State-level support

Although most research was conducted at facility, unit or ward level, authors of one study reported on how the efforts made by a State Mental Health Authority (SMHA) were associated with reductions of seclusion rates in 70 institutions under its influence (Reference LeBel, Stromberg and DuckworthLeBel et al, 2004). The SMHA assisted staff at child and adolescent inpatient facilities to reduce restraint and seclusion through frequent licensing and contract monitoring visits, in which strength-based care was discussed with staff, including the use of an individualised crisis prevention plan safety tool; assisting the organisation of peer-to-peer support for staff at the facilities to change workplace cultures and implement initiatives to reduce the use of restraint and seclusion; holding a state-wide best practice conference on restraint and seclusion reduction; requiring staff at each facility to develop a strategic plan incorporating strength-based care; facilitating restraint and seclusion grand rounds, in which conference presentations were made and SMHA staff assisted facility staff to develop their strategic plans and strength-based approaches; organising a conference, during which strategic plans and performance data relating to reduction of the use of restraint and seclusion were presented; and linking with other state agencies serving children and adolescents and enhancing supports for children and adolescents with histories of trauma. The reduced seclusion rates seem to have stemmed from the SMHA providing such support to institutions, rather than the SMHA changing regulations or policies and requiring institutions to adapt. During the 22-month period of the intervention the SMHA made no change to its regulations or policies.

State policy and regulation changes

Changes in state policy and regulations can sometimes shape interventions designed to reduce the use of seclusion. In the two studies where the involvement of the state in the area of seclusion practices had changed, there was increased emphasis on having tighter controls on when and how seclusion may be used, greater oversight of seclusion episodes through the appointment of an independent advocate for consumers, the introduction of a ‘recovery approach’ to caring for patients (Reference Smith, Davis and BixlerSmith et al, 2005) and the requirement for post-seclusion debriefings with staff and patients. These changes necessitated, or formed part of, initiatives within the psychiatric facilities to reduce rates of seclusion.

Leadership

Although leadership would have had some impact on the design, implementation and monitoring of all the interventions included in this review, several authors described some of the leadership behaviours that contributed to organisational changes. External to psychiatric facilities, chief psychiatrists and community advocates for psychiatric patients can influence the policies and practices of those facilities (Reference Smith, Davis and BixlerSmith et al, 2005). Internally, the management of these facilities were involved with setting new expectations for staff to reduce the use of seclusion (Reference Sullivan, Bezmen and BarronSullivan et al, 2005), reviewing seclusion policies (Reference Kalogjera, Bedi and WatsonKalogjera et al, 1989; Reference FisherFisher, 2003), publicly advocating for seclusion reduction (Reference FisherFisher, 2003; Reference Sullivan, Bezmen and BarronSullivan et al, 2005), changing systems of practice to make seclusion reduction a priority (Reference Schreiner, Crafton and SevinSchreiner et al, 2004), providing staff with resources to enable seclusion rates to be reduced (e.g. education; Reference Schreiner, Crafton and SevinSchreiner et al, 2004), introducing an audit tool to capture information about each restraint or seclusion episode (Reference TaxisTaxis, 2002) and modelling crisis de-escalation techniques (Reference Schreiner, Crafton and SevinSchreiner et al, 2004).

Examinations of the practice contexts

Some psychiatric facilities formally established the context in which staff intended to make changes (Reference FisherFisher, 2003; Reference Schreiner, Crafton and SevinSchreiner et al, 2004). Through such an evaluation, systemic weaknesses that contributed to patients being secluded could be identified. Tools such as staff surveys (Reference FisherFisher, 2003), collecting baseline data on the use of seclusion, interviews with staff and patients, and observations of crisis events on units (Reference Schreiner, Crafton and SevinSchreiner et al, 2004) have informed the development of interventions that have contributed to decreases in seclusion rates. Once weaknesses had been highlighted, programmes were designed to improve how staff manage crises or potential crises.

