seclusion in new zealand mental health services · (4), pp. 137-142; also gutheil, t. g. (1978)...

APRIL 2004

Seclusion in New ZealandMental Health Services

SECLUSION IN NEW ZEALAND MENTAL HEALTH SERVICESII

Published by the

Mental Health CommissionWellington

2004

ISBN: 0-478-11393-5

CONTENTS III

Contents

Foreword from Chair, Mental Health Commission ............................................................................................... v

Comment from Director Mental Health, Ministry of Health .................................................................. vi

CHAPTER ONE: INTRODUCTION ........................................................................................................................................1

CHAPTER TWO: WHAT IS SECLUSION? .................................................................................................................... 3

2.1 Theory and rationale ...................................................................................................................................................................3

2.1.1 Seclusion as therapy ...................................................................................................................................................3

2.1.2 Seclusion as containment ..................................................................................................................................... 3

2.1.3 Seclusion as punishment .......................................................................................................................................3

2.2 Statute and guidelines ...............................................................................................................................................................4

CHAPTER THREE: WHAT DID THE SECLUSION PROJECT INVOLVE? .................................. 5

CHAPTER FOUR: FINDINGS .......................................................................................................................................................7

4.1 The magnitude of seclusion practice ......................................................................................................................... 7

4.2 The consequences of seclusion on people ........................................................................................................... 7

4.3 What factors influence seclusion practice? ........................................................................................................ 8

4.4 Human rights and duty of care issues ................................................................................................................... 10

4.5 Monitoring .......................................................................................................................................................................................... 11

CHAPTER FIVE: CONCLUSION ............................................................................................................................................ 13

CHAPTER SIX: NEXT STEPS .................................................................................................................................................... 15

APPENDICES .............................................................................................................................................................................................. 17

Appendix A: Alty and Mason’s Benevolent-Malevolent Scale Model ........................................ 17

Appendix B: Key Seclusion Documents ........................................................................................................................ 18

Appendix C: Methods and Methodology (including bibliography) ............................................ 19

Appendix D: Resources for the Reduction of Seclusion ............................................................................. 20

SECLUSION IN NEW ZEALAND MENTAL HEALTH SERVICESIV

Without the help of many, many people this paper would not have been possible.The assistance of service users, clinicians, District Health Boards, Mental HealthCommission Advisory and Reference Groups and government agencies is gratefullyacknowledged. A special thanks to Johanna Reidy and Seth Bateman.

Acknowledgments

FOREWORD V

Foreword

This report on seclusion practice in New Zealand has been a long time in preparation. Throughthe process it has attracted great interest from the sector and from service users. The discussionswith service users, families, managers and clinicians generated a wealth of views.

The Commission has taken care to reflect these perspectives and to acknowledge the context inwhich seclusion occurs. Factors such as poor ward design, inexperienced staff, failure to shareinformation across services, unclear policy and guidelines and high levels of acuity undoubtedlyinfluence the use of seclusion. We have visited District Health Boards where seclusion practicehas been dramatically reduced by an investment in staff training and the introduction of routineand thorough debriefing after each use of seclusion.

At the same time, we must also acknowledge that seclusion is a form of detention that has humanrights consequences. The rights of those people placed in seclusion must be upheld and thisrequires rigorous adherence to legislative protections and the implementation of a thorough andtransparent monitoring system.

The Commission would like to see seclusion eliminated. This has prompted debate and given riseto concerns about increased use of medication, physical restraint and the criminalisation of serviceusers who require seclusion facilities.

We accept that a commitment to a substantial reduction in use is an important first step andbelieve a strengthened monitoring regime is critical to assessing progress towards that goal. Weacknowledge the willingness of the Ministry to undertake the work required to help ensure seclusionis substantially reduced.

Jan DowlandChairMental Health CommissionWellington

SECLUSION IN NEW ZEALAND MENTAL HEALTH SERVICESVI

Comment from Director Mental Health

Seclusion is one management strategy for mental illness. It offers containment, isolation andreduction of sensory input. Ideally its efficacy should be measured in terms of a better outcomefor the person than would have occurred had they not been secluded (Fisher 1994) and betteroutcomes for other patients, considering the duty of care that each unit has for all within theirjurisdiction.

However, better outcomes are notoriously difficult to measure. ‘Better for whom’ is a pertinentquestion. In a practical sense it might be measured in terms of safety and protection or a quieterenvironment that is less stimulating and more conducive to recovery.

Sadly, as with all treatments, worthy intentions and aims can fail. Seclusion can and is sometimesused for the wrong reasons (such as staff pressure) and can be used in the place of more appropriateand therapeutic interventions (such as engaging with a person and addressing their needs byexplanation and reassurance). Thus it can be a substitute for interpersonal and therapeuticengagement (which take time and skill) and be symptomatic of poor unit design, lack of space,lack of options, lack of staff numbers and training. It can also be a reflection of inappropriate staffgender and ethnic mix.

This Mental Health Commission paper is a serious step to examine the extent of appropriate use,as well as abuse, of seclusion as a management strategy. It debates how an evidence base can beestablished through audit procedures that can be used to inform future policy and practice.

Many clinicians would like to restrict its use to when all other avenues of therapeutic interventionhave been considered inappropriate and when its use can be combined with a ‘debrief’ andtherapeutic feedback as to the reasons for its use.

‘Primum non nocere’ (‘first, do no harm’) is a fundamental obligation for all clinicians. It is in thisregard that seclusion use must only be used as a thoughtful and planned intervention strategy toimprove outcomes for all.

Dr D G ChaplowDirector Mental HealthMinistry of HealthWellington

CHAPTER ONE: INTRODUCTION 1

Introduction

In June 2001, the Mental Health Commission initiateda review of seclusion practice in New Zealand mentalhealth services. The project was instigated becauseof concerns expressed by clinicians, service users andresearchers about the legitimacy, therapeutic valueand reported overuse of seclusion.2 Often perceivedas a punishment by service users and traumatising forall involved, seclusion has been widely debatedaround the world.

