The use of seclusion in the management of violence in psychiatric

The Use of Seclusion in the
Management of Violence within
Psychiatric Settings
Aggressive and violent incidents in health care
settings are reported to be increasing
worldwide. Research suggests that despite
attempts to introduce new methods of
managing violence and aggression traditional
methods such as seclusion, restraints and closed
wards still dominate present practice.
(Bloor et al, 2004)
Seclusion elicits different views and opinions
from healthcare professionals, service users and
society at large. Seclusion is very controversial
practice as it is in stark contrast with the
principle of treating people with mental illness
in the least restrictive environment which has
been adopted in most developed countries.
(Husum et al, 2010; Happell & Koehn, 2010a)
Defining Seclusion
There is no single agreed definition for the term
seclusion but the general consensus is that it
involves the placement of a patient alone in a
locked room, from which he/she cannot freely
(Meehan et al, 2000)
Defining Seclusion
Different definitions over the last three decades
may highlight both the positive and negative
outlooks on this practice. These include
• Forcible denial of the company of other people
• Isolation of client who may be dangerous to self
and others
• Providing a safe environment
• Confinement
(Leopoldt, 1985; De Cangas, 1993; Finke, 2001)
Defining Seclusion
The ISPN (2001) defined seclusion as an
emergency intervention employed as a last
effort involving a patient in a room especially
designed for the purpose usually because the
patient is combatant and dangerous to self and
The basic tenets underlying the use of seclusion
• Containment of violent and aggressive
• Prevention of injury
• Reduction in sensory stimuli
• Isolation from interpersonal contact
• Special protection and observation
(Martinez et al, 1999; Oberleitner 2000)
Concerns and Justification
Justification for
health settings
awareness that
the use of seclusion in mental
continues despite increasing
this intervention has negative
(Happell & Koehn, 2011)
Voices of concern regarding seclusion must be
balanced with the realities of managing highly
aggressive patients.
(Delaney, 2001)
Concerns and Justification
The ISPN (2001) suggested caution in a blanket
endorsement of zero seclusion policies. Serious
adverse consequences can be a potential byproduct such as insidious escalation in the use
of medications.
Literature also highlights the impact of seclusion
both on patients and staff as well as different
views and opinions on this subject
Effects on Patients
Feelings usually reported by patients regarding their
seclusion experience include:
• Humiliation
• Fear
• Loss of control
• Vulnerability
• Worthlessness
• A sense of being punished
(Happell & Koehn, 2011; Le Gris et al , 1999;
Meehan et al, 2000; Oberleitner, 2000)
Effects on Patients
Different authors highlighted the fact that seclusion
may result in sensory deprivation, restlessness,
mood swings, heightened awareness of sounds,
difficulty in judging time. Also dysfunctional
thought sometimes also involving hallucinatory or
delusional experiences. Moreover seclusion is often
associated with physical injuries and longer hospital
(Happell & Koehn, 2011; Le Gris et al , 1999; Meehan et al, 2000; Oberleitner, 2000)
Effects on Nurses
Literature also outlines the fact that seclusion ay
also have negative consequences on nurses. In fact
in some studies the practice of seclusion has been
associated with higher rates of injuries on staff and
higher incidence of burnout.
Nurses may also be more at risk for legal liability,
and also the fact that seclusion may be detrimental
to the therapeutic nurse – patient relationship thus
affecting the outcomes of care
(Forster, Caveness & Phelps, 1999;Happell & Koehn,2011)
Seclusion may also be used abusively which usually
• duration of time spent in the single room
• use of excessive force in secluding a patient
• overuse of medication while patient is in
• non-adherence to policy guidelines and
• the use of seclusion as punishment
(Alty, 1997; LeGris et al, 1999; Savage & Salib,1999)
Positive Outlooks
It would appear that the benefits of seclusion
arise from the belief that :
• Patients can feel safe from persecutors and
external stimuli
• Is effective in controlling and preventing
• Rather than a final solution seclusion may be
viewed as an effective starting point for
focused emotional care
Positive Outlooks
• Containment in limiting the environment in
which the disturbed patient operates
• Isolation in providing respite from the pain
and difficulties which tax the individual’s
coping abilities
• Providing a relief from stimuli that seem
ordinary to others but prove unbearable for
those in psychosis
(Alty, 1997; Le Gris et al, 1999; Meehan et al, 2000;Happell & Koehn, 2011;
Steele, 1993)
Considering Perceptions
It is important to consider both nurses and
patients perceptions in order that a full picture
about the practice of seclusion may emerge.
