A review of nursing practice Seclusion of a client admitted to intensive psychiatric care unit (IPCU) Seclusion of a client admitted to IPCU

of Centre for Mental Health (CMH) is regulated by the Policy Directive / Seclusion Policy, document number MH_PD2008_C1026 (Sydney South West Area Health Service [SSWAHS], 2007). The client who are admitted to IPCU and the clients family are consulted and involved in planning and developing of adequate, acceptable and personalised alternative interventions, as opposite to seclusion and restraint, in containing clients behavioural disturbances (Noorthoorn, et al., 2008). Seclusion of a client admitted to IPCU is a regulated risk management emergency intervention which is undertaken only as a last resort when preventive and other alternative less restrictive interventions in containing emerging crisis situation were considered first and have not been successful. Duration of seclusion is limited by the duration of the crisis period. Compliance with the Policy Directive is mandatory (SSWAHS, 2007). The Seclusion Policy of CMH directs the clinicians to explain to the client the procedure before commencing the procedure and to ensure clients privacy and safety. The Seclusion Policy emphasises the need to promote the clients self-respect and to consider any cultural or other special needs that the client might have. The purpose of seclusion is to prevent injury and to provide safety to the client being secluded (e.g. by reducing stimuli and allowing time for extra medication take the effect), or to prevent injury and to provide safety to other clients or the staff in the ward Konito et al., 2010; Larue, Piat, Racine, Menard, & Goulet, 2010; Noorthoorn et al., 2008; SSWAHS, 2007). In an emerging crisis situation when a client behavioural disturbance and the risk were identified, the Seclusion Policy of CMH directs that a multidisciplinary team (e.g. a doctor and nurses on duty) assess the situation before implementing the agreed prevention and alternative strategies. If these first step intervention strategies were successful, the team continues with implementation of these intervention strategies and the incident, implemented strategies and the outcome are documented in the clients Care plan, Clinical record and in the Shift report (Jayasekara, 2009; SSWAHS, 2007). If the initial intervention strategies were unsuccessful and the clients behavioural disturbance continues, further intervention strategies are implemented and documented through Incident Information Management System (IIMS) Report and Clinical record. If these prevention and alternative intervention strategies were successful, then their implementation is continued and documented in appropriate documents. However, if these intervention strategies were not successful and the seclusion is required, approvals for seclusion (from a senior nurse and a medical officer) are to be obtained, risk assessment and risk management are completed and the incident is documented through IIMS Report, Seclusion Authorisation & Register Form, Observation Checklist Seclusion & Body Restraint Form and Clinical record (SSWAHS, 2007).

Djekic Zarko Page 1 of 7

The clients behavioural disturbance as the reason for seclusion and the alternative interventions are assessed and discussed with the client as soon as it is safe to do so. Every case of seclusion is discussed and analysed at shifts handover and at the wards Seclusion Committees weekly meeting.

A systematic review of research evidence related to identified area of specialised practice is Seclusion and restraint for people with serious mental illnesses (Review) (Sailas & Fenton, 2000). The research question (PICO) is clearly stated in the abstract of the review: the effects of seclusion and restraint compared to the alternatives the effects of strategies to prevent seclusion and restraint in those with serious mental illnesses (Sailas & Fenton, 2000, p. 3). Population of interest are people with serious mental illness. Interventions being reviewed are seclusion and restraint, and strategies to prevent seclusion and restraint. Comparison of these interventions is done in relation to alternatives to seclusion and restraint. Outcome measures (primary and secondary) were described and grouped according to time period as shown on pages 3 and 4 of the review (Sailas & Fenton, 2000). The topic of a systematic review Seclusion and restraint in acute mental health settings (Sailas & Fenton, 2000) is relevant to the area of nursing practice in my specialisation. I am a registered nurse in the intensive psychiatric care unit within CMH. In CMH there are in average 3 to 4 seclusions a week. The electronic searches of the multiple data bases were conducted (e.g. The Cochrane Controlled Trials Register, The Cochrane Schizophrenia Groups Register, CINAHL, EMbase, MEDLINE, and PsycLIT) while the conference abstracts and the reference lists of all identified studies were hand searched. A total of 2155 citations were yielded and full articles were obtained for 35 studies. The researchers of the systematic review contacted the first author of each relevant study (Sailas & Fenton, 2000). There were two reviewers, Eila E. S. Sailas and Mark Fenton, who conducted the search, reviewed the literature and contacted the first author of each relevant study. The inclusion criteria for this systematic review are: all assessed to be up to date as at 25/10/1999 relevant randomised controlled trials (RCT) of restraint or seclusion in treating people with serious or chronic mental illness and all relevant RCT of strategies used to reduce the need for restraint or seclusion in the treatment of serious mental illness. Exclusion criteria are all studies of use of restraint or seclusion in treating people with dementia or people with cognitive impairment that is not caused by psychotic disorders (Sailas & Fenton, 2000).

