Journal of Psychiatric and Mental Health Nursing, 2015, 22, 333–336
Seclusion experienced by mental health professionals L . K U O S M A N E N 1 , 2 , 3 P h D R N , P. M A K K O N E N 4 , 5 H . L E H T I L A 6 MHN & H . S A L M I N E N 7 MA
MNSc
RN,
1
Adjunct Professor, and 4PhD student, Department of Nursing Science, University of Turku, and 5Nursing Planner, and 6Mental Health Nurse, Department of Psychiatry, Hospital District of Southwest Finland, and 7Member, Mental Health Service User Association, ITU, Turku, 2Service Manager, Social and Healthcare Department, City of Vantaa, Vantaa, and 3Coordinator, Nordic Network for Reducing Coercion in Care, National Institute for Health and Welfare, Helsinki, Finland
Keywords: narratives, patient rights,
Accessible summary
professional development, seclusion and restraint
•
Correspondence: L. Kuosmanen
•
University of Turku Department of Nursing Science
•
20014 Turun yliopisto Finland E-mail: [email protected]
•
Accepted for publication: 24 March 2015
Abstract
doi: 10.1111/jpm.12224
Seclusion in psychiatric inpatient care means confining service users in a locked room. Service users and staff seem to have different opinions on the usefulness of seclusion. This is possibly the first time when two mental health nurses went voluntarily into seclusion and reported their experiences. The nurses felt that the seclusion room was inhumane and proposed improvements to seclusion in general and to the seclusion facilities in particular.
Seclusion in psychiatric hospital care refers to isolating a service user from other service users and staff, most often in a locked and unfurnished room. Service users’ experiences of seclusion are mostly negative, and although some have seen a rationale for its use, mental health nurses should be encouraged to evaluate current seclusion practices from the service user’s perspective. In this small-scale experiment, two mental health nurses were voluntarily secluded for 24 h. The aim was to explore the experience of being secluded, to understand and evaluate the impact of seclusion in greater detail, and to encourage discussion on one of the controversies in mental health nursing. To the best of our knowledge, this is the first attempt to evaluate the impact of seclusion based on mental health nurses’ firsthand experiences. The nurses received usual seclusion treatment and described their experiences of this every 6 h. Based on the nurses’ experiences, seclusion, even in voluntary, safe and planned circumstances, may increase anxiety and frustration. Seclusion was viewed negatively and the physical environment was considered inhumane. The nurses offered some practical suggestions for updating seclusion practices and re-designing seclusion facilities. Mental health nurses, who frequently decide on and invariably implement seclusion, are key to improving seclusion practices.
Background In Finland, seclusion in psychiatric care refers to isolating a service user from other service users and staff, most often in a locked, unfurnished room with no option to exit the space © 2015 John Wiley & Sons Ltd
and monitored by nurses (Kontio et al. 2011). Seclusion may be used to control service users’ aggressive or disturbed behaviour (Mental Health Act 1116/1990, Wright 2003). During 2013 in Finland 1444 service users in psychiatric hospital care were secluded (6.1% of all; 27/100 000 333
