The practice of seclusion and restraint

This work is using two original research papers and their findings to analyse the validity of the practice of SR (seclusion and restraint) in psychiatric inpatient facilities. The research papers chosen shed light on this questionable practice by analysing multiple patient characteristics and the events leading to SR. The other chosen research paper evaluates the inpatients perception of SR.

The first research was found in the ‘Journal of the American Psychiatric Nurses Association’ titled ‘Characteristics of patients with histories of multiple seclusion and restraint events during a single psychiatric hospitalisation’ and aimed by means of a quantitative study to find solutions to minimise the inpatients need for SR. The research methodology science used was descriptive (cor relational / observational) with no manipulation of the inpatients or their environment. The information in this retrospective study was collected in a methodical way by extracting inpatient characteristics and events from their medical charts.

The findings are presented in two tables of detailed and organised data, highlighting the collected and structured phenomenological experiences of 63 hospitalised inpatients. Summing up the findings it can be said that mainly male inpatients experienced multiple SR events. Further analysis showed that this class of inpatients had previous episodes of aggression either during their stay as an inpatient or before. It also showed that their inpatient period was longer compared to other inpatients.

The key findings also showed younger inpatients being the ones experiencing seclusion, whilst restrained happened more to older inpatients. Multiple SR during a single hospital stay attracts longer hospital stay, which in turn would expose the inpatients to multiple SR events. An interesting fact crystallised in a tendency of inpatients experiencing SR being cognitive impaired, which can be detected at admission of the inpatient into the hospital, which in turn can be responded to by initiating preventative strategies (Cornaggia et al.2011), therefore minimising the use of SR.

The second research paper chosen is in its design qualitative and located in the ‘International Journal of Mental Health Nursing’ with the title ‘Secluded and restrained patients’ perceptions of their treatment’. The title is one of three research questions, whilst another two questions asked: ‘What are the patients’ perceptions of cooperation with staff’ and ‘are there any associations of basic background variables such as age, sex, duration of S/R, diagnoses, choice of S/R (seclusion, restraint, or both)’.

This constitutes a phenomenological research because it collected inpatients experiences of SR and tried to focus on the implications of SR (Beck, C, T 2006). The information was collected by means of 90 analysed S/R-PPT (Secluded and Restrained Patients’ Perceptions of their Treatment) questionnaires, collected from 18 to 65 year old inpatients of three Finnish hospitals, who had sufficient knowledge of the Finnish language and had had given informed consent to participate (no severe mental illnesses or delirium were considered (International Statistical Classification of Diseases and Related Health Problems-10, World Health Organization)).

There were other criteria of participant selection in place to assure a variety of inpatients with different characteristics and SR methods that fulfilled certain criteria. The overall findings of that research indicate that SR has dramatic experiences for inpatients, which calls for an empowerment of the inpatients having to be restraint or secluded, by being able to have a say their opinions about the treatment given to them and being able to choose an alternative.

Better communication between the health care professional and the impatient, a change of culture and more individual assessment of each inpatient. Research Paper Relating research to practice The clinical question chosen is ‘Is SR (seclusion or restraint affect) a valid method to change a psychiatric inpatient’s aggressive or violent behaviour’. First we need to explain what SR is in detail and why it is applied to manage inpatients. SR are interventions to manage violent and/or aggressive behaviours that are evident but have yet to be managed.

According to the recommendation of the UN and as adopted by the law of many countries SR is to be the last resort (Australian Government, Department of Health 2005) ‘Physical restraint or involuntary seclusion of a patient shall not be employed except in accordance with the officially approved procedures of the mental health facility and only when it is the only means available to prevent immediate or imminent harm to the patient or others. It shall not be prolonged beyond the period which is strictly necessary for this purpose.

All instances of physical restraint or involuntary seclusion, the reasons for them and their nature and extent shall be recorded in the patient’s medical record. A patient who is restrained or secluded shall be kept under humane conditions and be under the care and close and regular supervision of qualified members of the staff. A personal representative, if any and if relevant, shall be given prompt notice of any physical restraint or involuntary seclusion of the patient. ‘.

In various facilities in Tasmania operated by the Department of Mental Health, SR is also part of the strategies to manage inpatients aggressive or violent behaviours and the health care professionals involved are convinced or at least state that SR is therapeutic and necessary. The observation of these strategies and their impact on the person experiencing it, but also how it affects staff members, has led to the clinical question of this paper. For example inpatients have many times vocalised and/or shown by their response to SR, that they believe this strategy is merely used to exert power over them (Mehan et al.2004).

(Taylor et al. 2012) quoted in their discussion ‘The results of the present study suggest that patients’ opinions were not included in treatment planning. This might show that paternalistic decision-making still exists in psychiatric hospitals. ‘ Both research papers selected allow for transferability since their findings in mental health facilities located in the USA and Finland are the same as the observations gained in Tasmania, ranging from age, sex, aggression criteria and inpatient perceptions of SR (Colorado State University 2011).

