Journal of Child and Adolescent Psychiatric Nursing , Oct-Dec 2001 by Finke, Linda M
TOPIC. Published articles on the use of seclusion in psychiatric care.
PURPOSE. To present the argument that the use of seclusion in the psychiatric care of children is not evidence-based practice.
SOURCE. Review of the scientific study literature of the last 30 years on the use of seclusion.
CONCULSION. The scientific evidence available illustrates that the use of selcusion with children is not therapeutic and is, in fact, harmful to patients.
Search terms: Isolation, Seclusion, solitary cofinement
In ancient Greece, those who behaved in what was deemed an inappropriate manner were exiled from society. It is said that this form of sanction was viewed as such a horrible punishment that Socrates chose to drink poison rather than suffer such banishment, a form of isolation or seclusion. The same conclusion can be drawn from the use of solitary confinement in the penal system. Throughout history, the worst punishment deemed possible in prisons is seclusion/solitary confinement. In psychiatric care, patients who behave inappropriately are placed in seclusion. Perhaps the only thing different in psychiatric care is that we call seclusion therapeutic.
The use of seclusion remains common practice in psychiatric care (Lendemeijer & Shortridge-Baggett, 1997). The purpose of this article is not to repeat the numerous reviews of the literature on seclusion that have been conducted (Brown & Tooke, 1992; Fisher, 1994; Lendemeijer & Shortridge-Baggett; Sailas & Fenton, 2000) but to present the case that the use of seclusion in the psychiatric care of children is not evidence-based practice. This article will further document that the research has found seclusion to be harmful to patients and not related to positive patient outcomes.
Discussions of restraints and seclusion frequently pair the two interventions as though they are closely linked. Moreover, the literature often speaks of both as if they are the same intervention. The use of restraints in psychiatric settings has received wide discussion, and there has been some reluctant change in practice. The use of seclusion as an intervention has received less attention but needs the same scrutiny. This is especially true when the use of seclusion is implemented with children, a particularly vulnerable population. This article summarizes the available literature on the use of evidence-based seclusion practices.
Definitions
Seclusion. The definition of seclusion can vary, but usually the term refers to some form of isolation. The isolation may occur in a locked, bare room or it may take place within the confines of a patient's room. It may entail a requirement to sit in a chair or involve serving a time-out period (Miller, 1986). Seclusion also means some form of involuntary or voluntary confinement (Lendemeijer & Shortridge-Baggett, 1997). Timeout rooms are considered seclusion by most authors (Landau & MacLeish, 1988). Landau and MacLeish also state that the legal definition of seclusion in most states equates with isolation. For the purposes of this paper, a broad definition of isolation is used that includes all forms of isolation, including being sent to one's room or time-out.
Evidence-based practice. According to Brown (1999), evidenced-based practice involves the critical review of research findings to evaluate their usefulness in patient care. Ingersoll (2000) further contends that evidenced-based nursing practice is theory-driven, research-informed decision making. It follows that the use of seclusion in psychiatric care would need to be theory based and supported by research findings to be deemed evidence-based practice.
Seclusion and Research Findings
Numerous articles in the literature theorize and present philosophies about the need for seclusion with psychiatric patients. The majority are not supported in any way with research. Further, most of the research that has been conducted on the use of seclusion has been chart reviews that record the demographics of patients or count the documented use of seclusion. Few research studies are available that incorporate a methodology that includes some kind of rigor able to support generalized conclusions. Such methodological rigor could include control groups or even measured patient outcomes. Sailas and Fenton (2000) conducted a review of 2,155 citations from 1974 to 1999 and found not one controlled study of seclusion. The published research also does not have a theoretical foundation. No attempt has been made to connect theory with research methodology when studying seclusion.
Child-Related Research
To add to the concern about methodology, the majority of the research examining the use of seclusion in the psychiatric setting has been done with adult patients. Little research has examined the use of seclusion with children; therefore, clinicians are left in part to draw conclusions from studies of adult patients.
Miller (1986) is one of the few researchers who have examined the use of seclusion specifically with children. His definition of seclusion ranged from use of a locked isolation room, to sitting on a chair, to being sent to one's room. The 40 children included in the study, ranging in age from 5 to 13, were asked to draw and comment about seclusion or time-out. The pictures they drew that portrayed people did not seem to convey the concept of children gaining self-control while in seclusion, but rather conveyed punishment, where the child was crying and pleading for help. The children's descriptions of seclusion also included feeling very afraid and abandoned.
Millstein and Cotton (1990) also conducted a study specifically exploring the use of seclusion with 102 children. These investigators found that children who were secluded in a child psychiatric inpatient unit in a general hospital were more likely to have a history of physical abuse, neurological impairment, lower verbal skills, and suicide attempts than those who were not secluded. They found that seclusion was used more frequently on Mondays and Wednesdays, when staff members were the busiest, and during the most stimulating and demanding times on the unit. They further found that the use of seclusion did not differentiate among the children in their ability to cope with the environment using the Adaptive Behavior Index. They also found an increase in the time a child spent in seclusion with each occurrence, rather than the expected decrease in time related to learning new behavior from the experience.
