When reduction strategies are put in place and mental health consumers are still secluded: An analysis of clinical and sociodemographic characteristics

Internationally, seclusion practices continue to be the subject of intense clinical health service and academic scrutiny. Despite extensive efforts to reduce and eliminate this controversial practice, seclusion remains a clinical intervention widely used in contemporary mental health service settings. Early identification of people who are at risk for seclusion and the timely application of alternative evidence‐based interventions are critical for reducing incidents of seclusion in real‐world practice settings. This retrospective study aimed to determine the relationship between sociodemographic and clinical characteristics, and the use of seclusion for those mental health consumers for whom evidence‐based seclusion‐reduction initiatives had little impact. A 12‐month centred moving average was fitted to seclusion data from a psychiatric inpatient unit over 2 years to determine stabilization in seclusion reduction. The number of consumers admitted was calculated from the point of stabilization for 1 year (n = 469). In this cohort, univariate analysis sought to compare the characteristics of those who were secluded and those who were not. A multivariate logistic regression model was undertaken to associate future seclusion based on significant independent variables. Of those people admitted, 88 (19%) were secluded. The majority of seclusions occurred in the first 5 days (70/88, 79%). Multivariate logistic regression indicated that three variables maintained their independent associative risk of seclusion: (i) age less than 35 years; (ii) assessment of risk of violence to others; and (iii) a history of seclusion. The implications of these findings for nursing practice are discussed.     

From numbers to understanding: The impact of demographic factors on seclusion rates

The reduction and, where possible, elimination of seclusion has been recognized as a national safety priority for mental health services in Australia, with significant attention devoted to strategies to achieve this goal. The aim of this study was to compare specific demographic characteristics between consumers who have been secluded to those who have not. Patient data (n = 3244) collected by 11 mental health services across Australia for six months over a 12 month period were analysed using demographic statistics. A comparison was undertaken between those who were secluded one or more times (n = 271) and those who were not secluded (n = 2973). Differences were measured with the use of independent samples t‐tests and chi‐square statistics. Age, gender, diagnosis, indigenous status and Health of the National Outcomes Scores (HoNOS) were found to be significant factors in relation to seclusion. Men, younger people, and indigenous people were found to be more likely to be secluded. In addition, consumers who scored higher on the behaviour,impairment and social subscales of HoNOS were more likely to be secluded. Comparative analysis of demographic characteristics of secluded and non‐secluded patients can provide vital information for consideration when planning and evaluating seclusion reduction strategies.     

Nurses' and consumers' shared experiences of seclusion and restraint: A qualitative literature review

Seclusion and restraint are coercive practices associated with physical and psychological harm. International bodies have called for an end to these practices. However, these practices continue to be used. Elimination programmes have had some success in reducing the rates of these practices. Understanding coercive practices through the perspectives of involved individuals may facilitate a complete cessation of seclusion and restraint from the practice. Therefore, this qualitative review explored how nurses and consumers experienced seclusion and restraint events in mental health care. Five databases were searched. The search strategy resulted in the inclusion of fourteen qualitative papers. A thematic analysis was used to synthesize the findings. Six themes emerged under three main categories; shared experiences: disruption in care, disruption in the therapeutic relationship and shared negative impacts; nurses’ experiences: Absence of less coercive alternatives; and consumers’ experiences: overpowered, humiliated and punished. Considering these experiences during planning for seclusion and restraint prevention might facilitate more effective implementation of seclusion and restraint elimination programmes. Our findings suggested that consumers should receive recovery‐oriented, trauma‐informed and consumer‐centred care; while nurses should be better supported through personal, professional and organizational developmental strategies. Further research should focus on investigating shared interventions among consumers and nurses and exploring carers’ experiences with coercive practices.     

