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Reviewing seclusion and restraint in mental health practice

Australian College of Mental Health Nurses chief e
Photo: Australian College of Mental Health Nurses chief executive Kim Ryan
Mental health nurses will be able to have their say on some of the barriers and enablers when it comes to the use of seclusion and restraint in mental health wards.

The Australian College of Mental Health Nurses (ACMHN) will gauge the views of mental health nurses through an online survey as part of a project it’s conducting for the National Mental Health Commission.

In 2005, all Australian governments agreed to move to reduce and, where possible, eliminate the use of seclusion and restraint interventions for people with mental health issues.

“There is a lack of evidence internationally to support seclusion and restraint in mental health services,” the Commission states on its website.
“There is strong agreement that it is a human rights issue, that it has no therapeutic value, that it has resulted in emotional and physical harm, and that it can be a sign of a system under stress.” 

ACMHN chief executive Kim Ryan says while the Commission has conducted research investigating the consumer experiences of seclusion and restraint, it’s paramount that the views and the safety of mental health nurses, working at the healthcare coalface, are also examined.

“Nurses keep hearing that we’ve got to reduce seclusion and restraint, but they’re at the frontline, wondering - what’s going to happen to me if I can’t do that?

"We need to look at whether all the things that we know help to reduce seclusion and restraint practices are actually in place, and whether nurses are getting the support that they need to change their practice and to keep patients, themselves and others safe…what are the alternative practices and what is it that we need to do to support nurses in this task,” she says.

“Nurses don’t like being involved in seclusion and restraint - and it’s important to note that some reduction in seclusion and restraint rates has occurred.

"But until we explore what the nurses' perceptions are around some of the well known barriers and enablers to reduction and elimination, we are not going to be able to support them to go the next step. We need to know more about how we do all we can to support nurses and keep everyone safe.”

Ms Ryan says it’s a complex issue, particularly in the face of significant drug problems, including the ice epidemic.

“Methamphetamine is, for one, a serious problem that causes distress for the community at large and in health care settings is a very, very difficult issue to manage,” she says.

“We need to know how we can address situations where people are vulnerable, staff are vulnerable and a difficult situation raises safety issues for everyone."

Seclusion and restraint

The Commission defines seclusion as interventions used in mental health facilities and other settings to control or manage an individual’s behaviour:

“Seclusion is when someone is isolated and confined in a specific room from which they cannot leave. Restraint is when someone’s movements are restricted by another person or persons, or the use of straps or belts (physical or mechanical restraint) or sedation medication (chemical restraint).”

Health Ministers have backed the National safety priorities in mental health - a national plan for reducing harm, which outlined four key priorities - including reducing the use of and, where possible, eliminating restraint and seclusion.

In its 2016 position statement on seclusion and restraint, the College states the “use of seclusion and restraint, as defined in this document, in acute and all mental health services settings, is a harmful practice that is traumatic for consumers, their families as well as staff, which should be reduced and ultimately ended”.

It outlines that restricted practices “are never ‘therapeutic’, should ultimately be considered a ‘treatment failure’, and only implemented as a last resort. They should never be used for the purposes of punishment, discipline, negative inducement, coercion or staff convenience, or where less restrictive practices are accessible and achievable.”

The statement also says mental health nurses require appropriate training in de-escalation techniques and critical incident management, opportunities to implement alternatives or change to the environment, such as calming or safe spaces for consumers.

Nurses also require policies, procedures and adequate staffing levels to prevent and manage behavioural emergencies along with the implementation of alternatives to seclusion and restraint.

Ms Ryan says nurses can’t do it alone – significant leadership from every level of health is important.

Alternatives to seclusion and restraint

A range of alternatives are being trialled and implemented in Australia and internationally, including de-escalation techniques, sensory modulation rooms or areas, and initiatives such as renowned UK evidence-based practice model, Safewards.

“There are processes that the wards can look at in terms of better identification of people who are at risk for increased aggression, and for those who may be escalating or becoming distressed," Ms Ryan says.

"Nurses need to understand and respond to what are the drivers for people towards becoming agitated, and what are the triggers that affect people when they are in the hospital.

“There are alternatives, but the services have got to invest in and support these alternatives. If the inpatient unit is crowded, if there’s no space for people to go and be by themselves, if there’s no opportunity to go outside and get fresh air and let off steam…that puts everyone in a much more difficult situation.

"We need to work with people to try and manage their stress or their agitation, and services need to help by providing all the supportive mechanisms that can help too.”

Listening to nurses

The College has commissioned a literature review, which will soon be submitted to the Commission, and will open up the online survey for mental health nurses in coming weeks. The results of the survey will be sent to the Commission within the next few months.

Ms Ryan says mental health nurses have a crucial role to play in reducing and ultimately ending the use of seclusion and restraint.

“There are so many issues to consider. We don’t want to go from a situation where a reduction in seclusion and restraint results in a higher rate of chemical restraint. These issues are not easy to unpack - but we’ve just got to start somewhere,” she says.

“What we’re trying to do is to begin the conversation with mental health nurses. To say - well, does this happen in the unit you work in, how does it work, what alternatives have been made available to you, what are the barriers, and what do you think could actually improve the system in your workplace and across the system more broadly?

“We would like to work towards reduction of seclusion and restraint particularly, but we are also very mindful of the fact that we can’t do that in the absence of better information and knowledge and ways of responding, to ensure that the frontline workers who are involved in these activities every day are safe, and that the patients are safe.”

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Karen Keast

Karen Keast is a freelance health journalist who writes news and feature articles for HealthTimes.

Karen regularly writes for some of Australia’s leading health news websites and magazines.  In a media career spanning 20 years, Karen has worked as a senior journalist in newspapers and television. She has covered the grind of daily news and worked as a politics reporter at countless state and federal elections.

Since venturing into freelance writing five years ago, Karen has found her niche in writing about the health sector for editors, businesses and corporations.

Karen has interviewed the heads of peak health organisations in Australia and overseas, and written hundreds of news and feature articles covering the dedicated work of health professionals who tread the corridors of hospitals and health services, universities, aged care facilities and practices, day in and day out.

Follow Karen Keast on Twitter @stylemywords