Does policy and procedure keep service users secluded longer than necessary?

International concerns (United Nations, 2013; World Health Organisation, 2017; Duxbury, 2019) have been expressed about seclusion use in mental health settings. Although initiatives such as Safewards and No Force First recommended strategies staff can use to prevent aggression or de-escalate potential incidents, healthcare staff continue to support its use (Muir-Cochrane, 2018). Our study ‘Factors influencing decisions of mental health professionals to release service users from seclusion’ – published recently in the Journal of Advanced Nursing – echoed these findings. We found previous research focussed upon which services are likely to be secluded and why they may be secluded (Bowers et al, 2017), plus how professionals’ decision-making to seclude service users is heavily influenced by local ward cultures and team personalities (Larue, 2009; Mann-Poll, 2011). However our work was the first to explore the factors that professionals consider when deciding to release a person from seclusion.

The Mental Health Code of Practice and NICE Guidance requires involvement from a range of professionals from the multi-disciplinary team (MDT) and outline a strict schedule for reviews:

  • medical review within 1 hour of seclusion starting,
  • 2 hourly nursing reviews,
  • 4 hourly medical reviews, and
  • 8 hourly multi-disciplinary team reviews.

Our findings raise questions about policy and procedure for reviewing the use of seclusion. We also found that, despite policy, decisions to release service users from seclusion were highly subjective and may be eroding professional skills, autonomy and confidence:

‘…the policy provides safeguards but years ago it was different. We once used a low stimulus room, after around 20 minutes went in. We de‐escalated through the door. Got him to move back, put his weapon down. Now it would be more formal, get a doctor, start the paperwork. It would probably would have turned out different and lasted longer and affected our relationship with him.’

Following instructions

The professionals in our study admitted – with some discomfort – that they told secluded service users to ‘calm down’ and ‘behave’ as it was important to be satisfied they would cooperate and comply with instructions when released. Professionals said they thought they had no choice but to use seclusion as they were unsure how else they could manage some incidents of violence and aggression. Professionals explained that they drew on their previous knowledge of the service user when considering what someone could or could not realistically manage and deciding how trustworthy they were:

‘We have all seen patients who say the right the right things to get out, hold it together for so long and then it all spills out’

Others warned against ‘being played’ by service users showing remorse that might be insincere or temporary. Service users in seclusion were not seen as passive, however. Professionals suggested release was as much in service users’ hands as theirs, because they knew what was expected and had the choice to take control and engage appropriately if they wanted to be released.

Fear of getting it wrong

These decisions also took into account the physical and ‘emotional tone’ of the ward: professionals acknowledged they could not release someone into ‘chaos’. They thought about the resources such as the size, permanency and skill-set of the team they had at their disposal asking themselves would the team cope post-release and deliberated about the consequences if they did not:

‘If you’re wrong, there goes your credibility’.

The nurses interviewed suggested that they could sometimes lose focus on the service user in seclusion as they struggled to manage the review timetable, assemble MDT colleagues and ensure documentation was correct. Nurses talked about needing to protect themselves and feared ‘getting it wrong’, ‘being judged incompetent’, or being ‘taken down a formal capability route’. In contrast, medical professionals did not feel this pressure, stating that as long the service user was safe they were not concerned about reviews being overdue or that their practice would be subject to scrutiny.

Daring to make bolder decisions

Staff numbers, permanency and skills were described as important, particularly the experience and confidence of the decision maker which had a strong influence on the likelihood of release and length of seclusion. Junior doctors depicted their role as managing physical health and supporting the nurses, and junior nurses worried about maintaining safety and supporting their team. Some Allied Health Professionals interviewed appeared confused as to why they were included, felt their skills were not used and doubted they had any influence on decisions. In contrast senior staff, who had greater experience and authority to move service users to other wards, said they made bolder choices and did not feel constrained by policy:

‘I’ll be honest and say if I want to bring somebody out then I’ll do that and I’ll let a medic know that’s what I have done’.

Our recommendations

Based on our findings, we made some recommendations:

  • We need to have conversations about how current policy is applied to ensure impracticable and counterproductive standards do not hamper efforts to release people from seclusion at the earliest opportunity:
    • Senior staff should be available to facilitate release, and,
    • Organisational procedures and support for staff nurses should enhance (not undermine) their confidence or autonomy to manage situations.
  • There could be better use of the skills of Allied Health Professionals to support planning for release.

Professionals would benefit from greater awareness of the factors that hinder or facilitate decisions to release people from seclusion. This study did not examine how the person secluded was involved in the planning or decision-making about their release. Increased understanding of how service users could be empowered to be involved in such decisions certainly warrants further investigation and is the focus of future research.