There are many opinions. Topping-Morris3 stated thatseclusion is ‘anti-therapeutic’, while others suggest itis a ‘treatment relic of the past’4 and an ‘embarrassingreality’.5 Those who support seclusion see it as a validtreatment intervention to control agitation and reducesensory stimuli.6

After decades of research and debate, these polarisedviews have reached a degree of consensus. Mostwould now agree that seclusion is potentially harmful,contradictory to recovery models of care, andsurrounded by serious ethical and moral issues. Arecently released report in the US, Achieving thePromise: Transforming Mental Health Care inAmerica, (July 2003)7 stated that:

...the use of seclusion.. in mental health treatmentsettings creates significant risks for adults andchildren with psychiatric disabilities. These risksinclude serious injury or death, re-traumatizingpeople who have a history of trauma, loss ofdignity, and other psychological harm.Consequently, it is inappropriate to use seclusion...for the purposes of discipline, coercion, or staffconvenience. (pg. 34)

Furthermore,

Seclusion [is a] safety intervention of last resort...[itis] not a treatment...In light of the potentially seriousconsequences...it is inappropriate to use [this]intervention instead of providing adequate levelsof staff or active treatment. (pg. 34)

Human rights issues have also been raised whereseclusion practice is seen to sit uneasily withinternational human rights principles, althoughseclusion itself does not breach current human rightslaw.

This report discusses the findings of the Commission’stwo year review of seclusion from human rights, policyand practice perspectives. It examines the magnitudeof seclusion use in New Zealand, provides anexplanation of that magnitude by explaining the contextof the acute unit, and investigates argumentssurrounding human rights, duty of care, and therapeuticvalue.

1 Johnson, D. J. (December, 1997) Factors in the Continuance andDiscontinuance of Seclusion in a Special Hospital, Unpublished MScThesis, University of Liverpool. Online Document, Available from:http://www.fnrh.freeserve.co.uk/docs/report2.pdf.

2 Use of Seclusion in Mental Health Services, Mental HealthCommission (1999)

3 Topping-Morris, B. (1993) Seclusion (RCN Forum for Nursing in aContinued Environment), Royal College of Nursing, London, cited inJohnson (1997).

4 Pilette, P. C. (October, 1978) The Tyranny of Seclusion: A Brief Essay,JPN and Mental Health Services cited in Johnson (1997).

5 Soloff, P. H. (1979) Physical Restraint and the Non-Psychotic Patient:Clinical and Legal Perspectives, Journal of Clinical Psychiatry, 40 (7)pp. 302-305.

6 Grigson, J. W. (1984) Beyond Patient Management: The TherapeuticUse of Seclusion and Restraints, Perspectives in Psychiatric Care, 22(4), pp. 137-142; also Gutheil, T. G. (1978) Observations on theTheoretical Bases for Seclusion of the Psychiatric In-Patient,American Journal of Psychiatry, 135 (3), pp. 325-328.

7 From The President’s New Freedom Commission on Mental Health,USA.

CHAPTER one

“[seclusion] ... [t]he confinement of an individual in a locked room from which theyhave no means of egress is widely regarded as one of the most restrictive practicesused in modern psychiatry”1

SECLUSION IN NEW ZEALAND MENTAL HEALTH SERVICES2

CHAPTER TWO: WHAT IS SECLUSION? 3

CHAPTER two

2.1 THEORY AND RATIONALE

In theory, persons requiring seclusion are usuallyconsidered out of control, aggressive and in need ofcontainment and isolation in a controlled, restrictivesetting under close observation and monitoring byappropriately qualified and experienced staff. Seclusioninvolves:

• Containment – A person is contained within a roomwhere the door is shut and freedom to exit is decidedby clinical staff.

• Isolation – The person is in a room alone.

• Reduction in sensory input – The room is reasonablybare, often containing no more than a bed andsometimes a toilet.

The theoretical rationale for the use of seclusion variesdepending on whether seclusion is viewed as a validtherapeutic intervention in itself, a method ofcontainment of a psychiatric emergency, or a form ofpunishment that maintains physical and, at times,psychological control over the secluded person.8

2.1.1 Seclusion as therapy

As a therapy, seclusion is often seen as a ‘treatment’that ‘improves’ ‘illness’; for,

[c]ontainment limits the environment of the client,protecting her or him from self-injury or hurtingothers. This is said to provide the client with feelingsof safety and reassurance. Isolation removes theclient from personal interactions that may tax theclient’s coping abilities. [Reduction in sensory input]may calm clients who have escalating psychoticbehaviours. Inherent in these principles is theassumption that clients are secluded because theyare unable to control their behaviour.9(pg. 37)

Few would argue that the individual components ofseclusion (containment, isolation, and reduction insensory input) are not helpful at certain times. The

question is: do all service users who are placed inseclusion require containment, isolation and areduction in sensory input; or do they require only oneor two of these components to improve their conditionor protect others?

2.1.2 Seclusion as containment

Seclusion is often used as a risk management procedurewhere potentially violent persons are secluded to‘decrease opportunities [for them] to do damage tothemselves, others, or the environment’ (pg. 33).10

The validity of the containment rationale rests on theargument that there is a lack of effective alternatives tocontrol violent people on the ward and containmentby seclusion is simply the most pragmatic ofinterventions. Containment is however only onecomponent of seclusion, as suggested above. The needto contain a person may not necessitate the need forisolation and the reduction of sensory input as well.

2.1.3 Seclusion as punishment

Punishment is an emotive word that ‘conjures upfeelings of abuse, neglect, tyranny and persecution’.11

And although few would condone punishment as anappropriate justification for seclusion, there arearguments that suggest punishment may be a legitimatemeans to modify behaviour. Tardiff,12 for example,suggests that seclusionary time out can be therapeuticif used briefly in behavioural programmes. Of course,

What is seclusion?

8 Martinez et al (1999) From the other side of the door: Patient viewsof seclusion. Journal of Psychosocial Nursing. Vol. 37. No. 3. Also seeAppendix A which details Alty and Mason’s (1994) Benevolent-Malevolent Scale Model of various rationales.

9 McBride, S. (August, 1996) Seclusion Versus Empowerment: APsychiatric Care Dilemma, The Canadian Nurse, pp. 36-39.

10 Walsh, E. (January-March, 1995) Seclusion and Restraint: What WeNeed to Know, Journal of Child and Adolescent Psychiatric Nursing,pp. 28-40.

11 Johnson, D. J. (1997)12 Tardiff, K. (Ed) (1984) The Psychiatric Uses of Seclusion and Restraint,

American Psychiatric Press, Wasington D.C.


13 Based on findings from the seclusion survey conducted by theMinistry of Health and the Mental Health Commission (2001).

seclusion is supposed to be an emergency procedureused when people are highly agitated and unable tocontrol their behaviour. If seclusion worked, from abehavioural standpoint, one would expect service usersto experience seclusion only once or twice, but thispattern has not been observed. Multiple seclusionevents are common for extended amounts of time.13

2.2 STATUTE AND GUIDELINES

The Mental Health (Compulsory Assessment andTreatment) Act 1992 (the Act) requires that every serviceuser is entitled to the company of others, except incertain circumstances when they may be placed inseclusion. The Act also states that seclusion may beused for the ‘care’ or ‘treatment’ of the service user, orprotection of other persons in the ward (section 71). Inother words, legally, seclusion can be used as a therapyand as a containment procedure, while it cannot beused as a form of punishment.

