Introduction
Mental health care settings present a series of challenges, more so when patients are children and adolescents. One of these controversial issues is the use of seclusion and restraint. Many nursing practitioners find that it is extremely difficult trying to balance between the civil rights of the child or adolescent patient and the needs of the patient as a health care consumer. When most people think about seclusion and restraint, they imagine that it is a form of punishment, neglect, institutional abuse or custodial care. However, certain instances necessitate its use and if used in the right manner, it may even be regarded as a form of therapeutic treatment.
However, in order to place restraint and seclusion in mental health care settings, it is imperative to understand its definition. Huckshorn (2004) defines restraint as a form of intervention that is intended on limiting the freedom to move. Seclusion on the hand refers to the placement of an individual in a solitary area that may be a room, unit or any other form of confinement that ensures that the patient’s interactions are limited. Usually, restraint or seclusion is necessary when a child or adolescent patient is exhibiting acute behvaioral disturbance. At this point, there is a need to protect the safety of the people around the patient, deal with the behavioural disturbance and provide therapeutic alternatives. These goals are only achievable upon application of restraint or seclusion.
Statistics show that a series of children and adolescents have been physically restrained in psychiatric institutions. However, media reports and research also indicate that some deaths have occurred as a direct result of this form of treatment. These statistics have sparked off a lot of debate about the issue especially because it involves a series of professionals, family members and other stakeholders in health care. There is evidence to suggest that some psychiatric institutions tend to overuse seclusion and restraint as asserted by Donat (2003). This author also asserts that the utilisation of this form of intervention among children and adolescents is a sign of poor quality health care or oversight on the part of the government. As a result, he believes that the government should step in to ascertain that the safety of children and adolescents is preserved.
Assessment of risks nurses make leading to secluding or restraining a child or adolescent
Seclusion and restraint are primarily utilised in nursing practice to prevent children and adolescents from injuring themselves, their colleagues in psychiatric institutions or the institutional staff. This is especially in the case when the patient has depicted signs of violence and aggression. Consequently, nursing personnel and institutional staff need to be well trained in this area because if implemented wrongly, it could cause serious harm to the patient or to the workers themselves.
Curie (2005) suggests that whenever psychiatric institutions choose to implement seclusion and restraint, they place themselves at a serious risk of getting injured. Also, they place the rights of the adolescent patient or young patient at risk. It is essential to remember that seclusion and restraint can cause emotional impact among mental health patients hence promoting the need for evaluation of the method. Children and adolescents have a right to dignity in health care just the way their adult counterparts do.
Given the latter concerns, certain risks may necessitate this kind of approach to mental health care provision among children or adolescents. First of all, when the medical needs of the patient have been clearly assessed and it has been found that seclusion and restraint are the most appropriate modes of action. Glover (2005) explains that this method should only be adopted when less restrictive techniques have been applied and have failed. Also, they need to be applied when the patients is seen as a threat to his own life or to the life of others around him/her. It is also applicable when the patients may present certain safety concerns within the institutions even if those safety concerns may not be life threatening.
Psychiatric institutions should only apply restraint and seclusion procedures after it has been ascertained that the implementation of the latter procedures will not impose any more danger to the patient or to other persons. In order to do this, Keski Valkama (2007) explains that institutions should document all the necessary procedures that had been taken prior to seclusion or restraint in order to provide proof that they had indeed been pursued but they failed.
Sometimes, some nursing personnel may think of using seclusion and restraint as forms of punishment. This is highly unethical and should never be the case for any staff member. Additionally, it should not be used as a form of convenience. In order to curb such practices, Keski Valkama (2007) explains that there should be proper documentation of the justification for applying such a method. Besides this, he also explains that seclusion and restraint should only be applied during the period of time in which it will be of use to the institution or patient. In other words, when security & safety are no longer a concern for the affected party, then there is no need for continuing with the methodology.
