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Interventions for reducing the use of seclusion in psychiatric facilities

Review of the literature

Published online by Cambridge University Press:  02 January 2018

Cadeyrn J. Gaskin
Affiliation:
Centre for Psychiatric Nursing, University of Melbourne, Victoria, Australia
Stephen J. Elsom
Affiliation:
Centre for Psychiatric Nursing, University of Melbourne, Victoria, Australia
Brenda Happell
Affiliation:
Centre for Psychiatric Nursing, University of Melbourne, Victoria, Australia
Corresponding
E-mail address:
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Abstract

Background

The authors of a recent systematic review concluded that the use of non-pharmacological containment methods, excluding restraint and seclusion, was not supported by evidence. Their focus on randomised, controlled trials, however, does not reflect the research that has been, or could be, conducted.

Aims

To find empirically supported interventions that allow reduction in the use of seclusion in psychiatric facilities.

Method

We reviewed English-language, peer-reviewed literature on interventions that allow reduction in the use of seclusion.

Results

Staff typically used multiple interventions, including state-level support, state policy and regulation changes, leadership, examinations of the practice contexts, staff integration, treatment plan improvement, increased staff to patient ratios, monitoring seclusion episodes, psychiatric emergency response teams, staff education, monitoring of patients, pharmacological interventions, treating patients as active participants in seclusion reduction interventions, changing the therapeutic environment, changing the facility environment, adopting a facility focus, and improving staff safety and welfare.

Conclusions

Reducing seclusion rates is challenging and generally requires staff to implement several interventions.

Type
Review Articles
Copyright
Copyright © Royal College of Psychiatrists, 2007 

Although some researchers have argued that the use of seclusion (the solitary confinement of psychiatric patients in bare rooms) can be of therapeutic value (Reference CottonCotton, 1995), can prevent injuries and can reduce agitation (Reference FisherFisher, 1994), this practice has been described as a form of social control over people already experiencing exclusion from the community (Reference Morrall and Muir-CochraneMorrall & Muir-Cochrane, 2002) and is frequently harmful or traumatic to patients (Reference Frueh, Knapp and CusackFrueh et al, 2005). Despite general movements in ethical principles and international law towards treating psychiatric patients within the least restrictive environment possible (Reference Muir-Cochrane and HolmesMuir-Cochrane & Holmes, 2001), seclusion is still legally permitted (e.g. United Nations, 1991; Parliament of Victoria, 2006). Reducing the rates of seclusion requires the availability of feasible alternatives. Recently the authors of a systematic review concluded that current non-pharmacological practices for the containment of the behaviours of people who are disturbed or violent (excluding restraint and seclusion) were difficult to justify because their use was not supported by evidence from randomised controlled studies (Reference Muralidharan and FentonMuralidharan & Fenton, 2006). Owing to their complexity, interventions to reduce seclusion rates do not lend themselves to evaluation using randomised controlled trials. There are many studies, however, in which researchers have used other methods to investigate the changes made in psychiatric settings to reduce the use of seclusion. We reviewed this literature.