In terms of monitoring and quality assurance, eachhospital or service must keep a register of seclusion(section 129b). The responsible clinician has theauthority to use seclusion in accordance with theprovisions of the Act and any concerns regarding theuse of seclusion can be referred to the Director ofMental Health, who can direct District Inspectors toinvestigate any concerns.

In regards to operational guidance, the Ministry ofHealth has a Restraint Minimisation and Safe PracticeStandard (2001), which replaces the ProceduralGuidelines for the Use of Seclusion (1995) as theprimary reference document for practice. Seclusion isdefined as a form of restraint and the Standard sets outtwelve outcome measures, one of which dealsspecifically with seclusion. Many of the 1995Procedural Guidelines for seclusion are contained inthe appendices to the Standard.

CHAPTER THREE: WHAT DID THE SECLUSION PROJECT INVOLVE? 5

The Commission’s review of seclusion involved avariety of components, each adding to ourunderstanding of seclusion practice in the New Zealandmental health setting.

These components were:

1. A survey of all District Health Boards (DHBs)conducted with the Ministry of Health capturingdata for the 2000/01 financial year.

2. An analysis of the literature on seclusion.

CHAPTER three

What did the seclusion project involve?

14 See Appendix B for a list of these.

3. A review of key policy documents that relate toseclusion practice.14

4. Consultation with practitioners and site visits toselected DHBs.

A detailed discussion of methods is contained inAppendix C, which outlines the survey process andanalysis, the literature analysis (including a full list ofreferences), and the process used for policy analysis,consultation and site visits.

CHAPTER FOUR: FINDINGS 7

Detailed analysis of the four data components revealedthat seclusion was used widely and often across DHBs.And although it was generally perceived as a negativeintervention by both services users and clinical staff,its use was influenced by systemic, resourcing,architectural, management and practice constraints.

4.1 THE MAGNITUDE OF SECLUSIONPRACTICE

Although seclusion varied over time and betweenDHBs, all DHBs surveyed used seclusion, with 37% ofservice users under the Act experiencing time in aseclusion room. On average, secluded persons spent50 hours per month in seclusion. Monthly hours rangedfrom 1 to 600 hours, while most seclusion events werebetween 8-24 hours in duration. Biographical dataindicates that males and females are secluded at aboutthe same rate and Maori tend to be secluded more thanothers.

4.2 THE CONSEQUENCES OFSECLUSION ON PEOPLE

The research evidence does not support seclusion as atreatment or therapy. Rather, seclusion can be seen asan adjunct to treatment.15 The research literature alsosees seclusion as a containment procedure that can bepsychologically damaging for some people.16

Qualitative literature indicates that feelings ofhelplessness, punishment and depression arecommon,17 as are feelings of anger, frustration,confusion and fear.18 Martinez et al’s19 quantitativestudy confirms these findings as widely applicable.They found that 76.5% of people felt punished, 63.8%felt fearful, 64.4% felt worthless, and 54.3% of peoplefelt a loss of control. These findings contradict thetherapeutic rationale for seclusion that has long beenthe primary justification for its use.

Investigations of solitary confinement in prisons20

provides further evidence to challenge the ‘seclusionas therapy’ argument; for although solitary confinementis intended primarily as a punishment, the impact onpeople is the same as seclusion. Scott and Gandreau,21

for example, found that solitary confinement led todeclining mental functioning, hallucinations anddelusions22, while psychologists at the Maine StatePrison in 1975 argued that excessive time in solitaryconfinement caused depression, withdrawal andpsychotic behaviour.23 More recently, Grassian andFriedman24 (pg.278) stated, ‘the more recent literatureon [solitary confinement] has also nearly uniformlydescribed or speculated that solitary confinement hasserious psychopathological consequences’. Any formof solitary confinement then, seclusion included, canbe psychologically damaging for those who experienceit.

CHAPTER four

Findings

15 Exworth, T., Mohan, D., Hindley, N., and Basson, J. (2001) Seclusion:Punitive or Protective?, The Journal of Forensic Psychiatry, Vol. 12,No. 2 pp. 423-433

16 Terpstra, T. L., Terpstra, T. L., Pettee, E. J., and Hunter, M. (2001)Nursing Staff’s Attitude Toward Seclusion, Journal of PsychosocialNursing, Vol. 39. No. 5. pp. 21-27.

17 Heyman, E. (1987) Seclusion, Journal of Psychological Nursing andMental Health Services, 25 (11), pp. 9-12.

18 Binder, R. L., and McCoy, S. M. (1983) A Study of Patient Attitudestoward Placement in Seclusion, Hospitals and Community Psychiatry,34, pp. 1052-1054.

19 Martinez, R. J., Grimm, M., and Adamson, M. (1999) From the OtherSide of the Door: Patient Views of Seclusion, Journal of PsychosocialNursing, Vol. 37, No. 3, pp. 13-22.

20 Solitary confinement is defined as containment, isolation and sensorydeprivation. In other words, it is the prison term for seclusion.

21 Scott, M. and Gendreau, P. (1969) Psychological Implications ofSensory Deprivation in a Maximum Security Prison, CanadianPsychiatric Journal 337, cited in Benamin, T and Lux, K. (1976-7)Solitary Confinement as Psychological Punishment, 13 Calif. W. L. R.265 at pg. 268.

22 M Scott and P Gendreau (1969) Psychological Implications of SensoryDeprivation in a Maximum Security Prison, Canadian PsychiatricJournal 337, cited in T Benjamin and K Lux Solitary Confinement asPsychological Punishment (1976-7) 13 Calif. W. L. R. 265 at pp. 268.

23 D Hasson and J Quinsey (April 10, 1975) unpublished article cited in TBenjamin and K Lux Solitary Confinement as PsychologicalPunishment (1976-7) 13 Calif. W. L. R. 265 at pp. 266-7.

24 Grassian, S. and Friedman, N. (1986) Effects of Sensory Deprivation inPsychiatric Seclusion and Solitary Confinement, 8 Int’l J.L. andPsychiatry, 49 at pg. 54.


25 Norris, M. K. and Kennedy, C. W. (1992) How Patients Perceive theSeclusion Process, Journal of Psychosocial Nursing, 30 (3), p.7.