L. Kuosmanen et al.
inhabitants) (National Institute for Health and Welfare 2015). Although comparisons between countries are difficult because of different legislation and statistics, Finland seems to be one country frequently using seclusion and other forms of coercive measures in psychiatric care (Salize & Dressing 2004). Due to this, The National Plan for Mental Health and Substance Abuse Work requires a 40% decrease in coercive measures in psychiatric hospitals by 2015 (Ministry of Social Affairs and Health 2009). Data are available up to 2013 and shows that the use of seclusion, for example, has decreased by 22% from 2009 to 2013 (National Institute for Health and Welfare 2015). The use of seclusion is a complex ethical dilemma in psychiatric care (WHO 2005). Seclusion is linked to issues of self-determination, human rights and to the ethical responsibilities of psychiatric personnel (Council of Europe 2000, Salize et al. 2002). In addition, evidence is still lacking regarding its effectiveness in reducing service user aggression or alleviating serious mental illness (Sailas & Wahlbeck 2005). Service users’ perceptions of seclusion are mainly negative (Van Der Merwe et al. 2013). They have experienced seclusion as a violation of their autonomy (Hoekstra et al. 2004), as a safety precaution or even as punishment or a form of torture (Holmes et al. 2004, Meehan et al. 2004, Kuosmanen et al. 2007, Veltkamp et al. 2008). On the other hand, some service users have reported seclusion to be beneficial in controlling one’s own behaviour (Keski-Valkama et al. 2010) and have seen the rationale for its use as part of treatment (Kuosmanen et al. 2007). Among mental health personnel, seclusion has been viewed as both treatment and a security measure, and it has been claimed that psychiatric units could not operate effectively without it (Husum et al. 2008, Van Der Merwe et al. 2013). For mental health nurses, it is essential to empathize with service users emotionally and to make an active effort to understand their experiences (Norman & Ryrie 2004, Stewart et al. 2015). One way to increase nurses’ understanding of treatment methods from the service user’s perspective is for nurses to test these methods on themselves. Our experiment aimed to explore seclusion as experienced by two mental health nurses. The assumption was that seclusion causes distress. It was further hypothesized that these nurses might identify a need for improvement in both the seclusion process and the facilities. This is a narrative based on the subjective experiences of two mental health nurses (L.K., P.M.) who were voluntarily secluded for 24 h.
Methods Two separate seclusion rooms located in an empty psychiatric unit were used from 5 pm on 21 October 2011 to 5.00 334
pm on 22 October 2011. An experienced mental health nurse (H.L.) and a mental health service user (H.S.) acted as moderators of the study. The moderators carried out the ‘treatment as usual’ for the nurses in seclusion. Contact with moderators was possible during meals, toilet visits and research measurements. The seclusion was carried out according to Hospital District of Southwest Finland treatment guidelines. The seclusion rooms were empty and lockable, each with a mattress and blanket on the floor. The rooms had windows, but in one of them it was opaque (and one could not see outside). There was no clock, radio or call system available. Toilet facilities were outside the room, lighting was controlled from outside and participants were monitored through a small window in the door. Participants were given their meals in the seclusion room and according to the hospital schedule. Toilet access was arranged when needed and one shower was allowed. No personal belongings were allowed and the participants wore hospital pyjamas. The two participants dictated their experiences every 6 h to a dictation machine, addressing the following themes: (1) seclusion in general, (2) the seclusion room environment, (3) activities during seclusion, and (4) other perceptions related to seclusion. The dictations were later transcribed verbatim and analysed using inductive content analysis (Burns & Grove 2005). The nurses’ experiences are derived from the two participants’ transcribed accounts as per given themes.
Participants’ experiences of seclusion Participants’ general experiences of seclusion Seclusion was viewed negatively; it caused the participants anxiety and boredom and they both questioned seclusion as a treatment method. They described feelings of suspicion. In the silent environment, the participants started to listen to all possible sounds and each suspected that the other participant was getting more moderator attention.
Participants’ experiences of the seclusion room environment The seclusion room environment was found too basic, ascetic and humiliating. The empty room with no opportunity for activity forced the participants to seek activity by doing exercises and banging on the door to attract the moderators’ attention. Lack of normal furniture forced the participants to eat on the floor, which felt humiliating. Their sense of time was impaired as there was no clock in the room. In one room, the opaque window allowed no contact to the outside world. © 2015 John Wiley & Sons Ltd
Seclusion experienced by mental health professionals
Participants’ experiences of activities during seclusion Both participants felt that the most important moments during their seclusion were when there was moderator contact. Meals, toilet visits, study measurements and the shower were important. Although of short duration and minimal in verbal contact, these moments helped the participants to make plans for the hours ahead because there was something to wait for.
