ethical challenges of seclusion in psychiatric inpatient wards

Safewards, introduced by Bowers (2014), is an evidence-based model formulated specifically for use on inpatient mental health wards. It might be helpful to formulate the different ethical dilemmas experienced by the professionals as conflicts between ethical principles. 2008;79(2):97–109. 19, No. The ethical principles of the World Medical Association’s Declaration of Helsinki were followed. Mental Health Policy and Service Development Department of Mental Health and Substance Abuse World Health Organization, Geneva 2017. Cochrane Database Syst Rev. Goulet M-H, Larue C, Dumais A. The aim of this study is to examine how clinical staff in psychiatric inpatient wards describes and assess the ethical challenges of seclusion. J Adv Nurs. These factors are proven to affect both treatment outcomes and patient satisfaction [60, 61]. The controversial practice of seclusion creates a complicated and significant ethical dilemma in healthcare. 2015;10(6):e0128536. doi:https://doi.org/10.1111/jpm.12246. https://doi.org/10.1177/2158244016629526. Gaskin CJ, Elsom SJ, Happell B. Shielding in Mental Health Hospitals:Description and Assessment by Staff. Background: This study is to our knowledge the first health service study on staff’s experiences of the ethical dimensions of seclusion; their main ethical challenge is the relationship between treatment and control when seclusion is used. 1 The project was approved as a quality improvement project based on anonymous data (reg. New York: Oxford University Press; 2013. https://doi.org/10.7748/nr2010.01.17.2.16.c7458. However, it may also be argued that the disadvantage for the other patients is so great in not using seclusion that ‘do no harm’ (non-maleficence) to the other patients should be prioritized, i.e., a patient needing to be secluded could be so disruptive and chaotic that he/she impedes the recovery process for other patients. 2017;34:139–46. J Med Ethics. 2006;60(2):144–9. The analytic steps are outlined to strengthen trustworthiness [47]. We believe that a constant reflective process challenging foreknowledge and working to bring preconceptions to the level on consciousness was of help. The study was approved by the Data Protection Officer at Akershus University Hospital (reg. Few studies examine how staff members describe, assess, and perceive ethical challenges that they encounter during coercion, including seclusion [40, 41]. O'Neal EL, Adams JR, McHugo GJ, Van Citters AD, Drake RE, Bartels SJ. Keski-Valkama A, Sailas E, Eronen M, Koivisto AM, Lonnqvist J, Kaltiala-Heino R. The reasons for using restraint and seclusion in psychiatric inpatient care: a nationwide 15-year study. There may be partial limitations or no access whatsoever. Concerning the method of this study, the data are based on what clinical staff members write when they answer open questions about ethical aspects of seclusion. Hosp Community Psychiatry. The main finding is that the relationship between treatment and control during seclusion produces ethical challenges. The sections on ethical aspects from all 149 cases were included in the study. The clinical implications are that the findings may contribute to a better understanding of how to use seclusion in a better way as well as when not to use it. The review concluded that more research is needed to draw more robust conclusions. COVID-19 is an emerging, rapidly evolving situation. Psychiatr Q. Summary . 2005;43(2):31-37 ... about 40 in number, have been removed from the wards. Understanding the concentration of containment episodes can support the development of effective interventions. Using a qualitative methodology, we obtained empirical, in-depth knowledge of seclusion cases. https://doi.org/10.1136/jme.2010.035402. Participants described that it is: ‘important for the staff with breaks to be able to do a focused and good therapeutic job’. Aggress Violent Behav. https://doi.org/10.1111/j.1365-2850.2009.01396.x. Despite this, ‘patients could benefit from fewer staff’, but they are striving to find an optimal solution due to the psychosocial strain on staff. NIH Moral case deliberation may improve the overall ethical quality of the organization, e.g., by facilitating reflection on good care in general and seclusion in particular [79]. PubMed  Bowers L, Alexander J, Simpson A, Ryan C, Carr-Walker P. Cultures of psychiatry and the professional socialization process: the case of containment methods for disturbed patients. The meaning unit was identified by reading the text while searching for words, sentences or paragraphs relating to each other through their content and context. Nord J Psychiatry. The authors declare that they have no competing interests. However, patient preferences should be acknowledged, and staff should weigh all available options and carry out seclusion only when the benefits exceed the disadvantages [72]. Google ScholarÂ. Am J Geriatr Psychiatry. Article  Several participants describe that working with secluded patients is challenging in different ways. A participant describes that it is stressful to see that the patient is bothered when you do not have an optimal solution. CAS  We are also thankful for feedback on the ethical principles section from Morten Magelssen, The Centre for Medical Ethics, University of Oslo. 2012;48(1):16–24. 