26 Mental Health Act Commission – Response to Women’s MentalHealth: Into the Mainstream, Strategic Development of MentalHealth Care for Women, December 2002.

But seclusion also impacts on clinical staff. There aremany reports of staff trauma and unease with seclusionpractice,25 especially where the journey from the openward to the seclusion room is fraught with resistanceand physical restraint is necessary along with forcedmedication. From a therapeutic standpoint, any formof coercive practice has the potential to damage thetherapeutic relationship between clinical staff andservice user, for the power differential is highlighted inthese circumstances. The therapeutic mode of care isreplaced by a custodial mode of care.

Perhaps seclusion is best conceived as a safetymechanism rather than a therapeutic intervention. TheHealth and Safety in Employment Act 1992 defines theright to workplace safety. Section 6 of this Act statesthat employers have a duty to ensure the safety ofemployees. Furthermore, employers have the duty toidentify and regularly review potential hazards (Section7), to eliminate a hazard if practicable (Section 8), andif it is impossible to eliminate the hazard, the employermust take steps to isolate it from an employee (Section9). In relation to seclusion, this means seclusion couldbe justified in terms of minimising a workplace hazard,thus legitimating the ‘seclusion as management’philosophy to some degree. Obviously, a balancingact is required in terms of service user and staff rights.No clear indication is given in statute to how this canbe achieved.

Finally, gender and cultural issues create their ownunique set of circumstances in relation to seclusion.Safety issues are paramount for women, especially ina mixed sex environment and the de-escalationintervention process may be different. Women may,for example, prefer talking therapies.26 Specific issuesalso emerge for various cultural groups, whereseclusion may, or may not, be seen as culturallyappropriate. Likewise, the process of how seclusionoccurs may need to take into account culturaldifferences. Male staff touching a Muslim womanwould not be appropriate, for example. Also importantare issues for refugees and asylum seekers who mayhave had traumatic experiences.

In spite of these evident concerns, seclusion is stillperceived as a ‘necessary evil’ by many clinical staff.To explore why seclusion is perceived this way, andwhy seclusion events in New Zealand mental healthservices are reasonably common with long durations,the context of the acute unit must be understood.

4.3 WHAT FACTORS INFLUENCESECLUSION PRACTICE?

There are a number of factors that influence seclusionpractice, including systemic constraints, resourcelimitations, architectural issues, staffing andmanagement processes, and service usercharacteristics. Key factors however are:

• Unclear policy and guidelines – Guidelinedocuments do not clearly define seclusion ordifferentiate it from other practices, such as NightSafety Orders (the locking of bedroom doors atnight within an acute unit). As a consequence ultravires practice is common. The RestraintMinimisation and Safe Practice Standard (theStandard) does acknowledge ultra vires seclusionpractice (section 1.3.12 pg. 7) but gives littleguidance on how to clarify the issue, especially inregards to monitoring.

Also, the Mental Health (Compulsory Assessmentand Treatment) Act 1992 does justify the use ofseclusion as a ‘treatment’. The Standard, however,indicates that seclusion is a containment procedurethat can be used to manage potentially violent ordestructive behaviour. This discrepancy needsclarification. If seclusion is a ‘treatment’ then itsrationale becomes one of therapy. If seclusion is a‘containment’ procedure, then its rationale is oneof management, with no expectation that theservice user will get ‘better’ through the procedure.

The intention that lies behind the use of seclusioncould significantly influence its frequency of use.Seclusion as a therapy would encourage use, as it‘makes people better’. Seclusion as a containmentprocedure, however, should discourage use, as ittakes on a custodial perspective against thephilosophy of nursing care and therapeuticintervention.

• Overcrowding – Seclusion can be influenced byhigh demands on a service, which causesovercrowding within the acute setting, thusincreasing the likelihood of agitated behaviouramongst service users.


Overcrowding also alters the nature of nursing careby creating an environment that requires extensivemanagement. Cleary et al (pg. 509)27 suggests:

Recently, claims have been made that psychiatricnurses do not interact in a therapeutic manner...The need to maintain ward order, to managepatients, other staff and the environment, placespressure on nursing staff who cope by utilisinga custodial model of care thereby creating abarrier to effective therapeutic interaction.

An overcrowded acute ward can be seen toencourage the use of seclusion as a containmentprocedure, to manage risk and to manage availableresources.

• Poor ward design – A ward that lacks quiet rooms,personal space, and is not conducive to staff-serviceuser interaction tends to increase the likelihood ofagitation and hence seclusion. There is an inverserelationship between a ward environment thatenables easy observation and the level of agitationby service users. Old psychiatric institutions tendedto have large open spaces, bright lighting and seatsarranged so nurses could easily observe people.Unfortunately, such spaces are often counter totherapeutic needs and can increase the degree ofagitation experienced on a ward. Conversely, award environment that has a lot of private spacealso demands greater interaction from staff in orderto maintain the necessary level of observation.

Issues of dignity and cultural appropriateness arealso impacted by ward design, which could alsoincrease the levels of agitation within the ward; theuse of surveillance cameras, and the availability oftoilets and showers for example. These issues areof particular concern to Maori and Pacific people.

• Low or inflexible staff numbers – Low staff numberscompromise the care and philosophy of care byincreasing the demand upon nurses to ‘manage’ theward environment and thus interact less with serviceusers. So although Higgins28 suggests that a staff-service user ratio of 1:1.5 was ideal to minimisingseclusion use, staff availability and quality ofinteraction may be more important. The tendencyfor seclusion to be used least at night when staff-service user ratios are often high supports thisview.29 Low staff numbers do influence theavailability of staff and the quality of interactionshowever.

Low staff numbers can also increase real andperceived risk on the ward. Real risk can beincreased where regular observation of people in

seclusion is compromised. Perceived risk can beincreased where clinical staff become more anxiousabout managing the ward environment and placepeople in seclusion as a risk managementprocedure.

• Inexperienced staff – Experienced staff are key tobest practice. Considerable skill is required to usealternative interventions such as de-escalation andspecialling (one-to-one or two-to-one nursing).Likewise, managing the ward environment andbeing able to interpret early signs of agitation canonly be learnt over time.

The interpretation of behaviour by staff is alsoculturally bound. Agitation can be displayeddifferently depending on the group in question. Thiscan increase the likelihood of seclusion use as arisk management procedure. Maori and Pacificpeople are most likely to be affected in this regard.

• Poor staff retention – Retaining quality staff isimportant because there is a need to ensurecontinuity in the care environment. Good carerequires good relationships and communicationbetween staff and service users and these can onlybe built over time. Seclusion often results frommisunderstanding and inaccurate perceptions ofrisk. Moreover, staff retention aids the developmentof information sharing between the acute unit andcommunity services as relationships are builtbetween key personnel.

