Position Statement: The Use of Seclusion in Psychiatric Settings

(	Anas Husam Khalifeh Correspondence: Anas Husam Khalifeh, MSN, RN Master Degree in psychiatric and mental health nursing Hashemite University Jordan Email: anaskhalifeh@yahoo.com

Abstract This position statement is aimed to reduce psychiatric inpatient seclusion by improving nurses role and providing opponents and proponents legal overviews; this issue is one of the most controversial practices in psychiatric care according to legal perspective; the differences in legal supply make differences of using seclusion; patients who experience psychosis need management and control challenging behavior to contain this behavior; seclusion is used in psychiatric setting significantly and is the most important debatable issue in the psychiatric field; nurses must balance the responsibility for protecting patient rights with the duty to protect patients from harming themselves especially in situations that have escalated to the point of danger; there are suggestions for a course of action and possible solutions to movement action in reduction of seclusion included for clinical practice, staff training and education, research, and staffing and policy change parts, which increase the quality of care and to choose the best decision. Key words: Position statement, Seclusion, Psychiatric setting, Legal, Policy.

Introduction
There are many issues in debate that need more studies and analysis to meet an appropriate position on these issues. A position statement is defined as standing on a topic or a debate to let people know where they are standing in this topic; also it can be used in policy, literature, ethics, and legislation (Education Portal, 2013). According to American Nurses Association, a position statement is defined as showing your opinion of action by explanation, justification or recommendation for this action (American Nurses Association [ANA], 2014).

In the psychiatric field there are many issues that need a position statement to increase the quality of care and to choose the best decision. Mental disorders account for a significant and growing proportion of the global burden of disease, yet remain a low priority in many low and middle income countries (Chan, 2010).

The diagnostically acute psychiatric patients are the most disturbed (Happell & Harrow, 2010). Patients who experience psychosis need management and control challenging behavior to contain this behavior (Whittington, Bowers, Nolan, Simpson, & Lindsay, 2009). These behaviors of psychiatric inpatients cause severe complications during treatment (Ketelsen, Zechert, Driessen, & Schulz, 2007). There are several interventions used to control agitation or disorientation behaviors (Keski-Valkama et al., 2010); such behaviors include violent behavior or threatening violence which commonly lead to the use of many interventions (Whittington et al., 2009). The aggressive behavior is defined as the behavior in which the patient harms self or other, physically or emotionally (Siever, 2008).

The aggressive and violent behaviors could be controlled by several interventions including: seclusion, physical restraints, time out and chemical restraints (Migon et al., 2008). Seclusion has more than one definition but all definitions mean the same, seclusion means isolating psychiatric inpatients in locked rooms which are specially prepared and safely separated from other patients. This method is used internationally to manage and control disturbed behavior by psychiatric inpatients (Bowers et al., 2010; Bowers et al., 2011). Seclusion involves placing the service user in a locked room; it also involves isolation and reduction of sensory stimuli (Mayers, Keet, Winkler, & Flisher, 2010).

There are several reasons causing the isolation of psychiatric inpatients in seclusion, such as: violence to property, verbal aggression or threats, threats of self harm or actual self harm, physical aggression to others, and severe psychiatric symptoms or disturbed behavior (Bowers et al., 2011). However, the prevalence of seclusion is lacking (Stewart, Van der Merwe, Bowers, Simpson & Jones, 2010); although many studies have investigated the intervention, the methods of calculation and reported prevalence rates vary widely (Janssen et al., 2008).
Therefore, many studies showed this topic in dilemmas of using seclusion with aggressive psychiatric patients. Many studies expound that authors advocated against its use in the psychiatric field, conversely others consider as necessary the use of seclusion to manage these aggressive behaviors.

The purpose of the current position statement paper is to reduce the use of patient seclusion by improving registered nurses' role in this issue.

Background
While reading what the articles have concluded and discussed, most of the discussion was about reducing seclusion among psychiatric inpatients which is related to more than one reason. There is some debate about this topic; however, the author will be touching on views regarding this topic and will look at more than one point of view.