Participants’ other perceptions related to seclusion During seclusion, the participants thought out some suggestions for improving the seclusion environment – a bed of normal height, a chair to sit on and a table to eat at. A clock was deemed essential, preferably also a clock counting down the time to the end of their seclusion or to their next contact with the nurses or physician in charge. Control over the lighting was deemed desirable. A window is important and should be built so that nobody can see in. TV and radio would have helped, but were not deemed more important than basic needs. Both participants felt that the meals were quite big in relation to the energy they were expending. In the seclusion room, sleep served as an escape from reality and helped to pass the time.
Summary of our experiences and recommendations for nursing practice We (L.K., P.M.) present here our firsthand experiences of seclusion, and in many ways, they were totally different from those of service users. In contrast to real world, we knew when we would be released and also that we could discontinue the experiment at will. This experiment and this narrative are motivated by a large amount of research literature on the negative or even harmful experiences of secluded service users. Our findings differ from those of existing research because as far as we know, this is the first time the impacts of seclusion have been evaluated through mental health nurses’ firsthand experiences. With this experiment, we want to share a small part of the experiences of service users who have been secluded. Further, we want to make some recommendations on how to improve seclusion facilities. Finally, we hope that this narrative will increase the discussion around the topic and confirm the national goal in Finland to decrease the use of seclusion and other forms of coercive measures in psychiatric care. We found no elements in seclusion that could be called nursing or caring. This personal experience raised doubts as to whether an intervention involving minimal interaction in a socially deprived space can help people with
© 2015 John Wiley & Sons Ltd
aggressive or disturbed behaviour. In addition, this treatment method where hardly anything happened felt more like a punishment or safety precaution. This experience reflects earlier accounts (Holmes et al. 2004, Kuosmanen et al. 2007). It is essential to increase activating and caring elements in seclusion such as increased communication between the secluded person and staff (see Van Der Merwe et al. 2013, Kontio et al. 2011, Keski-Valkama et al. 2010). For us, even ostensibly brief interaction during meals and toilet visits served as a therapeutic intervention. The design of the seclusion room appeared outdated and we saw no reason why it should look like a prison cell (see Kontio et al. 2011). Acute psychiatric units need to initiate discussions with managers and other stakeholders to ensure comfortable and safely furnished seclusion environments. A bed of normal height, a chair and a table in safe and easily cleaned materials could change the whole atmosphere of the seclusion room. In addition, a clock, a radio, a one-way window and therapeutic colors could all be arranged on a moderate budget (in Finland approximately 5000 euros/room). Yet such an effort would transform a seclusion room into a comfort room (see Cummings et al. 2010) and change its primary function. In light of this personal firsthand experience of 24 h in seclusion, we hope that our colleagues may feel encouraged to further evaluate current seclusion practices often dating from the 1950s or 1960s. Will we still need seclusion rooms in the 2020s? Should they look as they do today? Is it possible to increase the caring/nursing elements of this intervention? We believe that further research and development should be based on collaborative efforts between researchers, clinical nurses and service users in order to collect and produce new and novel information on seclusion. Further, making the improvements needed in seclusion is neither complex nor difficult. Mental health nurses, who frequently decide on and invariably implement seclusion, are key to improving seclusion practices.
Conclusion This narrative shows that seclusion, even in voluntary, safe and planned circumstances, may increase anxiety and frustration in participants. It therefore offers new perspective which could open up the debate around seclusion practice even more. In many countries, the use of seclusion is being discontinued and it is no longer considered recommended practice (e.g. Te Pou 2014). Where seclusion is still in practice, like Finland, we have offered some practical suggestions for updating seclusion practices and re-designing
335
L. Kuosmanen et al.
seclusion facilities. However, parallel to these changes, all possible alternatives to seclusion need to be developed (Te Pou 2014, Nordic network for reducing the use of coercion in care 2014, National Institute for Health and Welfare 2009).