• Poor information sharing – Seclusion can occurwhen appropriate information is not shared with aservice. Information about agitation risk, besttreatment options and so on need to be sharedbetween community services and acute units. Lackof information can lead to inappropriate use ofseclusion.

• Service user acuity – Service users who areextremely agitated and pose serious risks to self andothers leave clinical staff with few alternatives butto use some form of containment or restraint.Seclusion rooms may be the only facility availablewhere such a person can be contained safely. Theevidence points to high levels of acuity amongstthose presenting to acute inpatient units and a view

27 Cleary, M., Edwards, C., and Meehan, T. (n.d.) Factors InfluencingNurse-Patient Interaction in the Acute Psychiatric Setting: AnExploratory Investigation, unpublished paper.

28 Higgins, J. (1981) Four Years Experience of an Interim Secure Unit,British Medical Journal, 292, pp. 889-893.

29 Oldham, J. M., Russakoff, L. M. and Prusnofsky, L. (1983) Seclusion:Patterns and Milieu, The Journal of Nervous and Mental Disease, 171(11), pp. 645-650.


that seclusion is a necessary tool to manageprofound levels of disturbance and agitation, whichmay be drug induced.

Seclusion is supposed to be a ‘last resort’ intervention.However, in practice the resources, staffing constraintsand the operational environment limit the use ofalternative practices (e.g., quiet lounges, specialling,time out, confinement without isolation or reducedsensory input). Seclusion reduces risks and ambiguityfor staff and is a procedure justified by legislation andpolicy. Within such an environment, seclusion canbecome an all too easy intervention. This raises seriousquestions about human rights and the duty of care.

4.4 HUMAN RIGHTS AND DUTY OFCARE ISSUES

As a form of detention, seclusion practice does requirecommentary from a human rights perspective. TheHuman Rights Commission’s 1991 report to the PrimeMinister (“Mental Health - Patient Rights and the PublicInterest”) sets out a detailed discussion of the interfacebetween mental health detention and human rights law.

More recently, the Human Rights Commission, as acomponent of the National Action Plan, has lookedagain at the issue of detention, which includes issuesrelating to seclusion in the mental health setting. Thatreport is to be submitted to the Prime Minister by theend of 2004. This brief commentary on human rightsand seclusion is a continuation of a debate initiatedover a decade ago and is part of a growing humanrights discourse in New Zealand.

In 1991, the Human Rights Commission stated:

International instruments on human rights set thestandards by which all people should be permittedto live. The ideal standards for treatment of mentallyill people are delineated in a number of them.Although the Commission acknowledges thatconforming with all the principles laid down in theinstruments is difficult, and providing a service thatsatisfies everyone even more so, neverthelessattempts should be made to meet the criteriaoutlined. (pg. 59)

The Mental Health Commission does not suggest thatthe seclusion legal framework breaches human rightslaw. The Commission does suggest that seclusionpractice sits uneasily with a number of internationalagreements to which New Zealand is a signatory. Forexample, The Universal Declaration of Human Rights(Article 5) and the International Covenant on Civil and

Political Rights (Article 7) both prohibit practices thatcan be perceived as torturous, cruel, inhumane ordegrading, whether as a treatment or punishment. NewZealand was also one of 119 countries to ratify theConvention Against Torture and other forms of Cruel,Inhuman and Degrading Treatment (CAT). The CATdefines torture as:

...any act by which severe pain or suffering, whetherphysical or mental, is intentionally inflicted on aperson for such purposes as...punishing him for anact which he or a third person has committed...when such pain and suffering is inflicted by or atthe instigation or with the consent or acquiescenceof a public official or other person acting in anofficial capacity.30

Section 9 of the New Zealand Bill of Rights Act 1990and the United Nations Principles for the Protection ofPersons with Mental Illness and for the Improvementof Mental Health Care (1991) reiterate these statementson torture, cruel, inhumane and degrading treatment.

Although seclusion is not legally sanctioned in NewZealand as a punishment, it is clearly perceived as apunishment by many service users and the potentialharm is the same regardless of whether seclusion isused for therapy, containment or punishment.

The term ‘torture’ is however debatable and rests onthe interpretation of the phrase ‘severe pain or suffering’in the CAT. Case law in the UK has concluded thatsolitary confinement in itself is not torture but theconditions of the confinement may lend themselves tocruel and inhumane treatment; for example, wherepersons are placed in a room that lacks sanitation.31

Individual responses to such conditions may vary, sowhereas unsanitary conditions are tolerable for some,they may be intolerable, cruel and inhumane for others.What can be said, then, is that in rare cases seclusionplaces some people at risk of cruel, inhumane anddegrading treatment, which can lead to significantpsychological harm.

In regards to the duty of care, staff within inpatient unitshave an obligation to protect all service users frompotential harm. This is particularly pertinent whereservice users are committed under the Act and deprivedof their liberty. The environment of the acute unit, orany other mental health facility, should be therapeuticnot custodial.

30 Dec 10 1984, GA Res 39/46, U.N. GAOR 39th Session Supp No 51 at197, UN Doc E/CN 4/1984/72 (1984), Article 1.

31 Foley, K. (2000) Solitary Confinement: A Violation of InternationalLaw?, e-valuate, Vol. 3, Online Document, Available at:www.law.ecel.uwa.edu/elawjournal.


4.5 MONITORING

Seclusion incidents are recorded in a register that canbe scrutinised by District Inspectors (required undersection 129b of the Act). The Standard also requiresthat a specific form be used, and that 10 minute andtwo-hourly observations are made and noted. It is upto the discretion of District Inspectors as to thefrequency of seclusion monitoring. No centralmonitoring of seclusion currently occurs.

As mentioned above, although guideline documentsacknowledge that ‘practices similar to seclusion occurin many health and disability settings...[including] nightsafety orders... “time out” and isolating consumers forthe protection of themselves and/or others’ (TheStandard, pg. 7), these practices do not receive the samelevel of scrutiny as seclusion proper. It is up to eachindividual service to develop policies and proceduresto ensure these practices are used appropriately.

Also, given the research evidence sees seclusion aspotentially psychologically damaging, seclusion eventsshould therefore be classified as ‘critical incidents’.32

Critical incidents are defined as an ‘event that isphysically, psychologically, spiritually or culturallyharmful or potentially harmful to a client or otherperson’ (pg. 2).33 This reclassification would add anadditional layer of quality assurance and add robustnessto the monitoring of seclusion practice.

