder (2006) explored the nurses’ perception on the use of seclusion

31 The Local Perspective Findings in this study generally agreed with similar studies carried out elsewhere. Participants generally agreed that seclusion should be used as a last resort measure. Findings also outlined violence as a determining factor in the use of seclusion. Alternative strategies such as one to one nursing supervision were also highlighted. Issues including shortage of staff and the ward environment were also pointed out. Findings indicated that secluding a patient might have an emotional impact on the nurses involved. This implied that to improve psychiatric nursing care and the patients’ quality of life one has to reduce the use of seclusion by means of improvement in practice, further research and nurses’ training and education. (Gouder, 2006 )

32 The Local Perspective In another Maltese study by Pace (2011) using a descriptive design, the author investigated whether local policies and practices at a psychiatric hospital in Malta reflected research based guidelines for the use of seclusion and possibly employ the results in redesigning such policies with the aim to reduce seclusion use locally.

33 The Local Perspective Results indicated that as in other international studies the presence of law and policies on their own is not sufficient in regulating the use of seclusion. Findings also suggested that apart from patient characteristics; gender and cultural influences may also impinge on the use of seclusion. (Pace, 2011)

34 Conclusion The continued use of coercive measures of which the therapeutic value is questioned such as seclusion and restraints has a major implication for mental health nursing. Being the mental health professionals who are most likely to face and manage violence thus initiating and implementing strategies. Therefore mental health nurses should be leading the way forward for more humane and ethical care for acutely distressed individuals

35 References Allen, J. J. (2000). Seclusion and restraint of children: a literature review. Journal of Child and Adolescent Psychiatric Nursing, 13(4), 159-167. Alty, A. (1997). Nurses’ learning experience and expressed opinions regarding seclusion practice within one NHS trust. Journal of Advanced Nursing, 25(4), 786-793. Beech, B., & Bowyer, D. (2004). Management of aggression and violence in mental health settings. Mental Health Practice, 7(7), 31-37. Bloor, R., McHugh, A., Pearson, D., & Wain, I. (2004). A training course for psychiatric nurses in Russia. Nursing standard, 18(39), 39-41. De Cangas, J. P. (1993). Nursing staff and unit characteristics: Do they affect the use of seclusion?. Perspectives in Psychiatric Care, 29(3), 15-22. Delaney, K. R. (2007). Developing a Restraint‐Reduction Program for Child/Adolescent Inpatient Treatment. Journal of Child and Adolescent Psychiatric Nursing, 14(3), 128-140.

36 References El-Badri, S. M., & Mellsop, G. (2002). A study of the use of seclusion in an acute psychiatric service. Australian and New Zealand Journal of Psychiatry, 36(3), 399-403. Finke, L. M. (2001). The Use of Seclusion Is Not Evidence‐Based Practice. Journal of Child and Adolescent Psychiatric Nursing, 14(4), 186-190. Gouder, D. (2006) The perceptions of nurses working in mental health about the practice of seclusion in Malta. Unpublished manuscript, University of Malta. Forster, P. L., Cavness, C., & Phelps, M. A. (1999). Staff training decreases use of seclusion and restraint in an acute psychiatric hospital. Archives of Psychiatric Nursing, 13(5), 269- 271. Happell, B., & Harrow, A. (2010). Nurses' attitudes to the use of seclusion: a review of the literature. International Journal of Mental Health Nursing, 19(3), 162-168. Happell, B., & Koehn, S. (2010a). Attitudes to the use of seclusion: has contemporary mental health policy made a difference?. Journal of clinical nursing, 19(21‐22), 3208-3217.

