Seclusion reduction in a forensic mental health setting

Abstract

Seclusion has become a contentious practice and initiatives have commenced to reduce or eliminate its use. This paper presents the initiatives that were introduced during a seclusion reduction project that was undertaken at an Australian forensic hospital. These initiatives are based on the six core strategies that have been successfully used in North America to reduce seclusion. However, there are challenges (patient characteristics, prisoner culture and ensuring safety) and opportunities (longer admissions, higher staff-patient ratio, staff confidence, sound risk assessment and management) that can influence projects to reduce seclusion in a forensic hospital. During this project, the frequency (mainly multiple seclusions of patients) and duration of seclusion events were reduced but there was less reduction in the number of patients that were secluded. It is possible that the strategies were successfully supported by the identified opportunities to reduce the frequency and duration of seclusion but the challenges were significantly powerful in the early period of admission to prompt the need for seclusion. Reducing seclusion in a forensic hospital is a complex undertaking as nurses must provide a safe environment while dealing with volatile patients and may have little alternative at present but to use seclusion after exhausting other interventions.

Seclusion and restraint use in adult inpatient mental health care: An Australian perspective

“…Patients in forensic hospitals reportedly present with high levels of aggression and violence (Maguire, Young & Martin, 2012;Dickens, Picchioni, & Long, 2013), thus higher levels of containment than general acute units could be expected. The rates of containment in forensic units in our study were higher than the general units without HDUs in 2010 and similar in 2011.…”

“…These include strategies focused on broader, hospital-based change, in addition to interventions targeting patients and behaviours. For example, the six core strategies used in the Australian Beacon Project include leadership, continuous workforce development, genuine consumer involvement, assessment and planning tools, use of data to support practice and debriefing techniques (Maguire et al, 2012). Fisher (2003) also reports the effectiveness of action at a systemic level, including high level administrative endorsement, participation by recipients of mental health services, culture change, training and data analysis, in addition to individualised treatment, in reducing the rate of restraint and seclusion.…”

Fear and blame in mental health nurses’ accounts of restrictive practices: Implications for the elimination of seclusion and restraint

“…Consumers and carers, while at times identifying some benefit to restrictive practices, predominantly express negative perceptions of seclusion and restraint use and are unlikely to view these interventions as therapeutic (Brophy et al 2016;Kinner et al 2017). Nurses express a range of views about seclusion and restraint: from unease and avoidance, through to accepting that the use of the intervention is necessary and even therapeutic (Goethals et al 2011;Happell & Koehn 2011;Maguire et al 2012;Perkins et al 2012). Overall, while there is support for a reduction in the use of seclusion and restraint, the majority of mental health professionals defend the continued use of some form of restrictive practice in regard to the management of violence and aggression (Happell & Harrow 2010;Kinner et al 2017), viewing these practices as a 'necessary evil' to be used as a last resort (Wilson et al 2017).…”

Prolonged use of seclusion and mechanical restraint in mental health services: A statewide retrospective cohort study

“…In Australia, the Commonwealth Government's National Mental Health Working Group (2005) identified reducing the use of restrictive interventions as one of four safety priorities for mental health services. The National Mental Health Seclusion andRestraint Project (2007-2009), known as the 'Beacon Project', was developed to establish centres of excellence aimed towards reducing seclusion and restraint in public mental health facilities, including forensic mental health services (Maguire et al 2012). The Beacon Project used the 'six core strategies' (Huckshorn 2004) to develop a systemic response to drive change.…”