During searching about the benefits and drawbacks of seclusion, the author was faced with a lack of evidence based knowledge, although, there are a bulk of studies that recommend using this method of intervention to prevent self or other harming (Keski-Valkama et al., 2010). But still the use of seclusion in the inpatients psychiatric setting is debatable. However, the American Psychiatric Association determined the indications of the usage of seclusion by the following: the prevention of harm to self and others, the prevention of damage to the physical environment, the prevention of serious disruption of the treatment program, a contingency in the behavior therapy of dangerous behaviors, a decrease of stimulation, and the patient's request (American Psychiatric Association [APA], 2006).

The differences in legal supply make differences of using seclusion. This was shown by the Netherlands, who had a high rate of violence in Europe related to restrictive use of involuntary medication. In Canada, their 2-year retrospective trial showed that 23.2 % were secluded with or without restraints and 17.5 % were secluded with restraints (Dumais, Larue, Drapeau, Ménard, & Giguère Allard, 2011).

The purpose of the background is to highlight opponents and proponents of using seclusion from policies and governmental perspectives and the structure of the background will first explain the opponents then proponents of using seclusion.

Opponents of Using Seclusion
In various countries, there are policies and guidelines that are established by governmental authorities and social consensus supported an adoption to reduce and even eliminate seclusion (Larue, Piat, Racine, Ménard, & Goulet, 2010). Seclusion is used in the management of risky and disturbed behavior on psychiatric wards, and can't be eliminated completely from psychiatric units and the topics under discussion (Bowers et al., 2011). Also, Bowers et al. (2010) reported that some hospitals in UK work on without using seclusion in their psychiatric setting whether in acute psychiatric ward or psychiatric intensive care units, and in these hospitals the aggressive behavior is not that high. Although, several hospitals in several countries have a high level system of action to reduce seclusion use, however; hospitals in the UK use to have a low usage of seclusion (Bowers et al., 2011).

Bowers et al. (2011) and Whittington et al. (2009) explained that with the physically aggressive there are more tendencies to use seclusion and other methods for other types of aggressive behavior. Also, may be there will be repetition in the aggressive behavior while the patient is still in the hospital when using seclusion more than using other methods. Thus in this case seclusion is not acceptable for patient and staff nurse. In addition, the use of seclusion that is linked with the availability of a seclusion room increases the rate of seclusion use, and that does not show any connection with reducing aggressive behavior, self harm and medication related conflict (Bowers et al., 2009; Baker, Bowers, & Owiti, 2009). Thus, the removing of a seclusion room will not affect the staff and patient safety, but will cause the reduction of using it (Bowers et al., 2010).

Most likely, using seclusion will prevent injury for both patients and staff. However, the brawl with patients may produce injuries to both, in addition, when using effective ways these injuries can be avoided by managing without using seclusion (Knox & Holloman, 2012). There are several management ways other than seclusion used to contain patients. Vruwink et al. (2012) stated that there are nursing practices which should be focused on how to prevent seclusion such as de-escalation. In acute psychiatry cases, there is an effective management way other than seclusion, which is time out (Bowers et al., 2011). However, early prediction of aggressive behaviors and initiation of medication for newly admitted patients are related with the reduction of seclusion usage (Goldbloom, Mojtabai, & Serby, 2010).

Moreover, Lloyd, King, and Machingura (2014) conducted a study, using sensory modulation; which is the neurological regulation of response to sensory stimuli. The aims of study were to determine, firstly if sensory modulation can reduce the level of distress experienced for patients in an acute psychiatric unit, and secondly if sensory modulation can reduce the usage of seclusion. The result for the first aim was effective therapeutic response to patient distress, for the second aim frequency of seclusion episodes was reduced after introducing the sensory modulation but there was no evidence that sensory modulation reduced the duration of seclusion.

The practices of secluding in the psychiatric setting are high risk practices, so there is a program built upon the public health prevention model called crisis prevention management which focuses on changing the culture of patient care, by changing the philosophy of care to reduce the usage of seclusion (Lewis, Taylor, & Parks, 2009).

Furthermore, seclusion may affect on quality of life of patients. Pitkänen, Hätönen, Kollanen, Kuosmanen, and Välimäki (2010) concluded that quality of life of patients is affected by use of seclusion and patients considered seclusion as punishment, not treatment and unnecessary to be used, and patients like the medication which shows a high rate of quality of life. In addition, seclusion shows factors that impact and affect on patient's quality of life such as holistic care, rehabilitation, therapeutic relationship, and long hospitalization (Soininen et al., 2013).

