Patient concerns about seclusion: developing a leaflet

To what extent are patients involved in researching safety in acute mental healthcare?

BACKGROUND

There is a growing need to involve patients in the development of patient safety interventions. Mental health services, despite their strong history of patient involvement, have been slow to develop patient safety interventions, particularly in inpatient settings.

METHODS

A systematic search was undertaken of both academic and grey literature. Whilst no lay member of the team worked directly on the review, they were part of the project steering group which provided oversight throughout the review process. This included people with lived experience of mental health services. From a research perspective the main focus for lay members was in co-producing the digital technology, the key project output. Smits et al.'s (Res Involv Engagem 6:1-30, 2020) Involvement Matrix was used to taxonomise levels of patient involvement. Studies were included if they were set in any inpatient mental health care context regardless of design. The quality of all selected studies was appraised using Mixed Methods Appraisal Methodology (MMAT).

RESULTS

Fifty-two studies were classified, synthesised and their levels of patient involvement in the research and development of patient safety interventions were taxonomised. Almost two-thirds of studies (n = 33) researched reducing restrictive practices. Only four studies reported engaging patients in the research process as decision-makers, with the remaining studies divided almost equally between engaging patients in the research process as partners, advisors and co-thinkers. Just under half of all studies engaged patients in just one stage of the research process.

CONCLUSION

Involvement of patients in researching patient safety and developing interventions in an inpatient mental health context seems diverse in its nature. Researchers need to both more fully consider and better describe their approaches to involving patients in safety research in inpatient mental health. Doing so will likely lead to the development of higher quality safety interventions.

Experiencing Seclusion in a Forensic Psychiatric Setting: A Phenomenological Study

In hospital settings, and especially in forensic psychiatric ones, restlessness, aggression, and even violence are familiar issues to healthcare workers. Under these circumstances, the need for restrictive measures (seclusion, mechanical/chemical restraints) is sometimes needed. Although such measures should be considered as exceptional interventions, they continue to be widespread in general, psychiatric, and forensic psychiatric settings. Although there is a great deal of literature on a myriad of issues associated with the use of seclusion, very little research has focused on the lived experience of the seclusion room in forensic psychiatric settings, whether from the patient's perspective or from the perspective of nursing staff responsible for these patients. Such an examination could help ameliorate the experience of secluded forensic psychiatric patients while informing nursing staff about the impacts of seclusion. This article reports the results of a federally funded qualitative, phenomenological research study conducted in a Canadian forensic psychiatric environment. Our results show that the "structure of place" matters for both patients who experience seclusion and nursing staff who work therapeutically in these settings. "Place" is irreducible to the physical "space" in which bodies find themselves; this study of place took into consideration the ways the lived body experiences seclusion and interrelates with others. Although there can be no doubt that many patients who experience seclusion are oftentimes objectively at risk, with a heightened potential to self-harm and to harm other inpatients and nursing staff as well, as our study participants attested, the bodies secluded in this space are not "objects."

Post-seclusion debriefing: a core nursing intervention

PURPOSE

The purpose of this study was to investigate the frequency and type of post-seclusion debriefing provided by nurses at a psychiatric unit in Melbourne, Australia.

DESIGN AND METHODS

The study employed an exploratory research design. An analysis of the seclusion register was undertaken to identify the total number of seclusions over a 1-year period. A file audit tool was developed to identify seclusion debriefing interventions documented in consumer case files.

FINDINGS

Post-seclusion debriefing is not routinely performed following an episode of seclusion.

PRACTICE IMPLICATIONS

A post-seclusion debriefing framework needs to be developed to support best practice in managing seclusion.

From numbers to understanding: the impact of demographic factors on seclusion rates

The reduction and, where possible, elimination of seclusion has been recognized as a national safety priority for mental health services in Australia, with significant attention devoted to strategies to achieve this goal. The aim of this study was to compare specific demographic characteristics between consumers who have been secluded to those who have not. Patient data (n = 3244) collected by 11 mental health services across Australia for six months over a 12 month period were analysed using demographic statistics. A comparison was undertaken between those who were secluded one or more times (n = 271) and those who were not secluded (n = 2973). Differences were measured with the use of independent samples t-tests and chi-square statistics. Age, gender, diagnosis, indigenous status and Health of the National Outcomes Scores (HoNOS) were found to be significant factors in relation to seclusion. Men, younger people, and indigenous people were found to be more likely to be secluded. In addition, consumers who scored higher on the behaviour,impairment and social subscales of HoNOS were more likely to be secluded. Comparative analysis of demographic characteristics of secluded and non-secluded patients can provide vital information for consideration when planning and evaluating seclusion reduction strategies.

Restraint and seclusion: a distressing treatment option?

The effectiveness of restraint and seclusion interventions in the nursing management of disturbed and aggressive clients remains questionable. Considerable debate continues regarding the use of these treatment options in psychiatric hospitals. The existing literature suggests that the controversial nature of restraint and seclusion creates a complex dilemma for nurses, which initiates emotional distress. This study specifically explored the emotions and feelings experienced by a group of psychiatric nurses working in Ireland in relation to incidents of restraint and seclusion. A qualitative research approach was employed incorporating focus group discussions. A total of 23 nurses participated in three focus group interviews. The data were analysed using qualitative interpretive analysis. Three themes were created consisting of: (1) the last resort - restraint and seclusion; (2) emotional distress; and (3) suppressing unpleasant emotions. It is suggested that the nurses' experience of restraint and seclusion created a dynamic movement between the release and suppression of distressing emotions. The oscillatory characteristics embedded within the nurses' emotional responses were reminiscent of a model of suffering developed by Morse in 2001. Consequently, this model is incorporated throughout the discussion of the findings to provide a more in-depth description of the emotional distress experienced by the nurses in the study.

The mentally ill and social exclusion: a critical examination of the use of seclusion from the patient's perspective

Nurses in psychiatric settings have an important role to play in the application of seclusion, a measure that continues to be a frequently used intervention for the management of disturbing patient behaviours. Albeit a controversial measure, isolating patients remains a common institutional practice that has received widespread attention from a political, ethical, legal, and clinical standpoint. Although there is an abundance of scientific work on the subject, few studies have examined the experience of patients being confined. In order to improve the quality of nursing care surrounding this measure it appeared essential to obtain data on patients' perspectives, information deemed valuable in orienting nursing interventions. This qualitative study, guided by a phenomenological research design, aimed at describing and gaining a better understanding of patients with a severe and persistent psychiatric disorder who were placed in a seclusion room while hospitalized on a closed psychiatric unit. Using a semi-structured, non-directive interview format, a total of six patients participated in this study. Content analysis of participants' narratives yielded three main themes that appeared to be central to their experience of seclusion: their experience of seclusion on an emotional level, their perception of this intervention, and how they coped during their stay in the seclusion room. Major findings emerging from this nursing study centred on the following dimensions: patients' perceptions of seclusion as a punitive measure and a modality for social control and, the experience of seclusion serving as an intensification of already existing feelings of exclusion, rejection, abandonment, and isolation. In addition the findings also suggest that it is not seclusion per se that impacts on their negative perception and negative emotional experience but rather the lack of nurse-patient contact during the seclusion experience. Furthermore, whether patients coped by regressing, acting out, or taking on a more compliant stance, they appeared to be motivated by a need to connect with staff. This points to the importance of the relational aspects of nursing care when applying this restrictive measure. A need for modifying the institutional culture surrounding seclusion and transforming nursing practices are discussed as are future research endeavours.