Irwin (1987) approached the use of seclusion with a different strategy. The study was conducted to explore the effect of avoiding the use of seclusion on a child psychiatric unit with 21 patients in Providence, RI. Interventions such as negotiation, avoidance of power struggles, de-escalation, relaxation techniques, and the teaching of positive coping strategies were used to replace seclusion. The study, conducted over 8 months, concluded that a safe and therapeutic milieu could be organized to care for children without the use of seclusion.
Tsemberis and Sullivan (1988) studied the introduction of a seclusion room to reduce the use of a "straitjacket" on a children's unit in a large municipal hospital. First, they found that the use of seclusion did not decrease the use of restraints. Second, the isolation of the children from staff and peers had a negative psychological effect on the children.
Adult-Related Research
Mattson and Sacks (1978) studied the use of seclusion in a private psychiatric hospital and found that staff tended to view the use of seclusion as a strategy to control the therapeutic milieu instead of as an intensive care environment in which the patients should be carefully monitored.
Schwab and Lahmeyer (1979) conducted a study of a busy inpatient psychiatric unit with 300 patients (age range 13 - 78 years) in Chicago over a 6-month period. It is important to note they found that younger patients were secluded more often than older patients. Thirty-six percent of the patients were placed in seclusion during their hospitalization. The reasons given by staff for using seclusion were "dissimulation, agitation, and poor impulse control," but the investigators found that seclusion was used most often during the night (10 P.M. to 2 A.M.), when the unit census was high and staffing was low. Patients who were placed in seclusion were younger, hospitalized longer, more manic, and on more medications.
Converting, Pinto, and Fiester (1980), in a study of adult patients in a large, community mental health center, also found a relationship between the use of seclusion and staffing patterns. They called for national standards concerning the use of seclusion to ensure the intervention was safe and humane. Phillips and Nasr (1983) drew similar conclusions from their study of patients in an inpatient state psychiatric hospital.
Soloff and Turner (1981) studied patterns of seclusion and found no relationship between seclusion and the mental status and diagnosis of patients. Rather, seclusion's purpose was to contain possible threat of assaults on staff, and there was a strong cultural bias toward secluding committed, chronically ill, and black patients.
Brown and Tooke (1992) reached similar conclusions. They found that the data available on the use of seclusion did not distinguish seclusion as a treatment from seclusion as a tool of social control. Again, wheras staff stated that patients were placed in seclusion due to agitation and violence, the data pointed to staff and unit factors more than to the violent or agitated behavior of patients. The authors also brought attention to the fact that patients often were secluded on admission without the possibility of appropriate assessment and intervention beofre its use. Brown and Tooke stated, based on their review:
No systematic or controlled evaluations have been undertaken of the effectiveness of seclusion relative to other strategies in achieving its intended goals, whether a) to avert violence and prevent injury, b) to maintain a therapeutic milieu, or c) to benefit the secluded patient." (p. 717)
Fisher (1994) conducted a review of the research literature that reinforced the previous findings. He concluded that the use of seclusion, although widespread, was harmful to patients. He stated that cultural biases, staff role perception, and administrator attitudes had a greater influence on the use of seclusion than patient demographics or clinical factors.
LeGris, Walters, and Browne (1999) conducted a chart review of a patient sample of 85 adults in a Canadian inpatient psychiatric setting. They found no difference in mental status at discharge after the use of seclusion, but did find a 12-day increase in length of hospital stay. These researchers also found, as did previous findings, that the patients who were younger and on more medication tended to be secluded more. Patient gender, diagnosis, and number of previous admissions did not differ between the secluded group of patients and those not secluded.
Patient View of Seclusion Experience
Studies that examined the patient view of being in seclusion consistently found that seclusion is a very negative experience and is seen as punishment (Binder & McCoy, 1983; Brown & Tooke, 1992; Fisher, 1994; Heyman, 1987; LeGris et al., 1999; Martinez, Grimm, & Adamson, 1999; Meehan, Vermeer, & Windsor, 2000). LeGris et al. found, as did previous researchers, that patients perceived seclusion to be very uncomfortable and nontherapeutic. The patients also felt that the negative experience produced negative behavior. Patients saw the use of seclusion as a reaction to poor staffing and the lack of a therapeutic milieu. One patient described her experience in seclusion as being led "naked and without armor" to seclusion to think about the "lie they have given me to live" (Fisher, p. 1585).
Martinez et al. (1999) conducted a study specifically examining the experience of seclusion from the patient's perspective. The population these nurses studied included 15 children, 13 adolescents, and 41 adults in a Denver psychiatric setting. As in other studies, patients stated that they experienced vulnerability, neglect, and a sense of punishment while in seclusion. Both patient groups -- those secluded and those not - expressed concern that seclusion was used too much. Patients who were secluded also stated that anger and agitation were a result of being placed in seclusion. Secluded patients expressed feelings of fear, rejection, boredom, and claustrophobia. Mann, Wise, and Shay (1993) studied the views of 50 patients shortly after they were "released" from seclusion and found similar conclusions.
The conclusion that can be drawn from the current literature is that the use of seclusion on a child psychiatric unit is not evidenced-based practice.