Nursing emotions and feelings toward seclusion
Secluding patients are dilemmas and conflicts for nurse. There are policies that lead to reduction of seclusion, for example, the Australian government policy identified a safety priority by reduction or possible elimination of seclusion and facilitates to explore the indications and intervention to reduce seclusion (Happell & Harrow, 2010). The staff nurse who experiences large numbers of secluded patients felt negative emotions; conversely staff nurses who experienced lower levels felt less negative emotions (Gelkopf et al., 2009). Moran et al. (2009) reported that nurses experienced distressing emotions in response to seclusion as well as the nurse who tries to suppress emotions going in interventions.

Moreover, Happell and Koehn (2011) concluded after examining the relationship between burnout, job satisfaction and therapeutic optimism justification of the use of seclusion according to use self-report questionnaire. The Elsom Therapeutic Optimism Scale (ETOS) which is designed to measure clinicians' level of optimism in conjunction with treatment outcome. The researchers report that the nurses who have less support for the use of seclusion are those who have a higher score on the ETOS and lower on emotional exhaustion, that may affect their negative attitudes on seclusion.

Seclusion affects emotionally stress on the therapeutic nurse patient relationship, increasing patient aggression (Ashcraft & Anthony, 2008; Moran et al., 2009). Furthermore, Kontio et al. (2010) reported that previous studies of seclusion and relationship with emotional describe the physical and emotional damage that can be present to nurses and patients.

Gelkopf et al. (2009) found that there are variables that affect on the nurse goals of seclusion such as level of qualification, gender of the nurse, the department where he or she works, the set of instruments available to the staff to cope with violence, and environmental conditions.
Many patients placed in seclusion are left with negative views of the event. During work in psychiatric settings nurses may be exposed to aggressive behaviors from patients that affect on the physical and psychological health of nurses and may produce increased absence of nurses related to illness (De Benedictis, 2011). Seclusion may affect on psychiatric patients by developing negative perceptions of the center of mental health, hence will affect on treatment (Steinert, Bergbauer, Schmid, & Gebhardt, 2007).

Ethical issues facing seclusion
There are studies showing the ethical and moral dilemma of using seclusion with psychiatric patients. Kontio et al. (2011) reported the requirements required to change the culture of seclusion to nurses about the attitudes of negligenceof basic needs like access to the toilet and washing. Furthermore, ethical issues divided autonomy of free self control, human dignity by affecting violation to dignity, and experiences of patients showing negative perception, although, there are differences in perception of benefits of seclusion between patients and staff (Prinsen & van Delden, 2009).

Proponents of Using Seclusion
As mentioned previously, the usage of seclusion in the inpatient psychiatric setting remains controversial. Prinsen and van Delden (2009) stated that seclusion is not a form of treatment but considered as an intervention to facilitate the treatment. Maintaining safety and avoiding injury to both patient and staff is associated with favorable use of seclusion (Stewart et al., 2010). Keski-Valkama et al. (2010) stated that there is no problem to use seclusion but a humanitarian manner should be taken into consideration when using it.

Happell and Koehn (2011) conducted a survey of nurses' attitudes to seclusion on 123 nurses from eight mental health services from Queensland, Australia. Despite the negative impact of seclusion in patients there was continued support of the use of seclusion by staff to the management of some behaviors such as violence and aggression. Although, in most circumstances where seclusion is considered justified appears to be the patient is hitting a staff member (80%) and the patient hitting another patient (70%).

Furthermore, the responses of patients to seclusion were different, they showed anger. Nurses' attitudes, affected by use of seclusion, reported that most responses were relief , that the problems have been resolved and there is satisfaction with helping the patient. Moreover; the seclusion rooms have a good impact on patients and help them to calm down, make them behave better, disempower, control their behavior, and allow them to express angry feelings in a way that's not destructive to the rest of the ward (Happell & Harrow, 2010).

Prinsen and van Delden (2009) stated that seclusion can be used as an intervention for reaching autonomy instead of violating autonomy which is the last reason for eliminating seclusion and there are not sufficient reasons in autonomy and the violation of human dignity to eliminate seclusion. Moreover, Knox and Holloman (2012) reported the seclusion is necessary in case of ineffective verbal and behavioral techniques to prevent harming of the patient and staff. On other hand, the quality of the patients' life may be enhanced by isolating them from the ward (Pitkänen et al., 2010).

