The Ethics of Seclusion in Acute Psychiatric Care



The Ethics of Seclusion in Acute Psychiatric CareRoberta PowerStenberg CollegeThe Ethics of Seclusion in Acute Psychiatric CareOf the many issues that can be debated in the arena of psychiatric care, one of the most pressing is the use of seclusion. Seclusion is defined as, “…placing a service user in a locked room from which free exit is denied; it also involves isolation and the reduction of sensory stimuli” (Georgieva, Mulder, & Wierdsma, 2012, p. 2). This paper will look at three problems with the use of seclusion in acute inpatient psychiatric settings. The first one is the infringement of personal rights of a patient subjected to the practice of seclusion. The Canadian Charter of Rights and Freedoms states that everyone has the right not to be subjected to cruel and unusual treatment or punishment, and also the right to self-determination and autonomy (Charter of Rights website, 2006). The use of seclusion has questioned these rights. The second problem is there is little evidence in the literature that supports the use of seclusion as a therapeutic intervention. Despite this, the use is widespread throughout many countries. The Ministry of Health Canada (2012) produced a policy manual on the use of seclusion and noted, “At present, seclusion practices internationally are insufficiently regulated, especially given the high risk is poses to patient safety…” (Ministry of Health website, 2012, p. 14). The third problem is the nature of mental illness sometimes causes a person to become a danger to themselves or others, thus necessitating the use of seclusion despite the obvious ethical considerations. Based on review of the literature, seclusion as a therapeutic intervention is not an evidence-based practice and is only to be used in emergency situations. However, widespread use of seclusion is evident in many practice settings and is considered to be a necessary intervention, unlikely to be eliminated due to the behavioral issues often presented with mental illness and the lack of other options for staff.Rights and FreedomsCanadian society recognizes that people can expect certain personal rights and freedoms to be upheld. However, when a person poses a risk to either themselves or others those rights can be infringed upon for the good of all concerned. When a person’s actions become threatening due to a mental illness, their rights to autonomy and self-determination can be overridden. The Mental Health Act of British Columbia states that a person can be apprehended by police if upon observation, or reports from others, the person is acting in a manner that poses a danger to themselves or others (Ministry of Health website, 2005). A person may be involuntarily admitted to a medical facility if deemed in need of treatment by a physician. The theoretical guidance for these actions is referred to as bioethics which is a specific domain of ethics focusing on moral issues in the field of healthcare (Butts & Rich, 2005). Within the framework of bioethics are four guiding principles which include autonomy, beneficence, nonmaleficence, and justice (Butts & Rich, 2005). Patients receiving involuntary care may be unable or unwilling to choose what is deemed best for them, and as such, practices such as seclusion may be utilized. The process of overriding another’s wishes is referred to as paternalism and has negative connotations for patients (Butts & Rich, 2005). There is a fine line between doing what is best for a patient and infringing upon their right to autonomy. The practice of seclusion may be deemed as one of those occasions and, therefore, needs to be used only under careful scrutiny by nursing staff (Chaimowitz, 2011). “Restrictions on autonomy may occur in cases where there is a potential for harm to others through acts of violence…” (Butts & Rich, 2005, p. 12). As well, the principle of nonmaleficence has many implications in the area of healthcare, which primarily means ‘do no harm’; this includes avoiding negligent or harmful care (Butts & Rich, 2005). Considering the evidence-based opinions in the literature stating the use of seclusion does more harm than good, the question of whether it can ever be justified is a valid one. Chaimowitz’s (2011) position statement on the use of seclusion in psychiatry describes this ethical dilemma as such, “Ideally, no person should lose their right to liberty and freedom, but unfortunately, acute mental illness may make that impossible, albeit for brief periods” (p. 2). The balance between the rights of patients to autonomy and the rights of their carers to safety is at the heart of this debate.Lack