METHOD

The first author (C.J.G.) searched a number of databases (Academic Search Premier, Biomedical Reference Collection, CINAHL, Medline, Pre-CINAHL, PsycINFO) using the terms seclusion WITH mental OR psychiatric. When permissible by the individual databases, the search was limited to papers published in English and in peer-reviewed journals. In view of the considerable changes within the mental health service delivery system during the past 20 years, the search was restricted to papers published during this period. With this search strategy, 501 papers were identified; C.J.G. then read the abstracts and selected those papers in which the authors reported on interventions to reduce seclusion rates. Opinion-based papers (e.g. commentaries, letters to editors) were excluded, as were papers in which the interventions were solely based on changes to medications, and those in which seclusion rates pre- and post-intervention were not provided. From this search, 40 papers appeared to meet the inclusion and exclusion criteria. These papers were sourced and read to ensure they did meet the criteria; only 16 were agreed to do so (Reference Kalogjera, Bedi and WatsonKalogjera et al, 1989; Reference Mistral, Hall and McKeeMistral et al, 2002; Reference TaxisTaxis, 2002; Reference DonatDonat, 2003; Reference Donovan, Siegel and ZeraDonovan et al, 2003; Reference FisherFisher, 2003; Reference D'Orio, Purselle and StevensD'Orio et al, 2004; Reference LeBel, Stromberg and DuckworthLeBel et al, 2004; Reference Schreiner, Crafton and SevinSchreiner et al, 2004; Sullivan et al, Reference Sullivan, Wallis and Lloyd2004, Reference Sullivan, Bezmen and Barron2005; Reference Smith, Davis and BixlerSmith et al, 2005; Reference Bowers, Brennan and FloodBowers et al, 2006; Reference FowlerFowler, 2006; Reference Greene, Ablon and MartinGreene et al, 2006; Reference Regan, Curtin and VordererRegan et al, 2006). A common reason for the exclusion of papers at this stage was that no information on seclusion rates or on the reduction in seclusion rates was reported. The first author (C.J.G.) also scanned the reference lists of the selected papers to find additional papers that were not identified in the original search. From the selected papers we extracted data on the types of facilities (including the populations they treated), study designs, interventions and findings.

RESULTS

Interventions to reduce rates of seclusion

Most of the studies on this topic are descriptions of how staff in psychiatric settings have developed complex interventions to reduce rates of seclusion. These interventions emerged following pressures, in either the internal or external environments, to reduce seclusion rates. Because the environments within these psychiatric facilities seem to have been quite heterogeneous, so too have been the approaches to reducing seclusion rates. We have synthesised the essences of each intervention, and this information, along with the outcomes of the changes, is presented in a data supplement to the online version of this paper. To compare and contrast the interventions, we looked for common and unique features in the changes that were made in these psychiatric facilities. Although we discuss each feature separately, it is not our contention that any one of them would be sufficiently powerful in itself to reduce rates of seclusion; rather, successfully reducing seclusion rates may require the systematic use of several of these interventions – and possibly others – in response to the practice environments within psychiatric facilities. The interventions that we identified include state-level support, state policy and regulation changes, leadership, examinations of the practice contexts, staff integration, treatment plan improvement, increased staff to patient ratios, monitoring seclusion episodes, psychiatric emergency response teams, staff education, monitoring of patients, pharmacological interventions, treating patients as active participants in seclusion reduction interventions, changing the therapeutic environment, changing the facility environment, adopting a facility focus, and improving staff safety and welfare.

State-level support

Although most research was conducted at facility, unit or ward level, authors of one study reported on how the efforts made by a State Mental Health Authority (SMHA) were associated with reductions of seclusion rates in 70 institutions under its influence (Reference LeBel, Stromberg and DuckworthLeBel et al, 2004). The SMHA assisted staff at child and adolescent inpatient facilities to reduce restraint and seclusion through frequent licensing and contract monitoring visits, in which strength-based care was discussed with staff, including the use of an individualised crisis prevention plan safety tool; assisting the organisation of peer-to-peer support for staff at the facilities to change workplace cultures and implement initiatives to reduce the use of restraint and seclusion; holding a state-wide best practice conference on restraint and seclusion reduction; requiring staff at each facility to develop a strategic plan incorporating strength-based care; facilitating restraint and seclusion grand rounds, in which conference presentations were made and SMHA staff assisted facility staff to develop their strategic plans and strength-based approaches; organising a conference, during which strategic plans and performance data relating to reduction of the use of restraint and seclusion were presented; and linking with other state agencies serving children and adolescents and enhancing supports for children and adolescents with histories of trauma. The reduced seclusion rates seem to have stemmed from the SMHA providing such support to institutions, rather than the SMHA changing regulations or policies and requiring institutions to adapt. During the 22-month period of the intervention the SMHA made no change to its regulations or policies.