Curie (2005) explains that risk assessment in nursing should also entail the assessment of personnel capability in implementing it. In other words, staff members need to be trained on chemical or mechanical methods of restraining. Also, they need to demonstrate that they are competent enough in handling non-physical techniques. In order to ascertain that this risk assessment is done, then facilities need to hold their personnel accountable. Institutional administrators need to confirm that data collection is done and reports have been made about these issues. After the latter have been ascertained, then it may be considered safe to implement such a form of mental health approach among children or adolescents.
Lebel (2004) also asserts that mental health institutions dealing with children need to clarify to the patient prior to admission (If they are in a position to understand) that certain types of behaviour may necessitate the use of seclusion and restraint. By doing this, nursing personnel will have created a positive relationship with the patient and will have clarified the issue. It should be noted that if all these early interventions have not solicited a positive response from the child or adolescent and they continue to present a threat to the danger and safety of themselves or others, then it may be suitable to use seclusion or restraint.
Champagne and Sayer (2004) claim that a large percentage of injuries associated with seclusion and restraint represent child or adolescent patients. Consequently, the latter approach should only be applied in instances where due procedures designed for this age group specifically have been followed. It should be noted that a large number of mental health care institutions lack procedures that apply to children alone and to adults. This is because sometimes, children may be given time out as a form of punishment. But such is never the case for adults. As a result, it is possible that psychiatric personnel may misuse or confuse the applicability of ‘time out’ and seclusion.
In order to minimise risk during the implementation of restraint and seclusions, there should be an allowance that checks whether the personnel are well equipped with CPR knowledge in order to administer it if necessary. If the latter measures are present, then one can apply the methodology.
In order to promote accountability in this kind of procedure, it is necessary for the affected person to be held accountable by ensuring that all cases of abuses or data related to seclusion and restraint have been unearthed and prosecuted. (Donovan et al, 2003) According to these authors, it is necessary for psychiatric institutions and mental health facilities to expose cases in which a death was directly related to the issue of seclusion or restraint. By doing this, there will be more accountability and also there will also be better implementation of the methodology. In line with this is the issue of protecting whistle blowers who may have witnessed a case of abuse through seclusion or restraint. The latter groups need to be protected in order to ensure sound application of the procedure.
Glover (2005) summarises the issues by asserting that seclusion should only be applied as a method of treatment if it is the last resort. Issues such as personal requests from patients need not be considered. This is because some patients may demand for confinement when they want to get some time out away from their normal environment, their other patients or even certain unit personnel. Alternatively, patients may seek confinement when they want some time to think about their lives. Regardless of this willingness, it is debatable whether patients have the ability to make their own choices, consequently, confinement should only be as a last result.
Legal and ethical dilemmas from a UK perspective
It should be noted that number of legal regulations exist within the UK concerning seclusion. However, application of this methodology has no clear cut regulation or standards. Consequently, this leaves a lot of room for error during its administration. (Anthony, 2004) the latter author cites some examples of children and adolescents in mental health care institution who have been placed in considerable danger as a result of this form of treatment. There are various categories revealed by him concerning persons who are affected by seclusion and restraint within mental institutions. This means that that the possibility of the occurrence of harm to patients present ethical dilemmas to nursing personnel concerning this issue. (Anthony, 2004)
The first category are those patients who die as a direct result of seclusion and restraint. This usually occurs when a patient is left for long hours in restraint or seclusion and a physical health issue develops along the way. In other situations, children or adolescents may die as a result of the methods used to restrain them. For instance, if the mechanical methods used are not checked properly, then there is a chance that they can crush that patient. Children are especially vulnerable because of their small sizes.
Mohr (2004) reports that the rate of injuries that occur among institutional personnel implementing seclusion and restraint is as high as the rate of injury among construction workers, miners and lumbers. Consequently, such high chances of injury present ethical dilemmas for psychiatric personnel because they have to choose between their safety and that of the patient.