37 References Happell, B., & Koehn, S. (2010b). From numbers to understanding: the impact of demographic factors on seclusion rates. International Journal of Mental Health Nursing, 19(3), 169-176. Happell, B., & Koehn, S. (2011). Impacts of seclusion and the seclusion room: exploring the perceptions of mental health nurses in Australia. Archives of psychiatric nursing, 25(2), 109-119. Huf, G., Coutinho, E. S., Ferreira, M. A., Ferreira, S., Mello, F., & Adams, C. E. (2011). TREC-SAVE: a randomised trial comparing mechanical restraints with use of seclusion for aggressive or violent seriously mentally ill people: study protocol for a randomised controlled trial. Trials, 12(1), 180. Hopton, J. (1995). Control and restraint in contemporary psychiatric nursing: some ethical considerations. Journal of Advanced Nursing, 22(1), 110-115. Husum, T. L., Bjørngaard, J. H., Finset, A., & Ruud, T. (2010). A cross-sectional prospective study of seclusion, restraint and involuntary medication in acute psychiatric wards: patient, staff and ward characteristics. BMC health services research, 10(1), 89. Hyde, S., Fulbrook, P., Fenton, K., & Kilshaw, M. (2009). A clinical improvement project to develop and implement a decision‐making framework for the use of seclusion. International Journal of Mental Health Nursing, 18(6), 398-408.

38 References International Society of Psychiatric- Mental Health Nurses. (2001). ISPN position statement on the use of restraint and seclusion. Retrieved 10th October, 2012, from http://www.highbeam.com Knight, M. (2011). Precursors to seclusion or restraint: An analysis. Mental Health Practice, 14(10), 14. Leggett, J., & Silvester, J. (2003). Care staff attributions for violent incidents involving male and female patients: a field study. British Journal of Clinical Psychology, 42(4), 393-406. LeGris, J., Walters, M., & Browne, G. (1999). The impact of seclusion on the treatment outcomes of psychotic in-patients. Journal of Advanced Nursing, 30, 448-459. Leopoldt, H. (1985). A secure and secluded spot. Nursing times, 81(6), 26. Mann-Poll, P. S., Smit, A., de Vries, W. J., Boumans, C. E., & Hutschemaekers, G. J. (2011). Factors contributing to mental health professionals' decision to use seclusion. Psychiatric Services, 62(5), 498- 503.

39 References Martinez, R. J., Grimm, M., & Adamson, M. (1999). From the other side of the door: patient views of seclusion. Journal of psychosocial nursing and mental health services, 37(3), 13. Meehan, T., Vermeer, C., & Windsor, C. (2008). Patients’ perceptions of seclusion: a qualitative investigation. Journal of Advanced Nursing, 31(2), 370-377. Oberleitner, L. L. (2000). Aversiveness of traditional psychiatric patient restriction. Archives of psychiatric nursing, 14(2), 93-97. Pace, J. (2011) A survey of the use of seclusion in a psychiatric hospital: a quantitative study. Unpublished manuscript, University of Malta. Paterson, B., & Leadbetter, D. (2004). Learning the right lessons. Mental Health Practice, 7(7), 12- 15. Savage, L., & Salib, E. (1999). Seclusion in psychiatry. Nursing standard (Royal College of Nursing (Great Britain): 1987), 13(50), 34.

40 References Steinert, T., Lepping, P., Bernhardsgrütter, R., Conca, A., Hatling, T., Janssen, W.,... & Whittington, R. (2010). Incidence of seclusion and restraint in psychiatric hospitals: a literature review and survey of international trends. Social psychiatry and psychiatric epidemiology, 45(9), 889-897. VanDerNagel, J. E. L., Tuts, K. P., Hoekstra, T., & Noorthoorn, E. O. (2009). Seclusion: The perspective of nurses. International Journal of Law and Psychiatry, 32(6), 408-412. Vruwink, F. J., Noorthoorn, E. O., Nijman, H. L., VanDerNagel, J. E., Hox, J. J., & Mulder, C. L. (2012). Determinants of Seclusion After Aggression in Psychiatric Inpatients. Archives of Psychiatric Nursing. Wynn, R. (2002). Medicate, restrain or seclude? Strategies for dealing with violent and threatening behaviour in a Norwegian university psychiatric hospital. Scandinavian Journal of Caring Sciences, 16(3), 287-291.

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