The purpose of this study was to investigate the experience of seclusion (without physical restraint) from the perspective of inpatient psychiatric patients in the midwestern United States. The appropriateness of seclusion with or without restraint as an intervention for violence in inpatient psychiatric settings has received widespread attention from political, ethical, legal, and clinical standpoints over the past 3 decades (American Psychiatric Nurses Association Seclusion and Restraint Task Force, 2007; Appelbaum, 1999; Carmel & Hunter, 1989; Higgins & Hanna, 2000). The American Psychiatric Association (2000) proposed federal guidelines for seclusion and restraint that were enacted in 1999. The guidelines reinforce that the only acceptable use of seclusion and restraint is for imminent danger to self or others. Although nurses in psychiatric settings have many important roles, maintaining a safe and secure environment has always been a priority. It is this priority that brings the controversial practice of seclusion to the forefront.
Seclusion is the practice of placing an aggressive or violent patient in a specifically designated safe room where they can be carefully observed by staff for short-term management of his or her inappropriate behavior. It has been suggested that seclusion includes three important elements: containment, isolation, and reduction in sensory stimuli (Gutheil, 1978). Despite significant advances in our understanding of mental illness, physical mechanisms such as seclusion are still used to control disruptive patients. Proponents for seclusion argue that this practice helps the patient feel safe from external stimuli that may have contributed to the disruptive behavior. Current literature regarding patients’ perceptions of seclusion is limited, especially in the United States.
Seclusion prevalence statistics in the United States are outdated, but have been reported to range anywhere from 2% to 66% of all admitted patients to psychiatric units (Fisher, 1994; Legris, Walters, & Browne, 1999). A more recent study from Canada reported that of 2,127 psychiatric inpatients hospitalized, 23.2% were secluded with or without restraint (Dumais, Larue, Drapeau, Ménard, & Giguére Allard, 2011). Restraint data, not including seclusion, have been collected since 2006 with the National Database of Nursing Quality Indicators. Legris et al. (1999) found that although seclusion itself was not associated with improvement in mental status at discharge, it was associated with a 12-day increase in length of stay.
The Joint Commission monitors quality measures for seclusion. One of the quality measures for the midwestern hospital in the current study was to decrease the amount of time a patient is in seclusion for behavioral reasons to ⩽2 hours. There was a 50% success rate. Other indicators monitored include regulatory requirements from the Joint Commission and Centers for Medicare & Medicaid Services (CMS): (a) presence of order; (b) face-to-face for seclusion for violent behavior; (c) alternatives to seclusion; and (d) monitoring during seclusion including psychological status; physical safety and comfort; circulation, motion, and sensation; skin condition; hydration; nutrition; and elimination. Reasons cited justifying seclusion included withdrawing the patient from an overstimulating environment and preventing endangerment of self or others. Meehan, Bergen, and Fjeldsoe (2004) demonstrated that differences existed in patient and staff perceptions of seclusion. Nurses believed seclusion was not punitive, but a necessary therapeutic practice to assist patients in calming down and keeping the inpatient unit safe. However, patients believed seclusion was used as a means for staff to punish them and exert power and control. Thus, patients did not believe seclusion had a therapeutic benefit. Keski-Valkama, Koivisto, Eronen, and Kaltiala-Heino (2010) found more than half of the patients regarded being secluded as a negative experience. In a systematic review, Nelstrop et al. (2006) found insufficient evidence to determine the safety and effectiveness of seclusion for the short-term management of disturbed or violent behavior in adult psychiatric patients. Nelstrop et al. cautioned that seclusion should only be used as a last resort after other methods of calming a patient or situation have failed. Mason (1994) concluded that seclusion is inhumane and associated with control, power, and punishment.
Seven relatively recent qualitative studies from Australia, New Zealand, Canada, Africa, the Netherlands, and Finland have explored inpatient psychiatric patients’ experiences of seclusion. Review of this global literature identified the following eight common themes related to psychiatric inpatients’ perceptions of seclusion and restraint: (a) punishment or violation of human rights by being imprisoned/abandoned/kept at a distance from staff without proper care or information about seclusion; (b) perception of seclusion as inappropriate with unjustifiable uses of force; (c) sensory deprivation demonstrated by heightened awareness of sounds, dysfunctional thought patterns and feelings of losing control, difficulty judging time, and boredom; (d) emotional impact in the form of predominant negative feelings of fear/anger/hurt, sadness, frustration/powerlessness, and vulnerability versus a positive sense of calm from a safe environment; (e) negative coping strategies such as regressing, crying, expressing anger, resisting staff with defiant or acting out behavior, attention-seeking behavior; (f) autonomy or powerlessness with regard to nursing staff; (g) lack of trust manifested by the firm belief in the reliability of a person; and (h) loneliness or the drastic restriction of relationships with others (El-Badri & Mellsop, 2008; Hoekstra, Lendemeijer, & Jansen, 2004; Holmes, Kennedy, & Perron, 2004; Keski-Valkama et al., 2010; Kontio et al., 2012; Meehan, Vermeer, & Windsor, 2000; Ntsaba & Havenga, 2007).