For the potential impact seclusion can have on a personthere do not appear to be sufficient checks and balancesin place to encourage best practice. Evidence doessuggest, however, that close monitoring may providean incentive for this to occur.

32 ‘Critical Incidents’ are now referred to as ‘Reportable Events’ by theMinistry of Health.

33 Guidelines for Reporting and Review of Incidents in Mental HealthServices: Revised Version (December 1995), Ministry of Health.

CHAPTER FIVE: CONCLUSION 13

Over the last three decades, researchers, clinicians andservice users have put forward a range of views onseclusion. These views are the product of research,clinical practice and personal testimony. And as diverseas these views are, a consensus is now emerging thatquestions the legitimacy of seclusion practice in themodern mental health setting. As a therapeuticintervention, seclusion was portrayed as solitude – calm,serene and contemplative. Evidence now suggests thatseclusion poses significant risks to service users,including death, re-traumatisation, loss of dignity andother psychological harm. As a punishment, seclusionhas been portrayed as remedial, although this rationaleis not sanctioned under New Zealand law.

Seclusion as a containment procedure requires morecareful examination. This rationale is sanctioned instatute34 and is justified by quite reasonable arguments.Containment is seen as a mechanism to protect theservice user and others from harm, and until betteralternatives arise, containing people in seclusion roomsis perceived as a ‘necessary evil’. Questions can be askedregarding the degree of restriction imposed by seclusion,though. Does seclusion impose an unnecessary degreeof restriction on people where least restrictive practiceis the most desirable model of care? In other words, doescontainment of a person also necessitate the need forisolation and reduced sensory input? Seclusion appearsto be an all-or-nothing approach and consequently thedegree of restriction may pose unjustifiable infringementson rights, freedoms and privileges.

Finally, as a form of detention, seclusion requires humanrights considerations. It is important to note that there isno evidence that seclusion practice breaches NewZealand human rights law. Seclusion practice does situneasily with international human rights instrumentshowever. Human rights considerations can be seen toadd a layer of protection in seclusion practice.

These things considered, the issue at hand appears notto be a question concerning the appropriateness ofseclusion practice, but rather how extreme violence, or

the risk of extreme violence, can be managed within apsychiatric acute ward? If this is the true problem, thenthe focus changes. All factors that relate to violenceshould come under scrutiny, this includes the origin ofviolence, ways to divert, predict and prevent itsoccurrence.35 Our examination of the acute ward contextgives some insight into factors that may influenceagitation on the ward. Outside of the ward, crisisprevention strategies such as greater access to supportworkers, psychotherapy, alternative treatments, peersupport and recovery education options may preventcrises from occurring.36 Minimising the pressure on acutewards by building community capacity and intersectoralcooperation could also resolve many of the systemicissues that influence ward agitation and violence.

The Commission would like to see a significant reductionin seclusion use and its eventual eradication. Thepathway towards eradication would require several yearsof development work including research, staff trainingprogrammes, which would promote ways to preventseclusion and identify humane alternatives, and astrengthened monitoring regime. The last of these is ofutmost importance for it would allow the measurementof progress towards eradication. Redefining seclusionas a ‘critical incident’ or ‘reportable event’ would addto a strengthened monitoring programme.

It is noteworthy that under the existing RestraintMinimisation and Safe Practice Standard (2001) leastrestrictive practice is a requirement, and demonstratedcompetence focusing on de-escalation skills and theminimisation and elimination of restraint is emphasised.The Commission supports these requirementswholeheartedly, but sees stringent monitoring as themost useful tool to encourage best practice and clarifythe pathway towards eradication.

Conclusion

CHAPTER five

34 The Mental Health (Compulsory Treatment and Assessment) Act 1992.35 Alty, A. and Mason, T. (1994) Seclusion and Mental Health: A Break

with the Past, London, Chapman and Hall.36 O’Hagan, M. (2003) Force in Mental Health Services: International

User/Survivor Perspectives, Incite, Vol. 2, No. 1, pp. 3-14.

CHAPTER SIX: NEXT STEPS 15

Next Steps

CHAPTER six

The Minister of Health Hon Annette King, the Ministryof Health and the Mental Health Commission agreethat this review of seclusion in mental health servicesis the beginning of a path forward, which will enableus to understand seclusion better and substantiallyreduce its use.

The Mental Health Commission is to ask the Ministryof Health and Standards New Zealand to redefineseclusion in current guideline documents, ensuring thatall practice that embodies confinement, isolation anda reduction in sensory input is acknowledged asseclusion.

The Ministry of Health is developing an auditablerequirement for each District Health Board to establisha debriefing system which provides that each seclusionevent is followed by a formal debriefing of staff andthe person secluded, and a formal report is preparedfor file and the relevant District Inspector for his/herconsideration.

By June 2006 the Ministry of Health will capture detaileddata surrounding seclusion events as part of the MentalHealth Information National Collection (MHINC).

To enable the progress towards significant reduction inseclusion use to be monitored, the Commission is torequest the Ministry to include rates of seclusion use inDHB service profiles.

Collaborative work will be undertaken between theMental Health Commission, the Human RightsCommission and the Health and DisabilityCommissioner to clarify the human rights issues aroundthe use of seclusion.

These initiatives will make a substantial contribution toa unified understanding of what seclusion is and theestablishment of a stringent monitoring regime to enableinformation on seclusion to be compared andbenchmarked. As a result, we will be able to assess ourprogress toward the reduction and the eventualeradication of seclusion.

APPENDICES 17

Alty and Mason’s (1994)Benevolent-Malevolent Scale Model

APPENDIX A

Relationship formation

Maturation

Mastering of Space

Isolation

Decrease in Sensory Input

Protection of Milieu

Place where Other Therapies Applied

Emergency Medication

Facilitates Diagnosis

Social Control

Safety of Self

Repression of Aggression

No Other Alternative

Mitigating Staff Anxiety

Elective Seclusion

Durations of Seclusion

Safety of Others

Safety of Property

Internal/External Control

Paternalism

Behaviour Modification

Ethological Model

Institutional Control

Sensory Deprivation

Revenge/Sadism

PUNISHMENT

CONTAINMENT

THERAPY

BENEVOLENT

MALEVOLENT

BENEVOLENT

MALEVOLENT

BENEVOLENT

MALEVOLENT

S E C L U S I O N


Key Seclusion Documents

Key documents that relate to seclusion and its operationare:

• Guidelines for Effective Consumer Participation inMental Health Services (1995)

• Guidelines to the Mental Health (CompulsoryAssessment and Treatment) Act 1992 (1995)

• Guidelines for Cultural Assessment in Mental HealthServices (1995)

• Guidelines for Reducing Violence in Mental HealthServices (1994)

• Guidelines for Clinical Risk Assessment andManagement in Mental Health Services (1998)

• Restraint Minimization and Safe Practice (Feb 2001)

• Procedural Guidelines for the Use of Seclusion(Revised Edition) (1995)

• Guidelines for Reporting and Review of Incidentsin Mental Health Services: Revised Version(December 1995)

• Guidelines for Discharge Planning for People withMental Illness (1993)

The ordering for these documents is not random. Theyare organised to match the process of a consumermoving through an acute unit and back into thecommunity. These documents provide an overview ofprocesses, procedures and approaches within mentalhealth services. The important point is that seclusionis not an isolated process, and as such, the proceduralguidelines for seclusion (or the Restraint Minimisationand Safe Practice Standard) should not be consideredthe only relevant guide document.

