Abstract
Seclusion is one of the methods in controlling violent behavior of inpatients in psychiatric wards. In current descriptive analytic study, data collection instrument included the seclusion list of inpatients by considering individual, social and clinical characteristics in one of the psychiatry wards In the Razi teaching hospital of Tabriz in the first six months of 2012. Among 264 admitted patients, 24 patients (9.1%) had been secluded and a total of 29 isolated incidents were recorded. Most of secluded incidents occurred on weekdays (75.9%), first week of inpatient (87.7%), and during the evening shifts (48.3%). The results obtained in this study demonstrate that in 55.2% cases, the duration of isolation was two hours and the most common cause of seclusion was aggressive behaviors. Most of secluded patients (66.7%) were diagnosed with mood disorders.
Introduction
Control of aggressive behavior is a major problem (a great challenge) in the care of psychiatric patients. Seclusion is a restrictive procedure that is used to manage aggressive behavior of patients and can be defined as a detention of a patient in a room at any time of day or night to prevent the patient from leaving the room freely.1 Previous studies were reported a different statistics regarding the frequency of using seclusion in psychiatric facilities.2-5 Recently, some clinical, ethical, and legal challenges have been raised around the application of this procedure,6,7 because seclusion restricts patients’ freedom and is a contrary to their wishes. Unfortunately, there is not much evidence about the effectiveness of seclusion as a medical intervention.8 In addition, some researchers believe that using of seclusion as a medical intervention is an indicator of failure in providing high quality psychiatric care.2 Also, many patients and health care personnel reported adverse physical and mental effects for seclusion. Thus, in some Western countries, reducing or eliminating isolated incidents considered as a priority for supervisory agencies.9-11
It should be noted that obtaining essential information about the frequency and pattern of using seclusion may provide a basis for the design and implementation of interventions to reduce using of this procedure. On the other hand, in spite of a wide review of relevant literature, there is no studies investigated using of seclusion in Iranian psychiatric settings. So, the aim of this study was to describe isolated incidents in Tabriz Razi teaching hospital in Iran.
Materials and Methods
In this descriptive analytic study, the archival medical records of all patients admitted to a male psychiatric in the Razi teaching hospital of Tabriz were reviewed from March to September in 2012.
Three instruments, i.e. demographic checklist, clinical characteristics checklist and information about seclusion incidents were administrated to collect the required data sets. These instruments were developed by researchers via reviewing scientific papers, textbooks, and experts’ comments and were used after determining its content validity and inter-rater reliability (88%).
Incomplete medical records were not included in the study. Data analysis was performed using descriptive (frequency, percentage, mean, and standard deviation) and inferential (Mann-Whitney, chi-square, and logistic regression) statistic by SPSS software version 13. P-value less than 0.05 were considered as statistically meaningful.
All ethical considerations, including informational privacy, collecting questionnaires without gathering, identifying information about patients, obtaining permission from the head of center, and presenting the results to the proper official authorities were respected.
Results
Medical records of 264 admitted patients encountered the inclusion criteria; the mean age of these patients was 33.81 years (standard deviation = 13.00 years) and most of them had a diagnosis of mood disorders (53.6%). Among all hospitalized patients, 24 patients (9.1%) were secluded and totally 29 incidents of seclusion were recorded.
Among them, one patient had experienced four seclusion incidents; two of them had experienced two seclusion incidents; others had experienced one seclusion incident. Also, amongst all secluded patients, sixteen ones (66.7%) had a diagnosis of mood disorders.
Most frequent reasons for seclusion were included: risk of harm to others (51.7%); risk of self-harm (6.9%); damage of hospital properties (10.3%); threats of violence (10.3%); disorientation and agitation (10.3%); lack of cooperation for hospitalization (6.9%). In addition, about two patients the reason for of seclusion had not been recorded. At 53.3%, 33.3%, and 13.3% of cases the violent incidents were toward other patients, medical staff, and family members respectively.
About two cases the duration was not recorded and about 22 cases; duration of seclusion was reported as an hour (20.6%), two hours (55.2%), and more than two hours (17.2%). Most of seclusion incidents had occurred during the evening and night shifts (79.3%). seclusion of patients were occurred during the first day of admission, between second and seventh days, and during the second week of admission in 34.5%, 48.2%, and 17.2% of cases respectively.
The results of the univariate logistic regression analysis showed that only education has a significant relationship with seclusion incidents. However, in the final model, there was no significant relationship among age, education, occupation, residence, diagnosis, and length of hospital stay with seclusion.
Discussion
In this study the frequency of using seclusion was 9.1% and this percent is higher than the reports from some previous studies2,12 and less than the results of some other studies.3,4,10,13 This difference may be due to some reasons such as type of hospitals, mode of admission, institutions’ policies on control of aggressive behaviors, and differences in definition of seclusion in different studies.
Similar to previous studies10,14 in current study, the majority of patients experienced the isolation in the first day of admission and thereafter in the first week of admission.
In the first days of hospitalization the effectiveness of treatments was not started and many of the patients reveal aggressive behaviors. So, using seclusion for the control of aggressive behaviors during this period is more predictable.15
In this study, similar to previous studies3,10,14 the seclusion rate on weekdays was more compared to weekends. It seems that less workload on weekends and having more time to answer the questions and needs of patients is an acceptable justification for this finding. Furthermore, the results showed that the probability of seclusion was further in the evening and night shifts, compared to the morning shifts.
The low ratio of nurses to patients, lack of recreational facilities, and quiet atmosphere of the evening and night shifts are possible reasons for this finding.
The main reason for seclusion incidents was aggressive behavior. This finding is consistent with finding from other previous studies.10,12,13 In addition, the majority of seclusion incidents were for patients diagnosed with mood disorders. Diagnosis is a challenging issue in previous studies and the relationship of diagnosis and seclusion incidents was different.3,4,14,16In this study, in contrast to the results of some previous studies,4,5there was no significant relationship between age, diagnosis, and length of hospitalization with seclusion incidents. The possible explanation for these results is a homogenous sample of patients participated in this study.
The main limitation of this study is to select one male psychiatric ward as a setting for data collection. So, these results are not generalizable to all psychiatric wards. Also, due to the lack of accurate recording some seclusion ceases may not be recorded exactly.
Conclusion
The results obtained in this study also demonstrate that seclusion is a procedures used in psychiatric settings. In most cases, this procedure was used for the control of aggressive behavior and its use is further during the evening and night shifts and during working days. Therefore, in order to reduce the use of seclusion as a medical intervention in psychiatric settings, the education of nurses about alternative methods for control of aggressive behaviors and increase the ratio of nurses to patients is necessary.
Ethical issues
None to be declared.
Conflict of Interest
The authors declare no conflict of interest in this study
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