Only two published studies on seclusion have been conducted in the United States. Richardson (1987) examined the experiences of inpatient psychiatric patients within 3 days after the episode of seclusion using a structured questionnaire. Patients were interviewed after they were released from seclusion. The questionnaire focused on patient experiences prior, during, and after seclusion. The majority of patients responded that prior to seclusion, the most overwhelming emotions were anger, hate, worry, loneliness, feeling trapped, and frustration. Some patients reported feeling that they wanted to hurt themselves or others. During the seclusion process, the majority of patients reported feeling anger and some reported feeling better. After seclusion, patients reported thinking about getting out of the hospital, family, being glad to be out of seclusion, feeling better, and taking medication. The majority of patients said other patients needed to be secluded and half the patients reported that they needed to be secluded.
In an exploratory, descriptive study of 20 inpatients on a psychiatric unit, Norris and Kennedy (1992) examined patients’ perceptions of seclusion related to sensory stimuli. In addition, the researchers compared patient–nurse reasons for seclusion, feelings of patients’ behavior during seclusion, and patients’ suggestions for improvement of the seclusion process. The majority of patients found the space around them in seclusion to be claustrophobic, degrading, and threatening. Nurses perceived numerous reasons for seclusion, whereas patients thought there was only one reason (e.g., being misunderstood or out of control). Patients described strong feelings and emotions during the seclusion process and most thought they should have gotten control of their behavior or avoided staff using seclusion on a regular basis. In a comparison study by Keski-Valkama et al. (2010), patients proposed at least one alternative to seclusion that potentially would have been more helpful. The most common alternative was resting in one’s own room followed by verbal de-escalation, medication, and activities. Patients also wanted more comforting interaction with staff, less regulated use of toilet facilities, and shorter duration of seclusion episodes.
A phenomenological approach was used in the current study to answer the research question: What is the lived experience of inpatient psychiatric patients who are placed in seclusion? Phenomenology as an inductive research method is defined as follows: the study of the lived experiences, the explication of phenomena as they present themselves to consciousness, the study of essences and the description of experiential meaning, the study of phenomena in human science, and the search for what it means to be human (Van Manen, 1990).
In-depth, unstructured interviews were conducted with inpatient psychiatric patients upon completion of a seclusion episode. In phenomenological research, 6 to 12 participants are suggested for an intensive investigation of the particular experience (Morse, 1994). We approached 51 patients who were secluded in the 2-year time frame of our study. Of the 51 patients, only 12 met inclusion criteria and agreed to participate in the study. Inclusion criteria for the study were current cooperation with the treatment plan; active participation in unit programs; no further physical or verbal abuse of staff, patients, or visitors on the unit; and no further threat or harm to self or others. Exclusion criteria were patients who were developmentally delayed; non-English speaking; not oriented with reality at the time of the interview; and not secluded.
The study was approved by our institution’s institutional review board where data were collected and informed consent was obtained prior to each interview. Interviews occurred at least 24 hours after the seclusion episode, but before 7 days, to allow patients to process their emotions and allow any anger to dissipate so they were able to freely share their experience. Interviews lasted approximately 1 hour and took place in a closed conference room off the mental health unit for patient privacy. Interviews were conducted by a psychiatric social worker with expertise in interviewing who was not involved in the patients’ care prior to or after the seclusion episode.
Each interview was audiorecorded and transcribed verbatim into written text for analysis. The grand tour question was: “I understand that you were recently placed in seclusion. Please tell me your story and how you felt during this experience.” Probing questions were asked in three areas if not addressed by the patient, including: (a) What interventions could have prevented the seclusion?; (b) How were you treated during seclusion?; and (c) Were there any comfort measures that were missing during seclusion that could have supported you? Other questions were asked only for clarification purposes.