Nursing Implications
Allen (2000) conducted a literature search of nurses' attitudes about the therapeutics of seclusion. He found that nurses still have a positive view of seclusion in spite of the lack of supportive scientific evidence. Practice must begin to match the evidence. The use of seclusion in psychiatric care must be replaced with researched interventions that have been found to be helpful in the progression of patients' mental health. Children are very vulnerable, and the continued use of techniques that are traumatic and harmful cannot be tolerated.
Studies are needed that explore the use of therapeutic interventions using methodological rigor and theoretical foundations. Measured effects of interventions over time are needed, especially when interventions are used with children. The psychological and biological outcomes are important to measure and monitor over time. Psychiatric nursing practice cannot be evidence based until we have research that connects theory to findings.
Conclusion
The research on the use of seclusion with children or adults provides evidence that the experience actually may cause additional trauma and harm. There is no research to support a theoretical foundation for the use of seclusion with children. Evidence has been building for more than 30 years that the practice of seclusion does not add to therapeutic goals and is in fact a method to control the environment instead of a therapeutic intervention.
Furthermore, no study has been found in the literature that examined the physical effects of the use of seclusion. With the mounting evidence of the dangerous physical effects of restraints, it is a major oversight that the physical effects of seclusion have received no attention.
References
Allen, J.J. (2000). Seclusion and restraint of children: A literature review. Journal of Child and Adolescent Psychiatric Nursing, 13, 159-167.
Binder, R.L., & McCoy, S.M. (1983). A study of patients' attitudes toward placement in seclusion. Hospital and Community Psychiatry, 34, 1052-1054.
Brown, J.S., & Tooke, S.K. (1992). On the seclusion of psychiatric patients. Social Science Medicine, 35, 711-721.
Brown, S. (1999). Knowledge for health care practice: A guide to using research evidence. Philadelphia: Saunders.
Convertino, K., Pinto, R.P., & Fiester, A.R., (1980). Use of inpatient seclusion at a community mental health center. Hospital and Community Psychiatry, 31, 848-850.
Fisher, W.A. (1994). Restraint and seclusion: A review of literature. American Journal of Psychiatry, 151, 1584-1591.
Heyman, E. (1987). Seclusion. Journal of Psychosocial Nursing and Mental Health Services, 25(11), 9-12.
Ingersoll, G. (2000). Evidence-based nursing: What it is and what it isn't. Nursing Outlook, 48,151-152.
Irwin, M. (1987). Are seclusion rooms needed on child psychiatric units? American Journal of Orthopsychiatry, 57,125-126.
Landau, R., & MacLeish, R. (1988). When does time-out become seclusion, and what must be done when this line is crossed? Residential Treatment for Children anda Youth, 60, 33-38.
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.
Lendemeijer, B., & Shortridge-Baggett, L. (1997). The use of seclusion in psychiatry: A literature review. Scholarly Inquiry for Nursing Practice, 11,299-315.
Mann, L.S., Wise, T.N., & Shay, L. (1993). A prospective study of psychiatry patients! attitudes toward the seclusion room experience. General Hospital Psychiatry, 15, 177-182.
Martinez, RJ., Grimm, M., & Adamson, M. (1999). From the other side of the door: Patient views of seclusion. Journal of Psychosocial Nursing and Mental Health Services, 370,12 -22.
Mattson, M.R., & Sacks, M.H. (1978). Seclusion: Uses and complications. American Journal of Psychiatry, 135,1210-1213.
Meehan, T., Vermeer, C., & Windsor, C. (2000). Patients' perception of seclusion: A qualitative investigation. Issues and Innovations in Nursing Practice, 31, 370-377.
Miller, D.E. (1986). The management ot misbehavior by seclusion. Residential Treatment for Children and Youth, 4(1),63-73.
Millstein, K.H., & Cotton, N.S. (1990). Predictors of the use of seclusion on an inpatient child psychiatric unit. Journal of American Academy Child Adolescent Psychiatry, 29,256-264.
Phillips, P, & Nasr, S.J. (1983). Seclusion and restraint and prediction of violence. American Journal of Psychiatry, 140, 229- 232.
Sailas, E., & Fenton, M. (2000). Seclusion and restraint for people with serious mental illness. Cochrane Database of Systematic Reviews, (2):CD001163,2000.
Schwab, PJ., & Lahmeyer, C.B. (1979). The uses of seclusion on a general hospital psychiatric unit. Journal of Clinical Psychiatry, 40, 228-231.
Soloff, PH., & Turner, S.M. (1981). Patterns of seclusion. Journal of Nervous and Mental Disease, 169(1), 37-45.
Tsemberis, S., & Sullivan, C. (1988). Seclusion in context: Introducing a seclusion room into a children's unit of a municipal hospital. American Journal of Orthopsychiatry, 58, 462-465.
Linda M. Finke, PhD, RN, is Director of Professional Development Services, Sigma Theta Tau International, Indianapolis, IN.
Author contact: This e-mail address is being protected from spambots. You need JavaScript enabled to view it , with a copy to the Editor: This e-mail address is being protected from spambots. You need JavaScript enabled to view it
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