Literature outlines the fact that staff and
patients tend to have different if not opposing
views regarding seclusion
(Allen, 2000; Delaney, 2001)
Considering Perceptions
The split field of perception regarding seclusion
consists in that patents more often attribute
environmental factors such as noise levels or lack of
space which may result in seclusion
On the other hand nurses seem to attribute
patient’s disposition such adherence to treatment
or behavioural aspects such as violence which
determine the use of seclusion
(Allen, 2000; Delaney, 2001)
Violence and Seclusion
Work place violence has been actively addressed by
a number of disciplines in various work places
including retail, public transport, factories etc.
Workplace violence refers to a broad range of
behaviours including harassment, bullying, verbal
abuse and physical violence.
Metal health nurse have had a long standing
interest in the study and management of violence
and aggression. The main focus being the
aggressive mental health patient and great efforts
were made to develop accurate assessments.
(Beech & Bowyer, 2009)
Violence and Seclusion
Amongst individuals with major psychiatric
disorders dangerous behaviour is often preceded by
the rapid escalation of acute symptoms all of which
can trigger aggressive behaviour. These include:
• Paranoia
• Psychomotor restlessness
• Agitation
• Auditory or visual disturbances
• Disorganised thinking
(Knight, 2011; Paterson & Leadbetter, 2004; Van der Nagel et al, 2009)
Violence and Seclusion
Care providers may not recognise the subtle
changes in behaviour or symptoms and are
therefore unable to intervene early in the
escalation process.
Once the symptoms become more obvious, safety
of the patient and others in the immediate
environment becomes a pressing concern
Despite reassurance and redirection from staff,
some people’s symptoms continue to escalate and
seclusion or restraint become necessary
(Knight, 2011)
Violence and Seclusion
Several authors argued that symptoms and
behaviour that lead to seclusion occur in the
context of illness and rarely manifest
independently. However
such symptoms and
patterns of escalation have not been fully described
in the literature
Thus understanding the process and patterns of
symptom escalation might allow early effective
interventions which are vital in reducing the use of
(Knight, 2011; Paterson & Leadbetter, 2004; Van der Nagel t al, 2009)
Violence and Seclusion
There are other factors which may be related to the
use of seclusion. Vruwink et al (2012) pointed out
that determinants of seclusion and violence have in
most cases been studied separately. The same
authors however argue that in many studies such
determinants overlap thus pointing towards a close
association between aggressive and violent
behaviour and the use of seclusion
(El-badri & Mellsop, 2002; Leggett & Silvester, 2003; Mann-Poll et al 2011; Vruwink et
al ,2012)
Other Determinants of Seclusion
These include:
Gender (male)
Age (young)
Diagnosis (psychotic, bi-polar,
• Involuntary hospitalisation
• Ethnic minority
(Mann-Poll et al 2011; Vruwink et al ,2012)
Other Determinants of Seclusion
Other determinants of seclusion and aggressive
behaviour include contextual characteristics. These
• Length of hospitalisation
• Number of previous hospitalisation
• Time of day
• Ward/unit characteristics
• Work place culture
Literature however outlines that differences in the trend
on the use of seclusion may vary according to differences
in legislation, policy guidelines as well as staff training
and alternative measures available
(Le Gris et al, 1999; Steinhart et al, 2010; VanDerNagel et al, 2009; Vruwink
et al, 2012; Wynn 2002)
Reducing the Use of Seclusion
Increased concern for Human Rights, increased
awareness about the adverse effect of coercive
practices such as seclusion and restraint as well as
promotion of safe work environments have led to
changes in legislation and policies regarding
In most developed and developing countries efforts
by governments and interested parties are striving
towards reduction and were possible elimination of
seclusion in mental health settings.
(Beech & Bowyer, 2009; Happell & Harrow, 2010; Happell & Koehn, 2010; Huf et
al, 2011; Hyde et al, 2009)
Reducing the Use of Seclusion
There are several alternative measures to the use of
seclusion. These may be other coercive
(controversial) measures such as physical or
chemical restraints
On the other hand there are also other noncoercive measures such as de-escalation
techniques. This outlines the importance of staff
training and education in the management of
violence and the care of the acute mentally ill
patient if reduction in the use of seclusion is to
(Bloor et al, 2004; Hyde et al, 2009; Mann-Poll et al, 2011)
Reducing the Use of Seclusion
The use of training systems in the management of
violence and aggression as well as providing
decision frameworks in deciding what options to
use during intervention and resolution of an
incident is important.
Literature outlines the fact that training and
education has been associated with positive
changes in staff’s attitudes, knowledge and
confidence thus leading in the decrease of the use
of coercive measures such as seclusion
(Beech & Bowyer, 2009; Happell & Koehn, 2010; Huf et al, 2011; Hyde et al, 2009)
Training and Education
Staff education may include training regarding
assessment and intervention in the cycle of aggression,
symptom recognition, verbal intervention skills and the
critical thinking strategies designed to select the least
restrictive intervention best suited to the presenting
needs of the patient.
