Context
Seclusions cause distress in patients and lead to negative outcomes, including death. Growing research demonstrates that seclusion rates vary by age, sex, race, diagnosis and personal history of adverse events.1 In fact, seclusion rates among youth are higher than among adults. While research involving staff in adult inpatient psychiatric units demonstrates that staff and patients experience negative reactions,2 more specific research is needed related to staff in adolescent inpatient units, given this population’s unique developmental stage.
Methods
Yurtbasi and colleagues3 used a mixed-methods approach to explore staff perspectives on the effects of seclusions on patients and staff. They administered a modified Attitudes to Seclusion Survey to 31 staff members on reasons for seclusion, opinions about patients’ related feelings and effects on staff. They then conducted semistructured interviews with 24 staff members to explore attitudes, experiences and beliefs about seclusion in adolescent psychiatric inpatient care until reaching information saturation. The interviews were held in the hospital and recorded with permission. Descriptive analyses for quantitative and thematic analyses for the qualitative data were conducted.
Findings
Most participants were women, trained in nursing and had worked in the inpatient unit for more than 5 years. Almost 9 out of 10 had been part of a seclusion event. All participants agreed that patients experienced anger, fear and confusion while in seclusion, but perceived seclusions helped patients feel calmer, and almost all believed they improved patient behaviour. The interviews presented five recurring themes, including (1) effects of seclusion, (2) staff reluctancy to use seclusion, (3) under-resourcing as a risk factor for seclusions, (4) seclusion negatively impacting staff–patient relationships and the patients and (5) negative effects of seclusion on staff. Staff admitted that when understaffed, seclusions tended to happen more frequently as less time was spent providing therapeutic support, that sometimes seclusions were used inadequately as a punitive measure, and that there was potential for re-traumatisation in victims of violence. In some cases, participants believed seclusions helped patients regulate their emotions, gave time for medications to work and allowed patients to feel calmer in a safe environment.
Commentary
Even though youth experience seclusions more frequently than adults, the research on paediatric seclusions is limited. This study focuses on staff working with adolescents.
Since the 18th century,4 support for and opposition to the use of seclusions have led to regulations in Europe and the USA. Just a few decades ago, seclusion use in youth was promoted to help develop coping and interpersonal skills. Yet, experts agree that seclusions are not therapeutic. More recently, U.S. federal initiatives have emphasised the need to decrease seclusion rates in behavioural settings. As the authors suggest, differences across psychiatric units suggest a role of the environment, including staff culture and attitudes, on seclusion rates. Indeed, seclusion superusers among residential youth centre workers have greater fear of violence, levels of traumatic stress and perceived verbal and physical aggression than normal users, supporting the notion that staff perceptions may affect seclusion use.5
Yurtbasi et al3 recommend systematically debriefing, planning unit staffing based on acuity rather than occupancy and looking for alternatives to seclusion, in addition to assessing individuals at higher risk and providing additional staff support. These recommendations align with those of professional organisations like the American Academy of Child and Adolescent Psychiatry, which supports interventions at all stages of aggression prevention.
A recent review of strategies to reduce seclusions in the past 10 years showed promising evidence to successfully reduce adolescent seclusions.6 More research is needed on interventions perceived as therapeutic by both staff and patients in behavioural settings.2
Implications for clinical practice and research.
Nursing staff find adolescent seclusions necessary but also experience related guilt and self-doubt.
Seclusion protocols in adolescent psychiatric units should include alternatives to seclusion and debriefing processes.
Footnotes
Competing interests None declared.
References
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