The Ministry of Health has been updating thesedocuments. The Restraint Minimisation and SafePractice Standard, for example, replaces the ProceduralGuidelines for the Use of Seclusion.

APPENDIX B

APPENDICES 19

Methods and Methodology

APPENDIX C

1. SURVEY

Process

The Mental Health Commission and the Ministry ofHealth conducted a joint survey of all DHBs starting inJune 2001. The Commission was responsible for thedevelopment of the survey and the data analysis. TheMinistry was responsible for sending out the surveyand collecting the returns.

The survey had four sections relating to themanagement of seclusion – admissions statistics,information on service users who were placed inseclusion, and general feedback from the service aboutseclusion and the survey itself. From this information,a spreadsheet database was developed with quantitativeanalysis identifying key trends, such as the level ofseclusion in New Zealand, both at national and regionallevels; the biographical make-up of people who weresecluded; duration in seclusion; details of the acuteward environment; and information on themanagement of seclusion.

Issues

The survey process was constrained by a number offactors. The most significant of these was that morethan one version of the survey questionnaire was sentout to DHBs. Of those who filled out the survey,approximately half filled out version 1, while the otherhalf filled out version 3. While both versions had thesame general format and schemata, there werefundamental differences in the way the data wascategorised.

Section 3, for example, which related to informationon service users that have been in seclusion, was aconcern. Version 1 categorised the data in terms ofindividual service users, their biographical categories,and the amount of time spent in seclusion per month.Version 1 allowed for an analysis of full biographicalstatistics per service user, and the hours that each

person had spent in seclusion on a monthly basis.Version 3 categorised each individual episode ofseclusion by category of hours spent in seclusion andbiographical categories, but there was no way ofknowing which person (e.g. Maori, aged 31, male) hadbeen put in seclusion and for how long. This not onlymade it difficult to compare accurately between surveyversions, due to the incongruity of format, but it alsomade it difficult to get the individual service userprofiles from those services that had answered surveyversion 3.

2. LITERATURE ANALYSIS

Aspects of constant comparative analysis and meta-synthesis were used to formulate the findings of thisreport. Meta-synthesis is a means whereby “scholars[can] find ways to apprehend and re-present differentrepresentations to achieve fuller knowing”(Sandelowski, 1993:3). It has been justified by Jensenand Allen (1996) in the following way:

Although informative, isolated studies in and ofthemselves, like the pieces of a jigsaw puzzle, donot contribute significantly to our full understandingof the phenomenon of interest. In order to advanceknowledge and influence practice, a synthesis ofrepresentations is essential. This synthesis of findingsacross studies is a type of secondary analysisparticular to qualitative research, which provides apowerful approach to theory development.

(Proquest electronic document)

Meta-synthesis is significantly different than reviewingthe literature. A literature review attempts to cover therange of work done on a particular area (e.g., seclusion).The more work that is covered, the more thorough theliterature review is perceived to be. Also, withinliterature reviews methodologies are commented onto show the strengths or weaknesses of certain researchapproaches. Literature reviews typically describe theresearch domain.


By contrast, our approach conceptualises the literatureby seeing the literature as data able to be merged orsynthesised to achieve a higher level of understanding.This approach is not too dissimilar to the Hegelianapproach to theory development (thesis + anti-thesis =synthesis). Essentially, a research article may be brokendown into component parts through a process ofqualitative coding. Similar and dissimilar codes arecompared constantly. Codes are refined through aniterative process of moving between data and ouremergent synthesis. Eventually, codes and the conceptsthey represent are positioned logically into a suggestedmodel of the phenomenon under study.

Data Selection

There are a number of issues relating to sampling. Theboundaries of the study must be clearly defined. In ourstudy, the boundaries can be seen as ‘inappropriateuse’ and ‘overuse’ of seclusion as indicated in theMental Health Commission’s seclusion discussiondocument (Use of Seclusion in New Zealand MentalHealth Services, 1999). This defines the issue understudy. The sampling of literature was also based on aclear definition of seclusion. We suggested thatseclusion is comprised of three key components:containment, isolation and reduction in sensory input.

Theoretical sampling was used to guide the ongoingselection of data and refine theory development. Thisapproach is fundamentally different from randomsampling, the normative sampling technique.Theoretical sampling is used to discover concepts andtheir properties, and to reveal interconnections in atheory. Random sampling is used to “obtain accurateevidence on distributions of people among categoriesto be used in descriptions or verifications” (Glaser andStrauss, 1967:62-3). Given this distinction, sample sizeis less relevant for our purposes. Our aim is to suggesttheory and to verify it only within the confines of thestudy itself.

Constraint Composition Analysis

Constraint composition analysis is a useful way ofunderstanding the imperfections in research. It statesthat constraints are built into all researches; theseaccumulate over the course of a study and eventuallylead to a problem being resolved (Haig, 1987 in Yee,2001). Constraints can take many forms; time is a goodexample of a constraint. The less time one has the moreinnovative one must become to complete the project.Lack of specific data is another common constraint.

The dearth of New Zealand-based research onseclusion was a clear limitation of this study. Constraintcomposition analysis allows us to understand researchin a real world context and shows us how researchlimitations can shape a research report.

Credibility

The term credibility is used in qualitative research moreoften than validity because the latter is bundled withmeanings associated with quantitative (or positivistic)work. Jensen and Allen (1996) describe credibility asan inherent component of rigour when they write:

...rigor is essential to achieve credible and consistentdescriptions of the phenomenon. The generalthemes of credibility, auditability, and fittingnesspersist as criteria for scientific rigor. The truth valueof qualitative account synthesis would reside in thediscovery of human phenomena or experiences asthey are lived and perceived by subjects, rather thanin the verification of a prior conceptions of thoseexperience. Thus, a meta-synthesis is rooted in theoriginal data and is credible when it re-presents suchfaithful descriptions or interpretations of a humanexperience that the people having that experiencewould immediately recognize it from thosedescriptions or interpretations as their own.Consequently, achieving credible interpretations isfostered if original studies provide exemplars.