Staff integration

During three of the interventions, management enhanced the focus on reducing seclusion rates through employing new staff (Reference Smith, Davis and BixlerSmith et al, 2005) or by increasing the extent of cross-disciplinary collaboration (Reference Donovan, Siegel and ZeraDonovan et al, 2003). In the first of these studies (Reference Smith, Davis and BixlerSmith et al, 2005), new staff became available for employment owing to the closures of other facilities across the state. These new staff were already challenging the use of restrictive procedures in the facilities at which they were previously employed and, therefore, were able to contribute positively to efforts to reduce the rates of seclusion. In the other study (Reference Donovan, Siegel and ZeraDonovan et al, 2003) an interdisciplinary committee was established to oversee the development of the programme to reduce the use of seclusion. This committee comprised administrators and staff who had different roles within the hospital (e.g. counsellors, nurses, physicians, psychologists and social workers). This cross-disciplinary involvement helped engender widespread support for the reform of seclusion and restraint practices.

Treatment plan improvement

In one study the authors described how initiatives were undertaken to improve the patients’ treatment plans (Reference DonatDonat, 2003). The hospital management created a behavioural consultation team to work with all areas within the hospital to provide input into treatment plans from a behavioural perspective. There was also an increase in the number of quality standards for assessing behaviour plans (from 16 to 44) and the introduction of an additional set of 54 quality standards for formal behavioural assessments.

Increased staff to patient ratios

In two studies improvements in the staff to patient ratios were part of the agenda for change (Reference DonatDonat, 2003; Reference Smith, Davis and BixlerSmith et al, 2005). During 5 years of an intervention in a public psychiatric hospital, the ratio of staff (including all facility staff) to patients increased from 2 to 1 in the first month to 3.3 to 1 in the last month (Reference DonatDonat, 2003). The authors did not report, however, how staff to patient ratios changed in the wards. At Pennsylvania State Hospital the staff to patient ratios on hospital units improved over a 10-year period, through decreasing the number of patients on a typical unit (from 36 to 32 or fewer) and increasing the number of staff per unit (from one licensed nurse and three psychiatric aides to two licensed nurses and four psychiatric aides; Reference Smith, Davis and BixlerSmith et al, 2005). The authors contend that this change in the staff to patient ratio contributed to staff being able to provide more sensitive care than they had been able to give in the past and to a safer environment for both staff and patients.

Monitoring seclusion episodes

Psychiatric facilities commonly collected data on episodes of seclusion and these data were used for clinical, educational, managerial, and publicity purposes (Reference Kalogjera, Bedi and WatsonKalogjera et al, 1989; Reference TaxisTaxis, 2002; Reference DonatDonat, 2003; Reference Donovan, Siegel and ZeraDonovan et al, 2003; Reference FisherFisher, 2003; Reference Schreiner, Crafton and SevinSchreiner et al, 2004; Reference Smith, Davis and BixlerSmith et al, 2005). Management used these data to detect both general seclusion patterns over time and to identify outlier patients (Reference Schreiner, Crafton and SevinSchreiner et al, 2004). Data on general patterns were used to facilitate interhospital comparison of the use of seclusion (Reference Smith, Davis and BixlerSmith et al, 2005), to enable performance to be compared with unit and hospital goals (Reference Donovan, Siegel and ZeraDonovan et al, 2003) and to inform the development of staff education programmes (Reference TaxisTaxis, 2002). In an adolescent in-patient unit (Reference Schreiner, Crafton and SevinSchreiner et al, 2004) and a public psychiatric hospital for adults (Reference DonatDonat, 2003), one of the foci for staff was on analysing outlier data. At the public hospital, for example, the criteria for the review of patients with multiple episodes of seclusion or restraint were modified so that they were evaluated after fewer episodes or less time in seclusion or restraint (Reference DonatDonat, 2003). The necessity for patients to exceed six episodes or 72 h of restraint or seclusion within 1 month before a review would occur was replaced with the criteria of two episodes or 8 h during 1 week.