References
Acknowledgements We want to thank Mr. Juha Koivu, MD, Chief of Division of Psychiatry in Hospital District of Southwest Finland, for his valuable help in making this experiment possible.
Kontio R., Joffe G., Putkonen H., et al. (2011)
Norman I. & Ryrie I. (2004) The art and science of
Seclusion and restraint in psychiatry: patients’
mental health nursing: a textbook of principles.
experiences and practical suggestions on how to Burns N. & Grove S. (2005) The Practice of Nursing Research. Conduct, Critique, and Utilization,
5th
edn.
Elsevier
Saunders,
USA. Council of Europe (2000) White paper on the protection of the human rights and dignity of people
improve practices and use alternatives. Perspec-
and seclusion in psychiatric inpatient wards.
tives in Psychiatric Care 48, 16–24. Kuosmanen L., Hätönen H., Malkavaara H., et al.
Salize H. & Dressing H. (2004) Epidemiology of
pital care: the patient’s perspective. Nursing
involuntary placement of mentally ill people
Ethics 14, 597–607.
across the European Union. The British Journal
Meehan T., Bergen H. & Fjeldsoe K. (2004)
placed as involuntary service users in a psychiat-
Personnel and patient perceptions of seclusion:
ric establishment. Available at: http://www
has anything changed? Journal of Advanced
.coe.int/t/dg3/healthbioethic/Activities/08_
Nursing 47, 33–38.
JUR%282000%292WhitePaper.pdf
(accessed
25 February 2015). Cummings K.S., Grandfield S.A. & Coldwell C.M. (2010) Caring with comfort rooms. Reducing
Current Opinion in Psychiatry 18, 555–559.
(2007) Deprivation of liberty in psychiatric hos-
suffering from mental disorder, especially those
Psychiatry_and_human_rights_en/DIR-
Open University Press. Sailas E. & Wahlbeck K. (2005) Restraint
of Psychiatry; the Journal of Mental Science 184, 163–168. Stewart
D.,
Burrow
H.,
Duckworth
A.,
et al. (2015) Thematic analysis of psychiatric
Mental Health Act 1116/1990 (1990) Helsinki:
patients’ perceptions of nursing staff. Interna-
Suomen Säädöskokoelma. Edita Publishing
tional Journal of Mental Health Nursing 24,
Oy. Available at: http://www.finlex.fi/en/laki/ kaannokset/1990/en19901116.pdf (accessed 10
82–90. Te Pou (2014) Reducing seclusion and restraint. Available at: http://www.tepou.co.nz/ (accessed
March 2014).
17 November 2014).
seclusion and restraint use in psychiatric facil-
Ministry of Social Affairs and Health (2009) Plan
ities. Journal of Psychosocial Nursing and
for mental health and substance abuse work.
Van Der Merwe M., Muir-Cochrane E., Jones J.,
Mental Health Services 48, 26–30.
Available at: https://www.thl.fi/fi/tutkimus-ja-
et al. (2013) Improving seclusion practice:
asiantuntijatyo/hankkeet-ja-ohjelmat/
implications of a review of staff and patient
(2004) Seclusion: the inside story. Journal of
kansallinen-mielenterveys-ja-
views. Journal of Psychiatric and Mental Health
Psychiatric and Mental Health Nursing 11,
paihdesuunnitelma (accessed 15 April 2015).
Hoekstra T., Lendemeijer H.H. & Jansen M.G.
Nursing 20, 203–215.
National Institute for Health and Welfare (2015)
Veltkamp E., Nijman H., Stolker J.J., et al. (2008)
Holmes D., Kennedy S. & Perron A. (2004) The
Psychiatric specialist medical care 2013. Statis-
Patients’ preferences for seclusion or forced
mentally ill and social exclusion: a critical
tical report 2/2015. Available at: http://www
medication in acute psychiatric emergency in
examination of the use of seclusion from the
.julkari.fi/bitstream/handle/10024/125570/
the Netherlands. Psychiatric Services 59, 209–
patient’s perspective. Issues in Mental Health
Tr01_15_psyk2013.pdf?sequence=5
Nursing 25, 559–578.
