Does seclusion have a role to play in modern mental health nursing?

Worker and perceived team climate factors influence the use of restraint and seclusion in youth residential treatment centers: Results from a mixed-method longitudinal study

BACKGROUND

Restraint and seclusion (R&S) are controversial methods of intervention aimed at protecting children from immediate harm in residential treatment centers (RTC). Previous studies have mainly focused on situational factors and youth characteristics to predict its use.

OBJECTIVES

This study sought to evaluate the role other potential predictors could play in the decision to use R&S, namely characteristics of residential workers and their perceived team climate.

METHODS

For two months, a total of 132 residential workers from different RTC in the greater Montreal area completed weekly diaries of standardized questionnaires. Using an explanatory sequential design (i.e., mixed methods), this study aimed at exploring the role of residential workers' characteristics (e.g., exposure to client aggression, stress and fatigue) and aspects of their perceived team climate (e.g., order and organization, communication and openness) as predictors of R&S use. Survey results were later also presented to four focus groups for discussion.

RESULTS

Results indicated that exposure to verbal violence from youths was associated with the increased use of R&S. Meanwhile, perceived communication and openness were associated with lower rates of R&S use. Participants shared that repeated exposure to verbal violence diminished their level of tolerance while teamwork provided them with the emotional space needed to focus on the needs of youths and find alternatives to R&S.

CONCLUSION

This study sheds light on the complex role of human emotions in the decision to use of R&S. Specifically, intense momentary emotions during crisis interventions had a greater influence on the use R&S than chronic states, such as fatigue.

Patients' lived seclusion experience in acute psychiatric hospital in the United States: a qualitative study

The findings revealed that the patients perceived seclusion as an intervention that is punitive and a means used by the staff to exert control. Patients perceived that staff incitements and lack of communication skills led to their being secluded. The findings provided recommendations and strategies for seclusion reduction that were based on the patients' first-hand seclusion experiences. This phenomenological study used Husserlian's philosophy to explore and describe the lived experiences of psychiatric patients who were secluded at a free-standing acute care hospital located in South-western United States (US). The study is crucial because very few studies have been conducted in this area in the US. The study examined a purposive sample of 20 patients, 3 days post-seclusion. Data were generated through face-to-face, semi-structured interviews incorporating open-ended questions and probes to facilitate discussion until saturation was reached. Interviews were transcribed verbatim and data analysed using Colaizzi's seven steps method. Results were described according to the themes and subthemes identified. Findings uncovered four themes: (1) alone in the world; (2) staff exert power and control; (3) resentment towards staff; and (4) time for meditation. The findings from this study illuminated the views surrounding patients' seclusion experience. It provided first-hand information on the patients' seclusion experience that might be helpful to the mental health professionals in the seclusion reduction process.

The nursing decision making process in seclusion episodes in a psychiatric facility

This study explores and describes nursing interventions performed during episodes of seclusion with or without restraint in a psychiatric facility and examines the relationship between the interventions' local protocols and best-practice guidelines. Twenty-four nurses working in a psychiatric facility were interviewed about the nursing interventions they performed before, during, and after an episode of seclusion with or without using restraint. Analysis of the data reveals that the interventions meet quality standards. However, nursing practice would be further refined by conducting post-event reviews, especially by discussing how a client's aggressive behaviour is to be understood.

Nurses' and physicians' educational needs in seclusion and restraint practices

PURPOSE

This study aimed to explore nurses' (N= 22) and physicians' (N= 5) educational needs in the context of their perceived seclusion and restraint-related mode of action and need for support.

METHOD

The data were collected by focus group (N= 4) interviews and analyzed with inductive content analysis.

RESULTS

Participants recognized a need for on-ward and problem-based education and infrastructural and managerial support. The declared high ethical principles were not in accordance with the participants' reliance on manpower and the high seclusion and restraint rates.

PRACTICE IMPLICATIONS

Future educational programs should bring together written clinical guidelines, education on ethical and legal issues, and the staff's support aspect.

Factors influencing decisions on seclusion and restraint

Seclusion with or without restraint is a measure for managing aggressive or agitated clients and promoting site security, particularly in an emergency psychiatric setting. The decision to control a potentially dangerous person's behaviour by removal or seclusion seems ethically justifiable in such a setting. However, although the decisions on these restrictive measures are based on rational needs, they are also influenced by the healthcare team's perceptions of the client and by the characteristics of the team and the environment. The purpose of this paper is to set out and categorize the factors in play in aggression- and agitation-management situations as perceived by the healthcare teams, particularly the nurses. The first part of the paper deals briefly with the settings in which control measures are applied in a province in eastern Canada and the effect of such measures on patients and healthcare teams. The second part identifies the factors involved in the management of agitation and aggression behaviour. The final part discusses the current spin-offs from this knowledge as well as promising paths for further research on the factors involved. The ultimate objective is to reduce recourse to coercive measures and enhance professional practices.

Feasibility of randomized controlled trials on seclusion and mechanical restraint

Background In psychiatry seclusion and mechanical restraint are most commonly used in the management of violence and self-directed aggression. Both interventions are considered as efficacious and indispensable. Yet, these measures can have deleterious effects on patients. The least restrictive alternative is recommended. Evidence about what kind of intervention is least restrictive is only scarcely available. Up to now, no randomized controlled trial (RCT) on this subject has been conducted.

Purpose To describe ethical, methodological and legal problems of RCTs on coercive interventions and to suggest possible solutions.

Methods Literature research on possible study designs, ethical considerations and legal regulations was conducted in PubMed.

Results Corresponding to the procedures in emergency medicine informed consent can be obtained after the intervention when the patients are capable again. Informed consent refers only to participation in an interview and utilization of data. Randomization can be ethically approved, if exclusion criteria for randomization are defined. A comprehensive cohort study seems to be the most practicable study design. As primary outcome variable an assessment of subjective experiences of the patients' restrictions to human rights. Clinical Trials 2008; 5: 356—363. http://ctjsagepub.com

Professionals' attitudes toward reducing restraint: the case of seclusion in the Netherlands

INTRODUCTION

Despite public opinion and policy interventions, restraint remains a common practice. This is also the case in the Netherlands, where projects aimed to reduce seclusion, have not led to a decreased use of restraint. Is this lack of effectiveness related to attitudes of the professionals? The aim of this study was to explore the attitudes of professionals working in mental health care toward restraint.

METHOD

A questionnaire with eight scales was constructed for measuring attitudes of professionals. Scores of 540 professionals were studied, using analysis of variance and cluster analysis and related to several personnel and organizational characteristics.

RESULTS

The more professionals were personally involved in seclusion, the more they believed in it. Three types of professionals were identified: Transformers, Doubters and Maintainers. More than half of the psychiatrists (56%) belonged to the type of maintainers. Nurses were more divided.

CONCLUSION

Professionals working in clinical settings are not really opposed to restraint. This could explain the limited effects of innovation projects.

An examination of the last 10 years of mental health nursing

This article offers an examination of the mental health nursing articles published in the British Journal of Nursing during the last 10 years, and a commentary on how these reflect developments within this specialism. It identifies a number of clinical and professional issues, which have emerged over the last decade, including: community care; concerns over the quality of acute inpatient services; clinical supervision; and the integration of schools of nursing into higher education. Finally, the article identifies some clinical areas which it suggests warrant attention in the next decade such as child and adolescent mental health and mental health care for older people.