State policy and regulation changes

Changes in state policy and regulations can sometimes shape interventions designed to reduce the use of seclusion. In the two studies where the involvement of the state in the area of seclusion practices had changed, there was increased emphasis on having tighter controls on when and how seclusion may be used, greater oversight of seclusion episodes through the appointment of an independent advocate for consumers, the introduction of a ‘recovery approach’ to caring for patients (Reference Smith, Davis and BixlerSmith et al, 2005) and the requirement for post-seclusion debriefings with staff and patients. These changes necessitated, or formed part of, initiatives within the psychiatric facilities to reduce rates of seclusion.

Leadership

Although leadership would have had some impact on the design, implementation and monitoring of all the interventions included in this review, several authors described some of the leadership behaviours that contributed to organisational changes. External to psychiatric facilities, chief psychiatrists and community advocates for psychiatric patients can influence the policies and practices of those facilities (Reference Smith, Davis and BixlerSmith et al, 2005). Internally, the management of these facilities were involved with setting new expectations for staff to reduce the use of seclusion (Reference Sullivan, Bezmen and BarronSullivan et al, 2005), reviewing seclusion policies (Reference Kalogjera, Bedi and WatsonKalogjera et al, 1989; Reference FisherFisher, 2003), publicly advocating for seclusion reduction (Reference FisherFisher, 2003; Reference Sullivan, Bezmen and BarronSullivan et al, 2005), changing systems of practice to make seclusion reduction a priority (Reference Schreiner, Crafton and SevinSchreiner et al, 2004), providing staff with resources to enable seclusion rates to be reduced (e.g. education; Reference Schreiner, Crafton and SevinSchreiner et al, 2004), introducing an audit tool to capture information about each restraint or seclusion episode (Reference TaxisTaxis, 2002) and modelling crisis de-escalation techniques (Reference Schreiner, Crafton and SevinSchreiner et al, 2004).

Examinations of the practice contexts

Some psychiatric facilities formally established the context in which staff intended to make changes (Reference FisherFisher, 2003; Reference Schreiner, Crafton and SevinSchreiner et al, 2004). Through such an evaluation, systemic weaknesses that contributed to patients being secluded could be identified. Tools such as staff surveys (Reference FisherFisher, 2003), collecting baseline data on the use of seclusion, interviews with staff and patients, and observations of crisis events on units (Reference Schreiner, Crafton and SevinSchreiner et al, 2004) have informed the development of interventions that have contributed to decreases in seclusion rates. Once weaknesses had been highlighted, programmes were designed to improve how staff manage crises or potential crises.

Staff integration

During three of the interventions, management enhanced the focus on reducing seclusion rates through employing new staff (Reference Smith, Davis and BixlerSmith et al, 2005) or by increasing the extent of cross-disciplinary collaboration (Reference Donovan, Siegel and ZeraDonovan et al, 2003). In the first of these studies (Reference Smith, Davis and BixlerSmith et al, 2005), new staff became available for employment owing to the closures of other facilities across the state. These new staff were already challenging the use of restrictive procedures in the facilities at which they were previously employed and, therefore, were able to contribute positively to efforts to reduce the rates of seclusion. In the other study (Reference Donovan, Siegel and ZeraDonovan et al, 2003) an interdisciplinary committee was established to oversee the development of the programme to reduce the use of seclusion. This committee comprised administrators and staff who had different roles within the hospital (e.g. counsellors, nurses, physicians, psychologists and social workers). This cross-disciplinary involvement helped engender widespread support for the reform of seclusion and restraint practices.

Treatment plan improvement

In one study the authors described how initiatives were undertaken to improve the patients’ treatment plans (Reference DonatDonat, 2003). The hospital management created a behavioural consultation team to work with all areas within the hospital to provide input into treatment plans from a behavioural perspective. There was also an increase in the number of quality standards for assessing behaviour plans (from 16 to 44) and the introduction of an additional set of 54 quality standards for formal behavioural assessments.