25 February 2015).
276–283.
(accessed
211. WHO (2005) Mental Health Declaration for
Husum T., Finset A. & Ruud T. (2008) The staff
Nordic network for reducing the use of coercion
Europe. Facing the Challenges, Building Solu-
attitude to coercion scale (SACS): reliability,
in care (2014) National Institute for health
tions. WHO European Ministerial Conference
validity and feasibility. International Journal of
and Welfare, The Nordic Council of Ministers.
on Mental Health. Helsinki, Finland 12–15
Law and Psychiatry 31, 417–422.
Available
Keski-Valkama A., Koivisto A.M., Eronen M.,
at:
http://www.thl.fi/en/tutkimus
-ja-asiantuntijatyo/hankkeet-ja-ohjelmat/
January, 2005, Helsinki. Wright S. (2003) Control and restraint techniques
et al. (2010) Forensic and general psychiatric
kansallinen-mielenterveys-ja-paihdesuunni
in the management of violence in inpatient psy-
patients’ views of seclusion: a comparison
telma/yhteistyoohjelmat/pohjoimainen
chiatry: a critical review. Medical Science and
study. Journal of Forensic Psychiatry and Psy-
-verkosto-pakon-kayton-vahentamiseksi
the Law 43, 31–38.
chology 21, 446–461.
(accessed 17 November 2014).
336
© 2015 John Wiley & Sons Ltd
Seclusion experienced by mental health professionals L . K U O S M A N E N 1 , 2 , 3 P h D R N , P. M A K K O N E N 4 , 5 H . L E H T I L A 6 MHN & H . S A L M I N E N 7 MA
MNSc
RN,
1
Adjunct Professor, and 4PhD student, Department of Nursing Science, University of Turku, and 5Nursing Planner, and 6Mental Health Nurse, Department of Psychiatry, Hospital District of Southwest Finland, and 7Member, Mental Health Service User Association, ITU, Turku, 2Service Manager, Social and Healthcare Department, City of Vantaa, Vantaa, and 3Coordinator, Nordic Network for Reducing Coercion in Care, National Institute for Health and Welfare, Helsinki, Finland
Keywords: narratives, patient rights,
Accessible summary
professional development, seclusion and restraint
•
Correspondence: L. Kuosmanen
•
University of Turku Department of Nursing Science
•
20014 Turun yliopisto Finland E-mail: [email protected]
•
Accepted for publication: 24 March 2015
Abstract
doi: 10.1111/jpm.12224
Seclusion in psychiatric inpatient care means confining service users in a locked room. Service users and staff seem to have different opinions on the usefulness of seclusion. This is possibly the first time when two mental health nurses went voluntarily into seclusion and reported their experiences. The nurses felt that the seclusion room was inhumane and proposed improvements to seclusion in general and to the seclusion facilities in particular.
Seclusion in psychiatric hospital care refers to isolating a service user from other service users and staff, most often in a locked and unfurnished room. Service users’ experiences of seclusion are mostly negative, and although some have seen a rationale for its use, mental health nurses should be encouraged to evaluate current seclusion practices from the service user’s perspective. In this small-scale experiment, two mental health nurses were voluntarily secluded for 24 h. The aim was to explore the experience of being secluded, to understand and evaluate the impact of seclusion in greater detail, and to encourage discussion on one of the controversies in mental health nursing. To the best of our knowledge, this is the first attempt to evaluate the impact of seclusion based on mental health nurses’ firsthand experiences. The nurses received usual seclusion treatment and described their experiences of this every 6 h. Based on the nurses’ experiences, seclusion, even in voluntary, safe and planned circumstances, may increase anxiety and frustration. Seclusion was viewed negatively and the physical environment was considered inhumane. The nurses offered some practical suggestions for updating seclusion practices and re-designing seclusion facilities. Mental health nurses, who frequently decide on and invariably implement seclusion, are key to improving seclusion practices.