The interview text was analyzed by adapting Van Manen’s (1990) phenomenological approach for text analysis. Van Manen (1990) contends that the fundamental level of human existence can be captured in themes representing the phenomenon; the themes can be differentiated but not separated and form an intricate unity (e.g., the experience of inpatient psychiatric patients who are placed in seclusion). As the initial step in data analysis, each transcript was read multiple times to “get a sense of the whole” and then each transcript was coded line by line to compile common categories. The categories were further analyzed by question posing and reflecting on the text to arrive at common themes. Interpretations of the themes were then written. The themes and their respective interpretations were reread and revised considering the text, and exemplars illustrating each theme were added.
Rigor in the study was attended to by using Lincoln and Guba’s (1985) evaluation criteria for qualitative research (Polit & Beck, 2008). Credibility and dependability were addressed by a well thought-out research design written as a guide that was implemented to complete the study in terms of participant selection, data collection, and plans for analysis of the text that enhanced believability of the findings. Confirmability was achieved by using a three-member research team during the analysis phase who worked together to come to a consensus on the interpretation and ensure the findings were grounded in the text. Transferability was achieved by providing descriptions in the findings so that others can evaluate the transfer of findings to other contexts. Authenticity was addressed by writing evocative and compelling descriptions that reflected the multiple realities of the experiences. Auditability was maintained by mapping the interpretations of key decision points in the analysis.
Of the 12 participants, 6 were men and 6 were women, ranging in age from 18 to 50 (mean age = 33). Eight participants were Caucasian, 2 were Native American, and 2 were African American. Primary diagnoses of the participants included bipolar disorders, posttraumatic stress disorder (PTSD), major depression, substance abuse, and borderline personality disorder. Three themes emerged from the analysis of the text: (a) Patient Hope for Respect and Open Communication; (b) Patient Emotional Response to the Seclusion Process; and (c) Patient Insight Into Behavior and the Importance of Positive Coping Skills. Patients’ perceptions of the need for open communication and respect emerged as the central concern or essence of their experience of seclusion. The importance of the need for a therapeutic communication process is clearly evident in each of the three themes.
Theme One: Patient Hope for Respect and Open Communication
In all of the texts, patients discussed their hope and expectations for being respected by staff during and after the seclusion process. All patients commented that they desired open communication about their individual needs. Open communication meant talking about the patient’s feelings and individual problem before his or her behavior escalated and could not be controlled. Patients wanted to discuss their inappropriate behavior and be given a chance to calm down before seclusion was used:
Well, I’d like to find out what I did in the first place. I mean, if he would have come to me, he could have at least approached me like a responsible adult, and he could just come up to me with “Sir” or call me by my name, or whatever, “Hey, could you just calm your swearing down?” or “Are you angry or is something bothering you?”
Patients asked questions about the possibilities of working with staff to come up with an alternative solution to seclusion while they perceived their behavior was still manageable. Patients spoke about how they liked to be asked to do something instead of being told what to do. Patients also talked about the possibility of being offered as-needed (PRN) medications earlier to control behaviors. They wanted staff to know their specific medical and psychiatric background and history and believed this was imperative to understanding their personal needs and idiosyncrasies (e.g., claustrophobia): “I know that I don’t like to be told what to do. I like to be asked if I would do something, rather than told to do it. That approach to me would have been able to avoid seclusion completely.” Another patient commented:
I feel that if they would have known that I was claustrophobic and a little of my background, the outcome could have been different. I mean, being cooped up in one floor, you can’t really exercise. And that’s how I was trying; normally I would blow off the steam that away. I would go for a leisurely jog or walk, but you know, I can’t do that in here.
Patients felt respected by staff when they did not feel violated during the seclusion episode. When staff explained the reason for seclusion, such as unsafe behavior towards self and others, the patient felt respected during the process. Being attended to and not ignored during the seclusion was important to patients. Being given a timetable of when staff would return to check on the patient in seclusion was viewed as respectful:
That’s why I didn’t put up a fight or nothing, she explained the process.… Then the nurse said, “Well you seem like you’re doing better.” And she said, “I’ll be back in 30 minutes, and if you feel like you want to get out, you can get out.” And I was like, alright that’s fair enough.
Theme Two: Patient Emotional Response to the Seclusion Process
Patients had multiple reactions to the seclusion process. Primarily, patients discussed accelerating emotions such as anxiety, anger, hurt, and humiliation. Some patients described their behavior as so out of control they ended up hurting themselves prior to and when in seclusion. They told stories of being secluded for long periods of time after calming down and being cooperative. One patient described feeling so angry she was not able to control her behavior: “And that’s another thing… that’s out of control behavior, is when you are fighting so hard that you hurt yourself. That’s really out of control.”