Djekic Zarko Page 2 of 7

Data from all identified RCTs were independently extracted by both reviewers. Disagreements were resolved by discussion and clarification of the issues was sought from the authors of the studies. Among 35 identified studies there were no studies that met the minimum inclusion criteria and no data were synthesised. The discussion of the results is appropriate and it points directly and clearly to absence of evidence to support or refute the use of seclusion and restraint for people with serious mental illness. Lack of data was identified due to absence of any relevant RCT. The authors of the review highlighted reports of serious adverse effects of use of seclusion and restraint interventions on both clients and staff (Fisher, as cited in Sailas & Fenton, 2000). The implications of the review for practice and research are feasible; the need to find alternative methods of dealing with behavioural disturbance is clearly and explicitly identified. Based on non-randomised studies the reviewers concluded that for ethical reasons the use of seclusion and restraint should be minimised. The authors of the review recommended undertaking of further well planned random studies focused on the use of seclusion and restraint for people with serious mental illness (Sailas & Fenton, 2000).

The two different appraisal guidelines/tools that could be effectively used to appraise the systematic review by Sailas and Fenton (2000) are: 10 questions to help make sense of review (Public Health Resources Unit, England, 2006) and Critical appraisal of systematic review for nursing practice (Scanlon, 2007). The rigour of the systematic review should be the same as the rigour of qualitative random controlled studies. Both appraisal tools are focused on examining the scientific review methods used by the reviewers in order to minimise the risk of bias and error. In determining the rigour of the systematic review both tools direct the reader to examine the processes of literature search, study selection, critical appraisal of selected studies and the process of data synthesis. Both tools enable the reader of the systematic review to come to initial decision whether to continue assessing the systematic review by focusing readers attention on what the research question is and how clearly focused the research question is. Both tools have the guidelines for their use, thus enabling the user to apply and interpret the tools in a standardised manner however Scanlon (2007) has also published evidence of empirical basis for the construction of the tool within the text of the tools (Joana Briggs Institute [JBI], 2000; Katrak, Bialocerkowski, Massy-Westropp, Kumar, & Grimmer, 2004). There are some differences between the two tools. For example, Scanlon (2007) has more detailed explanations which at the same time serve as an educational tool to a less experienced reader how to appraise a systematic review. Scanlon looks for the answer to the question as to whether the topic of the systematic review is relevant to the readers needs at the beginning of appraising the review; and Scanlon concludes the appraisal of the systematic review by examining recommendation of the systematic review related to further research of the question of interest. The appraisal tool published by Public Health Resources Unit, England (2006) is easy to use but it requires more in depth knowledge of research and review processes.

Djekic Zarko Page 3 of 7

In an effort to appraise the systematic review conducted by Sailas and Fenton (2000) I would apply these two appraisal tools firstly by examining the research questions which should be clearly stated at the abstract of the systematic review and then by examining the conclusion of the systematic review to ascertain if the results can be applied in my clinical practice. My decision whether to use the finding of the systematic review would be based on the established rigour of the systematic review.

Based on the analysis and the evidence discussed in the systematic review (Sailas & Fenton, 2000) and other related literature (Jayasekara, 2009), underlined by absence of evidence to support or refute the use of seclusion and restraint for people with serious mental illness (Sailas & Fenton), at this time I would not recommend changes in the Seclusion policy and in the implementation of seclusion and restraint of clients with serious mental illnesses admitted to IPCU of CMH. According to Sailas and Fenton the use of seclusion and restraint should be tested in well-designed and reported RCT. However, in addition to the current practice, I would recommend continuous professional development of all clinical staff who are involved in decision making process related to seclusion and restraint. I would also recommend strengthening of existing collaboration between the clinicians and the clients in order to reduce and if possible to avoid seclusion and restraint. According to Sailas and Fenton (2000) the use of seclusion and restraint should be minimised for ethical reasons. There is strong evidence which points to adverse effect of seclusion and restraint on both the client and the staff, and on damaging effect of seclusion and restraint on psychotherapeutic relationship. Although seclusion and restraint are used only as an emergency intervention of the last resort, aimed solely to containing emerging crisis situation, the use of seclusion and restraint should be closely monitored and if possible avoided in order to prevent damaging effect of seclusion and restraint (Gaskin, Elsom, & Happell, 2007; Konito et al., 2010; Larue, Piat, Racine, Menard, & Goulet, 2010; Stewart, Van der Merwe, Bowers, Simpson, & Jones, 2010; Terpstra, Terpstra, Pettee, & Hunter, 2001). Continuing professional education of all allied mental health professionals in recognising early signs of behavioural changes that indicate emerging crisis situation is essential in development of therapeutic relationship and in avoiding of seclusion and restraint. Continuing skills training of mental health nursing and medical staff in implementation of alternative strategies in containing and deescalating emerging crisis situation caused by behavioural disturbance of clients with serious mental illness greatly contribute to successful early intervention that will result in clients collaboration thus avoiding of seclusion and restraint (Hyde, Fulbrook, Fenton, & Kilshaw, 2009; Jayasekara, 2009; Konito, et al., 2009). Every seclusion episode is discussed with the client as soon as it is safe to do so. According to Needham and Sands (2010) Post seclusion debriefingsupports consumers natural recovery mechanism after seclusion event (p.231). I would further recommend debriefing of every staff members involved in seclusion incident and that every mental health nursing and medical staff employed at CMH familiarise themselves with discussions and findings of Seclusion committees meetings in relation to incidences of seclusion within the previous period.
Djekic Zarko Page 4 of 7