[Our study] meets the criterion of fittingness whenthe findings can fit into contexts outside the studiesand when the findings are grounded in the lifeexperience studied and reflect their typical andatypical elements. Furthermore, an interpretivesynthesis is auditable when the same or comparableconclusions can be achieved, given the data.Findings are internally validated through the quotesof the studies’ participants and the metaphors usedto describe these experiences and externallyvalidated through comparisons with theoreticalliterature. Lastly, confirmability is achieved whenauditability, truth value, and applicability areachieved.

(Proquest electronic document)

APPENDICES 21

Other Methodological Issues

Questions must be asked regarding the comparabilityof research literature that adopt different methods andunderlying philosophies. How comparable can thesestudies be? Can they be synthesised at all? The answerto this question is partially answered in the abovesection on credibility, where any study that captureshuman experience should be recognisable to peoplein the field. If a synthesised study captures arecognisable process, then the methodological orphilosophical differences between studies becomesirrelevant. In essence, if the social world is seen asintegrated and seamless by ordinary people, then atheory that is equally so is credible.

3. POLICY ANALYSIS

Key policy documents relating to seclusion werecollected. These included service policy, DHB policyand the guiding documents from central government(e.g., Restraint Minimisation and Safe Practice Standard,and others listed in Appendix B). DHB and servicepolicies were compared to central governmentguideline documents to identify similarities, differences,and the findings from the literature analysis wereutilised to identify the degree of relevance to operation.

4. CONSULTATION AND SITE VISITS

Throughout the seclusion project, consultation andadvice was taken from a variety of groups. In particular,the Mental Health Commission’s clinical and serviceuser reference groups commented on significant partsof the project. An external service user advisor alsocontributed to the project and an external academicpeer reviewer assessed the literature analysis.

Site visits were conducted after the survey, literatureand policy analyses were complete. From thisinformation, four DHBs were selected to test ourfindings and ground our analysis. The selection criteriaincluded geographical variation, demographic profilevariation, and the magnitude of seclusion. Letters werewritten to the CEOs of each selected DHB and followingacceptance of our visit, seclusion data on each specificDHB and letters of introduction were sent to relevantmental health services. Site visits included one-to-onediscussion with service managers, clinical staff andconsumer advisors. Open forums were held in oneDHB. A tour through acute wards was also requested,which included an examination of seclusion areas.

Notes were taken during each session and these wereanalysed using qualitative methods against ouremergent framework developed from the literature andpolicy analysis, survey findings and a prioriconsultations.


5. BIBLIOGRAPHY

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Binder, R. L., and McCoy, S. M. (1983) A Study of Patient Attitudes toward Placement in Seclusion,Hospitals and Community Psychiatry, 34, pp. 1052-1054.

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de Cangas, J. P. C. (July-September, 1993) Nursing Staff and Unit Characteristics: Do They Affect theUse of Seclusion? Perspectives in Psychiatric Care, Vol. 29, No. 3, pp. 15-21.

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Glaser, B. G. (1978) Theoretical Sensitivity: Advances in the Methodology of Grounded Theory,California, Sociology Press.

Glaser, B. G. and Strauss, A. L. (1967) The Discovery of Grounded Theory: Strategies for QualitativeResearch, Chicago, Aldine Publishers.

Goffman, E. (1961) Asylums: Essays on the Social Situation of Mental Patients and Other Inmates,New York, Doubleday Anchor.

Guidelines for Reducing Violence in Mental Health Services, Ministry of Health, (1994)

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Jackson, M. (1983) Prison and Isolation: Solitary Confinement in Canada, Toronto, University ofToronto Press.

APPENDICES 23

Jensen, L. A. and Allen, M. N. (November, 1996) Meta-Synthesis of Qualitative Research Findings,Qualitative Health Research, [Electronic Document] Proquest Database, University of Waikato.

Kalogjera, I. J., Bedi, A., Watson, W. N., and Meyer, A. D. (1989) Impact of Therapeutic Managementon Use of Seclusion and Restraint with Disruptive Adolescent Inpatients, Hospital and CommunityPsychiatry, Vol. 40, No. 3, March, pp. 280-285.

Lapsley, H (2003) Mental Health Sector Systems Approach to Recovery, Unpublished Mental HealthCommission Discussion Document.

Learning from Each Other: Success Stories and Ideas for Reducing Restraint/Seclusion in BehavioralHealth, American Psychiatric Association, American Psychiatric Nurses Association, National Associationof Psychiatric Health Systems (2003).Available at http://www.psych.org/clin_res/LearningfromEachOther.pdf.

MacKenzie, H. (2002) An Evaluation Framework for Mental Illness Anti-Discrimination, unpublishedreport prepared for the Mental Health Commission.

Martinez, R. J., Grimm, M., and Adamson, M. (1999) From the Other Side of the Door: Patient Views ofSeclusion, Journal of Psychosocial Nursing, Vol. 37, No. 3, pp. 13-22.

Mason, T. (1997) An Ethnomethodological Analysis of the Use of Seclusion, Journal of Advanced Nursing,Vol. 26, pp. 780-789.

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APPENDICES 25

Resources for the Reduction of Seclusion

APPENDIX D

A Toolkit for Reducing/Eliminating the Use of Seclusion and Restraint in Psychiatric InpatientSettings, available from Professor Judith Cook, Mental Health Services Research Program,Department of Psychiatry, University of Illinois at Chicago.

Leading the Way Toward a Seclusion and Restraint-Free Environment – Pennsylvania’s Seclusionand Restraint Reduction Initiative, Harrisburg Office of Mental Health and Substance AbuseServices, 2000.

Learning from each other – Success Stories and Ideas for Reducing Restraint/Seclusion inBehavioural Health, American Psychiatric Association, American Psychiatric NursesAssociation, National Association of Psychiatric Health Systems (2003), available from http://omni.ac.uk/whatsnew/detail/17011971.html

Reducing Staff Injuries and Violence in A Forensic Psychiatric Setting, Archives of PsychiatricNursing, Vol. XVI, No. 3 (June) 2002 pp. 108-117, Morrison, E., Morman, G., Bonner, G.,Taylor, C., Abraham, I., and Lathan, L.