Increased staff to patient ratios

In two studies improvements in the staff to patient ratios were part of the agenda for change (Reference DonatDonat, 2003; Reference Smith, Davis and BixlerSmith et al, 2005). During 5 years of an intervention in a public psychiatric hospital, the ratio of staff (including all facility staff) to patients increased from 2 to 1 in the first month to 3.3 to 1 in the last month (Reference DonatDonat, 2003). The authors did not report, however, how staff to patient ratios changed in the wards. At Pennsylvania State Hospital the staff to patient ratios on hospital units improved over a 10-year period, through decreasing the number of patients on a typical unit (from 36 to 32 or fewer) and increasing the number of staff per unit (from one licensed nurse and three psychiatric aides to two licensed nurses and four psychiatric aides; Reference Smith, Davis and BixlerSmith et al, 2005). The authors contend that this change in the staff to patient ratio contributed to staff being able to provide more sensitive care than they had been able to give in the past and to a safer environment for both staff and patients.

Monitoring seclusion episodes

Psychiatric facilities commonly collected data on episodes of seclusion and these data were used for clinical, educational, managerial, and publicity purposes (Reference Kalogjera, Bedi and WatsonKalogjera et al, 1989; Reference TaxisTaxis, 2002; Reference DonatDonat, 2003; Reference Donovan, Siegel and ZeraDonovan et al, 2003; Reference FisherFisher, 2003; Reference Schreiner, Crafton and SevinSchreiner et al, 2004; Reference Smith, Davis and BixlerSmith et al, 2005). Management used these data to detect both general seclusion patterns over time and to identify outlier patients (Reference Schreiner, Crafton and SevinSchreiner et al, 2004). Data on general patterns were used to facilitate interhospital comparison of the use of seclusion (Reference Smith, Davis and BixlerSmith et al, 2005), to enable performance to be compared with unit and hospital goals (Reference Donovan, Siegel and ZeraDonovan et al, 2003) and to inform the development of staff education programmes (Reference TaxisTaxis, 2002). In an adolescent in-patient unit (Reference Schreiner, Crafton and SevinSchreiner et al, 2004) and a public psychiatric hospital for adults (Reference DonatDonat, 2003), one of the foci for staff was on analysing outlier data. At the public hospital, for example, the criteria for the review of patients with multiple episodes of seclusion or restraint were modified so that they were evaluated after fewer episodes or less time in seclusion or restraint (Reference DonatDonat, 2003). The necessity for patients to exceed six episodes or 72 h of restraint or seclusion within 1 month before a review would occur was replaced with the criteria of two episodes or 8 h during 1 week.

In contrast to most of these facilities, in which staff monitored data on seclusion and restraint, members from a development committee in a child and adolescent psychiatric hospital were involved with observing the behaviours of staff and patients on hospital wards (Reference Donovan, Siegel and ZeraDonovan et al, 2003). These observations were undertaken to ascertain the frequency with which aspects of an intervention to reduce the use of seclusion and restraint were carried out. Using data gained from these observations, committee members also provided staff with additional education about aspects of the intervention that staff were not employing effectively or that concerned staff, reinforcement of the intervention's philosophy and support for staff skill development.

Post-event analyses were a further method by which seclusion episodes were monitored (Reference FisherFisher, 2003). In a state psychiatric hospital, changes in policies at state and hospital levels required that all episodes of seclusion be subject to post-event analyses, which staff involved in the seclusion or restraint, along with their supervisors, conducted. The focus of these analyses was on ascertaining how staff handled the events, on what staff could have done differently to avoid placing patients in seclusion or restraints, and on developing plans to try to prevent such episodes recurring.

Psychiatric emergency response teams

In several state hospitals (Reference Smith, Davis and BixlerSmith et al, 2005) and in a psychiatric emergency service (Reference D'Orio, Purselle and StevensD'Orio et al, 2004), staff introduced psychiatric emergency response teams for behavioural emergencies. To become a member of one of these teams, staff participated in additional training to enhance their skills to manage crisis situations in such ways that they refrain from using restrictive procedures. To defuse crisis situations, staff primarily used their skills in verbal de-escalation by way of violence prevention skills, therapeutic communication, mediation and conflict resolution.

