Proposed Action to Improve Seclusion Room Practices in a Tertiary Mental Health Facility: A Discourse Analysis
Abstract
The purpose of this paper is to challenge the current practice of seclusion room use within a tertiary mental health rehabilitation facility through conducting a critical discourse analysis. I asked the research questions, “what is the discourse surrounding current use of seclusion rooms within this practice setting, how does this influence health care delivery, and what are specific actions that could be used to transform the current discourse for the purpose of improving health care delivery?” Both textual and verbal communication between interdisciplinary staff are analyzed within this practice setting to determine the dominant paradigms, and uncover the overarching power dynamics and explore their influence on workplace culture and health care delivery. This discourse is situated within the current body of research on seclusion room use. The results show that many challenges emerge from the opposing client centred recovery oriented model that guides the program and the oppressive nature of seclusion use.
Proposed Action to Improve Seclusion Room Practices in a Tertiary Mental Health Facility: A Discourse Analysis
Recovery in mental health may be defined as a way of life; an attitude and a comprehensive approach to building on strengths of the individual that instils feelings of hope, empowerment, personal responsibility and autonomy (Higgins and McBennett, 2007; Lloyd et al, 2009). In the 1980s, recovery-oriented approaches were used widely in mental health practice because of their focus on quality of life, empowerment and autonomy (Buchanan-Barker, & Barker, 2006; Higgins & McBennett, 2007). Successful application of recovery-oriented models require a philosophical shift from traditional illness-oriented models of mental health that emerged from the dominant medical model; a model that conceptualizes the client as inevitably and persistently impaired by their illness diagnosis (Craig, 2008; McAllister, 2003).
Psychiatric inpatient care in Canada has traditionally been guided by custodial and paternalistic paradigms that emphasize control and containment (Tipliski, 2004). Once common practice within the custodial model of care, seclusion room use within inpatient psychiatric facilities is today considered controversial (Homes, Kennedy & Perron, 2004; Jacobs et al, 2009; Scanlan, 2010). The purpose of this paper is to challenge the practice of seclusion room use within a tertiary mental health rehabilitation facility because it directly contradicts the recovery-oriented philosophy of the program. Seclusion room use within this setting will be analyzed using a critical discourse perspective exploring both written policy and informal verbal discussion between myself and multiple members of my interdisciplinary health care team. The research questions that guide this analysis seek to answers the questions, “what is the current discourse surrounding use of seclusion rooms within this particular tertiary mental health rehabilitation setting, how does this influence health care delivery and what are specific actions that could be used to transform the current discourse for the purpose of improving health care delivery?” This analysis begins with a description of the practice setting and workplace culture in order to contextualize the discussion.
The Practice Setting
The practice setting in question is an unlocked, 30-bed, hospital-based inpatient tertiary mental health program. The mandate of the program to act as the sole specialized mental health hospital in British Columbia, and is one component of a greater mental health relocation project for clients originally admitted to Riverview Hospital (Marrow et. al, 2010). The opening of the unit explored in this paper came as one of the final steps in the “Riverview Redevelopment Project” (Marrow et. al, 2004 p. 43). The purpose of the tertiary mental health design is to create specialized inpatient psychiatric care outside of the hospital model, in smaller, home-like residential facilities that provide holistic programming including life skills training, rehabilitation and skill preparation for return to the community (Marrow et al, 2010). However, due to financial constraints, the current facility in which the unit is housed is designed for a psychiatric unit that will be housed there following the move of the facility to its permanent home. The current location is an institution-like environment, with high-security measures including two seclusion rooms, magnetic locking doors controlled by staff, and a fully enclosed and locked nursing station. Additionally, the unit follows the acute-care psychiatric policies of the hospital that houses the unit.
All clients are adults, ranging in age from 23 to 64 with multiple inpatient psychiatric admissions throughout their adulthood, many beginning in their teenage years. The major diagnosis of all clients involves some type of chronic psychosis. The range of the current hospital stay at Riverview Hospital ranges from one year to fifteen years. 26 of the clients have been identified as having a history of violence or aggression as evidenced by examination of old charts, though most incidences are not recent. Three clients have voluntary status, meaning they willingly agreed to remain in hospital for ongoing treatment and support while 25 clients have involuntary status, meaning that two psychiatrists deemed them unable to function safely without forced treatment in a health care facility (British Columbia Ministry of Health, 2005).