The issue of seclusion and restraint may present ethical dilemmas due to the personality of the respective nurse administering that form of treatment. Some nurses go about their duties in a dictatorial manner; others may be very sympathetic towards their patients while others may be remote from their patients. Consequently, all these personalities are expected to adhere to nursing regulations. Some personalities may not be compatible with confinement or restraint because they may too humanistic and may feel as though they are torturing their patients by doing so (Huckshorn, 2004)
In other situations, seclusion and confinement itself can worsen a patients’ mental health care situation. For instance, children are highly dependent on their parents for their emotional needs, consequently, when those children have been placed away from their parents for a long time because of their mental state, then chances are those children will be missing out on something. This situation is further aggravated by placing them in confinement or restraint. Consequently, such children or adolescents may feel more frustrated and their mental health may further deteriorate. Donovan et al (2003) explain that the possibility of such an occurrence implies that nurses have to choose between dealing with the patient’s safety issues or dealing with their psychiatric needs.
Some of the issues that have been brought about the nature of seclusion and restraint and its relation to patient recovery include
-Impeded social relationships between patients
-Ruins the relationship between the nurse and the child or adolescent
-There is minimal psycho social intervention
-etc
Another ethical dilemma also comes into play with some levels of ambiguity in current state law. Nurses may sometimes have difficulty deciding whether a patient’ level of violence is valid enough to solicit the use of seclusion and restraint as a way of handling them. This means that nurses need to be careful about the sort of decisions they make with regard to these kinds of issues. When a patient engages in sexually inappropriate behaviour in public, then some nurses may consider this plausible enough to solicit confinement while others may not. Usually, this is a dilemma because it becomes difficult to determine exactly what kind of behaviour is aggressive enough to impose danger to the patient’s surroundings. (DosReis, 2003)
Additionally, placing patients within confinement may also be problematic because it means that it will infringe a patents’ right to freedom. On the other hand, when left unguarded, that patient may present a risk to himself to to others. This means that it then becomes difficulty to institute the measure because very little information available about it.
The United Kingdom is governed by a series of legal regulations on administering psychiatric seclusion and restraint. Most of these regulations apply to adults but there may be others that apply to children alone Glover (2005) explains that the law requires psychiatric institutions to ensure that all the necessary fittings and devices are in place to prevent self harm to the patient or harm to others. Additionally, there should be staff present to operate these devices used in mechanical restraining.
The law requires that the amount of patient to staff ratio be monitored and checked. This is in order to ensure that the time spent between patient and nurses is heightened. Face to face contact with adolescent and children is instrumental in such procedures. In close relation to this issue is that of instituting systems and routines for checking on patients. Nurses must ensure that check on the movements and communication of the respective individuals in order to protect them. (Mohr, 2004)
At the institutional level, there should be certain arrangements to promote sound governance crisis planning and reviews once seclusion and restraint has been instated. Cases of neglect need to be prevented at all costs. It is essential for mental health institutions to protect the health and safety of patients by instituting certain managerial level measures in place. For instance, they need to ensure that resources allocated for seclusion and restraint are adequately monitored. Also, they need to make sure that they do monitoring on a weekly level and report whatever they witness. Such institutions need to have systems that ensure compliance with latter mentioned laws and regulations. All these issues are intended on streamlining the seclusion and restrain processes.
Alternatives/improvements to restraint and seclusion
Restraint and seclusion need not be regarded as the lowest of lows in nursing mental health care for children and adolescents. There are certain measures that can be instated to encourage greater outcome from such patients. Interventions can be conducted in order to encourage these elements in health care
- Doing for others
- Competence
- Belonging
- Autonomy
Mental health institutions dealing with children and adolescents need to promote the above qualities by giving positive feedback to the latter parties about their health. This can be done by creating relationships between these patients and staff members especially nurses. By instating such mechanism, then health institutions will have encouraged autonomy in health care. (Anthony, 2004)
Mental health institutions need to create a sense of belonging among the adolescent or child mental health care patient. They can do this by creating coaching relationships with members of staff and the patients. Also, they can teach those children or adolescents that violence and aggression is a violation of social norms and that it needs to be stopped when they can. Also, Donat (2003) explains that these relationships are usually fostered by engaging the children in activities that relate to their developmental activities, for instance, children may be given tasks such as artwork, projects and group work that encourage them to work together and to feel like they are part of the team. By doing this, mental institutions will be teaching children how to be confident in themselves and will also create a sense of competence amongst them.