It was about 3 a.m. when this happened, and I can’t sleep very well. I have night terrors from my PTSD. So, basically after I was in the seclusion room until about 7:00 or 8:00 in the morning. I don’t know; it was by the time the next shift came on I was locked in that seclusion room. I was awake the whole time I was in there. I was not threatening anybody.
Patients reported feeling ignored while in seclusion. Many perceived that staff did not check on them while in the seclusion room. Others perceived that their needs were not met and their rights were violated. Patients specifically described not being offered fluids, feeling cold, not being offered bathroom privileges, unclean surroundings, crying, and not given a tissue when asked. This patient describes neglect to the point of being incontinent:
I don’t ever have a problem urinating myself, never. I could use the bathroom just fine, I can talk just fine, I can walk just fine. But, to urinate myself and do that just because I was not given the chance to use the bathroom.… They refused to come and talk to me. They refused to give me a blanket. They refused to let me go to the bathroom. They refused to give me a pillow. They refused everything. All my rights were gone.
Patients perceived that staff were talking about them in a negative way and mocking them and laughing at them during the seclusion process. This was another source of resentment. Some patients perceived that they did not need seclusion and felt this was used as punishment:
They would not do anything for me, they just kind of basically were laughing. That almost set me off again, because, you know, these are your nurses, they are supposed to be taking care of you, and you don’t feel like you are being taken care of when someone is making fun or laughing at your situation.
Patients complained that treatment measures were forced on them unnecessarily and they were not listened to when relating their medical histories, symptoms, and methods of coping. They felt disrespected, mistreated, and hurt by the fact that someone in a power position would treat them “unfairly.” Security complaints were another significant power issue. Patients told stories of being secluded by security guards after making the right choices and calming down. The patient below describes an instance where she was physically hurt by security guards while being put into seclusion:
Oh, they [the staff] said she’s out of control when I’m just having fun, joking around with a few patients. I just wish he would have come up to me and asked me politely, and said, Hey, you know? What’s going on?
Then they [security guards] proceeded to spread me out on the bed, and they’re jamming knees into my shoulders and holding me on the bed, twisting my legs up behind me. It was the most uncomfortable and painful thing I’ve ever experienced. I yelled constantly, “I’m done! I’m done, okay! Let me go! I’m not going to do anything”—and then I was put into the seclusion room.
Theme Three: Patient Insight into Behavior and the Importance of Positive Coping Skills
Many patients expressed the importance of talking over the incident leading to seclusion after the episode, and they stated this was not commonly done. Patients also discussed their need to be given time to talk to staff early, before their behavior escalated and before the seclusion occurred. Most patients agreed that if there was a chance for early communication with staff they would have been able to discuss their individual situation and calm down by themselves. If there was no debriefing done before or after the seclusion incident, patients stated this impeded their ability to learn from the event.
A main strategy used by patients to calm down was talking to other peers on the unit. Social support from peers was a coping mechanism used by patients when they felt their behavior was getting out of control. Patients discussed the benefits of social support from peers, family friends, and staff who could relate to their needs and mental health issues. Many patients had been through behavior modification and anger management education classes and believed they could draw on this education when necessary: “Because I have a lot of frustration…I have already learned a lot of these [coping] behaviors. I’ve kind of taught myself the ropes and how to cope, and it’s being re-emphasized.”
Patients who did debrief with staff after the seclusion discussed how they could have used their coping skills to avoid seclusion before their behavior escalated. They mentioned that if staff pointed out appropriate coping skills prior to their behavior escalating they could have avoided seclusion. Patients discussed numerous types of coping skills that they could have benefited from prior to seclusion, including dialogue with the staff to identify possible triggers leading to agitation, removing oneself from a stressful situation when his or her behavior was escalating, and thinking about consequences prior to the acting-out behavior:
I’m sure I could have done my part to use better coping skills, I guess, to alleviate that. But, before they put me in there, I was just trying to blow off steam. In my workbooks, it said you could punch a pillow if you feel frustrated. That is what I was doing, and they had a problem with that, so then they put me in there. So that’s how that happened.
Looking back on it, I probably could have calmed myself down if I would have done something positive, maybe. I just think being in a unit for what would have been like 2 weeks on that day, it’s just…I was, like, kind of craving for something to change [for the better].