of EvidenceOne can only imagine the feeling of being confined and isolated unwillingly. Add to this a patient likely in emotional distress, confused, or possibly frightened due to a psychosis. According to Tunde-Ayinmode & Little (2004), the majority of secluded patients had a diagnosis of schizophrenia in their study. The concept of isolating a patient, who may be experiencing hallucinations, or frightening delusions, is obviously questionable. Moreover, when trying to establish a therapeutic relationship with a patient, the primary goal of the nurse is to establish trust. If the nurse and care team resort to using seclusion as an intervention, that relationship may be readily undermined by this decision (Kontio et al., 2010). Although seclusion is a potent method of restraint and ensuring security of the unit, the trade-off may be significant emotional or physical distress of the patient (Tunde-Ayinmode & Little, 2004). Happell and Harrow (2010) contend that “…it is now generally agreed that seclusion is a coercive practice that has a detrimental impact on the well-being of consumers” (Happell & Harrow, 2010, p. 163). Tunde-Ayinmode & Little (2004) also revealed secluded patients stayed significantly longer in hospital compared with non-secluded patients. Despite this knowledge, its use is still justified as an intervention in the management of aggression or violence within the ward environment (Happell & Harrow, 2010). Georgieva et al., (2012) report in their study that patients’ perceptions of seclusion was most negative when they did not understand it and had no options for discussing it with others. Indeed, some of the patients questioned had no explanations given for their confinement. As well, Georgieva et al., (2012) suggests debriefing with the patient should always take place after the fact to minimize the emotional impact, and this was done in only 67% of their study subjects. The decision to use seclusion is based on the idea that the low stimulation and isolation will be able to calm an ‘out of control’ patient. In contrast, Kontio et al., (2010) state “…there is a lack of evidence regarding the clinical effectiveness of seclusion or restraint in reducing or alleviating patients’ aggressive behavior or serious mental disorders” (p. 66). Unfortunately, seclusion is seen as one of the few options open to staff to manage violence or aggression (Happell & Harrow, 2010). According to Muir-Cochrane (2009), “The literature suggests that patients often associate seclusion with punishment…” (p. 235). As well, an American study found the majority of patients questioned (64%) preferred medication over seclusion as a choice for intervention (Georgieva et al., 2012). Ideally, the patient’s preferences would be considered in their care plan to ensure a more patient-centered method of treatment.The Realities in PracticeIn mental health settings, it is estimated between 64% and 80% of staff are assaulted while at work (Muir-Cochrane, 2009, p. 231). In light of this, it is imperative nursing staff receive adequate training in dealing with aggression and violence, but this does not seem to be the case. As seclusion is supposed to be a last resort to contain a patient who is violent, or threatening violence, it has been suggested there is a failure in the prediction and assessment of patients as they are escalating (Happell & Harrow, 2010). Jayaram, Samuels, & Konrad (2012) identified improving staff ability to detect precursors of violence, and utilizing diversion techniques and alternate coping methods as just some of the ways seclusion can be reduced in inpatient settings. Since the decision to seclude is primarily a nursing responsibility, “…the support of nurses for reduction strategies is a crucial component for the success of any initiatives” (Happell & Harrow, 2010, p. 166). It stands to reason when nurses are afraid of patients they will avoid them. According to Muir-Cochrane (2009), “Without education and skills training, nurses tend to respond to inappropriate and aggressive behaviors as they would outside of the work environment” (p. 232). This may explain the prevalence in the use of seclusion in that a great deal of skill in de-escalation techniques is required to be effective at interventions other than seclusion. In most areas of practice, aggressive behavior can be expected; therefore appropriate training will decrease fear and hostility and will also help staff maintain a therapeutic environment (Muir-Cochrane, 2009). Happell & Harrow (2010) reports that shifts with a higher proportion of female staff, as well as nurses with less education and training, tend to seclude patients