Workplace Culture
The workplace culture of the unit is mixed and interdisciplinary, consisting of nurses (Registered Nurses and Registered Psychiatric Nurses), rehabilitation workers, recreational therapists, social workers, occupational therapists, peer support workers and psychiatrists. The 24 hour care is provided by both mental health nurses and rehabilitation workers. The experience of the nurses ranges from three years to twenty-five years. The majority of professional health care and nursing staff had previously worked in the client’s previous residence of Riverview Hospital. All nursing staff have experience working in acute psychiatric facilities; few of the rehabilitation staff had any experience in acute mental health. The role of rehabilitation worker was newly introduced for this program. Rehabilitation workers have varied experience and education, the majority previously being employed in community mental health programs. This resulted in a steep learning curve for most rehabilitation staff at the outset of the program because the clientele require more support than care provided in their previous jobs. There has been some friction from nursing staff that are not used to having rehabilitation workers on the interdisciplinary team.
Although the guiding principle of the facility is a recovery oriented approach I have observed a tendency on the part of nursing staff, particularly those familiar with paternalistic models of custodial care, to revert to the paternalistic practice model used when employed at Riverview Hospital. This often conflicts with the practice of the rest of the health care team who design care planning in accordance with the recovery model. One major factor that perpetuates conflicting view of recovery results from the newness of the program. There were few formalized policies and procedures or any type of text resources found. As no text resource exist about seclusion room use in this practice setting this discourse analysis focused on written policy from acute care in addition to verbal communication with co-staff.
Resources Included in the Analysis
Two types of resources are used in this analysis, policy documents and informal conversations between me and the interdisciplinary health care team. It was extremely difficult to find any textual documents about this particular program because the tertiary mental health program is brand new in the health care region. The policies that management have directed staff to refer to are those borrowed from acute inpatient psychiatry, despite the fact that this program is community rehabilitation. Overall, in conducting an internal website search of the health care region there were few acute facility resources that had mention of seclusion rooms. The primary textual resources that I will use in this paper are a clinical practice documents. There are three clinical practice documents that guide patient care in seclusion, one entitled Care of the Patient requiring Seclusion (PCG S-050) and Care of the Patient at Risk for or Requiring Restrain (R-030) and the Workplace Violence Prevention Policy. The primary content of the discourse utilized in this paper came from informal conversations with coworkers.
The second resource utilized in this discourse analysis is informal conversation between me and the interdisciplinary health care team members. I engaged in informal conversations with both nursing and rehabilitation coworkers approximately six months after the opening of the program. I found that all nursing staff and psychiatrists reported familiarity with use of seclusion rooms. Although other team members were aware of seclusion room use few spoken to were familiar with policies and procedures within the inpatient acute care setting. Conversations consisted of discussion related to current beliefs of seclusion room use and need/applicability to the current practice setting. In the next section I will discuss each discourse more specifically, beginning with identifying the major paradigms present and the underlying assumptions that influence seclusion room use in the practice setting of an inpatient tertiary mental health rehabilitation.
Discourse Present in the Inpatient Tertiary Mental Health Setting
The following discourse analysis is broken down into three major sections, paradigms, power and silences. The influence of cultural variables will be discussed throughout each section. Examples of both discourses are integrated throughout to contextualize the analysis.
Paradigms
The positivist paradigm uses objective, quantitative data which results in uncovering facts that can be generalized to a population (Gephart, 1999; Weaver & Olson, 2006). This paradigm is guided by empiricist philosophy and relies on the principles of the scientific method. Research conducted within the positivist paradigm uses methods such as experimentation to uncover observable universal truths (Weaver & Olson, 2006). It is difficult to assess seclusion use from an objective perspective because there is so much variance among clients and subjective assessment that result in initiation of use. The positivist paradigm was not immediately apparent in the informal conversations with co-staff as there was no mention objective data that supported use of seclusion. However, on further reflection some nursing staff did use language that indicated generalized experiences from acute psychiatric settings as evidence for the utility of seclusion rooms and both therapeutic and for safety. Both nurses and psychiatrists generalized evidence of client’s past aggressive behaviour to prediction of future violence. Further, nursing staff sometimes mentioned potential for violence resulting from current diagnosis, such as features of antisocial personality disorder. This indicates their underlying belief that they were utilizing a positivist perspective to guide their practice.
