Reflection on the use of Seclusion Rooms on Inpatient Mental Health Units: A Discourse Analysis
Abstract
The purpose of this paper is to challenge the dominant social order in mental health that upholds the use of seclusion rooms as a means of therapeutic intervention using a critical discourse analysis method. This researcher asks the question, why do seclusion rooms continue to be common practice on acute inpatient psychiatric units when they are not evidenced based practice? A critical discourse analysis is conducted using 13 research studies found on the Google Scholar and CINAHL databases using the search terms: seclusion, seclusion room, psychiatry, inpatient and mental health. Each article is analyzed to determine the paradigm that was used to guide the research. The text of each article was analyzed to uncover the power dynamics present in the seclusion literature and how these interact with cultural variables. The results show that there are distinct power dynamics evident in the literature that present the mental health client in a position of subordination, controlled by both health care staff (namely nurses) while both are under the power of the greater mental health system dominated by the medical model.
Reflection on the Use of Seclusion Rooms on Inpatient Psychiatric Units: A Discourse Analysis
Reflection on the Use of Seclusion Rooms on Inpatient Psychiatric Units: A Discourse Analysis
The use of seclusion rooms is a widespread mental health intervention despite the lack of substantial evidence that supports its efficacy as a positive therapeutic technique. This paper seeks to answer the question, why do seclusion rooms continue to be used in mental health when they are not evidence based practice? Through examination of current academic literature this paper presents a discourse analysis that explores the overarching paradigms utilized in research, uncovers the power dynamics between those who perpetuate use of this intervention and those being secluded and examines how cultural variables influence this discourse. This analysis focuses on the content of 13 academic research articles that specifically examine seclusion room practices. It was found that much research approaches the issue from a positivist and interpretative paradigm with only two articles approaching the issue from a critical social theoretical perspective. Power relationships were found to consist of the mental health client in the position of the less powerful group while health care staff, primarily nurses and physicians and the health care system held a powerful position. The cultural variables found relate to the specific culture of the mental health unit which continues to be impacted by the historical perspective of the institutional asylum and the biomedical model. This paper will being by exploring background information about seclusion rooms as used in the current landscape of inpatient mental health.
Background
There have been various methods of behavioural control exerted by health care staff on the mental health client throughout the history of inpatient psychiatric facilities, for example, mechanical and chemical restraint and use of locked seclusion rooms (Homes, Kennedy & Perron, 2004; Jacobs et al, 2009). Seclusion in a psychiatric setting is defined as the forced isolation of an individual in a room, typically locked, with few furnishings including a mattress, possibly a toilet and a sink (Sullivan, Wallace & Lloyd, 2004). The act of confinement of individuals suffering from mental illness as used in the psychiatric hospital is a strategy that emerged out of need to control and behaviourally manage clients (Homes et al, 2004; Jacob et al, 2009). However, the act of locking up an individual under the guise of therapeutic benefit poses many moral and ethical dilemmas.
Seclusion rooms are one of the most controversial interventions used in psychiatric care because of the lack of evidence that supports their efficacy and increased evidence that supports the negative outcomes of the client placed in seclusion (Homes et al, 2004; Steinert et al, 2009; Sullivan, Wallace & Lloyd, 2004). The research on reasons for use of seclusion upholds three main principles (1) containment (2) isolation and (3) decrease of sensory output (Roberts et al, 2009; Sullivan, Wallace & Lloyd, 2004). The practice of seclusion rooms continues to be utilized on many acute inpatient psychiatric settings as a closely monitored, last means practice in order to maintain safety of individuals on the unit, that is the safety of the client, staff and other clients.
There is much research that focuses on the most recent policy and practice that guides seclusion room use, as well as research that explores experiences from client and staff perspectives for the purpose of informing how use may be decreased or even eliminated. There are global initiatives in many developed nations to reduce the use of restraint and seclusion (Steinert et al, 2009). Although today the use of seclusion rooms is extremely well regulated, restricted to use in only the most extreme situations, there remains no clear consensus or guideline on what an extreme situation entails which results in ambiguity (Landeweer, Abma & Widdershoven, 2011). The decisions about when to implement seclusion room use is often made at the discretion of nursing staff despite regulation that it should be physician or multidisciplinary team led practice (Kontio et al, 2010, Larue et al, 2010b; Sullivan et al, 004). When examining the current literature it is clear that there is consensus that seclusion room should be utilized either less or should be eliminated altogether yet they remain in use. The discussion will now turn to the process used for data collection in this paper.