Haley Jackson is a PhD student in the mental health research group. You can follow her @haleyj102 or contact her at hchj@leeds.ac.uk.

References

Bowers, L., Cullen, A.E., Achilla, E., Baker, J., Khondoker, M., Koeser, L., Moylan, L., Pettit, S., Quirk, A., Sethi, F., Stewart, D., McCrone, P. and Tulloch, A. 2017. Seclusion and Psychiatric Intensive Care Evaluation Study (SPICES): combined qualitative and quantitative approaches to the uses and outcomes of coercive practices in mental health services. Health Services and Delivery Research. pp. 1-142. ISSN 2050-4357.

Department of Health (DOH). 2015. Mental Health Act 1983: Code of Practice. London: DH.

Duxbury, J., Baker, J., Downe, S., Jones, F., Greenwood, P., Thygesen, H., McKeown, M., Price, O., Scholes, A., Thomson, G. and Whittington, R. 2019. Minimising the use of physical restraint in acute mental health services: The outcome of a restraint reduction programme (‘REsTRAIN YOURSELF’). International journal of nursing studies. 95, pp.40-48.

Jackson H, Baker J, Berzins K. (2019) Factors influencing decisions of mental health professionals to release service users from seclusion: A qualitative study. Journal of Advanced Nursing https://doi.org/10.1111/jan.14086.

Laiho, T., Lindberg, N., Joffe, G., Putkonen, H., Hottinen, A., Kontio, R. and Sailas, E. 2014. Psychiatric staff on the wards does not share attitudes on aggression International Journal of Mental Health Systems 8(1), pp.14-14.

Larue, C., Dumais, A. and Ahern, E. 2009. Factors influencing decisions on seclusion and restraint. Journal of Psychiatric and Mental Health Nursing. 16(5), pp.440-446.

Mann-Poll, P.S., Smit, A., de Vries, W.J., Boumans, C.E., Hutschemaekers, G.J., Mann-Poll, P.S., Smit, A., de Vries, W.J., Boumans, C.E. and Hutschemaekers, G.J.M. 2011. Factors contributing to mental health professionals’ decision to use seclusion. Psychiatric Services. 62(5), pp.498-503.

Muir-Cochrane, E., O’Kane, D. and Oster, C. 2018. Fear and blame in mental health nurses’ accounts of restrictive practices: Implications for the elimination of seclusion and restraint. International Journal of Mental Health Nursing. 27(5), pp.1511-1521.

National Institute for Clinical Excellence (NICE). 2015. Violence and aggression: short-term management in mental health, health and community settings (NG10). London: NICE.

United Nations. 2013. Report of the Special Rapporteur on torture and other cruel, inhuman or degrading treatment or punishment, Juan E. Méndez, 1 February 2013 (A/HRC/22/53). Para 78. Geneva: United Nations Human Rights Council (UNHRC).

World Health Organisation (WHO). 2017. Strategies to end the use of seclusion, restraint and other coercive practices. WHO QualityRights training to act, unite and empower for mental health (pilot version). Geneva: WHO.

Tickets Available – Reducing Restrictive Practices: Understanding Key Intervention Components

As we move into the final stages of COMPARE: Establishing components of programmes to reduce restrictive practices: an evidence synthesis, we are pleased to announce that we will share our findings at a dedicated event:

Reducing Restrictive Practices: Understanding Key Intervention Components

12.30-15.30 5 June 2019
Horizon Conference Centre, Leeds

We have identified and mapped over 100 interventions that have been implemented in various adult mental health settings across the world. A free, interactive directory will be made available following this event. Using a specially designed taxonomy, we were able to discern between the active components of a substantial proportion of these interventions. Consequently, for the first time, we will be able to indicate which intervention components have the most (or least) potential to reduce restrictive practices.

We will also introduce a new study that builds on and extends this work: CONTRAST: Establishing components of interventions to reduce restrictive practices with children and young people: an evidence synthesis. Here, we will seek to identify interventions to reduce restrictive practices with children in a range of residential settings.

“We particularly encourage service users and carers to come along and join in the discussion.”

A draft programme for the event can be found below. Please join us for a complimentary lunch from 12.30 onwards. We hope that we will be joined by a wide range of stakeholders with an interest in the reduction of restrictive practices for plenty of networking and discussion. We particularly encourage service users and carers to come along and join in the discussion and we can cover travel expenses for those who wish to do so. Please contact us to make arrangements.

If you have any questions about the event, please do not hesitate to contact us. For travel and parking information visit Horizon, Leeds

Tickets are available via Eventbrite.