The controversial practice of seclusion creates a complicated and significant ethical dilemma in healthcare.
Seclusion may even be considered a violation of a client’s fundamental human rights (Haugom, Ruud & Hynnekleiv 2019).
What is Seclusion?
Seclusion is a behavioural intervention used by mental health services, wherein a client is confined in a room alone and prevented from freely exiting. It can be enacted at any time of day or night (ACSQHC 2019).
Along with restraint, seclusion is a type of restrictive practice (ACSQHC 2019).
Restrictive practices are used as a last resort intervention in the event of a behavioural emergency. They may further exacerbate the client’s trauma or inflict physical or emotional harm, posing a profound risk to their safety and wellbeing. Furthermore, these interventions are not known to alter the client’s behaviour in the long-term (PSEP 2017).
For these reasons, seclusion must only be used if there are no other appropriate options (RANZCP 2016).
These emergencies may include:
Where there is a significant safety risk to the patient, staff or other people, and the risks of not restraining outweigh the risks of restraining.
Where there is a significant risk of persistent property damage.
Where the client requires essential medication or treatment immediately, and there is no other way to administer it.
Where the client is under care and control or an Inpatient Treatment Order (ITO) and needs to be prevented from leaving the premises.
(SA DoH 2015; RANZCP 2017)
Note: The situations wherein seclusion is permitted differ slightly between states and territories. Always refer to your state or territory’s legislation when considering seclusion. In all states and territories, seclusion is strictly a last resort and is only to be used if there are no other options.
Seclusion in the National Safety and Quality Health Service Standards
This action aims to minimise the use of seclusion in healthcare, and consequently, the harm incurred by clients. Providers are required to meet the following guidelines:
The use of seclusion is minimised and eliminated if possible;
Seclusion is used in accordance to legislation; and
Any use of seclusion is reported to the governing body.
Impacts of Seclusion on the Client
Seclusion can have a variety of severe, adverse consequences on the client, including:
Post-traumatic stress disorder, which is estimated to affect between 25 and 47% of clients who have experienced seclusion;
Violation of human rights;
Feelings of despair or hopelessness due to shame, stigma and social isolation;
Damage to the therapeutic relationship between the client and staff members;
Short or long-term psychological or physical harm;
Preventable injury or death;
Fear of readmission; and
Determent from voluntarily seeking healthcare services in the future.
(Chieze et al. 2019; PSEP 2017; Melbourne Social Equity Institute 2014)
Seclusion in Australia
Given the severe and ethically-challenging nature of seclusion, this practice is governed by strict legislation. Each state and territory has its own Act. Therefore, there are slight differences between them. You can find an overview of these differences on the RANZCP’s website.
Any seclusion or restrictive practice must be performed under the specified acceptable situations in your state or territory’s legislation.
In the year 2018-2019, there were 11,944 seclusion events recorded in Australia. This was an increase from 11,316 in 2017-2018. Despite this, the practice is on an overall downward trend (AIHW 2020).
According to the RANZCP (2016), barriers to decreasing the prevalence of seclusion include:
Lack of identified good practice and clinical standards;
Lack of quality improvement and clinical review;
Inappropriate use of seclusion (e.g. as a threat);
Lack of staff knowledge, education and training;
Lack of knowledge in de-escalating early warning signs; and
Lack of resources and inadequate facilities.
Given that seclusion is a non-therapeutic and potentially harmful practice, every effort must be taken to minimise or eliminate its use (SA DoH 2015).
While this partially involves exploring alternative options during challenging situations and learning how to effectively de-escalate conflict, preventing the use of restrictive practices means addressing the issue at a grassroots level. In other words, you should consciously ensure your interactions, communication and engagement with clients actively address their needs and make them feel comfortable. This, in turn, aims to reduce the incidence of challenging behaviours in the first place (SA DoH 2015).
The following are some practical suggestions for caring for clients in a way that will help minimise the risk of challenging behaviours.
Ensure you deliver trauma-informed care that takes into account the client’s past traumatic experiences. Make sure they feel welcome and provide them with options so that they do not feel trapped.
Engage with the client and develop a therapeutic relationship with them.
Always deliver person-centred care.
Be polite and respectful, and practice empathetic listening.
Meet the client’s immediate needs.
When meeting a client, introduce yourself, ask their name and confirm what they would like to be called. Ask if they would like food or a drink, whether you can do anything for them and whether they have any questions.
Practice effective and empathetic communication.
Provide the client with access to a range of meaningful activities they can choose from.
(SA DoH 2015)
Anxiety is the first sign of behavioural change and may lead to agitation or aggression if not addressed. There may be some environmental factors you can modify to help the client feel more comfortable, for example:
Ensuring the client has adequate privacy;
Ensuring the area is clean;
Orientating the client to their environment;
Providing natural lighting;
Providing access to other spaces; and
Providing access to outside spaces.
(SA DoH 2015)
If a client becomes agitated or aggressive, you will need to use de-escalation strategies to help calm them down and prevent the situation from intensifying further.
Observe the client’s body language and try to understand what they may be feeling.
Approach the client calmly, empathetically and respectfully. The aim is to evoke a positive response from the client.
If the situation escalates and the client becomes threatening, you may need to seek assistance from other staff.
If others are called to assist the situation, be aware that this situation may feel threatening for the client. Inform them that others have arrived to ensure everyone stays safe.
Consider the following:
Does the client need more information or an explanation?
If you are asking the client to do something, can this be done later?
Is the client able to make connections between their actions and the consequences?
The client is allowed to feel angry - is it possible for them to vent in private?
If the situation continues to escalate, assess whether other following options are viable before considering restraint. For example:
Access to a ‘comfort room’; and
Medication if appropriate.
(SA DoH 2015)
If the above strategies have been exhausted and the situation continues to escalate, you may be forced to consider seclusion.
It is essential to refer to your state or territory’s legislation when deciding a client needs to be secluded. As a general guideline:
Seclusion must only be implemented by staff members who have been appropriately trained in this area.
Seclusion will need to be authorised by the relevant party. This depends on your state or territory.
Most states and territories require certain parties to be notified in the event of seclusion.
Seclusion should only occur for the minimum amount of time necessary. There may be time limits and extension provisions depending on your state or territory.
The client should be observed while in seclusion.
The client should be debriefed after the incident.
(RANZCP 2017; SA DoH 2015; ACSQHC 2019)
Seclusion and other restrictive practices are interventions that should only be used as a last resort in the event of a behavioural emergency.
Remember that these practices are highly distressing for the client and may cause or exacerbate trauma. The goal is to minimise and hopefully prevent restrictive practices as much as possible.
Note: Always refer to your state or territory’s legislation, as well as your facility’s policies and procedures.