Staff education

The education of staff was central to the efforts of many organisations to reduce seclusion (Reference Kalogjera, Bedi and WatsonKalogjera et al, 1989; Reference TaxisTaxis, 2002; Reference FisherFisher, 2003; Reference D'Orio, Purselle and StevensD'Orio et al, 2004; Reference Schreiner, Crafton and SevinSchreiner et al, 2004; Sullivan et al, Reference Sullivan, Wallis and Lloyd2004, Reference Sullivan, Bezmen and Barron2005; Reference Smith, Davis and BixlerSmith et al, 2005; Reference Bowers, Brennan and FloodBowers et al, 2006; Reference Greene, Ablon and MartinGreene et al, 2006). Education was focused on two main areas: the implementation of new models of care and alternative behavioural interventions to seclusion. New models of care came from the authors’ work on the development of high-therapy, low-conflict wards (Reference Bowers, Brennan and FloodBowers et al, 2006) or on collaborative problem-solving (Reference Greene, Ablon and MartinGreene et al, 2006). Education in alternative behavioural interventions tended to have several components. The educational programme at one state psychiatric facility, for example, involved learning to identify the behavioural indicators of impending violence, to collaborate with others and to use verbal de-escalation techniques, to intervene in a crisis, to employ diversional activities, to consider the ethics involved with restraint and seclusion, to improve documentation skills, to apply therapeutic interventions with patients who had personality disorders, and the use of medications with aggressive patients (Reference TaxisTaxis, 2002). Some of this education occurred in one-to-one discussions and during problem-solving exercises. Staff at this facility also used information gained through their evaluations of restraint or seclusion episodes to design targeted education to address areas of concern.

On one adolescent in-patient unit, part of the education involved members of the committee responsible for implementing the intervention modelling de-escalation techniques for other staff (Reference Schreiner, Crafton and SevinSchreiner et al, 2004). The members of the committee were demonstrating how these techniques could be put into practice. This modelling was supported through training at in-service meetings, reviews that debunked myths about seclusion and restraint, continued reinforcement of strategies to reduce the use of restraint and seclusion, and providing staff who were key decision-makers in crisis situations with additional training in patient-specific de-escalation strategies and in early crisis intervention.

Monitoring of patients

In one study the monitoring of patients was increased through the installation of an additional camera (Reference D'Orio, Purselle and StevensD'Orio et al, 2004). This increase in the number of cameras in operation (from four to five) was in response to members of the safety committee perceiving that patients were being inadequately monitored.

Pharmacological interventions

Although we excluded studies from this review in which the prime focus was on the evaluation of pharmacological intervention, some researchers stated that changes in pharmacological interventions (chiefly the introduction of second-generation antipsychotics) occurred as part of several changes within the psychiatric facilities (Reference FisherFisher, 2003; Reference Smith, Davis and BixlerSmith et al, 2005). In one state psychiatric hospital, two aspects of the pharmacological treatment of patients were emphasised (Reference FisherFisher, 2003): first, clozapine was used more frequently to control aggressive behaviour; second, in their care of individual patients who showed no signs of improvement with established pharmacological solutions, staff continued to try other pharmacological treatments which had only received support from a few trials or case studies.

Treating patients as active participants in seclusion reduction interventions

Some staff at psychiatric facilities enlisted the support of patients in their efforts to reduce seclusion rates (Reference Mistral, Hall and McKeeMistral et al, 2002; Reference Schreiner, Crafton and SevinSchreiner et al, 2004). The staff at one adolescent in-patient unit gained support from patients through discussing the goal of seclusion reduction with them and emphasising the positive outcomes that might eventuate from reducing the use of seclusion and restraint on the unit (Reference Schreiner, Crafton and SevinSchreiner et al, 2004). Staff also reviewed standard therapeutic de-escalation strategies with patients and introduced a reward system for patients based on the number of seclusion and restraint episodes. On a high-care psychiatric ward, staff worked with patients to reduce the use of seclusion through clarifying therapeutic aims with patients and implementing rules with regards to drinking alcohol, using illicit substances, smoking and the upkeep of the environment. Patients seemed to internalise the rules for the upkeep of the environment and began enforcing these rules with fellow patients.