Management which over controls, stifles initiative and
promotes custodial regimens may hinder staff education
thus affecting delivery of care.
A leadership style which emphasises shared decision
making, recognition of the power already in staff role as
well as ownership and accountability for work is related
to higher job satisfaction and better care for acutely
distressed individuals.
(Beech & Bowyer, 2009; Happell & Koehn, 2010; Huf et al, 2011; Hyde et al, 2009)
Training and Education
Any physical contact skills should only be used as a last
resort. Moreover given that there will be inevitable
situations were it will be necessary to physically
restrain and seclude distressed individuals, ethical
behaviour by nurses can only be ensured if they are
trained in safe and effective ways of restraining
disturbed persons and analyse techniques which they
know to be both safe and effective
Patients have the right to be cared for in
developmentally appropriate ways by competent staff
members. This mandates for on going training in both
physical and verbal skills in the care of highly disturbed
(Bloor et al, 2004; Delaney, 2001; Hyde et al, 2009; Hopton, 1995; Mann-Poll et al, 2011)
The Local Perspective
To date there is little known about mental health
nurses’ views and perceptions on the use of
seclusion in Malta. However this issue was
addressed in two small scale unpublished
Using a qualitative approach Gouder (2006)
explored the nurses’ perception on the use of
The Local Perspective
Findings in this study generally agreed with similar studies
carried out elsewhere. Participants generally agreed that
seclusion should be used as a last resort measure. Findings
also outlined violence as a determining factor in the use of
seclusion. Alternative strategies such as one to one nursing
supervision were also highlighted. Issues including shortage of
staff and the ward environment were also pointed out.
Findings indicated that secluding a patient might have an
emotional impact on the nurses involved. This implied that to
improve psychiatric nursing care and the patients’ quality of
life one has to reduce the use of seclusion by means of
improvement in practice, further research and nurses’ training
and education.
(Gouder, 2006)
The Local Perspective
In another Maltese study by Pace (2011) using a
descriptive design, the author investigated
whether local policies and practices at a
psychiatric hospital in Malta reflected research
based guidelines for the use of seclusion and
possibly employ the results in redesigning such
policies with the aim to reduce seclusion use
The Local Perspective
Results indicated that as in other international
studies the presence of law and policies on their
own is not sufficient in regulating the use of
Findings also suggested that apart from patient
characteristics; gender and cultural influences
may also impinge on the use of seclusion.
(Pace, 2011)
The continued use of coercive measures of which
the therapeutic value is questioned such as
seclusion and restraints has a major implication for
mental health nursing.
Being the mental health professionals who are most
likely to face and manage violence thus initiating
and implementing strategies. Therefore mental
health nurses should be leading the way forward for
more humane and ethical care for acutely
distressed individuals
Allen, J. J. (2000). Seclusion and restraint of children: a literature review. Journal of Child
and Adolescent Psychiatric Nursing, 13(4), 159-167.
Alty, A. (1997). Nurses’ learning experience and expressed opinions regarding seclusion
practice within one NHS trust. Journal of Advanced Nursing, 25(4), 786-793.
Beech, B., & Bowyer, D. (2004). Management of aggression and violence in mental health
settings. Mental Health Practice, 7(7), 31-37.
Bloor, R., McHugh, A., Pearson, D., & Wain, I. (2004). A training course for psychiatric nurses
in Russia. Nursing standard, 18(39), 39-41.
De Cangas, J. P. (1993). Nursing staff and unit characteristics: Do they affect the use of
seclusion?. Perspectives in Psychiatric Care, 29(3), 15-22.
Delaney, K. R. (2007). Developing a Restraint‐Reduction Program for Child/Adolescent
Inpatient Treatment. Journal of Child and Adolescent Psychiatric Nursing, 14(3), 128-140.
El-Badri, S. M., & Mellsop, G. (2002). A study of the use of seclusion in an acute psychiatric
service. Australian and New Zealand Journal of Psychiatry, 36(3), 399-403.
Finke, L. M. (2001). The Use of Seclusion Is Not Evidence‐Based Practice. Journal of Child
and Adolescent Psychiatric Nursing, 14(4), 186-190.
Gouder, D. (2006) The perceptions of nurses working in mental health about the practice of
seclusion in Malta. Unpublished manuscript, University of Malta.
Forster, P. L., Cavness, C., & Phelps, M. A. (1999). Staff training decreases use of seclusion
and restraint in an acute psychiatric hospital. Archives of Psychiatric Nursing, 13(5), 269271.