Background In Finland, seclusion in psychiatric care refers to isolating a service user from other service users and staff, most often in a locked, unfurnished room with no option to exit the space © 2015 John Wiley & Sons Ltd
and monitored by nurses (Kontio et al. 2011). Seclusion may be used to control service users’ aggressive or disturbed behaviour (Mental Health Act 1116/1990, Wright 2003). During 2013 in Finland 1444 service users in psychiatric hospital care were secluded (6.1% of all; 27/100 000 333
L. Kuosmanen et al.
inhabitants) (National Institute for Health and Welfare 2015). Although comparisons between countries are difficult because of different legislation and statistics, Finland seems to be one country frequently using seclusion and other forms of coercive measures in psychiatric care (Salize & Dressing 2004). Due to this, The National Plan for Mental Health and Substance Abuse Work requires a 40% decrease in coercive measures in psychiatric hospitals by 2015 (Ministry of Social Affairs and Health 2009). Data are available up to 2013 and shows that the use of seclusion, for example, has decreased by 22% from 2009 to 2013 (National Institute for Health and Welfare 2015). The use of seclusion is a complex ethical dilemma in psychiatric care (WHO 2005). Seclusion is linked to issues of self-determination, human rights and to the ethical responsibilities of psychiatric personnel (Council of Europe 2000, Salize et al. 2002). In addition, evidence is still lacking regarding its effectiveness in reducing service user aggression or alleviating serious mental illness (Sailas & Wahlbeck 2005). Service users’ perceptions of seclusion are mainly negative (Van Der Merwe et al. 2013). They have experienced seclusion as a violation of their autonomy (Hoekstra et al. 2004), as a safety precaution or even as punishment or a form of torture (Holmes et al. 2004, Meehan et al. 2004, Kuosmanen et al. 2007, Veltkamp et al. 2008). On the other hand, some service users have reported seclusion to be beneficial in controlling one’s own behaviour (Keski-Valkama et al. 2010) and have seen the rationale for its use as part of treatment (Kuosmanen et al. 2007). Among mental health personnel, seclusion has been viewed as both treatment and a security measure, and it has been claimed that psychiatric units could not operate effectively without it (Husum et al. 2008, Van Der Merwe et al. 2013). For mental health nurses, it is essential to empathize with service users emotionally and to make an active effort to understand their experiences (Norman & Ryrie 2004, Stewart et al. 2015). One way to increase nurses’ understanding of treatment methods from the service user’s perspective is for nurses to test these methods on themselves. Our experiment aimed to explore seclusion as experienced by two mental health nurses. The assumption was that seclusion causes distress. It was further hypothesized that these nurses might identify a need for improvement in both the seclusion process and the facilities. This is a narrative based on the subjective experiences of two mental health nurses (L.K., P.M.) who were voluntarily secluded for 24 h.
Methods Two separate seclusion rooms located in an empty psychiatric unit were used from 5 pm on 21 October 2011 to 5.00 334
pm on 22 October 2011. An experienced mental health nurse (H.L.) and a mental health service user (H.S.) acted as moderators of the study. The moderators carried out the ‘treatment as usual’ for the nurses in seclusion. Contact with moderators was possible during meals, toilet visits and research measurements. The seclusion was carried out according to Hospital District of Southwest Finland treatment guidelines. The seclusion rooms were empty and lockable, each with a mattress and blanket on the floor. The rooms had windows, but in one of them it was opaque (and one could not see outside). There was no clock, radio or call system available. Toilet facilities were outside the room, lighting was controlled from outside and participants were monitored through a small window in the door. Participants were given their meals in the seclusion room and according to the hospital schedule. Toilet access was arranged when needed and one shower was allowed. No personal belongings were allowed and the participants wore hospital pyjamas. The two participants dictated their experiences every 6 h to a dictation machine, addressing the following themes: (1) seclusion in general, (2) the seclusion room environment, (3) activities during seclusion, and (4) other perceptions related to seclusion. The dictations were later transcribed verbatim and analysed using inductive content analysis (Burns & Grove 2005). The nurses’ experiences are derived from the two participants’ transcribed accounts as per given themes.