2010;64(2):136–44. Several of the participants describe the importance of being loyal to what is determined by the treatment group. Interventions for Reducing Seclusion and Restraint in Mental Health Care for Adults: A Systematic Review. Bruk av skjerming som behandling og kontroll i psykiatriske akuttposter. Bracketing of preconceptions were emphasized in order to draw critical attention to the seclusion cases. This also applies if the patient is being secluded. Our findings illustrate that working with patients being secluded is stressful due to lack of adequate solutions, and staff become tired, scared, and mentally exhausted from the psychosocial strain. The first author was supported by The Norwegian Union of Social Educators and Social Workers (FO) at the Profession for Social Educators. Int J Ment Health Nurs. This seems to be based on the ideology (of controversial research basis [1, 2, 36,37,38]) that stimulus reduction is useful for patients being secluded. Rapport, IS-2812. Seclusion and restraint in psychiatry: patients' experiences and practical suggestions on how to improve practices and use alternatives. https://doi.org/10.1111/j.1447-0349.2008.00567.x. Am J Psychiatry. In the same year, the rate of psychiatric admissions was 640 per 100,000 inhabitants [9]. Systematic ethical reflections are one way to process the ethical challenges that staff encounters. Violent and aggressive events occur commonly in mental health settings; this is supported by earlier research findings [48, 49]. 2010;36(8):459–62. The most common procedure is to use seclusion after mechanical restraints. The patient is, as a participant succinctly expresses, ‘voluntarily admitted, but treated as she is involuntary admitted’. 2007;30(2):118–26. Staff attitudes and use of coercion in acute psychiatric wards in Norway. https://doi.org/10.1111/j.1744-6163.2010.00301.x. 2018;54(2):212–20. Violence is a complex phenomenon that needs to be met with a multiprofessional approach. 2001;103(3):212–9. Iozzino L, Ferrari C, Large M, Nielssen O, de Girolamo G. Prevalence and risk factors of violence by psychiatric acute inpatients: a systematic review and meta-analysis. It appears to be an ethical challenge to provide adequate treatment during seclusion. 2008;1(1):57–65. 2017;30(2):90–7. Most participants describe an ethical awareness of the use of mechanical restraints, although there are some cases where staff does not reflect on this ethical challenge at all. This analysis was headed by the first author. 2009;32(6):408–12. Nord J Psychiatry. https://doi.org/10.1177/0969733009350140. Get the latest public health information from CDC: https://www.coronavirus.gov. In 2017 seclusion was carried out with 2517 adult patients in Norway, a rate of 58 per 100,000 inhabitants [8]. Kaltiala-Heino R, Tuohimäki C, Korkeila J, Lehtinen V. Reasons for using seclusion and restraint in psychiatric inpatient care. There is a need for more knowledge as to what assessments clinical staff must carry out when making decisions regarding seclusion. In addition, The Parliamentary Ombudsman works to prevent torture and inhuman treatment in institutions, according to a mandate set out by the UN optional protocol to the Convention against Torture (OPCAT). That the patient had a high risk of suicide or serious self-injury was used in 9 cases. Another aspect of ‘voluntary seclusion’ is the secluding of patients who are voluntarily admitted. This is supported in several previous studies where patients perceived seclusion to be a distinctly negative experience [32,33,34,35]. It was emphasized that the therapists who participated should have good knowledge of the patient through regular conversations and cooperation with the ward staff. A treatment situation like this might also conflict with the principle of justice as fairness, although justice is for every individual, not just the patient and will therefore have to take into consideration broader perspectives [65]. ‘Basically, the culture is that seclusion is a tool that can be used also for patients asking for this’. Springer Nature. The inpatient environments in psychiatric units are not always conducive to patients' recovery. ‘It this case, it can be discussed whether easier means are well tested. In China, the clinical use of seclusion was gradually increasing, which had led to ethical dilemma and had gained public concern. Nasjonal helse- og sykehusplan [National health and hospital plan] (2016-2019). Consideration for other patients is often necessary when a patient’s behaviour is very disturbing, annoying, or unfortunate for other patients, e.g., a patient that are aggressive and/or violent may be regarded as annoying for other patients [7]. There were 41 patients with a seclusion duration between 1 and 7 days and 40 patients with a duration between 8 and 14 days. Funk M, Drew N. Strategies to end the use of seclusion, restraint and other coercive practices. ‘He threatened staff but did not physically attack people, only ruined material things’. It shows that we have a good stance and that we are reflecting on what we do with our patients’. Nurse Educ Today. J Psychiatr Ment Health Nurs. Acta Psychiatr Scand. NLM The staff describes seclusion as an ethical challenge that affects them emotionally, while at the same time they describe having a basically good ethical attitude from which to address this challenge. A participant reports precisely about this dilemma: ‘There was a special challenge in relation to the patient admitted under section 2.1 of the Mental Health Care Act [Voluntary Section], which was simultaneously subject to seclusion’. Acta Psychiatr Scand. 2002;23(2):157–70. The patients who are described in the cases were either secluded in a regular patient room or in a secluded area. Some of the participants reflect on how drastic it is to restrict a patient’s freedom of movement, while others consider that the patient profits by limiting stimuli from the outside world. 2017;254. Unfortunately, there is not much evidence about the ‘We think it is positive to be touched. Therapeutic reasons may be present if it is necessary to limit the patient’s sensory impressions. Am J Psychiatry. International research suggests that number of containment events and hours spent in containment are often concentrated in a small number of patients. This contrasts with a questionnaire consisting of closed, predefined questions.

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