Similarly, the assumptions of positivist paradigm underlie the practice document as evident in the clear attempt to objectively quantify and standardize the specific reasons for initiating seclusion, assessment of the client while in seclusion and specific interventions directed at ensuring basic needs are met. These are the two professional groups identified that are able to initiate and continue use of seclusion, psychiatrists and nurses. Although there is brief mention of the doctor’s responsibility when writing seclusion room orders the majority of the practice documentation guides nursing practice, step by step from initiation to discontinuation. Once seclusion is initiated there is a seclusion check list which is used for client monitoring which consists of check boxes for specific behaviours and specific nursing inventions that are utilized (Vancouver Coastal Health, 2008). This is an attempt to objectively and concisely provide quick reference. Objective and quantitative methods for providing client care and for client monitoring help to remove the human factors from the client in attempt to standardize practice. However, doctors and more often nurses are the ones making clinical judgments subjectively about when to initiate seclusion indicating that the major paradigm guides this discourse is interpretive.
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 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). Both the practice documents and the informal conversation with staff clearly demonstrate the dominance of the interpretive paradigm from the perspective of health care staff, particularly the nursing staff. However, interestingly, there is no mention in the practice documents about care planning with the input of the client (Vancouver Coastal Health, 2008) which indicates the solely staff make these care planning decisions.
The voices that are present in the clinical policies are those of doctor’s and those of nurses. During informal conversations this subjective perspective was voiced under the guise of, “patient and staff safety,” the frequent term used was, “better safe than sorry” indicating that the most important voice in seclusion room situations is that of staff. Informal conversations with nursing staff provide evidence that there is much concern for staff about their own welfare. When I posed suggestion about the potential trauma that could be caused by use of seclusion I was often met with the challenge that staff safety and safety of other clients is a priority, therefore use of seclusion should be considered when any potential risk of violence is perceived by staff.
The paradigm that is clearly absent from both the policy and procedure manual and in information staff conversations is the critical social paradigm. The critical social perspective is concerned with countering the oppression and distributing power to the client which could aide in challenging the apparent power differentials embedded in use of constraint and confinement (Weaver & Olson, 2005). From this perspective 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). There was no evident use of the critical social perspective in the clinical practice documents or noted in conversations with coworkers as both focus on seclusion room use for the purpose of safety, primarily of staff and co-clients which may indicate lack of recognition of the full impact on client care.
Power
The analysis of the dominant paradigms in seclusion room discourse within this practice setting demonstrate that there are clearly a power differential between clients and staff. Although the model of the program is a recovery oriented approach the subjective criteria outlined for the initiation and discontinuation of seclusion coupled with the majority of client’s involuntary admission status place them in a very vulnerable position. Doctors and nursing have the majority of the power as they determine when to initiate and discontinue seclusion through subjective assessment, while clients have little power because they must comply with orders of staff. While doctors are able to write seclusion room orders, it is primarily the nursing staff who provide the 24 hour care who are viewed as best able to determine need for seclusion room use, exercise much influence for doctor’s to write these orders. There are two criteria that may result in initiation of seclusion, non-emergency and emergency. Emergency initiation, “may be initiated immediately, with an MD order, when a patient’s behaviour/state conveys imminent substantial and probably risk of serious injury to self, others, or property,” (Vancouver Coastal Health, 2008). Within emergency situations nursing staff have clear power in having sole ability to determine whether seclusion room use is necessary.
Power is evident in the ambiguity of the practice document and information left out of the document. For example, although it is clearly outlined that seclusion not be used as punishment as evidenced in the references provided within the practice document there is no mention of this in the document itself (Vancouver Coastal Health, 2008). Unfortunately, since this is not strictly prohibited there have been directives from management that seclusion be used as a punitive measure for clients that do not comply with certain rules which strictly defies the recovery oriented approach and best practice evidence of seclusion room use (Nelstrop et al, 2006; Stokowski, 2007). It is very clear that the policy is written for the purpose of protecting staff and maintain control as evidenced in language like, “consider a trial door open when a patient has demonstrated his/her behaviour is under control, able to follow simply direction, willing to accept limits set by staff, able to talk about what happened and able to give commitment to remain in control and contract for safety,” (Vancouver Coastal Health, 2008). This indicates that within this discourse it is the voice of the client that is silenced.
