NRSG 263 Mental Health - Restrictive Practices

Unit: NRSG 263 Mental Health
Assignment 1: Topic 2
Student Name:
Word Count:

1.

Restrictive practice is defined as the use of seclusion or restraint to control risky
behaviour of patient with serious mental illness. Seclusion is an intervention that involves
confining a person alone in a room and separating them from other patients, whereas restraint
involves restricting freedom of movement of a client by physically or mechanically
restricting them (Goulet, Larue & Dumais, 2017). Human Rights advocate across the world
are against the use of restrictive practices in mental health because of its potential to infringe
basic human right to freedom, dignity and autonomy. According to Australian Institute of
Health and Welfare (2020) report, the Australian National Human Commission has
encouraged all health leaders to monitor and control use of restrictive practices across their
respective jurisdictions. In the Australian mental health care system, eliminating use of
seclusion has become a policy priority too (AIHW, 2010). The Mental Health Act 2016
regulates the use of restrictive practices like seclusion and mechanical restraint too
(health.qld.gov.au 2020). Thus, as national and regulatory bodies have taken action regarding
this practice, understanding the reason behind the controversy is important. This essay will
argue regarding the adverse impact of seclusion on consumers and mental health care
professionals and discuss how registered nurse can take the initiative to adapt alternative
method to prevent use of such restrictive practice in mental health setting. To support the
argument, the essay will discuss about pros and cons of seclusion in terms of physical,
psychological and ethical outcome of care.
Different opinion exists among consumers regarding the experience of seclusion and
patients have mostly reacted negatively to the coercive practice because of its adverse
psychological consequences. The study by Prophy et al. (2016) defined impact of seclusion
by conducting focus group discussions with people with lived experience of seclusion.
Seclusion is an intervention which is beneficial to control or manage difficult behaviour of
patient and prevent them or other patient from any harm. By the analysis of the results,

several disadvantage of seclusion emerged. Both consumers and carers were against the use
of seclusion because of poor physical outcomes and overuse of the coercive practice leading
to poor staff-patient relationship. In addition, practice gap issues included inappropriate use
of force, lack of empathy, poor communication and interaction with patients and lack of
alternative approach to contain violent behaviours. Patients mainly reported being humiliated
and expressed feelings of helplessness, isolation and traumatization. They were also
overwhelmed with feelings of injustice and powerlessness. (Prophy et al., 2016). The study
by is Prophy et al., (2016) consistent with Larue et al. (2013) which revealed feelings of
shame and humiliation among patients who were secluded and Haugom, Ruud and
Hynnekleiv (2019) indicated about staff experience of feeling burdensome because of ethical
challenges associated with the procedure. Similarly, the evidence on poor practice related to
the coercive measure is consistent with other research papers too. Chieze et al. (2019)
revealed similar outcomes of seclusion by showing that 62% participants held negative
perception about seclusion because of overuse of the practice. Thus, the significance of the
paper by Prophy et al. (2016) is that gives valid and reliable data related to depict negative
impact of seclusion by review of lives experiences of consumers and supporters.
Seclusion is not favoured by many staff because of its adverse physical consequences
too. The systematic review by Chieze et al. (2019) opined regarding the lack of evidence on
efficacy and therapeutic benefit of coercive measures like seclusion. By the meta-analysis of
studies on impact of seclusion and restraint in adult psychiatry, the Chieze et al. (2019)
revealed that seclusion is associated with deleterious physical or psychological consequence.
It reported about high incidence of post-traumatic stress disorder (PTSD) after seclusion.
Participants also suffered from hallucinations and hopelessness due to exposure to trauma
during the process. The study gave evidence regarding the high and intense feelings of
negative emotions and distress in such patients. The only positive outcome reported in this

study was that seclusion is better accepted than other restrictive methods like forced
medications. This evidence suggests why there is controversy surrounding the issue and gave
the idea that adverse effects post seclusion is the main concern for patients. Although this
study used systematic review method to highlight about pros and cons of seclusion, however
a better perspective on the issue can be gained from primary research studies. A one-year
follow-up of randomized controlled trial justified that seclusion is accepted than other
coercive method because it is less restrictive. This is an example of the benefits associated
with the process. However, negative outcomes related to increase in morbidity and infection
is a concern that should be noted by mental health professionals while deciding to use the
measure (Steinert et al., 2013).
There is a need to understand pros and cons of seclusion by comparing it with best
practice and therapeutic standards too. When weighing the practice of seclusion based on
overall benefits and limitation, Völlm and Nedopil (2016) show that benefit is more only for
those patients for whom other measures of controlling aggression or violence has failed. This
indicates that seclusion is beneficial in specific scenarios such as for patients with serious
mental illness. Moreover, guideline related to use of seclusion also suggests that this
intervention should be used for a brief period only and not continued (Völlm & Nedopil,
2016). Implementing care as per ethical standard is also part of best quality care. The study
by Illingworth (2017) points to more harm than benefits for patients from the ethical
perspective too. This is because seclusion is a practice that violates all ethical principles
related to health care. Ethical care in health care setting requires adhering to the ethical
principle of autonomy, beneficence, justice and non-maleficence (Illingworth, 2017).
According to patient-centred care values as well as ethical principle, taking patient’s consent
and maintaining autonomy is crucial at all stage of treatment process. Zheng et al. (2020)
evaluated voice of staff regarding seclusion and restraint and revealed that staff oppose this

