The aim of the report paper part A is to develop a clinical audit question regarding the use of seclusion for the psychiatric patients in mental health hospitals. For this, the background and rationale will be discussed in the first section of the report. A clinical audit question will be outlined and the development of the PICO question is discussed in the following sections with the search strategy. Thereafter, part B will deal with the critical analysis of the evidences that will be obtained to develop the clinical bottom line and best recommendations for the evidence-based practice.
Background and Rationale
Although, seclusion is an emotive and controversial subject in mental health nursing, it is still practiced in the mental health hospitals widely. There are varied opinions regarding the use of this practice, however, it is still a legitimate intervention to use seclusion as compared to the efficacy of restraints to control aggressive behaviour in psychiatric patients (Knox & Holloman Jr, 2012). The focus of the paper is the use of seclusion to control aggressive behaviour through safe practice and guidelines in mental health patients as practiced in mental health institutions. The rationale for choosing this topic is that restraint in psychiatric patients has led to exacerbation of aggressive behaviour that cause harm to other patients and mental staffs. On the other hand, seclusion is preferred over restraint in managing and protecting the patients from aggressive behaviour. Seclusion causes no harm to the patients and is an effective intervention for the management of the aggressive incidents.
According to Perkins et al., (2012), the mental health nurses for inpatients in psychiatric wards practice restraint when a patient shows aggressive behaviour, acts out or does not follow the rules. However, current data suggests that restraints is not a therapeutic intervention, rather jeopardise the mental health status of the psychiatric patients. In a structured questionnaire study conducted by Vishnivetsky et al., (2013), secluding psychiatric adolescent inpatients was preferable as compared to physical restraint. About 82% of the total participants preferred secluding in the room is preferable as it was less frightening and improved their mental status as compared to restraint. On a contrary, seclusion is used that maximizes the freedom of the patients and protect them from risk by providing them a safe and secure environment (Vishnivetsky et al., 2013). However, there are various arguments reading the use of seclusion as it deprives them of liberty and practice social control as a coercive and negative experience. There is mixed literature regarding the use of seclusion as a way to control violent behaviour and have long-term benefits, however, seclusion is a safe option than restraints.
In seclusion, the psychiatric patient is locked in a room, is being isolated from other patients and medical staffs, with loose items, and is allowed to leave the room. The locked patient is continuously observed and is a direct response to their aggressive behaviour that it is because of a psychology behaviour. Thus, the clinical audit will be focusing on the seclusion practice as a better intervention in controlling aggressive behaviour than restraint in psychiatric patients. The best practice is to provide seclusion where as compared to restraint and the mental ward nurses consider it a clear benefit for the person who is being secluded. It is considered a protective measure where the mental ward nurses utilize seclusion complying with the best practice and for the benefit of the patient. Although, seclusion is used insufficiently in the current practice, however while using the nurses follow basic guidelines and standards while utilizing seclusion (Osborne & Webster, 2009). They follow safe delivery of seclusion in a secure environment that ensures patient safety prioritizing staff education and support so that there is patient-centred care and strong leadership, monitoring, commitment, oversight and transparency while using seclusion in psychiatric wards (Kuosmanen et al., 2015). The current practice also suggests that mental health staffs should abide by the principles of seclusion like use of positive behavioural support and decreased use of physical restraint. Mental health nurses also take into account the policy considerations that manage risk. According to Kontio et al., (2012), the nurses choose seclusion as the last option; however, they use it when they are not left with any other option. They do not continue it for longer and use it as a way to safeguard the patient and staffs from violent behaviour.
The care staffs keep the secluded person in sight, sound inside the secluded room, and observe them directly through CCTV or direct observation. The nurse ensures that the patient is safe inside the room and pay attention to the consciousness level of the secluded patient. They also stay alert and concerned about the particular needs of the patient and provide immediate care for the secluded patient. However, in the real world scenario, mental health nurses does not comply with the guidelines of seclusion and are attempting to include the best practice in the seclusion (Jacobsen, 2012). For this, the nurses need to be properly trained and be competent with the recovery principles after seclusion and informed care.
