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Seclusion to inclusion

Isolating extremely unwell psychiatric patients remains a common practice despite being seen as a measure of last resort. Genevieve Costigan reports on a project that has seen it significantly reduced.

A pilot project in an inner city Melbourne hospital has seen the practice of locking up extremely unwell psychiatric patients in isolation reduced by more than 50 per cent.

The practice, commonly called seclusion, involves placing acutely unwell psychiatric patients in a confined space to prevent immediate harm to the patient and other people and is considered a measure of last resort.

It is, however, a relatively common practice in acute psychiatric settings in Australia with thousands of people being secluded each year.

The project, Translating Evidence to Practice: Seclusion Reduction in Acute Psychiatry, was led by Dr Bridget Hamilton, director of nursing for mental health at St Vincent’s and senior lecturer in the University of Melbourne’s School of Nursing and Social Work.

“Seclusion is an issue that people often won’t want to think about or address, without significant support to do so – in some ways it’s treated like a dirty work practice and this is part of what stigmatises mental health practices,” says Hamilton.

Involuntary psychiatric patients often come through the emergency departments of hospitals and are commonly people who are having a psychotic episode as a result of schizophrenia, hypermania or drug-induced psychosis and sometimes they are people in crisis with borderline personality disorder.

“It is challenging for even highly skilled staff to communicate effectively with people when they are acutely unwell,” says Hamilton.

“Patients may express their fear and frustration being surrounded by unfamiliar people and places, they may be given directives they do not understand or may argue with, and the rising sense of injustice and distress can all lead to conflict situations where patients are manhandled into a seclusion room.

“Nurses don’t want to initiate physical restraint but as they are usually working within a constrained space in a psychiatric unit, they experience chaos, noise and verbal abuse and they work hard to meet the needs of the distressed patient but they are also trying to keep the other patients and staff safe.”

International focus on seclusion policies began in the United States in the early 1990s following a newspaper expose of a series of deaths in seclusion rooms in US mental health facilities. Enquiries into seclusion rates went to Congress which led to changes to legislation and practice.

Yet, Hamilton says, in 2006 when this project was planned, the idea of seclusion reduction wasn’t on the radar in clinical settings in Victoria.

“We need to think about seclusion from the point of view of the unintended harm it can do to the patients and not just from the perspective of safety,” she says.

Hamilton established a partnership with St Vincent’s Mental Health and sought support from the National Institute of Clinical Studies (NICS) and the Victorian government to undertake the project.

Based on the US research Hamilton used six core strategies to reduce the use of seclusion and restraint. The US strategies were adapted for the different mental health service structures and laws in Victoria.

Changes were made in St Vincent’s organisation and practice to reduce reliance on seclusion, including getting senior managers engaged in the goal of seclusion reduction, revising policy, focusing on available seclusion data and surveying staff attitudes to seclusion. Clinicians participated in training and senior clinicians reviewed all seclusion events.

Hamilton believes examining the data was essential as it confronted clinicians and managers with the detail of seclusion, for example how some patients had been secluded many times and it raised the question of why this was so and how it could be changed.

“It was a difficult project for any organisation to take on and needed leadership but with the backing of the University, NICS, many colleagues at the hospital and state government we managed to get it going.

“Patients who are secluded often experience terrible shame, a sense of a loss of control and dignity and it can also re-traumatise people who have been abused, neglected and isolated and putting them in a confined space can reignite memories of abuse.

“At the coalface we need nurses to be thinking hard and differently about what you can do in these situations, what you can do earlier, what you can do to address patients’ needs, concerns and fears which may help avert seclusion.

“We need to look at how we can orientate people to the ward, explain what the different spaces are and we need to expect that people are going to find it very difficult and so spend more time with them on admission to the unit.”

Hamilton says some of the things wards can do to support patients are to directly address patients’ concerns which may revolve around their domestic situations, for example they may need to make phone calls to check on family members or arrange for the care of their pets.

“If you see a patient getting upset, behaving erratically, you can speak to the patient and try to find out why they are upset; it may be something you can deal with and can be a better way of handling a situation rather than waiting until the situation escalates,” she says.

Changes in attitudes can be crucial in reducing seclusion rates and Hamilton suggests that the tendency to think that the person who is behaving badly does not deserve more attention needs to change to the idea that intensive work actually needs to be done with this person.

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