Silences
The voices that are clearly silenced in this discourse are the voices of the client. In the practice documents as well as in conversations with coworkers there is little mention of the impact of seclusion on the client. Although the practice document does state, “provide the patient opportunity to talk about their thoughts and the experience of being in seclusion,” and “discuss the problems that lead to seclusion and ways to cope to avoid seclusion,” there is no policy about conducting debriefing (Vancouver Coastal Health, 2008). In practice few staff I talked to actually do engage in therapeutic conversations with a client while in seclusion and conduct a comprehensive debriefing with the client following discontinuation of seclusion. Perhaps this may occur because there is no specific policy about engaging with the client to ascertain their perspective or potential for harm that could be done to the client through use of seclusion. Unfortunately, the direct result is that the client’s voice is not heard at any point in the seclusion room process as all decisions are made by health care staff.
The notion of the client’s voice being silenced directly contradicts the type of culture that should be fostered within a recovery oriented (Buchanan-Barker, & Barker, 2006) but upholds the paternalistic assumptions of the medical model (Cutcliffe & Happell, 2009). This supports that the medical model is deeply embedded within mental health practice even in the event that a more client centred, empowering approach is mandated to guide client care. Despite the best intention of creating a program in which the client is a collaborative partner specific practices, like seclusion room use, that work to reinforce power differentials and silence the voice of the client impede successful implementation of recovery oriented approach.
D. Influences on Health Care Delivery
The present discourse of seclusion room use is manifested as a means of control, viewed primarily by nursing staff as a necessary and therapeutic tool despite the fact that this is contrary to the research that has been published on use of seclusion. Although there is little empirical evidence supporting the safety and effectiveness of either seclusion room or restraints use as therapeutic interventions for the short-term management of disturbed/violent behaviour in psychiatric inpatient settings, this continues to guide practice (Nelstrop et al, 2006). One main influence on the use of seclusion in this setting is the simple physical existence and accessibility because the unit is designed for acute psychiatry, thus the environmental design is specific for the purpose of control and containment rather than empowerment and recovery. With access to seclusion comes the ability and opportunity to utilize this space.
Seclusion room practice also results in increased use of other potentially unnecessary means of client control and shows of authority. For example, under the guise of safety it is routine that three security guards are called to the unit to accompany two staff with the client to the seclusion room regardless of the specifics of the situation. This practice ignores the perspective of the client, for which use of seclusion is often a humiliating experience. Further, the simple existence of seclusion rooms on the unit, which is designed for an acute care population, rather than tertiary mental health rehabilitation clients, seems to encourage staff to utilize the seclusion room for any perceived risk rather than attempting to use the least invasive measures to deescalate situations.
Similarly, as discussed in the previous section a repeated theme heard from nursing staff is that it is “better to be safe than sorry,” meaning that staff is often guided by the belief that when carefully weighing out the risks and benefits it is necessary to use methods which restrict freedom most for the protection of staff and other clients. Another recurring theme heard from particularly nursing staff is the “potential” for future violent acts as evidenced by past violent acts with no consideration of the specifics of the past acts of violence, nor the time when these occurred. The encouragement to implement policies and practices designed for safety may actually facilitate a culture of fear. For example, there are often judgements made about clients because of previous acts of violence.
Although the guiding policy is written for seclusion room use, it is borrowed from acute psychiatric care and not written specifically for the population being cared for in tertiary mental health (Vancouver Coastal Health, 2008). However, the vague nature of both the non-emergency initiation of seclusion and the emergency initiation policy pose challenges in the tertiary mental health practice setting because they both rely on perception of the assessing staff, most often a nurse. The use of seclusion, coercion and control without a collaborative partnership with clients is in direct contradiction to the central tenets of the recovery oriented model that is supposed to be guiding practice in this particular mental health setting (Morrow et al, 2010). This disconnection between the guiding philosophy of the program and the practical implementation and regular use of seclusion has resulted in confusion, bewilderment, frustration and polarization of the unit staff. Perhaps the best way to realign with the original vision of a recovery oriented model is to focus on potential actions that could improve client care and decrease or even eliminate use of seclusion rooms in tertiary mental health practice.