If the findings can be generalised could be answered with ‘yes’ and ‘maybe’, ‘yes’ because the application of the research results can be applied beyond those examined, since the criteria are always the same, people with mental illnesses, SR in mental health facilities and aggression or violence shown, ‘maybe’ because similar research studies conducted in countries with a lower threshold for valuing human life and therefore higher thresholds of fair treatment expectancy by inpatients would change the research criteria and results (Collis and Hussey 2003, p.225).

How is my EPB awareness affected by this research? Another interesting finding of the two research papers were the inpatient participants perception of not being included in the decision making about their being prescribed SR. The Finnish National Plan for Mental Health and Substance Abuse Work (2009) highlights a necessity to enhance and support the choices psychiatric patients, which also includes the coercive measures of SR (Ministry of Social Affairs and Health, Finland 2009).

Participants expressed that even so health care professionals gave their time and understanding and that they could openly say their opinions, at the same time they felt that none of that changed the health care professionals proceeded in the same way of dealing with the subjects in their care. (PSEP 2010) quotes ‘Behavioural emergencies are often a manifestation of unmet health, functional, or psychosocial needs that can often be reduced, eliminated, or managed by addressing the conditions that produced them.

‘. Restraint and seclusion are not therapeutic care procedures. The fact is that added physical or psychosocial trauma will be added by SR and affect the inpatients emotional state, even their physical well-being of the person. More and more studies show that there is no short and long term benefit using SR as a method to change an inpatients behaviour. That presents a problem for any professional health care worker involved with inpatients with mental illnesses. Why?

First, because best research evidence shows clearly that SR in any form, physical restrained, seclusion in an isolated locked room with no sanitary facilities and just a bare mattress, or chemical restrained does not only achieve anything in the behaviour of the inpatient, but also increases the stress on the inpatient by boosting existing problems. Second, the inpatients (friends, relatives) rights, feelings, values and health is negatively impacted upon which is contrary to the desired goal of improving his/her mental health condition and discharge from the mental health facility to resuming a regular life.

Third, my own clinical expertise is compromised since the umbrella for any professional health care worker is the care for the good of his/her entrusted patient. Considering my own experience of being emotionally and consciously affected by experiencing SR for inpatients in mental health facilities and the findings of research studies that at least 100 inpatients died from SR in the USA (Bush cited in Taylor et al. 2012), adding to that are SR related injuries to staff and staff demoralisation is high (Chuang et al.2007), it is obvious that there is a conflict in the existing system of mental health facilities and the treatment of inpatients.

I personally have resorted to doing my best to establish good work relationships with inpatients and help changing the system where there is a legal opportunety. References Australian Government Department of Health 2005, National safety priorities in mental health: a national plan for reducing harm – Reducing use of, and where possible eliminating, restraint and seclusion, Canberra, Australian Government Department of Health, viewed 16 January 2014, Beck, C, T 2006, ‘Phenomenology’, Encyclopedia of Nursing Research, 2006, 2nd. ed. , pp. 463, viewed 15 January 2014, ProQuest Database. Chuang, YH, Huang, HT D 2007, ‘Nurses’ feelings and thoughts about using physical restraints on hospitalized older patients’ Journal of Clinical Nursing, vol. 16, pp. 486-494 Collis, J & Hussey B 2003.

Business research: a practical guide for undergraduate and postgraduate students, New York: Palgrave Macmillan 2003 Colorado State University 2011, Transferability: Definition, Colorado, Colorado State University, viewed 16 January 2014, Cornaggia, CM, Beghi, M, Pavone, F, Barale, F 2011, Aggression in psychiatry wards: A systematic review’, Psychiatry Research, vol. 189, no. 1, August, pp. 10 – 20 Meehan, T, Bergen, H, Fjeldsoe, K, 2013, ‘Staff and patient perceptions of seclusion: has anything changed? ‘, Journal of Advanced Nursing, 2004, vol. 47, no. 1, pp. 33-38, viewed 17 January 2014, Ministry of Social Affairs and Health, Finland 2009, Plan for mental health and substance abuse work.

Proposal of the Mieli 2009 working group to develop mental health and substance abuse work until 2015, Ministry of Social Affairs and Health, viewed 18 January 2014, The Patient Safety Education Program 2005, Module 13d: Mental Health Care: Seclusion and Restraint: When All Else Fails, Canada, Patient Safety Institute, viewed 18 January 2014. Soininen, P, Valimaki, M, Noda, T, Puukka, P, Korkeila, J, Joffe, G, Putkonen, H, O 2013, ‘Secluded and restrained patients’ perceptions of their treatment’, International Journal of Mental Health Nursing, 2013, vol.

22, no. 1, pp. 44-55, viewed 12 January 2014, Taylor, K, Mammen, K, Barnett, S, Hayat, M, Dosreis, S, Gross, D, O 2012, ‘Characteristics of patients with histories of multiple seclusion and restraint events during a single psychiatric hospitalisation’, Journal of the American Psychiatric Nurses Association, 2012, vol. 18, no. 3, pp. 159-165, viewed 10 January 2014, WHO 2010, International Classification of Diseases (ICD), WHO World Health Organisation, viewed 16 January 2014,