Innovation and pragmatism required to reduce seclusion practices

Abstract

Seclusion may be harmful and traumatic to patients, detrimental to therapeutic relationships, and can result in physical injury to staff. Further, strategies to reduce seclusion have been identified as a potential method of improving cost-effectiveness of psychiatric services. However, developing alternative strategies to seclusion can be difficult. Interventions to reduce seclusion do not lend themselves to evaluation using randomized controlled trials (RCTs), though comprehensive literature reviews have demonstrated considerable non-RCT evidence for interventions to reduce seclusion in psychiatric facilities. In the UK, a recent 5-year evaluation of seclusion practice in a high secure UK hospital revealed reduced rates of seclusion without an increase in adverse incidents. To assess the effect of a novel intervention strategy for reduction of long-term segregation on a high secure, high dependency forensic psychiatry ward in the UK, we introduced a pilot program involving stratified levels of seclusion ("long-term segregation"), multidisciplinary feedback and information sharing, and a bespoke occupational therapy program. Reduced seclusion was demonstrated and staff feedback was mainly positive, indicating increased dynamism and empowerment on the ward. A more structured, stratified approach to seclusion, incorporating multidisciplinary team-working, senior administrative involvement, dynamic risk assessment, and bespoke occupational therapy may lead to a more effective model of reducing seclusion in high secure hospitals and other psychiatric settings. While lacking an evidence base at the level of RCTs, innovative, pragmatic strategies are likely to have an impact at a clinical level and should guide future practice and research.

Non-pharmacological interventions to reduce restrictive practices in adult mental health inpatient settings: the COMPARE systematic mapping review

“…The remaining records included brief descriptions of interventions presented in reports by organisations such as the Agency for Healthcare Research and Quality (AHRQ), the Care Quality Commission (CQC), NHS, Mind, the RCP (practice examples), and NHS trusts and hospitals (service reports); these non-research reports focused on interventions rather than a service setting (intervention reports), instructions for the performance of an intervention (instructions), links to training organisation websites (training links) and tools used as part of an intervention (tools). The majority of these were journal articles but they also included websites, leaflets, theses, 69-75 abstracts, 76-81 booklets, [82][83][84][85][86][87] slides, 84,[88][89][90][91][92] videos, [93][94][95][96] a podcast 97 and a course syllabus. 98 Results of broad search The number of records available steadily increased over the search period (i.e.…”

“…Fletcher et al 181 and Noorthoorn et al 182 ) and identifying champions, experts or specialists (e.g. Bowers et al, 102 Tully et al 90 and Lombardo et al 159 ) to set an example to ward staff.…”

“…Eleven evaluations (n = 11) reported whether they tailored or modified the intervention protocol. Two described using some but not all of the Six Core Strategies 90,144 and three reported modifying a tool. 113,188,208 Others reported tailoring the intervention to meet service users' needs, 140 making modifications as the intervention proceeded 106 and allowing wards to choose the intervention.…”

“…Twelve interventions 85,88,90,97,[100][101][102][103]129,132,135,159,181,185,187,197,225 used expert practitioners on wards to disseminate good practice:…”

Occupational therapy with patients in forensic solitary confinement: A qualitative study

“…seclusion space in a highly secure hospital unit (Tully et al, 2016). No known studies report on 1) the occupations that are available in forensic solitary confinement settings where access to objects and spaces is very limited; 2) whether the solitary confinement setting influences the occupational therapy process; and 3) the work occupational therapists do in these settings.…”