In contrast to most of these facilities, in which staff monitored data on seclusion and restraint, members from a development committee in a child and adolescent psychiatric hospital were involved with observing the behaviours of staff and patients on hospital wards (Reference Donovan, Siegel and ZeraDonovan et al, 2003). These observations were undertaken to ascertain the frequency with which aspects of an intervention to reduce the use of seclusion and restraint were carried out. Using data gained from these observations, committee members also provided staff with additional education about aspects of the intervention that staff were not employing effectively or that concerned staff, reinforcement of the intervention's philosophy and support for staff skill development.

Post-event analyses were a further method by which seclusion episodes were monitored (Reference FisherFisher, 2003). In a state psychiatric hospital, changes in policies at state and hospital levels required that all episodes of seclusion be subject to post-event analyses, which staff involved in the seclusion or restraint, along with their supervisors, conducted. The focus of these analyses was on ascertaining how staff handled the events, on what staff could have done differently to avoid placing patients in seclusion or restraints, and on developing plans to try to prevent such episodes recurring.

Psychiatric emergency response teams

In several state hospitals (Reference Smith, Davis and BixlerSmith et al, 2005) and in a psychiatric emergency service (Reference D'Orio, Purselle and StevensD'Orio et al, 2004), staff introduced psychiatric emergency response teams for behavioural emergencies. To become a member of one of these teams, staff participated in additional training to enhance their skills to manage crisis situations in such ways that they refrain from using restrictive procedures. To defuse crisis situations, staff primarily used their skills in verbal de-escalation by way of violence prevention skills, therapeutic communication, mediation and conflict resolution.

Staff education

The education of staff was central to the efforts of many organisations to reduce seclusion (Reference Kalogjera, Bedi and WatsonKalogjera et al, 1989; Reference TaxisTaxis, 2002; Reference FisherFisher, 2003; Reference D'Orio, Purselle and StevensD'Orio et al, 2004; Reference Schreiner, Crafton and SevinSchreiner et al, 2004; Sullivan et al, Reference Sullivan, Wallis and Lloyd2004, Reference Sullivan, Bezmen and Barron2005; Reference Smith, Davis and BixlerSmith et al, 2005; Reference Bowers, Brennan and FloodBowers et al, 2006; Reference Greene, Ablon and MartinGreene et al, 2006). Education was focused on two main areas: the implementation of new models of care and alternative behavioural interventions to seclusion. New models of care came from the authors’ work on the development of high-therapy, low-conflict wards (Reference Bowers, Brennan and FloodBowers et al, 2006) or on collaborative problem-solving (Reference Greene, Ablon and MartinGreene et al, 2006). Education in alternative behavioural interventions tended to have several components. The educational programme at one state psychiatric facility, for example, involved learning to identify the behavioural indicators of impending violence, to collaborate with others and to use verbal de-escalation techniques, to intervene in a crisis, to employ diversional activities, to consider the ethics involved with restraint and seclusion, to improve documentation skills, to apply therapeutic interventions with patients who had personality disorders, and the use of medications with aggressive patients (Reference TaxisTaxis, 2002). Some of this education occurred in one-to-one discussions and during problem-solving exercises. Staff at this facility also used information gained through their evaluations of restraint or seclusion episodes to design targeted education to address areas of concern.

On one adolescent in-patient unit, part of the education involved members of the committee responsible for implementing the intervention modelling de-escalation techniques for other staff (Reference Schreiner, Crafton and SevinSchreiner et al, 2004). The members of the committee were demonstrating how these techniques could be put into practice. This modelling was supported through training at in-service meetings, reviews that debunked myths about seclusion and restraint, continued reinforcement of strategies to reduce the use of restraint and seclusion, and providing staff who were key decision-makers in crisis situations with additional training in patient-specific de-escalation strategies and in early crisis intervention.

Monitoring of patients

In one study the monitoring of patients was increased through the installation of an additional camera (Reference D'Orio, Purselle and StevensD'Orio et al, 2004). This increase in the number of cameras in operation (from four to five) was in response to members of the safety committee perceiving that patients were being inadequately monitored.

