NSM5CPR - Clinical Practice Development, Seclusion

Running head: SECLUSION
Seclusion
Name of the Student
Name of the University
Author note

1SECLUSION
Introduction
The aim of the report paper part A is to develop a clinical audit question regarding the
use of seclusion for the psychiatric patients in mental health hospitals. For this, the background
and rationale will be discussed in the first section of the report. A clinical audit question will be
outlined and the development of the PICO question is discussed in the following sections with
the search strategy. Thereafter, part B will deal with the critical analysis of the evidences that
will be obtained to develop the clinical bottom line and best recommendations for the evidence-
based practice.
Part A
Background and Rationale
Although, seclusion is an emotive and controversial subject in mental health nursing, it is
still practiced in the mental health hospitals widely. There are varied opinions regarding the use
of this practice, however, it is still a legitimate intervention to use seclusion as compared to the
efficacy of restraints to control aggressive behaviour in psychiatric patients (Knox & Holloman
Jr, 2012). The focus of the paper is the use of seclusion to control aggressive behaviour through
safe practice and guidelines in mental health patients as practiced in mental health institutions.
The rationale for choosing this topic is that restraint in psychiatric patients has led to
exacerbation of aggressive behaviour that cause harm to other patients and mental staffs. On the
other hand, seclusion is preferred over restraint in managing and protecting the patients from
aggressive behaviour. Seclusion causes no harm to the patients and is an effective intervention
for the management of the aggressive incidents.

2SECLUSION
According to Perkins et al., (2012), the mental health nurses for inpatients in psychiatric
wards practice restraint when a patient shows aggressive behaviour, acts out or does not follow
the rules. However, current data suggests that restraints is not a therapeutic intervention, rather
jeopardise the mental health status of the psychiatric patients. In a structured questionnaire study
conducted by Vishnivetsky et al., (2013), secluding psychiatric adolescent inpatients was
preferable as compared to physical restraint. About 82% of the total participants preferred
secluding in the room is preferable as it was less frightening and improved their mental status as
compared to restraint. On a contrary, seclusion is used that maximizes the freedom of the
patients and protect them from risk by providing them a safe and secure environment
(Vishnivetsky et al., 2013). However, there are various arguments reading the use of seclusion as
it deprives them of liberty and practice social control as a coercive and negative experience.
There is mixed literature regarding the use of seclusion as a way to control violent behaviour and
have long-term benefits, however, seclusion is a safe option than restraints.
In seclusion, the psychiatric patient is locked in a room, is being isolated from other
patients and medical staffs, with loose items, and is allowed to leave the room. The locked
patient is continuously observed and is a direct response to their aggressive behaviour that it is
because of a psychological behaviour. Thus, the clinical audit will be focusing on the seclusion
practice as a better intervention in controlling aggressive behaviour than restraint in psychiatric
patients. The best practice is to provide seclusion where as compared to restraint and the mental
ward nurses consider it a clear benefit for the person who is being secluded. It is considered a
protective measure where the mental ward nurses utilize seclusion complying with the best
practice and for the benefit of the patient. Although, seclusion is used insufficiently in the current
practice, however while using the nurses follow basic guidelines and standards while utilizing

3SECLUSION
seclusion (Osborne & Webster, 2009). They follow safe delivery of seclusion in a secure
environment that ensures patient safety prioritizing staff education and support so that there is
patient-centred care and strong leadership, monitoring, commitment, oversight and transparency
while using seclusion in psychiatric wards (Kuosmanen et al., 2015). The current practice also
suggests that mental health staffs should abide by the principles of seclusion like use of positive
behavioural support and decreased use of physical restraint. Mental health nurses also take into
account the policy considerations that manage risk. According to Kontio et al., (2012), the nurses
choose seclusion as the last option; however, they use it when they are not left with any other
option. They do not continue it for longer and use it as a way to safeguard the patient and staffs
from violent behaviour.
The care staffs keep the secluded person in sight, sound inside the secluded room, and
observe them directly through CCTV or direct observation. The nurse ensures that the patient is
safe inside the room and pay attention to the consciousness level of the secluded patient. They
also stay alert and concerned about the particular needs of the patient and provide immediate
care for the secluded patient. However, in the real world scenario, mental health nurses does not
comply with the guidelines of seclusion and are attempting to include the best practice in the
seclusion (Jacobsen, 2012). For this, the nurses need to be properly trained and be competent
with the recovery principles after seclusion and informed care.
Clinical audit topic
Do nurses in mental health wards comply with best practice when utilising seclusion?

4SECLUSION
Application of PICO
The audit topic is broken into a PICO format that explains that Population, Intervention
as a treatment option, procedure or a diagnostic test as compared to another intervention and the
outcome of the applied intervention (Methley et al., 2014). This format is helpful in defining the
clinical audit topic and enables us to carry out a useful search by using keywords and Boolean
operators (Robinson, Saldanha & Mckoy, 2011).
Table 1 (Application of PICO)
Population Psychiatric patients who show aggressive
behaviour due to psychological disorders are
not managed or controlled in a proper way by
the nursing staffs. Incorrect management can
harm the other patients and staffs in the wards
and have serious consequences to the patient’s
well-being.
Intervention Seclusion is an intervention that can be used
for controlling aggressive behaviour in
inpatients in a psychiatric ward.
Comparison The multidisciplinary team (MDT) should also
utilize the same guidelines or approach while
using seclusion. According to New South
Wales (NSW) for Clinical Innovation, although
seclusion need to be reduced in the psychiatric

5SECLUSION
units, there should be proper care plan, staff
training and education and well handover
meetings to ensure safety of the patient and
staffs (Callaghan & Ryan, 2014).
Outcome It is reasonable to suggest that although
seclusion has no proper therapeutic benefits, it
is used by the nurses, at the same time should
assure that everyone is safe, and causes no
harm.
Search strategy and findings
The search strategy for the clinical audit question will be through the database search,
keywords and Boolean operators, selection process through inclusion and exclusion criteria and
data analysis. For carrying out an effective search for the clinical audit question, one has to
conduct an extensive search and come up with strong evidence and best research that can be
analysed in a comprehensive manner (Smith et al., 2011). Relevant literature will be drawn from
the vast pool of existing literature so that one can reach to a conclusion and summarise findings
to indentify gaps and answer the main audit question.
Specific databases will be used which are powerful tools that can be utilized to carry an
effective search. The electronic databases were used like CINAHL, Ovid, Web search and
Medline. All these databases have peer-reviewed and full-text journals that are authentic and
reliable sources. The keywords used for the search are crucial elements, consists of short phrases,