Process of the Literature Search
To find academic articles specifically researching seclusion room practices on acute inpatient psychiatric facilities a literature search was conducted using Google Scholar and CINAHL. The key terms utilized in a search included: seclusion, seclusion room, psychiatry, inpatient and mental health. Only research articles from peer reviewed academic journals focused specifically on seclusion within adult populations were chosen. Articles published from 1999 to 2011 were assessed for their relevancy to the research question, why do seclusion rooms continue to be used in mental health when they are not evidence based practice? The articles used are from developed nations only including Canada, Australia, the United Kingdom, The Netherlands and Finland. The first 13 articles found from both database searches that met the screening criteria are included in this discourse analysis.
Research Paradigms
There was a diverse mix of research found that explored seclusion room practice from positivist, interpretive and critical social perspectives. However, the majority of research articles found are studies that explore seclusion rooms from either the positivist or interpretive perspective.
The positivist paradigm uses objective, quantitative data which is results in facts that can be generalized to a population (Gephart, 1999; Weaver & Olson, 2006). This paradigm relies on the principles of the scientific method. Typically the positivist paradigm relies on using methods such as experimentation to uncover universal truths (Weaver & Olson, 2006). However, for ethical reasons experimental means cannot be used to study seclusion room use there are many studies found that use statistics to construct a clearer picture of when, how and why seclusion room are used. Methods such as retrospective studies that examine nurse charting and quantitative survey using scaling questions are utilized to obtain data that can be statistically analyzed and from which conclusions can be drawn.
Five articles found utilize the positivist paradigm. There were some studies that explored this from the client perspective. For example, Veltkamp et al (2008) conducted a quantitative study to study whether client’s preferred seclusion to forced medication. Other quantitative studies examined nursing perspectives, collecting data from charting retrospectively for the purpose of statistical analysis to find the impacts of being placed in seclusion during an inpatient stay (LeGris et al, 1999), attempt to quantify the different reasons why nurses placed clients were placed in seclusion (Larue et al, 2010a) and examines whether the use of pro re nata medication, length of stay and number of physically violent incidents toward staff, co-patients or property changed after client-centred nursing practices were implemented (Sullivan et al, 2004). Psychosocial measures like insight and family/social support were quantified (LeGris et al, 1999). One study found utilized a literature review method to identify quantitative data on the use of seclusion and restraint in different countries and on initiatives to reduce these interventions (Steinert et al, 2008). These positivist studies present numerical data from which objective conclusions are drawn and presented as evidence for why seclusion room use should be decreased or more closely monitored.
Seven of the research articles found are written using the interpretative perspective, meaning that they seek to uncover the meaning of seclusion and events related to use of seclusion rooms as experienced from the client perspective (Homes et al, 2004; Mayers et al, 2010; Roberts et al, 2009; Ryan & Happell, 2009) from nurses perspectives (Ryan & Happell, 2009) and also from the perspectives of interdisciplinary staff members (Kontio et al, 2010; Roberts et al, 2009). The interpretative paradigm differs from the positivist paradigm because takes a subjective view that seeks to identify meaning of situations and uncover the voices, concerns and practices of those being researched (Gephart, 1999; Weaver & Olson, 2006). The emphasis of the research is placed on making meaning of situations as constructed from studying the interaction between the researcher and participant in the natural environment (Weaver & Olson, 2006). The interpretive paradigm strongly contrasts the universal truths pursued within the positivist perspective because social meaning shifts depending on specific social contexts (Plack, 2005; Weaver & Olson, 2006).
Surprisingly, there were few studies that researched seclusion room practice from a critical social perspective. This seems unusual because the critical social perspective is concerned with countering the oppression and distributing power to the client which seems to lend itself well to the power differentials embedded in use of constraint and confinement (Weaver & Olson, 2005). The two studies found explored the issue of seclusion room use from the perspective of the health care staff. Landeweer et al (2011) explore the moral decision making process that health care staff, identified as primarily a nursing decision, surrounding use of seclusion rooms. The purpose of the study is to uncovering social dynamics as evidence to reduce seclusion room use (Landeweer et al, 2011). The research of Jacob et al (2009) focused on the use of seclusion rooms as a punitive nursing intervention utilized as a behavioural modification technique for client conformity. The study attempts to uncover the political forces of this coercive practice as sovereign power (Jacob et al, 2009). Both of these studies explore seclusion from critical social paradigm as evidenced in the researchers attempt to expose oppression of the mental health client through understanding shared meanings of political, social, historical and cultural practices that impede equal participation (Weaver & Olson, 2006).