Clinical audit topic
Do nurses in mental health wards comply with best practice when utilising seclusion?
The audit topic is broken into a PICO format that explains that Population, Intervention as a treatment option, procedure or a diagnostic test as compared to another intervention and the outcome of the applied intervention (Methley et al., 2014). This format is helpful in defining the clinical audit topic and enables us to carry out a useful search by using keywords and Boolean operators (Robinson, Saldanha & Mckoy, 2011).
Population Psychiatric patients who show aggressive behaviour due to psychological disorders are not managed or controlled in a proper way by the nursing staffs. Incorrect management can harm the other patients and staffs in the wards and have serious consequences to the patient’s well-being.
Intervention Seclusion is an intervention that can be used for controlling aggressive behaviour in inpatients in a psychiatric ward.
Comparison The multidisciplinary team (MDT) should also utilize the same guidelines or approach while using seclusion. According to New South Wales (NSW) for Clinical Innovation, although seclusion need to be reduced in the psychiatric units, there should be proper care plan, staff training and education and well handover meetings to ensure safety of the patient and staffs (Callaghan & Ryan, 2014).
Outcome It is reasonable to suggest that although seclusion has no proper therapeutic benefits, it is used by the nurses, at the same time should assure that everyone is safe, and causes no harm.
The search strategy for the clinical audit question will be through the database search, keywords and Boolean operators, selection process through inclusion and exclusion criteria and data analysis. For carrying out an effective search for the clinical audit question, one has to conduct an extensive search and come up with strong evidence and best research that can be analysed in a comprehensive manner (Smith et al., 2011). Relevant literature will be drawn from the vast pool of existing literature so that one can reach to a conclusion and summarise findings to indentify gaps and answer the main audit question.
Specific databases will be used which are powerful tools that can be utilized to carry an effective search. The electronic databases were used like CINAHL, Ovid, Web search and Medline. All these databases have peer-reviewed and full-text journals that are authentic and reliable sources. The keywords used for the search are crucial elements, consists of short phrases, and commonly used words that extract the information required for the audit question. Boolean operators were also used where suitable keywords with respect to logical terms were streamlined in the right direction like AND and OR. After the meticulous search, relevant articles were included for the study. Rejection and exclusion criteria were used for the papers prior to search. For the present search, articles published after the year 2010 were included. Full-text and peer-reviewed articles were included and 20 articles were screened for studies. The selected articles were in English language form different countries and use of seclusion for aggression management in psychiatric patients.
Clinical Practice Guidelines from the (National Health and Medical Research Council) NHMRC suggest that under the Australian National Seclusion and Restraint Project, mental health facilities should follow the key principles while utilizing the seclusion. There should be protection of fundamental human rights, right to highest care, protection of the secluded person against degrading treatment, right to medical examination, compliance with regulations and legislation and most importantly, benefit of the secluded person (Runciman et al., 2012).
The literature regarding the clinical audit questions was reviewed through Joanna Briggs Institute through the levels of evidences and in different themes. The literature was then graded against the Joanna Briggs Levels of Evidence for Meaningfulness.
Recovery oriented support and care
Among the best practices, the level of use of seclusion varies with different psychiatric settings. The nurses protect the services users, their rights, advocacy, promotion of access and connections with the community and family members. In this, nurses work in partnership to comply with the best seclusion practice while working in partnership. In a study conducted by Kontio et al., (2012), (Level 1) illustrated the perspectives of the patients while using seclusion. The data was collected through a focused interview where 30 patients were interviewed with inductive content analysis. The results depicted that while performing seclusion, they receive insufficient attention and there is no recovery-oriented care towards them. The nurses do not focus on the best practice and follow guidelines while using seclusion. The basic need of the patients is not being met during seclusion and there was no recovery-oriented care and documentation of the patients’ wishes. In another study conducted by Bogaert et al., (2013) (Level 2), there is workload, stress leading to poor quality of care and burnout. In a psychiatric environmental setting, a survey data was taken from 357 registered nurses from December 2010–April 2011 and it was found that the workload and job demand acts as a mediating factor and they were unable to comply with the best practice while utilising seclusion. There was lack of patient oriented care for their recovery and well-being.