Seclusion and restraint is a last resort risk management emergency intervention which is regulated by the Policy Directive / Seclusion Policy. At present there is no evidence to support or refute the use of seclusion and restraint. Because of its damaging effects and for ethical reasons the use of seclusion and restraint should be minimised.

Reference:
Djekic Zarko Page 5 of 7

Gaskin, C. J., Elsom, S. J., & Happell, B. (2007). Interventions for reducing the use of seclusion in psychiatric facilities: review of the literature. British Journal of Psychiatry, 191(4), 298-303. 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, 398-408. Jayasekara, R. (2009). Violence management: Acute psychiatric facilities. JBI Retrieved from: http://0www.jbiconnectplus.org.library.newcastle.edu.au/ViewDocument.aspx?0=1735 Joana Briggs Institute. (2000). Appraising Systematic Reviews, Changing Practice, 1, 1-6. Retrieved from http://connect.jbiconnectplus.org/ViewSourceFile.aspx?0=4311 Katrak, P., Bialocerkowski, A. E., Massy-Westropp, N., Kumar, V. S. S., & Grimmer, K. A. (2004). A systematic review of the content of critical appraisal tools. BMC medical Research Methodology, 4(22), 1-22, retrieved from http://www.medicine.mcgill.ca/rtamblyn/Readings%5CBioMed%20%20quality%20appraisal%20instrument%20review.pdf Konito, R., Valimaki, M., Putkonen, H., Cocoman, A., Turpeinen, S., Kousmanen, L., & Joffe, G. (2009). Nurses and physician educational needs in seclusion and restraint practices. Perspectives in Psychiatric Care, 45(3) 198-207. Konito, R., Valimaki, M., Putkonen, H., Kousmanen, L., Scott, A., & Joffe, G. (2010). Client restrictions: Are there ethical alternatives to seclusion and restraint? Nursing Ethics, 17(1), 65-76. Larue, C., Piat, M., Racine, H., Menard, G., & Goulet, M-H. (2010). The nursing decision making process in seclusion episodes in a psychiatric facility. Issues in Mental Health Nursing, 31, 208-215. Needham, H., & Sands, N. (2010). Post-seclusion debriefing: A core nursing intervention. Perspectives in Psychiatric Care, 46(3), 221-233. Noorthoorn, E. O., Janssen, W. A., Theunissen, J., Hesta, H., de Vries, W. J., Hutschemaekers, G. J. M., Lendemeijer, H. H. G. (2008). The power of day-to-day motivational techniques and family participation in reducing seclusion. A comparison of two admission wards with and without a seclusion prevention protocol. International Journal of Mental Health, 37(3), 8198. Public Health Resources Unit, England. (2006). 10 questions to help you make sense of reviews. Critical Appraisal Skills Program (CASP). Retrieved from http://www.sph.nhs.uk/sph-files/casp-appraisaltools/Economic%20Evaluations%2010%20Questions.pdf
Djekic Zarko Page 6 of 7

Sailas, E. E. S., & Fenton, M. (2000). Seclusion and restraint for people with serious mental illnesses (Review). Cochrane Database of Systematic Reviews, 1. doi: 10.1002/14651858.CD001163 Scanlon, A. (2007). Critical appraisal of systematic review for nursing practice. Australian Journal of Neuroscience, 18(1), 8-14. Stewart, D., Van der Merwe, M., Bowers, L., Simpson, A., & Jones, J. (2010). A review of interventions to reduce mechanical restraint and seclusion among adult psychiatric inclients. Issues in Mental Health Nursing, 31, 413424. Sydney South West Area Health Service. ( 2007). Policy Directive / Seclusion Policy, (document number MH_PD2008_C1026) Terpstra, T. L., Terpstra, T, L., Pettee, E. J., & Hunter, M. (2001). Nursing staff's attitudes toward seclusions & restraint. Journal of Psychosocial Nursing & Mental Health Services, 39(5), 20-28.

Djekic Zarko Page 7 of 7