Although aggressive and violent behavior is a common reality in inpatient psychiatric settings, it is alarming that patients’ perceptions of the seclusion process found in this research study has changed little in 3 decades. The findings of this study echoed the findings of numerous other studies about how psychiatric inpatients perceive seclusion. Patients in this study, similar to previous studies conducted around the world, discussed perceptions of accelerating emotions that ranged from anxiety and anger to hurt and humiliation. They told stories of being secluded for long periods of time, not having their needs met, feeling ignored, and hearing staff talk about them in a negative way. Some patients reported that seclusion was used as punishment and staff were in a position of power and treated them unfairly.
Patients felt respected when they were attended to—not ignored—during seclusion and given a timetable of when staff would return to check on them. All of the emotional/physical/social responses and perceptions of violated autonomy are discussed in the second theme, Patient Emotional Response to the Seclusion Process. Patients perceived communication as the central issue or essence of their experience of seclusion—either positive or negative.
All patients in this study had expectations of having open respectful communication with staff before, during, or after seclusion. The majority of patients believed their seclusion experience could have been prevented by talking about the meaning of their feelings and the problem before their behavior escalated beyond control. They wanted to discuss alternative solutions and coping skills to deal with their feelings while their behavior was still manageable. Patients believed it was imperative that staff understood their medical, social, and psychiatric histories so needs could be met individually. The need to be treated as an individual came through strongly in the findings above. These findings suggest that attention to the individual’s needs in that short but critical time before the patient’s behavior escalates may prevent aggressive behavior that gets out of control.
Qualitative research literature on the practice of experienced nurses in managing aggressive and violent behavior in in-patient psychiatric settings holds promise for preventing and dealing with the seclusion process and parallels the findings of this study. McElroy (1996) and Cutcliffe (1997) reported studies of experienced psychiatric nurses that emphasized the primacy of the nurse–patient relationship and the importance of communication in this relationship to understand individual patient, nurse–patient boundaries, connections, and relationships. A compelling phenomenological investigation studied how experienced nurses de-escalate psychiatric inpatients. Johnson and Hauser (2001) described the quality of escalating patient behaviors as contextual, where intervening with patients requires understanding the meaning of subtle behavior patterns and where interventions must be based on the context of the situation. The researchers outline these critical patterns of action to de-escalate a patient based on principles of communication and interpretation that may lead to individualized interventions other than seclusion. These findings have major implications for communicating effectively with patients and suggest that prevention of escalating behavior is key.
The findings of this study also point to the need for debriefing with patients after a seclusion episode. Many patients expressed concern about not being given the chance to debrief with staff after being secluded. They believed that having a dialogue with staff could have helped identify their inappropriate behavior, specific triggers, and positive coping skills to use in the future.
Limitations of this study include investigating the seclusion experience of inpatient psychiatric patients in one hospital in the midwestern United States. Using one facility for data collection limits the transferability of the findings to different psychiatric units, unit cultures, and psychiatric hospitals. Interviewing inpatients with a diagnosis of mental illness can be challenging because of their varying abilities to articulate their experiences. The study findings underscore and support the findings of the dated literature on seclusion.
Conclusion and Implications for Nursing Practice
First and foremost, the findings support the importance of one-to-one, patient–nurse communication prior to escalating patient behavior. Knowing individual patient’s histories and behavior patterns is critical nursing knowledge and will help effectively manage a patient’s situation so that escalating behavior or agitation can be managed. Nurses must be attentive to patient needs during the seclusion process and offer support frequently so that the patient feels respected and cared for during the process. PRN medications need to be offered during seclusion to calm patient behavior and decrease length of time spent in seclusion. Nurses need to explain the reason for use of seclusion and ensure the patient’s understanding of the problem. Debriefing after the seclusion episode and frequent reinforcement is essential in assisting patients to move forward and understand behaviors. Nurses need to routinely teach effective coping skills to patients throughout their hospitalization in an effort to prevent the reoccurrence of escalating behavior leading to seclusion and restraint.
Through this study we were able to further highlight the importance of continued education for staff nurses to safely care for this population. Studies show that real-life seclusion events provide a more effective learning environment when compared to historical data and statistical analysis of the seclusion process. It is the goal of the mental health profession to understand the reasons these seclusion episodes occur to directly take steps to eliminate the need for the seclusion process entirely.
Staff member debriefing after the seclusion event is important to the process, allowing time for discussion to highlight what was done correctly and to uncover opportunities for improvement. Time should be allotted at staff meetings to review past episodes requiring seclusion. It is important for all staff, both present and absent from the incident, to have the opportunity to learn from past episodes to positively influence nursing practice.
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