The issue of doing for others also inhibits violent or aggressive behaviour by making children feel relevant. Usually, when children are encouraged to work in groups or to engage in activity that will benefit others, then those triggers that cause violent behaviour may be inhibited and this eliminates the need to use seclusion and restraint.
In order to ensure that the latter alternative works, then it is necessary for respective institutions to adhere to a number of procedures. First of all, that institution needs to set some goals for the program. For instance, they could state that the number of seclusion and restraint cases after a certain period of time need to have reduced by a certain percentage. (Keski Valkam, 2007)
Also, in order to ascertain that these goals have been met, then mental health care institutions need to engage in constant monitoring. They can do this by checking on the type of results that emanate after a short period of time and then evaluating it with regard to their goals. If the gaols have been met, then new ones ought to be set. In close relation to this is the need to have constant feedback between staff in the institution. This means that nurses need to collaborate with administrators and other primary care givers to ensure effective implementation of this alternative. (Mohr, 2004)
Conclusion
Making the choice to either restrain or seclude a patient is a critical matter in nursing mental health care. This is because there are certain dangers that may emanate out of it yet there are also some benefits of the procedure. Consequently, nurses should only resort to this methodology when the positives outnumber the negatives. Also, the method should be applied in a least restrictive manner. Care should be taken by mental health institutions to ascertain that their personnel have adequate capacity to asses a child’s risk of violence. This is done by instituting preventive procedures. Additionally, other alternatives should be sought that foster proactive responses or those that minimise violence and aggression.
Reference
Anthony, W. (2004): Overcoming Obstacles to a Recovery-Oriented System; National Association of State Mental Health Program Directors Report, No. 1-5
Champagne, T. & Strayer, N. (2004): Innovative Alternatives to Seclusion & Restraint- Sensory Approaches in Inpatient Psychiatric Settings; Journal of Psychosocial Nursing; 42, 9, 1-8
Curie, C. (2005): SAMHSA’s commitment to eliminating the use of seclusion and restraint; Psychiatric Services, 56, 9, 139-140
Donat, D. ( 2003): An analysis of successful efforts to reduce seclusion and restraint at a public psychiatric hospital; Psychiatric Services, 54, 8, 19-67
Donovan, A., Peller, A., Plant, R., Martin, A. & Siegel, L. (2003): Trends in the use of seclusion and restraint among psychiatrically hospitalized youths; Journal of Psychiatric Services; 54, 7, 287-293.
dosReis, S., Love, C., Barnett, S, & Riddle, A. (2003): A guide for managing acute aggressive behaviour of youths in residential and inpatient treatment facilities; Journal Psychiatric Services, 54, 10, 57-100
Glover, R. (2005): Reducing the use of seclusion and restraint; Psychiatric Services, 56, 9, 114
Huckshorn, K. (2004): Core strategies for prevention – reducing seclusion and restraint in mental health settings; Journal of Psychosocial Nursing and Mental Health Services, 42, 9, 22-33
Keski-Valkama, A., Eronen, T. Sailas, E., (2007): Legislation is not enough to reduce the use of seclusion and restraint; Soc Psychiatry Epidemiology 12, 42, 747–752
LeBel, J., et al (2004): Child and adolescent inpatient restraint reduction – A state initiative to promote strength-based care; Journal of the Academy of Child and Adolescent Psychiatry, 43(1), 37-45.
Mohr, W. (2004): Inpatient Programming Whose Time Has Passed – Level Systems; Journal of Child and Adolescent Psychiatric Nursing, 17, 3, 143-165
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