These studies delve deeper than the interpretive perspective as they seek social change rather than to simply find meaning in social phenomena for individuals of groups. From the critical social paradigm the researcher looks deeper than the superficial level to uncover embedded hidden truths and explore issues of power and justice for the purpose of challenging oppression (Plack, 2005; Thomas, 2006). Within the critical social paradigm theory and practice are closely linked as research is conducted for the purpose of facilitating action for the purpose of enacting change inequalities on both an individual and societal level (Plack, 2005; Weaver & Olson, 2006).
One component of this discourse analysis is to assess the specific paradigm that guides the research process in each article, the process involved in creating the text. Each research article can be further analyzed to uncover the power relationships by examining how each party involved in the seclusion room process is depicted in the article text. The next step of the critical discourse analysis process is to analyze how the language used within each study reveals the power, dominance and inequality that favours the interests of a particular group (McGregor, 2003).
Power Relationships
The research identified in the literature review process has been found to align with positivist, interpretive and critical social paradigms. In exploring the text of each article it is clear that use of seclusion room intervention in acute inpatient mental health settings demonstrates a power imbalance. The three main groups present in the power relationship are the client, the health care staff (primarily nursing staff) and the health care system. In all the articles, regardless of the guiding paradigm, it is clear that the mental health client less power as they are not the ones who control the use of the seclusion room intervention as it is something that is done to them. However, within the current literature explored the health care staff are presented as the group holding the power as they decide when to place a client in the seclusion room and also when to end this intervention. The decision of when to use of seclusion rooms is found to often be delegated to the nursing staff because they are on the front line, interacting with clients regularly and expected to carry out the physicians orders, which indicates that there are more powerful groups in the hierarchy of the mental health system (Landeweer et al, 2011). The physician has been uncovered as holding power above the nurse, a symbol of the greater mental health system continues to be led by the medical model (Landeweer et al, 2011).
The Client
Seclusion has been traditionally utilized for the maintenance of safety of others in the clinical environment, despite the uncertainty and difficulty in predicting violent or out of control patient behaviours (LeGris, Walters & Browne, 1999). Ideally, the client should be the focus of treatment in the mental health system, yet it seems that they are left powerless when it comes to situations of agitation and violence that could potentially lead to harm of others. Many of the articles analyzed do identify that alternative interventions are being used and ongoing research done to decrease the use of seclusion rooms (Landeweer et al, 2011; Steinart et al, 2009; Sullivan et al, 2004). Yet there continues to be research produced that presents seclusions rooms as an important means of patient safety. For example, Roberts et al (2009) presents the use of seclusion as a means of increasing patient safety. The study is an interpretive study that focuses on identifying existing patterns and reasons for use of seclusion in acute mental health facilities and to elicit staff and consumer perceptions with the aim of developing an informed and sustainable reduction in the use of seclusion (Roberts et al, 2009). The study aim of the study explored the experiences and views of staff and clients (Roberts et al, 2009).
It is recognized that seclusion room interventions do not meet client-centred nursing approaches. The use of seclusion has shifted as the profession of nursing has increasingly embraced philosophies of holism, humanism and client centre care which directly conflict with use of a locked seclusion room (LeGris et al, 1999). Further, LaRue et al (2010) identify that seclusion poses both a legal and ethical dilemma because it is administered to vulnerable clients and conflicts with ethical and legal principles that place the best interest of the client as paramount. Further, there are questions of misuse because seclusion is used as a means of protection, “containment while awaiting the therapeutic response to medication,” or as a pre-emptive measure when patient agitation is observed rather than after actual violent incident occur (LeGris et al, 1999, p.457). Certain types of clients are found to be more likely to experience seclusion room interventions.