In an adult psychiatric service, management placed an expectation on staff that they allow patients to choose interventions to be used in managing their aggression (Reference Sullivan, Bezmen and BarronSullivan et al, 2005). In consultation with patients, clinicians completed a patient violence assessment tool, which had sections requiring detail on the relevant histories of patients and precipitants to their violence; how patients tended to display agitation, aggression and violence; and interventions that patients might find useful at times when they potentially could lose control.

Changing the therapeutic environment

Making changes to the therapeutic environment was a common way in which staff at psychiatric facilities tried to reduce seclusion rates (Reference Kalogjera, Bedi and WatsonKalogjera et al, 1989; Reference Mistral, Hall and McKeeMistral et al, 2002; Reference TaxisTaxis, 2002; Reference Donovan, Siegel and ZeraDonovan et al, 2003; Reference FisherFisher, 2003; Sullivan et al, Reference Sullivan, Wallis and Lloyd2004, Reference Sullivan, Bezmen and Barron2005; Reference Smith, Davis and BixlerSmith et al, 2005; Reference Bowers, Brennan and FloodBowers et al, 2006; Reference FowlerFowler, 2006; Reference Greene, Ablon and MartinGreene et al, 2006; Reference Regan, Curtin and VordererRegan et al, 2006). Staff at some of these facilities adopted new therapeutic frameworks to guide practice. These frameworks included a collaborative problem-solving approach (Reference Greene, Ablon and GoringGreene et al, 2003) at a child in-patient psychiatric unit (Reference Greene, Ablon and MartinGreene et al, 2006); a working model for the development of high-therapy, low-conflict psychiatric wards (Reference Bowers, Brennan and FloodBowers et al, 2006); an ‘ABCD’ (autonomy, belonging, competence, doing for others) programme at an adolescent psychiatric hospital (Reference Donovan, Siegel and ZeraDonovan et al, 2003); the use of dialectic behaviour therapy (Reference LinehanLinehan, 1993) at a state psychiatric hospital (Reference FisherFisher, 2003); a therapeutic management protocol on three in-patient adolescent psychiatric units (Reference Kalogjera, Bedi and WatsonKalogjera et al, 1989); a philosophy of child- and family-centred care (Reference Ahmann and JohnsonAhmann & Johnson, 2000) at a child psychiatric unit (Reference Regan, Curtin and VordererRegan et al, 2006); and treatment based on therapeutic community principles (Reference JansenJansen, 1980) at a high-care psychiatric ward (Reference Mistral, Hall and McKeeMistral et al, 2002). In addition, staff at an adult psychiatric service shifted their treatment paradigm from one of staff fear and control to one of patient empowerment and collaborative relationships (Reference Sullivan, Bezmen and BarronSullivan et al, 2005).

Staff at some facilities improved the therapeutic environments through increasing the frequency with which they communicated with patients about their needs (Reference Sullivan, Wallis and LloydSullivan et al, 2004) and their care (Reference Mistral, Hall and McKeeMistral et al, 2002). On a daily basis at an in-patient acute psychiatric care unit, for example, staff assessed patients’ mental states and their risks of committing violent or harmful acts to themselves or to others (Reference Sullivan, Wallis and LloydSullivan et al, 2004). These assessments were used in the development of 24 h individual service plans for patients.

In two facilities the debriefing of patients following episodes of seclusion was part of the changes made to practice (Reference FisherFisher, 2003; Reference Sullivan, Wallis and LloydSullivan et al, 2004). In a psychiatric hospital, for example, debriefing occurred between the patients who were placed in seclusion and their treatment teams (Reference FisherFisher, 2003). These debriefings focused on the patient's and team's views of the patient's behaviours that led to the seclusion and on planning to avoid recurrences of such behaviours.

In a rare example of a single intervention being used in an attempt to reduce the use of seclusion, staff at a residential treatment centre for adolescents informed patients that they could request aromatherapy if they were feeling agitated (Reference FowlerFowler, 2006). This intervention appeared to have a positive effect on the number of seclusions, because there were more of these episodes in the 3 months prior to the use of aromatherapy (n=29) than during the 3 months following the introduction of this treatment (n=20).