In another qualitative study conducted by Al-Khafaji, Loy & Kelly, (2014) (Level 1) the service users (patients) conveyed that their needs are not responded promptly and effectively and there was no patient oriented care while using seclusion and their compliance with the best guideline practices.
Effective care and support
Before utilizing seclusion, care need to be planned that, meet the mental health needs of the patient and delivered in an effective way. There should be effective provision of care and support while making effective decision for the patient before utilizing seclusion. The nurses complying with the best procedure and practices should support the health and well-being of the patient. In a study conducted by Wale, Belkin & Moon, (2011) (Level 1) demonstrated that although the policy in Australia conveys that there should be elimination of seclusion and physical restraint, the nurses should utilize seclusion for better health outcomes of the patient. According to Borckardt et al., (2011), (Level 5) randomized control trials were carried out in five inpatients unit of a psychiatric hospital in South Caroline, USA. While using seclusion, there was proper care interventions where nurses were trained to positively support the client morale and through collaborative decision-making, seclusion rates reduced significantly. In another study, Wolf, (2012), reported that there are good and bad nursing and breakdown in practices. Although, nurses have the responsibility to work for the welfare of the patients, however, many nurses make mistakes and act recklessly at work. In a randomized control trail by Georgieva, Mulder & Noorthoorn, (2013) (Level 2), demonstrated that that there was less relative risk in seclusion with less injuries and it depicts that nurses comply with the best practice while utilizing seclusion as compared to involuntary medication where the relative risk was higher. It also suggests that they perform seclusion that provide effective care and support while safeguarding the patient and staffs.
Safe care and support
The mental ward nurses have the responsibility to protect the patient from major harm or risk associated with the delivery and designing of the seclusion process. For this, nurses need to gather enough information, monitor the secluded person and learn from the information that are intended to provide safe seclusion practice. However, in many psychiatric settings, patients perceive seclusion in a negative and unwelcoming manner. In a qualitative study (Level 1) conducted by Van Der Merwe et al., (2013), the seclusion is not practiced in compliance with the best guidelines. Through an extensive literature search, the results concluded that patients perceive seclusion negatively and mental ward nurses believe that it has a therapeutic effect and they cannot operate effectively without using seclusion. There is lack of communication between the patient and staff before and after the seclusion application that affect the care process and support. Staffs did not guide the seclusion process in an effective manner and failed to adopt a safe mechanism for utilizing it. It is evident that patients’ experiences during seclusion are negative and mental ward nurses believe that the units cannot function without operating it. There is increased risk for the staffs and so seclusion is employed to ensure safety and protect the patient from aggressive behaviour.
Leadership and management
The mental health services should have effective arrangements that are intended to deliver best care while utilizing seclusion. There should also be systematic monitoring of the seclusion process and provide opportunities for safety, quality care and reliability of the mental health services. For this, there is requirement of effective leadership by the managers that are intended to promote quality care and safety of the patient and ward staffs while utilizing seclusion. In a quantitative study conducted by Smith et al., (2015), (Level 1) in Pennsylvania state hospital system from 2001 to 2010 showed that there was decrease in the seclusion and mechanical restraint rates. The managers and nurse leaders advocated effective leadership qualities and transparency with better policy changes and enhanced workforce response and development that led to the decline in seclusion and restraint rates.
In a study conducted by Azeem et al., (2011) (Level 1), stated that after the implementation of the six core strategies in trauma informed care, the seclusion and restraint rates decreased in hospitalized youths. In this qualitative study, leadership and advocacy of the nurse managers helped to reduce the restraint and seclusion among the hospitalized youth based on trauma informed care.
The mental health services should advocate caring plan, organize and manage the mental health workforce that achieve the best care, recovery oriented and provide ample support to the secluded person. The nurses should be recruited through arduous training on seclusion application with required competencies for safe delivery and protection of the patient. The mental health workforce should possess competencies that are intended to deliver the best quality of care and safeguard the patient during seclusion. While utilizing seclusion, the mental health ward staffs should deliver high quality service that provide recovery oriented and safe services for the patients and the other staffs.