Violence is indicated as the most common reason for use of seclusion yet there are very diverse definitions of violence meaning that it is up to the health care staff’s interpretation of what a client’s behaviours mean (Larue et al, 2010a). Specific terms are utilized as causes for initiating seclusion such as agitation, disorganization and aggressive behaviour (Larue et al, 2010,). Further, the isolation caused by seclusion is found to reach beyond the walls of the institutions as few family members were contacted if their loved one was secluded (Larue et al, 2010). Nurses are depicted as those who cause harm by implementing the taken for granted assertion that seclusion room use is a therapeutic measure that is used for the benefit of the client (Larue, 2010).
The Nurse
The nurse is often depicted at the health care professional exercising power and control in the mental health hospital setting (Kontio et al, 2010). This is likely because they are the most readily visible staff and have the most interaction with clients. Some studies identify that the health care professional who initiates the seclusion room intervention is often the nurse despite the fact that the doctor is the one writing the order (Kontino et al, 2010; Ryan & Happell, 2009). Nurses are depicted as those in power yet they are working under the direction the physicians and the greater medical model that guides mental health practice (Larue et al, 2010).
Often nurses may hide behind the guise of carrying out orders, or maintaining safety (Kontino et al, 2010). Description of the seclusion room process as described by nursing staff included the terms “continuous monitoring,” “assessing,” and “charting” (LeGris et al, 1999, p. 452). The common criteria for seclusion room admission in the LeGris study (1999) was (1) patients pose a danger to themselves or others, (2) be considered an AWOL risk or (3) require close monitoring due to a deterioration in physical and/or mental status which is open to large differences in interpretation. The main discourse found to describe nurses practice in the seclusion room process is ‘control’ (Landeweer et al, 2011; Larue et al, 2010; Roberts et al, 2009). Nurses understanding of what is termed “agitated behaviour” is superficial and usually attributed to a single factor such as “the client took drugs,” “had a psychotic episode,” or “was discharged too early” (Larue et al, 2010b, p. 213).
Larue at al (2010b) found that despite the intention for collaborative and holistic practices to be used nurses continue to use words associated with the control perspective. Nurses verbalized reactive interventions of seclusion related to risk of attack or experiencing violence yet the assessment rarely focuses on the root cause of the behaviour (Larue et al, 2010b). Similarly, in debriefing with clients following a seclusion room intervention nurses were found to report that they believed they were using client focused debriefing techniques yet their verbal explanations of this did not follow the best practice models (Ryan & Happell, 2009). Larue reports that there is emphasis on evaluating client behaviour post seclusion room entry, concentrating on observing rather than seeking meaning of behaviour. The patient is rarely included in the post-incident review (Larue et al, 2010b). Clearly the practice of using the intervention of seclusion room is deeply embedded in the greater psychiatric institution.
The Psychiatric Institution
Another group that perhaps may be conceptualized as holding the most power in the seclusion room process is the psychiatric institution (Jacob et al, 2009; Landeweer et al, 2011). Although only two studies that explore the issue from a power perspective within the tradition of the psychiatric hospital as a means of controlling deviance (Jacob et al, 2009; Landeweer et al, 2011) the language used to describe seclusion room use appears embedded in power exerted by the institution for example, “doing what has always been done” (Kontio et al, 2010, p.73) and viewing it “as a useful tool,” (Roberts et al, 2009). Further, Jacob et al (2009) explore the use of seclusion rooms as a punitive intervention as a means of behaviour modification to enforce the rules of the unit. The use of seclusion is explored within the context of use as device to force clients to obey certain rules and to behave a certain way (Jacob et al, 2009). The author describes the tradition of the psychiatric institution and the progression of the restrictive practices utilized which eventually transitioned into what are now conceptualized therapeutic interventions implemented for the benefit of the client. This terminology shifted in order to meet the changing mandate from asylums which were established as means of confinement and exclusion to that of psychiatric hospitals that helped sick individuals (Jacob et al, 2009).
The data that Jacob et al (2009) presents brings to light the historical context where in the early stages of mental health language used in the asylums was that of punishment which transformed into discourse guided by the medical model as the development of psychiatry became was dedicated to the cure mentally ill individuals (Jacob et al, 2009). Seclusion is described as a form of control and coercion that is used to force clients to conform to a particular agenda (Jacob et al, 2009).