Changing the facility environment

Authors of three studies reported that facility environments were changed to reduce the likelihood that patients would be placed in seclusion (Reference Mistral, Hall and McKeeMistral et al, 2002; Reference TaxisTaxis, 2002; Reference Regan, Curtin and VordererRegan et al, 2006). In two of these facilities the physical environment was improved (Reference Mistral, Hall and McKeeMistral et al, 2002; Reference TaxisTaxis, 2002), whereas in the other facility the opening hours of the unit were extended to 24 h per day for parents, in keeping with the philosophy of child- and family-centred care (Reference Regan, Curtin and VordererRegan et al, 2006).

Adopting a facility focus

In one study, the objectives of the intervention were broader than focusing on reducing the numbers of episodes of seclusion and restraint (Reference Mistral, Hall and McKeeMistral et al, 2002). Through taking a broader approach to improving how a psychiatric facility operates, the use of seclusion and restraint may be reduced. Staff on this ward timetabled a schedule to improve how the ward operated. Regular staff meetings were held to discuss practical issues on the ward and monthly meetings were held between community and ward staff. In addition, meetings were conducted with an outside facilitator to analyse the root causes of ward issues and to produce possible solutions.

Improving staff safety and welfare

Staff at some psychiatric facilities instigated changes to practice to enhance the safety and welfare of staff (Reference Mistral, Hall and McKeeMistral et al, 2002; Reference Sullivan, Wallis and LloydSullivan et al, 2004). In one in-patient acute psychiatric unit, staff had reported experiencing burnout due to continuously caring for acutely unwell patients (Reference Sullivan, Wallis and LloydSullivan et al, 2004). To reduce this burnout, staff were rostered between caring for acutely unwell patients and caring for those who were less unwell. To improve staff safety on one ward at another facility, staff were educated in risk assessment and in techniques for controlling and restraining patients, and were issued with personal alarms (Reference Mistral, Hall and McKeeMistral et al, 2002). In addition, if a patient assaulted a member of staff the incident was immediately reported to police. This action reinforced patients’ awareness of how serious it was to assault a staff member.

Intervention outcomes

The main variable of interest in this review is the number of seclusion episodes. In all but one study in which the researchers reported seclusion data (Reference Bowers, Brennan and FloodBowers et al, 2006), the number of episodes of seclusion, or rate of seclusions, decreased with the implementation of the interventions (Reference Mistral, Hall and McKeeMistral et al, 2002; Reference Schreiner, Crafton and SevinSchreiner et al, 2004; Sullivan et al, Reference Sullivan, Wallis and Lloyd2004, Reference Sullivan, Bezmen and Barron2005; Reference Smith, Davis and BixlerSmith et al, 2005; Reference FowlerFowler, 2006). For the studies in which the data on seclusion are obscured through their combination with restraint data, the authors reported decreased use of seclusions and restraints with the implementation of the interventions (Reference Kalogjera, Bedi and WatsonKalogjera et al, 1989; Reference TaxisTaxis, 2002; Reference DonatDonat, 2003; Reference Donovan, Siegel and ZeraDonovan et al, 2003; Reference FisherFisher, 2003; Reference D'Orio, Purselle and StevensD'Orio et al, 2004; Reference LeBel, Stromberg and DuckworthLeBel et al, 2004; Reference Greene, Ablon and MartinGreene et al, 2006; Reference Regan, Curtin and VordererRegan et al, 2006). Although none of this research had an experimental design, and therefore causation cannot be implied, the weight in number of these studies provides strong evidence that the use of seclusion in psychiatric facilities might be greatly reduced, if not discontinued entirely.

DISCUSSION

There is strong evidence that supports the use of interventions to reduce the use of seclusion in psychiatric facilities. The interventions we reviewed were complex and typically involved changing several aspects of the organisation. The impetus for change came either from external pressures (e.g. state law changes, chief psychiatrists, consumer groups) or from staff within the organisations. Such changes tended to be unique to each facility and in response to practices and policies that staff perceived as enabling the use of seclusion. Common features of the programmes for change at many of these facilities, however, were leadership, the monitoring of seclusion episodes, staff education and changing the therapeutic environment.