According to Masters, (2015) (Level 5), the seclusion and restraint are dangerous coercive measures that have a negative psychological effect on the secluded person and is likely to create an unprepared or insensitive environment. Nurse Managers should advocate leadership that evaluate the data on seclusion and restraint that are carried out in inpatient mental health settings. Staff training is also important where the mental health workforce should be trained to use seclusion in a recovery oriented and safe manner. There should be collaborative training of the staffs so that they negotiate with the patients to resolve the disagreements. This increases the patient autonomy and strengthening their trust in staff resulting effective decision-making.
Clinical bottom line
- In qualitative and quantitative studies, recommend that the patients received seclusion in an ineffective manner where their needs were not addressed and no recovery-oriented care. Due to workload and demanding nature of job of the mental ward nurses, they fail to comply with the best practice while utilizing seclusion. As a result, there was lack of patient-oriented care. Kontio et al., (2012), (Level 1); Bogaert et al., (2013); Al-Khafaji, Loy & Kelly, (2014) (Level 1)
- There is lack of provision of care and support during seclusion utilization and nurses fail to comply with the best practices. However, there was proper care interventions that supported the patient needs and there was decline in seclusion rates. Wale, Belkin & Moon, (2011) (Level 1); Borckardt et al., (2011), (Level 5); Wolf, (2012), (Level 5); Georgieva, Mulder & Noorthoorn, (2013) (Level 2)
- Qualitative studies recommended that patients perceive negative seclusion and feel unsafe during the process. Mental ward nurses lack enough information and information regarding the process that provides safe seclusion practice. Seclusion does not comply with the best practice by mental wards nurses as they lack a safe mechanism while utilizing it. Van Der Merwe et al., (2013) (Level 1)
- During the execution of seclusion, there should be systematic monitoring of the process that ensures safety, care and reliability of the process. For this, effective leadership is required for the safe utilization of seclusion. However, in Pennsylvania state hospital system, nurse managers advocated effective leadership while utilizing seclusion. Smith et al., (2015), (Level 1); Azeem et al., (2011) (Level 1)
- For safe and best practice, expert opinion recommends that nurse managers should advocate effective training of the mental health workforce for a safe seclusion practice. This collaborative staff training is crucial so that they perform a recovery based and safe seclusion practice. This strengthens patient autonomy and their participation in effective decision-making. Masters, (2015) (Level 5)
Standards of Best Practice
- The mental health ward nurses should be intended to utilize seclusion that protect the patient, provide recovery oriented care, and support their well-being. There should be partnership approach towards recovery and provide ample care and support to the secluded patient. Kontio et al., (2012), (Level 1); Bogaert et al., (2013); Al-Khafaji, Loy & Kelly, (2014) (Level 1) (Grade B recommendation)
- The mental health ward nurses should practice seclusion in a safe manner to achieve the best health outcomes for the patient undergoing seclusion. Seclusion should be performed in a way that is intended to be meaningful and aimed at providing effective care and support. Wale, Belkin & Moon, (2011) (Level 1); Borckardt et al., (2011), (Level 5); Wolf, (2012), (Level 5); Georgieva, Mulder & Noorthoorn, (2013) (Level 2) (Grade B recommendation)
- For the best seclusion practice, safe care and support should be provided to the patient that reduce the harm, risk to injury, and safeguard the patient. This can be achieved through identification, assessment and monitoring of the risk and appropriate actions during adverse incidents. Van Der Merwe et al., (2013) (Level 1) (Grade B recommendation)
- For the safe and best seclusion practice, the nurse managers and ward leaders should perform effective leadership and management to manage the risk, govern the seclusion process and are held accountable for the safety, quality and satisfaction of the patients. They should advocate leadership for the delivery of care and find ways to meet the regulatory, strategic and financial obligations. Smith et al., (2015), (Level 1); Azeem et al., (2011) (Level 1) (Grade A recommendation)
- An effective mental health workforce is required who can plan, lead, organize, train and motivate the staffs to achieve the best seclusion practice guidelines and reliable mental health services. Masters, (2015) (Level 5) (Grade B recommendation)
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