Despite repeated mention that seclusion is not best practice there continues to be justification for its continued use. For example, staffing shortages impede ability to provide one-to-one care and the continued perception by nursing staff that it is a necessary therapeutic technique (LeGris, 1999). Further, the importance of safety of those individuals working in the institution is given priority. Nurses are described as working under the constraint of “institutional rules, discourses and societal trends, like the priority given today to the public order and safety,” (Landewee et al, 2011, p. 313). The voice of the institution and the nurse are evident in the literature while the voice of the client is less apparent but still visible. There are voices that are silent from this literature.
There are numerous studies found that research the use of seclusion rooms from the perspective of nursing staff, from the perspective of other interdisciplinary staff and also from the client being placed in seclusion. However, the voices that are silenced in the current body of research are that of the client, family members, security guards and other members of the interdisciplinary care team (Larue et al, 2010b). Similarly, there were no studies found that research the use of seclusion rooms from the perspective of other clients on mental health inpatient units who observed others being placed in seclusion.
Cultural Issues
One of the values upheld in developed nations is that of conformity. Mental illness, acts of aggression and behaviours that may threaten the social order of the psychiatric institution are viewed as an act of social deviance (Homes et al, 2004; Jacob et al, 2009). Those who are admitted to inpatient mental health units are culturally deemed as deviant (Jacobs et al, 2009). Further, quantitative studies demonstrate that it is a majority of male clients who are secluded (Larue et al, 2010a). Those who deviate more from what is considered ‘normal’ are more likely to be placed in seclusion as individuals experiencing psychosis are at greater risk for seclusion episodes (LeGris et al, 1999). Those who are socially constructed as posing a greater physical threat may be more at risk as younger patients are secluded more often than older patients (LeGris et al, 1999). In a culture of control and conformity the use of seclusion rooms is also presented as a means of behavioural modification when it is used to promote conformity of behaviour under the guise of therapeutic techniques (Jacob et al, 2009).
There are also cultural factors present related to specific health care teams. Larue et al (2010b) found that the health care team culture, the ward milieu and the understanding of the aggressive behaviour influenced the decision to seclude. Although many nurses reported belief in a collaborative model this was not the nature of their verbal responses in the interviews conducted. It can be said that the culture of psychiatry is based on the use of control and coercion to maintain the conformity of the client. Further the culture of psychiatry emerged from the asylum which was a punitive control to isolate those deemed mentally ill. As psychiatry gained popularity the current conception of the client is based on the medical model which continues to maintain a culture based on control and punishment. The culture is based on curing mental illness.
The illness orientation of the medical model that divides clients into the pieces of their diagnosis contrasts the holistic model that guides nursing. Yet, there are pieces of nursing culture that are extremely protective of traditional views and values related to self-preservation. For example, the teamwork culture in nursing may work to protect staff at the detriment of the client at risk for seclusion (Ryan & Happell, 2009). The culture of safety that is upheld by health region or hospitals is in contrast to best practice guidelines that do not support the use of seclusion as a therapeutic technique (Landewee et al, 2011). Nurses sheltered their judgements to use seclusion behind the policy of the hospital (Landewee et al, 2011). Moral judgements are found to be largely influenced by the closed culture of the institution (Landewee et al, 2011). In some studies nurses are depicted as passive vessels that carry out seclusion use however in other literature nurses are depicted as acting on “intuition” and then later “become more open to alternative option, and felt these to be better” (Landewee et al, 2001, p. 312). This may indicate that the culture of acute inpatient mental health remains deeply embedded in the traditional medical model that guides psychiatric practice.
Conclusion
The use of seclusion rooms is a widespread mental health intervention despite the lack of substantial evidence that supports its efficacy as a positive therapeutic technique. The purpose of this paper is to answer the question, why do seclusion rooms continue to be used in mental health when they are not evidence based practice? Through examination of the current academic literature a discourse analysis had been presented that explores the overarching paradigms utilized in research, uncovers the power dynamics between those who perpetuate use of this intervention and those being secluded and examines how cultural variables influence this discourse. It was found that much research approaches the issue from a positivist and interpretative paradigm with only two articles approaching the issue from a critical social theoretical perspective. Power relationships were found to consist of the mental health client in the position of the less powerful group while health care staff, primarily nurses and physicians and the health care system held a powerful position. The cultural variables found relate to the specific culture of the mental health unit which reveals that despite efforts for nursing to implement holistic approaches that empower the client the power in mental health continues to be controlled by the historical perspective of the institutional asylum and the biomedical model.
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