practice as it goes against patient’s will and produce negative effect on patients. Thus, the
main conclusion coming from this piece of literature is that seclusion is justified to protect
patients, however it is not appropriate when the process is implemented without respecting
patient’s autonomy. Mental health nurses have expressed challenges in decision making and
use of seclusion because of high risk of ethical violation. The significance of the study by
Zheng et al. (2020) is that instead of just highlighting the ethical concerns associated with
seclusion, the study points out some good practices that staff can use to reduce ethical
violations while caring for mentally ill patients. The alternative or good practice measures
included improving the therapeutic environment of patient, adapting de-escalation technique
and reducing adverse effects of seclusion. A study by Raveesh, Gowda and Gowda (2019)
which used a humanistic focus also suggested implementing safe environment for patient and
connecting with patient to prevent violent behaviours and avoid use of seclusion.
Seclusion is a practice that is not favoured by many mental health staff. For instance,
Kuosmanen et al. (2015) reported that staffs have expressed feelings of anxiety and
frustration because of exposure to the violent behaviours of patients and inability to cope with
the disturbing situation. Even if they managed to seclude patient, they complained about
feeling guilty and violating dignity of patient. It was associated with job dissatisfaction too.
Similar type of findings has been reported by Kinner et al. (2017) too which summarized the
findings from a large community-based survey done with carers and mental health
professionals. Kinner et al. (2017) reported regarding the benefits as well as disadvantage.
Some participants had the perception that seclusion in some form can produce small benefits
like ensuring consumer safety, promoting safety of staff and ensuring behavioural boundaries
in mental wards. However, majority of cares and staff had negative attitude towards the
practice as it resulted in compromise of trust, breaching of human rights and triggering past
trauma. Overall, mixed feelings were found with regards to feasibility and willingness to

eliminate the practice of seclusion. The above findings further validate why restricting or
controlling use of seclusion is important for patients well-being. The evidences clearly show
the significance of taking continued efforts to reduce restrictive practices.
Registered nurses, who are the frontline workers who spend the maximum time with
mentally ill patients have expressed about challenges due to the need to use seclusion to
control violent patients. Happell and Harrow (2010) investigated regarding the nurse’s
attitude towards the use of seclusion revealed that nurses support the use of seclusion for the
management of violence during care. However, they have also expressed concerns regarding
the challenges in the process (Happell & Harrow, 2010). Okanli, Yilmaz and Kavak (2016)
conducted a study with Turkish population regarding nurse’s attitude towards the use of
seclusion revealed that nurses were mostly upset when they decided to restrain a patient.
However, this could not give detailed information regarding how nurses are challenged by the
process. Haugom, Ruud and Hynnekleiv (2019) revealed that nurses were psychologically
affected because of the need to take tough decisions regarding either choosing seclusion or
respecting ethical rights of patients. Moral dilemma associated with decision making was a
major challenge for them. In contrast to this, Bowers et al. (2017) suggested that nurses were
disturbed by behaviours of patients and being almost at the verge of strangulation during the
process. The trauma for nurse is clear and they must have better training in order to ensure
they are not exposed to such risk while delivering care to patients with severe mental illness
patients.
In response to several burden and challenges associated with nurses in using seclusion
practice, nurses can adapt recovery oriented practice such as de-escalation techniques and
environmental modifications to create comfortable environment for patients and reduce the
trigger that leads to violent behaviours. The need for use of de-escalation was suggested by
Zheng et al. (2020) as it recommended humanistic care service based on excellent

communication skills and risk assessment in the early stages. The study gave evidence
regarding various studies that exhibited the effectiveness of the technique in supporting
patients to cope with aggressive behaviour in mental health settings. Many national initiatives
have been implemented by the Australian government to prevent or eliminate use of
seclusion. One example is the Safewards initiative which is a model of care to reduce conflict
and containment within mental health and it mainly focus on the triggers that lead to violence
or aggression in patient. It encourages staffs to reduce rate of conflict by eliminating conflict
originating sources, preventing flashpoints and judiciously choosing use of containment
measures (Bowers, 2014). Hence, the Safewards intervention gives the implication to
enhance communication skills of nursing staff too so that they can find out unmet needs of
patients and adequately address them too. Having sensitivity regarding holistic needs of
patient is the best measure to control use of restrictive practices.
From the analysis of literature on pros and cons of seclusion for consumers and health
care staff, it can be concluded that seclusion practice is associated with many negative effect
and lesser beneficial effects. Seclusion is beneficial only in exceptional context when there is
a need to protect staff or other patients from harm or injury from a patient with challenging
behaviour. In addition, it is beneficial only for a certain time period. However, many research
literatures advocated against the use of seclusion. The main harmful effects from the
perspective of patients were that it resulted in humiliation, anger, shame, hopelessness,
PTSD, poor care experience, violation of their basic human rights and lack of trust.
Moreover, the challenges or disadvantages associated with its use in mental health staff
included feelings of guilt, frustration, job dissatisfaction and challenges in decision making
due to risk of violation of ethical rights. Based on the review of challenges to nurses, it has
been found that there is a need to train nurse regarding use of recovery oriented approach and
other good practice alternatives that eliminates use of seclusion and promotes implementation

of patient-centred care that develops therapeutic relationship between nurses and mental
illness patient.

References:
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