Actions to Transform Health Care Delivery
Potential Actions to Improve Client Care in the Tertiary Mental Health Setting
The use of a critical social perspective is useful in challenging the apparent power differentials embedded in seclusion room use because this paradigm is concerned with countering the oppression (Weaver & Olson, 2005). This perspective promotes devising actions that help change the dominant social order. Two important actions that could help create improvements in health care delivery in the tertiary rehabilitation setting are staff education and creation of policies and procedures for managing incidents of client violence which are unique to the community mental health setting. Education of staff is necessary because the interdisciplinary team members in the practice setting have reported a wide range of differing views about the utility and application of seclusion rooms. For example, some of the health care professional staff such as social workers, occupational therapists and recreational therapists report lack of familiarity with seclusion room policy as this is believed to be the domain of psychiatrists and nursing staff. Nursing staff reported mixed beliefs about seclusion room use ranging from the view of this intervention being both unnecessary and harmful to the view of seclusion rooms as therapeutic and a necessary tool for crisis management and safety.
Despite personal beliefs the use of seclusion rooms in community mental health settings is not supported by any type of research data. Further, the majority of research on seclusion rooms in the inpatient acute psychiatric setting indicates the multiple harms associated with placing clients in locked room and provides evidence for the lack therapeutic value (Jacob et al, 2009). Thus, it stands to question whether there is any utility of seclusion room use within a recovery oriented community based mental health rehabilitation program. Practice documents should reflect the client centred, empowering approach that is the overarching philosophy of the program.
It is imperative to create a set of policies and procedures specific for the tertiary rehabilitation setting rather than simply borrowing existing ones that are written for an acute mental health population. There are distinct differences between the acute mental health client and the tertiary rehabilitation client (Marrow et al, 2010). The primary difference is that client deemed appropriate for the tertiary mental health setting are those assessed as able to successfully transition into community based care focused on maximizing independence. This is evidenced by the fact that most of the clients in the facility are on waiting lists for mental health housing meaning they are stable enough to live outside of a hospital setting.
Actions must be taken to ensure that clients can successfully live within mental health housing outside of an institutional setting. Further, when the facility moves to the new location the environmental design is a home-like setting without use of seclusion rooms, thus perhaps it is the time to recognize that just because seclusion rooms are accessible this does not mean that they should be utilized. The reliance of staff on seclusion rooms may impede the ability to fully implement a recovery oriented approach where collaborative care and strengths are focused on rather than control. Discontinuation of seclusion room use may encourage staff to work on client’s coping skills rather than simply locking them in a room.
Actions as a Discourse of Resistance
Within the research community it may be firmly established that seclusion rooms are supposed to be used as the last possible measure in terms of both staff and client safety but this seems a new idea to the staff that I am working with. The proposed actions require a philosophical shift similar to that required to implement the recovery oriented approach. The idea that there is no therapeutic use for seclusion rooms directly challenges traditional notions of what safety and control mean within the mental health setting. The action of staff education presents an opportunity to teach an alternative viewpoint and to educate staff about the current best practice models in mental health which indicate that there is no real therapeutic use of seclusion rooms.
Resistance to the dominant discourse is apparent in the inclusion of clients in creating plans for crisis management as this directly challenges the current view that staff control the decision making process in the community mental health setting. This is a new idea that a client would be asked about personal crisis management strategies in terms of their own care. This is in accordance with the central tenets of the recovery oriented approach which directly resists the medical illness model of mental health (Craig, 2008).
Although once common practice within the custodial model of care, today the issue of seclusion room use on inpatient psychiatric facilities is controversial (Homes, Kennedy & Perron, 2004; Jacobs et al, 2009; Scanlan, 2010). The purpose of this paper is to challenge the practice of seclusion room use within a tertiary mental health rehabilitation facility because it directly contradicts the recovery oriented philosophy of the program. Analysis is conducted using a critical discourse perspective to explore both written policy and informal verbal discussion between myself and multiple members of the interdisciplinary health care team. Findings show that interpretive paradigms from the perspective of staff are dominant within both discourses under the guise of safety which effectively silences the voice of the client and negatively impacts health care delivery because it results in a paternalistic approach that situates power in the hands of staff. The major actions that are proposed to challenge and resist the dominant discourse are increased staff education and creation of unique policies specific for tertiary mental health rehabilitation designed to be implemented in a community setting.
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