Pharmacological interventions

Although we excluded studies from this review in which the prime focus was on the evaluation of pharmacological intervention, some researchers stated that changes in pharmacological interventions (chiefly the introduction of second-generation antipsychotics) occurred as part of several changes within the psychiatric facilities (Reference FisherFisher, 2003; Reference Smith, Davis and BixlerSmith et al, 2005). In one state psychiatric hospital, two aspects of the pharmacological treatment of patients were emphasised (Reference FisherFisher, 2003): first, clozapine was used more frequently to control aggressive behaviour; second, in their care of individual patients who showed no signs of improvement with established pharmacological solutions, staff continued to try other pharmacological treatments which had only received support from a few trials or case studies.

Treating patients as active participants in seclusion reduction interventions

Some staff at psychiatric facilities enlisted the support of patients in their efforts to reduce seclusion rates (Reference Mistral, Hall and McKeeMistral et al, 2002; Reference Schreiner, Crafton and SevinSchreiner et al, 2004). The staff at one adolescent in-patient unit gained support from patients through discussing the goal of seclusion reduction with them and emphasising the positive outcomes that might eventuate from reducing the use of seclusion and restraint on the unit (Reference Schreiner, Crafton and SevinSchreiner et al, 2004). Staff also reviewed standard therapeutic de-escalation strategies with patients and introduced a reward system for patients based on the number of seclusion and restraint episodes. On a high-care psychiatric ward, staff worked with patients to reduce the use of seclusion through clarifying therapeutic aims with patients and implementing rules with regards to drinking alcohol, using illicit substances, smoking and the upkeep of the environment. Patients seemed to internalise the rules for the upkeep of the environment and began enforcing these rules with fellow patients.

In an adult psychiatric service, management placed an expectation on staff that they allow patients to choose interventions to be used in managing their aggression (Reference Sullivan, Bezmen and BarronSullivan et al, 2005). In consultation with patients, clinicians completed a patient violence assessment tool, which had sections requiring detail on the relevant histories of patients and precipitants to their violence; how patients tended to display agitation, aggression and violence; and interventions that patients might find useful at times when they potentially could lose control.

Changing the therapeutic environment

Making changes to the therapeutic environment was a common way in which staff at psychiatric facilities tried to reduce seclusion rates (Reference Kalogjera, Bedi and WatsonKalogjera et al, 1989; Reference Mistral, Hall and McKeeMistral et al, 2002; Reference TaxisTaxis, 2002; Reference Donovan, Siegel and ZeraDonovan et al, 2003; Reference FisherFisher, 2003; Sullivan et al, Reference Sullivan, Wallis and Lloyd2004, Reference Sullivan, Bezmen and Barron2005; Reference Smith, Davis and BixlerSmith et al, 2005; Reference Bowers, Brennan and FloodBowers et al, 2006; Reference FowlerFowler, 2006; Reference Greene, Ablon and MartinGreene et al, 2006; Reference Regan, Curtin and VordererRegan et al, 2006). Staff at some of these facilities adopted new therapeutic frameworks to guide practice. These frameworks included a collaborative problem-solving approach (Reference Greene, Ablon and GoringGreene et al, 2003) at a child in-patient psychiatric unit (Reference Greene, Ablon and MartinGreene et al, 2006); a working model for the development of high-therapy, low-conflict psychiatric wards (Reference Bowers, Brennan and FloodBowers et al, 2006); an ‘ABCD’ (autonomy, belonging, competence, doing for others) programme at an adolescent psychiatric hospital (Reference Donovan, Siegel and ZeraDonovan et al, 2003); the use of dialectic behaviour therapy (Reference LinehanLinehan, 1993) at a state psychiatric hospital (Reference FisherFisher, 2003); a therapeutic management protocol on three in-patient adolescent psychiatric units (Reference Kalogjera, Bedi and WatsonKalogjera et al, 1989); a philosophy of child- and family-centred care (Reference Ahmann and JohnsonAhmann & Johnson, 2000) at a child psychiatric unit (Reference Regan, Curtin and VordererRegan et al, 2006); and treatment based on therapeutic community principles (Reference JansenJansen, 1980) at a high-care psychiatric ward (Reference Mistral, Hall and McKeeMistral et al, 2002). In addition, staff at an adult psychiatric service shifted their treatment paradigm from one of staff fear and control to one of patient empowerment and collaborative relationships (Reference Sullivan, Bezmen and BarronSullivan et al, 2005).