The current author found a policy from the Jordanian nursing council for National Center for Mental Health about the use of seclusion. It includes: the purpose, reasons of action, and the guideline of action. This policy takes into consideration patient's safety, safety of others, and patient's right, in addition to observation patients, renewal order of seclusion by doctor, and meets the needs of patients (National Center for Mental Health [NCMH], 2011).

Summary and Conclusions
The purpose of the background was to highlight opponents and proponents of using seclusion, from policies and governmental perspectives. Most previous literature reviews of seclusion that was used among psychiatric inpatients setting work to reduce it and know the factors of aggressive behaviors to move away from using it. The author searched updated articles and the studies that were found talked about reducing these methods and using other methods. Seclusion is used in the psychiatric setting significantly and for many reasons which were mentioned. However, there are other methods used to manage aggressive behavior and reduce seclusion. The seclusion may negatively affect on staff and patients and ethically affect on autonomy and dignity. However, the priority in mental health hospitals is safety, and there is no effective treatment without safety.

Position Statement
The position statement of the current author is to reduce seclusion; nurses must balance the responsibility for protecting patient rights with the duty to protect patients from harming themselves especially in situations that escalate to the point of danger. However, improving this position through points and success to reduce seclusion from view of authors which included for clinical practice, staff training and education, research, and staffing and policy change.

Clinical Practice
Developed clinical practices recommendations is the goal of reducing the usage of seclusion, such practices which include:-
• Work as multidisciplinary team in seclusion process.
• Met the needs of staff by individual support for team members with stress
• Observe regarding patients considered at high risk of seclusion.
• Supportive observation and reassurance, debriefing sessions post seclusion and explaining procedures.
• Creating appropriate environment that may help to reduce use of seclusion by reducing the behaviors that affect on patient, one-self and others.
• Good communication and contact between nursing staff and patients.

Staff Training and Education
• Train staff that seclusion is intervention which may be used only as a last resort; when all other intervention attempts have been made.
• Train staff nurse to cope and deal with aggressive behaviors and to know when and how to use seclusion.
• Encourage the use of inter professional education to develop processes of a decision making ethically and integrated on higher level.
• Give staff nurse program of clinical supervision to assist in managing distressing emotions.
• Train staff, about communication and skills of dialogue which may also be effective in reducing and containing aggressive behaviors, and train in de-escalation techniques.
• Make daily stimulation sessions for staff and define a recovery approach to caring for patients.
• Explore patient and staff perceptions and improvement suggestions regarding seclusion in psychiatric inpatient settings.
• Train for post seclusion debriefings with staff and patients, promoting attitudinal change among staff; support the development of skills in crisis management, and implementation of new models of care.

Research
• Conducting of future research should focus on staff patient interaction, reasons for patient aggressiveness, how to meet patients' needs to avoid aggressive reactions and interventions to reduce the use of seclusion in mental health care.

Staffing and Policy Change
• Changes required in policy change, organizational and cultural change, staff culture, coaching and group support, staffing structures, and environmental and regulatory unit changes.

Summary and Conclusions
This position statement of the present position of the current author toward seclusion used in psychiatric hospitals, is to reduce the usage of seclusion. Dilemmas and conflicts through caring for patients produce nursing accountability and responsibilities which are inevitable. The duty is to prevent harm to patients and staff which produces the nurse's conflict to balance their responsibility to protect patients' rights of freedom. Safety is priority in mental health hospitals and without safety there is no effective treatment.

This position is supported by discussion through using articles which show background derived from two parts, proponents' and opponents' opinions of using seclusion. Opponents stated the reasons to reduce seclusion from more than one side through using other interventions; seclusion affect on emotion of nurses or patients, and the ethical side has a role in this part. Although, there are proponents that recommend using seclusion, included articles show nurses may favour to use seclusion from other interventions. Suggested course of action and possible solution is mentioned finally to movement of action to reduce seclusion and deal with these changes and involve the user in this action.

Acknowledgements
I would like to take this opportunity to express my gratitude to Professor Dr. Majd Mrayyan for her guidance, close supervision, understanding, patience, and support. Also, my great thanks to the Hashemite University for allowing me to use its facilities.

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