Participants’ experiences of seclusion Participants’ general experiences of seclusion Seclusion was viewed negatively; it caused the participants anxiety and boredom and they both questioned seclusion as a treatment method. They described feelings of suspicion. In the silent environment, the participants started to listen to all possible sounds and each suspected that the other participant was getting more moderator attention.
Participants’ experiences of the seclusion room environment The seclusion room environment was found too basic, ascetic and humiliating. The empty room with no opportunity for activity forced the participants to seek activity by doing exercises and banging on the door to attract the moderators’ attention. Lack of normal furniture forced the participants to eat on the floor, which felt humiliating. Their sense of time was impaired as there was no clock in the room. In one room, the opaque window allowed no contact to the outside world. © 2015 John Wiley & Sons Ltd
Seclusion experienced by mental health professionals
Participants’ experiences of activities during seclusion Both participants felt that the most important moments during their seclusion were when there was moderator contact. Meals, toilet visits, study measurements and the shower were important. Although of short duration and minimal in verbal contact, these moments helped the participants to make plans for the hours ahead because there was something to wait for.
Participants’ other perceptions related to seclusion During seclusion, the participants thought out some suggestions for improving the seclusion environment – a bed of normal height, a chair to sit on and a table to eat at. A clock was deemed essential, preferably also a clock counting down the time to the end of their seclusion or to their next contact with the nurses or physician in charge. Control over the lighting was deemed desirable. A window is important and should be built so that nobody can see in. TV and radio would have helped, but were not deemed more important than basic needs. Both participants felt that the meals were quite big in relation to the energy they were expending. In the seclusion room, sleep served as an escape from reality and helped to pass the time.
Summary of our experiences and recommendations for nursing practice We (L.K., P.M.) present here our firsthand experiences of seclusion, and in many ways, they were totally different from those of service users. In contrast to real world, we knew when we would be released and also that we could discontinue the experiment at will. This experiment and this narrative are motivated by a large amount of research literature on the negative or even harmful experiences of secluded service users. Our findings differ from those of existing research because as far as we know, this is the first time the impacts of seclusion have been evaluated through mental health nurses’ firsthand experiences. With this experiment, we want to share a small part of the experiences of service users who have been secluded. Further, we want to make some recommendations on how to improve seclusion facilities. Finally, we hope that this narrative will increase the discussion around the topic and confirm the national goal in Finland to decrease the use of seclusion and other forms of coercive measures in psychiatric care. We found no elements in seclusion that could be called nursing or caring. This personal experience raised doubts as to whether an intervention involving minimal interaction in a socially deprived space can help people with
© 2015 John Wiley & Sons Ltd
aggressive or disturbed behaviour. In addition, this treatment method where hardly anything happened felt more like a punishment or safety precaution. This experience reflects earlier accounts (Holmes et al. 2004, Kuosmanen et al. 2007). It is essential to increase activating and caring elements in seclusion such as increased communication between the secluded person and staff (see Van Der Merwe et al. 2013, Kontio et al. 2011, Keski-Valkama et al. 2010). For us, even ostensibly brief interaction during meals and toilet visits served as a therapeutic intervention. The design of the seclusion room appeared outdated and we saw no reason why it should look like a prison cell (see Kontio et al. 2011). Acute psychiatric units need to initiate discussions with managers and other stakeholders to ensure comfortable and safely furnished seclusion environments. A bed of normal height, a chair and a table in safe and easily cleaned materials could change the whole atmosphere of the seclusion room. In addition, a clock, a radio, a one-way window and therapeutic colors could all be arranged on a moderate budget (in Finland approximately 5000 euros/room). Yet such an effort would transform a seclusion room into a comfort room (see Cummings et al. 2010) and change its primary function. In light of this personal firsthand experience of 24 h in seclusion, we hope that our colleagues may feel encouraged to further evaluate current seclusion practices often dating from the 1950s or 1960s. Will we still need seclusion rooms in the 2020s? Should they look as they do today? Is it possible to increase the caring/nursing elements of this intervention? We believe that further research and development should be based on collaborative efforts between researchers, clinical nurses and service users in order to collect and produce new and novel information on seclusion. Further, making the improvements needed in seclusion is neither complex nor difficult. Mental health nurses, who frequently decide on and invariably implement seclusion, are key to improving seclusion practices.