Happell, B., & Harrow, A. (2010). Nurses' attitudes to the use of seclusion: a review of the
literature. International Journal of Mental Health Nursing, 19(3), 162-168.
Happell, B., & Koehn, S. (2010a). Attitudes to the use of seclusion: has contemporary
mental health policy made a difference?. Journal of clinical nursing, 19(21‐22), 3208-3217.
Happell, B., & Koehn, S. (2010b). From numbers to understanding: the impact of demographic factors on
seclusion rates. International Journal of Mental Health Nursing, 19(3), 169-176.
Happell, B., & Koehn, S. (2011). Impacts of seclusion and the seclusion room: exploring the perceptions
of mental health nurses in Australia. Archives of psychiatric nursing, 25(2), 109-119.
Huf, G., Coutinho, E. S., Ferreira, M. A., Ferreira, S., Mello, F., & Adams, C. E. (2011). TREC-SAVE: a
randomised trial comparing mechanical restraints with use of seclusion for aggressive or violent
seriously mentally ill people: study protocol for a randomised controlled trial. Trials, 12(1), 180.
Hopton, J. (1995). Control and restraint in contemporary psychiatric nursing: some ethical
considerations. Journal of Advanced Nursing, 22(1), 110-115.
Husum, T. L., Bjørngaard, J. H., Finset, A., & Ruud, T. (2010). A cross-sectional prospective study of
seclusion, restraint and involuntary medication in acute psychiatric wards: patient, staff and ward
characteristics. BMC health services research, 10(1), 89.
Hyde, S., Fulbrook, P., Fenton, K., & Kilshaw, M. (2009). A clinical improvement project to develop and
implement a decision‐making framework for the use of seclusion. International Journal of Mental
Health Nursing, 18(6), 398-408.
International Society of Psychiatric- Mental Health Nurses. (2001). ISPN position statement on the use
of restraint and seclusion. Retrieved 10th October, 2012, from
Knight, M. (2011). Precursors to seclusion or restraint: An analysis. Mental Health Practice, 14(10), 14.
Leggett, J., & Silvester, J. (2003). Care staff attributions for violent incidents involving male and female
patients: a field study. British Journal of Clinical Psychology, 42(4), 393-406.
LeGris, J., Walters, M., & Browne, G. (1999). The impact of seclusion on the treatment outcomes of
psychotic in-patients. Journal of Advanced Nursing, 30, 448-459.
Leopoldt, H. (1985). A secure and secluded spot. Nursing times, 81(6), 26.
Mann-Poll, P. S., Smit, A., de Vries, W. J., Boumans, C. E., & Hutschemaekers, G. J. (2011). Factors
contributing to mental health professionals' decision to use seclusion. Psychiatric Services, 62(5), 498503.
Martinez, R. J., Grimm, M., & Adamson, M. (1999). From the other side of the door: patient views
of seclusion. Journal of psychosocial nursing and mental health services, 37(3), 13.
Meehan, T., Vermeer, C., & Windsor, C. (2008). Patients’ perceptions of seclusion: a qualitative
investigation. Journal of Advanced Nursing, 31(2), 370-377.
Oberleitner, L. L. (2000). Aversiveness of traditional psychiatric patient restriction. Archives of
psychiatric nursing, 14(2), 93-97.
Pace, J. (2011) A survey of the use of seclusion in a psychiatric hospital: a quantitative study.
Unpublished manuscript, University of Malta.
Paterson, B., & Leadbetter, D. (2004). Learning the right lessons. Mental Health Practice, 7(7), 1215.
Savage, L., & Salib, E. (1999). Seclusion in psychiatry. Nursing standard (Royal College of Nursing
(Great Britain): 1987), 13(50), 34.
Steinert, T., Lepping, P., Bernhardsgrütter, R., Conca, A., Hatling, T., Janssen,
W., ... & Whittington, R. (2010). Incidence of seclusion and restraint in
psychiatric hospitals: a literature review and survey of international trends.
Social psychiatry and psychiatric epidemiology, 45(9), 889-897.
VanDerNagel, J. E. L., Tuts, K. P., Hoekstra, T., & Noorthoorn, E. O. (2009).
Seclusion: The perspective of nurses. International Journal of Law and
Psychiatry, 32(6), 408-412.
Vruwink, F. J., Noorthoorn, E. O., Nijman, H. L., VanDerNagel, J. E., Hox, J. J., &
Mulder, C. L. (2012). Determinants of Seclusion After Aggression in Psychiatric
Inpatients. Archives of Psychiatric Nursing.
Wynn, R. (2002). Medicate, restrain or seclude? Strategies for dealing with
violent and threatening behaviour in a Norwegian university psychiatric
hospital. Scandinavian Journal of Caring Sciences, 16(3), 287-291.

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