Our findings challenge the outcome of a recent systematic review in which it was concluded that the use of current non-pharmacological practices for the containment of the behaviours of people who are disturbed or violent (e.g. behavioural contracts, de-escalation, locking doors, special observations) were difficult to justify (Reference Muralidharan and FentonMuralidharan & Fenton, 2006). Although these authors’ conclusion is understandable with respect to the literature selected using the narrow criteria of the systematic review (e.g. randomised controlled trials), it does not reflect the research that has been conducted, or could possibly be performed, in psychiatric settings. Designing randomised controlled trials to evaluate the efficacy of alternative, non-pharmacological containment strategies in settings where there is much variability in facilities, in organisational culture, and in patient and staff behaviour is fraught with difficulties. Investigating alternative containment strategies, implemented to reduce seclusion rates, requires psychiatric facilities to be the unit of analysis, rather than staff and patients within one section (e.g. a ward) of a psychiatric facility. Finding a sample of psychiatric facilities that are sufficiently homogeneous to allow a randomised controlled trial that would involve significant organisation change seems overly ambitious, if not totally unfeasible. A more pragmatic approach, such as using rigorously designed case studies, may be needed for this line of research.

Owing to the complexity of the interventions used in these facilities, it is difficult to assess which interventions – if any – were efficacious in producing the reduction in the use of seclusion. Even so, knowledge in the area of reducing the use of seclusion can advance further if researchers continue to report the interventions that are effective in psychiatric facilities. The literature would also benefit greatly from reports of any failed attempts to reduce the use of seclusion. Through sharing such experiences, researchers and practitioners will be able to develop sound strategies for the reduction of the use of seclusion in psychiatric facilities.

Footnotes

Declaration of interest

None.

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Gaskin et al. supplementary material

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Gaskin et al. supplementary material

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eLetters

But seclusion necessary for needy ones?

27 February 2008
Om Prakash, Assistant Professor of Psychiatry
I read the review by Gaskin et al (2007) (1) of interventions to reduce use of seclusion with a great interest. I agree with comments by Scott and Deans (2) for the developmental needs between different patient populations. I feel this area still need more research in order to develop the need-based programs for the patients. One of the neglected area which needs more exploration is that... More
Conflict of interest: None Declared

Seclusion and Physical Restraint in Developing Countries

31 January 2008
Prof K.A.L.A. Kuruppuarachchi MD,FRCPsych(UK), Professor of Psychiatry
The review article on “Interventions for reducing the use of seclusion in psychiatric facilities: Review of the literature� by Gaskin CJ et al1 (2007) was read with interest .Its contents are very relevant to the practice of Psychiatry in developing countries like Sri Lanka as seclusion and physical restraint seems still to be widely used in this part of the world. This may be because of poor... More
Conflict of interest: None Declared

Seclusion-Reduction Interventions Need to be Individualised to Each Facility

06 December 2007
Cadeyrn J. Gaskin, Research Fellow
Reducing seclusion in psychiatric facilities often involves the co- ordination of a range of interventions to meet the needs of such organisations and their staff (Gaskin, Elsom & Happell, 2007). In their response to our review, Scott and Dean (2007) have helpfully highlighted the need to tailor suites of interventions to suit specific facilities through reminding readers of the differing determinants... More
Conflict of interest: None Declared

Developmental needs of patients must be considered when developing policies on seclusion

28 November 2007
James G Scott
We welcome the review by Gaskin et al (2007) of interventions to reduce use of seclusion. Although studies reviewed were conducted in adult and child settings, the authors did not differentiate the developmental needs between these patient populations. The determinants of emotional distress and aggression may differ between children and adults. In adult psychiatric units, aggression is... More
Conflict of interest: None Declared

Use of Seclusion - is it justified

18 October 2007
Aadil Jan Shah, Speciality Registrar
The seclusion of the patients with mental health problems remains a controversial and a delicate subject. Despite this, it is widely practised, especially in the forensic settings. There was a desperate need to review the present literature in order to gain an understanding of the current knowledge base in this controversial area and to find empirically if there are any supported interventions... More
Conflict of interest: None Declared

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