more often than more experienced nurses. Thus, a higher level of nursing skill has been identified as important in reducing the necessity to physically constrain patients. Tunde-Ayinmode & Little (2004) also agree that “Improvement in the skill of staff in predicting violent behavior, in self-defence, and better verbal and pharmacological interventions, may enable seclusion to be delayed, suspended or avoided” (p. 351). It appears the ethical dilemma some staff feel associated with seclusion does not translate into practice, possibly due to these reasons. Meaningful activity and regular conversation with patients throughout the day were also recommendations to help reduce anxiety on the units as Kontio et al., (2010) explains, “…idle days cause patients frustration, which could contribute to aggressive behavior on the ward” (p. 71). Overall, it seems much more could be done on the part of nursing education and in improving the ward environment to help reduce the instances and prevalence of seclusion interventions. SummaryIt is clear that although the use of seclusion in practice is considered contrary to therapeutic treatment, it is still a prevalent intervention despite its ethical implications. Society has come to know and expect basic rights and freedoms, so when these rights are overridden due to mental illness, it must be done in such a way that preserves human dignity. Most countries, including Canada, have strict guidelines regarding the overriding of patient autonomy, and practices such as seclusion are considered to be an intervention of last resort for emergency purposes only. As this policy is not reflected in practice in the literature, other factors contributing to its continued use must be examined. The therapeutic value of seclusion has been questioned and literature has shown that the practice is actually harmful and perceived as punitive by most patients. Secluded patients have also been shown to have longer hospital stays, compared with non-secluded patients. The overuse of seclusion may be an indication of inadequate training of staff, poor assessment of patients and recognition of their triggers for aggression, or little opportunity for structured activity throughout the day (Tunde-Ayinmode & Little, 2004). Complete elimination of seclusion may not be practical, but there seems to be a clear need for alternative considerations and a more patient-centered focus. In keeping with the right to autonomy and self-determination, collaborating with patients about their care plans and offering choices as to what interventions may be of most therapeutic value to them should be discussed well before actions need to be taken. Maintaining the therapeutic relationship with patients appears more likely if trust is not broken by coercive interventions. Jayaram et al., (2012) maintains that it is possible to predict the need for seclusion among inpatients with a systematic approach and proper training of staff. Through adequate assessment, regular communication between nurses and patients, an adequately structured milieu, and staff education and skill in alternative techniques, the need for seclusion would likely decrease dramatically. ReferencesButts, J., & Rich, K. (2005). Nursing ethics: Across the curriculum and into practice. Sudbury, MA: Jones and Bartlett.Chaimowitz, G. (2011). The use of seclusion and restraint in psychiatry. The Canadian Journal of Psychiatry, 56(8), 1-2. Retrieved from of Rights website. (2006). charterofrights.caGeorgieva, I., Mulder, C. L., & Wierdsma, A. (2012, April 24). Patients’ preference and experiences of forced medication and seclusion. Psychiatric Quarterly, 83(1), 1-13. , B., & Harrow, A. (2010). Nurses’ attitudes to the use of seclusion: A review of the literature. International Journal of Mental Health Nursing, 19, 162-168. , G., Samuels, J., & Konrad, S. S. (2012, July-August). Prediction and prevention of aggression and seclusion by early screening and comprehensive seclusion documentation. Innovations in Clinical Neuroscience, 9(7-8), 30-38. Retrieved from , R., Valimaki, M., Putkonen, H., Kuosmanen, L., Scott, A., & Joffe, G. (2010). Patient restrictions: Are there ethical alternatives to seclusion and restraint? Nursing Ethics, 17(1), 65-76. of Health website. (2005). of Health website. (2012). , E. (2009). Psychiatric mental health nursing: The craft of caring (2nd ed.). P. Barker (Ed.). London, United Kingdom: Edward Arnold.Tunde-Ayinmode, M., & Little, J. (2004, December). Use of seclusion in a psychiatric acute inpatient unit. Australasian Psychiatry, 12(4), 347-351. Retrieved from ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download