Staff at some facilities improved the therapeutic environments through increasing the frequency with which they communicated with patients about their needs (Reference Sullivan, Wallis and LloydSullivan et al, 2004) and their care (Reference Mistral, Hall and McKeeMistral et al, 2002). On a daily basis at an in-patient acute psychiatric care unit, for example, staff assessed patients’ mental states and their risks of committing violent or harmful acts to themselves or to others (Reference Sullivan, Wallis and LloydSullivan et al, 2004). These assessments were used in the development of 24 h individual service plans for patients.

In two facilities the debriefing of patients following episodes of seclusion was part of the changes made to practice (Reference FisherFisher, 2003; Reference Sullivan, Wallis and LloydSullivan et al, 2004). In a psychiatric hospital, for example, debriefing occurred between the patients who were placed in seclusion and their treatment teams (Reference FisherFisher, 2003). These debriefings focused on the patient's and team's views of the patient's behaviours that led to the seclusion and on planning to avoid recurrences of such behaviours.

In a rare example of a single intervention being used in an attempt to reduce the use of seclusion, staff at a residential treatment centre for adolescents informed patients that they could request aromatherapy if they were feeling agitated (Reference FowlerFowler, 2006). This intervention appeared to have a positive effect on the number of seclusions, because there were more of these episodes in the 3 months prior to the use of aromatherapy (n=29) than during the 3 months following the introduction of this treatment (n=20).

Changing the facility environment

Authors of three studies reported that facility environments were changed to reduce the likelihood that patients would be placed in seclusion (Reference Mistral, Hall and McKeeMistral et al, 2002; Reference TaxisTaxis, 2002; Reference Regan, Curtin and VordererRegan et al, 2006). In two of these facilities the physical environment was improved (Reference Mistral, Hall and McKeeMistral et al, 2002; Reference TaxisTaxis, 2002), whereas in the other facility the opening hours of the unit were extended to 24 h per day for parents, in keeping with the philosophy of child- and family-centred care (Reference Regan, Curtin and VordererRegan et al, 2006).

Adopting a facility focus

In one study, the objectives of the intervention were broader than focusing on reducing the numbers of episodes of seclusion and restraint (Reference Mistral, Hall and McKeeMistral et al, 2002). Through taking a broader approach to improving how a psychiatric facility operates, the use of seclusion and restraint may be reduced. Staff on this ward timetabled a schedule to improve how the ward operated. Regular staff meetings were held to discuss practical issues on the ward and monthly meetings were held between community and ward staff. In addition, meetings were conducted with an outside facilitator to analyse the root causes of ward issues and to produce possible solutions.

Improving staff safety and welfare

Staff at some psychiatric facilities instigated changes to practice to enhance the safety and welfare of staff (Reference Mistral, Hall and McKeeMistral et al, 2002; Reference Sullivan, Wallis and LloydSullivan et al, 2004). In one in-patient acute psychiatric unit, staff had reported experiencing burnout due to continuously caring for acutely unwell patients (Reference Sullivan, Wallis and LloydSullivan et al, 2004). To reduce this burnout, staff were rostered between caring for acutely unwell patients and caring for those who were less unwell. To improve staff safety on one ward at another facility, staff were educated in risk assessment and in techniques for controlling and restraining patients, and were issued with personal alarms (Reference Mistral, Hall and McKeeMistral et al, 2002). In addition, if a patient assaulted a member of staff the incident was immediately reported to police. This action reinforced patients’ awareness of how serious it was to assault a staff member.