Conclusion This narrative shows that seclusion, even in voluntary, safe and planned circumstances, may increase anxiety and frustration in participants. It therefore offers new perspective which could open up the debate around seclusion practice even more. In many countries, the use of seclusion is being discontinued and it is no longer considered recommended practice (e.g. Te Pou 2014). Where seclusion is still in practice, like Finland, we have offered some practical suggestions for updating seclusion practices and re-designing
335
L. Kuosmanen et al.
seclusion facilities. However, parallel to these changes, all possible alternatives to seclusion need to be developed (Te Pou 2014, Nordic network for reducing the use of coercion in care 2014, National Institute for Health and Welfare 2009).
References
Acknowledgements We want to thank Mr. Juha Koivu, MD, Chief of Division of Psychiatry in Hospital District of Southwest Finland, for his valuable help in making this experiment possible.
Kontio R., Joffe G., Putkonen H., et al. (2011)
Norman I. & Ryrie I. (2004) The art and science of
Seclusion and restraint in psychiatry: patients’
mental health nursing: a textbook of principles.
experiences and practical suggestions on how to Burns N. & Grove S. (2005) The Practice of Nursing Research. Conduct, Critique, and Utilization,
5th
edn.
Elsevier
Saunders,
USA. Council of Europe (2000) White paper on the protection of the human rights and dignity of people
improve practices and use alternatives. Perspec-
and seclusion in psychiatric inpatient wards.
tives in Psychiatric Care 48, 16–24. Kuosmanen L., Hätönen H., Malkavaara H., et al.
Salize H. & Dressing H. (2004) Epidemiology of
pital care: the patient’s perspective. Nursing
involuntary placement of mentally ill people
Ethics 14, 597–607.
across the European Union. The British Journal
Meehan T., Bergen H. & Fjeldsoe K. (2004)
placed as involuntary service users in a psychiat-
Personnel and patient perceptions of seclusion:
ric establishment. Available at: http://www
has anything changed? Journal of Advanced
.coe.int/t/dg3/healthbioethic/Activities/08_
Nursing 47, 33–38.
JUR%282000%292WhitePaper.pdf
(accessed
25 February 2015). Cummings K.S., Grandfield S.A. & Coldwell C.M. (2010) Caring with comfort rooms. Reducing
Current Opinion in Psychiatry 18, 555–559.
(2007) Deprivation of liberty in psychiatric hos-
suffering from mental disorder, especially those
Psychiatry_and_human_rights_en/DIR-
Open University Press. Sailas E. & Wahlbeck K. (2005) Restraint
of Psychiatry; the Journal of Mental Science 184, 163–168. Stewart
D.,
Burrow
H.,
Duckworth
A.,
et al. (2015) Thematic analysis of psychiatric
Mental Health Act 1116/1990 (1990) Helsinki:
patients’ perceptions of nursing staff. Interna-
Suomen Säädöskokoelma. Edita Publishing
tional Journal of Mental Health Nursing 24,
Oy. Available at: http://www.finlex.fi/en/laki/ kaannokset/1990/en19901116.pdf (accessed 10
82–90. Te Pou (2014) Reducing seclusion and restraint. Available at: http://www.tepou.co.nz/ (accessed
March 2014).
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