Perceptions of crisis care in populations who self‐referred to a telephone‐based mental health triage service

Although psychiatric crises are very common in people with mental illness, little is known about consumer perceptions of mental health crisis care. Given the current emphasis on recovery‐oriented approaches, shared decision‐making, and partnering with consumers in planning and delivering care, this knowledge gap is significant. Since the late 1990s, access to Australian mental health services has been facilitated by 24/7 telephone‐based mental health triage systems, which provide initial psychiatric assessment, referral, support, and advice. A significant proportion of consumers access telephone‐based mental health triage services in a state of crisis, but to date, there has been no published studies that specifically report on consumer perceptions on the quality and effectiveness of the care provided by these services. This article reports on a study that investigated consumer perceptions of accessing telephone‐based mental health triage services. Seventy‐five mental health consumers participated in a telephone interview about their triage service use experience. An eight‐item survey designed to measure the responsiveness of mental health services was used for data collection. The findings reported here focus on the qualitative data produced in the study. Consumer participants shared a range of perspectives on telephone‐based mental health triage that provide invaluable insights into the needs, expectations, and service use experiences of consumers seeking assistance with a mental health problem. Consumer perceptions of crisis care have important implications for practice. Approaches and interventions identified as important to quality care can be used to inform educational and practice initiatives that promote person‐centred, collaborative crisis care.     

‘They can't empower us’: The role of allies in the consumer movement

Goals of the mental health consumer movement include redressing inequality and increasing consumer leadership across the mental health sector. A means of achieving these goals is empowerment of consumers at systemic levels of the mental health sector. There have been calls for research to focus on allies – those who use their power to support and advocate for the goals of the consumer movement. This study aimed to examine the role of allies in consumer empowerment. Semi‐structured interviews were conducted with 15 individuals (including three consumers, nine allies, and three participants each identifying as both consumer and ally). Findings suggest that allies cannot directly empower consumers but should support opportunities for consumer leadership within the sector. We discuss how allies might do this and avoid paternalism in their allyship.     

Exploring patterns of seclusion use in Australian mental health services

Seclusion has remained a common practice in mental health services. In Australia, recent mental health policy has reflected a desire to reduce (and, if possible, eliminate) the use of seclusion. The collection and analysis of data on the use of seclusion have been identified as an important component of the success of reduction initiatives. A cross-sectional design was used in the collection of inpatient unit data on seclusions that occurred in 11 mental health services in Australia over a 6-month period. During this time, there were 4,337 episodes of care. One or more seclusions occurred in 6.8% of episodes of care, with consumers being secluded, on average, 2.32 times and with 44% of them having been secluded more than once. The average length of the seclusions was 2 hours 52 minutes, with 51.4% of seclusions being less than 2 hours. These rates were lower than those reported in previous research studies. The practice of seclusion occurred more commonly on the first 2 days following admission, on weekdays than weekends, and between the hours of 9:00 a.m. and midnight. An understanding of seclusion data can provide fundamental information from which strategies to reduce seclusion can be developed.     

Released potential: A qualitative study of the Mental Health Nurse Incentive Program in Australia

The Mental Health Nurse Incentive Program (MHNIP) is a Commonwealth Government funded scheme that supports people living with a mental illness. Despite its significance, the program has received little attention from researchers nor critical discussion within the published work. This paper first critically examines the MHNIP from the contexts of identities, autonomy, and capabilities of mental health nurses (MHN) and then reports on findings from a qualitative study that explored the experiences of staff working in the MHNIP. Key findings from this qualitative study include four main themes indicating that both the program and the nurses working within it are addressing the unmet needs of people living with a mental illness. They achieve these ends by adopting holistic and consumer‐centred approaches and by providing a wide range of therapeutic interventions. As well, the MHN in this study valued the freedom and autonomy of their practice outside public health services and the respect received from colleagues working in other disciplines. Findings suggest that MHN within the study were experienced as having autonomous identities and roles that may be in contrast to the restrictive understandings of MHN capability within the program's funding rules.     

Therapeutic engagement between consumers in suicidal crisis and mental health nurses

Registered nurses within public mental health services play crucial roles in helping people recover from suicidal crisis. However, there is a lack of understanding of how care is experienced in this context, and available evidence suggests that nurses and consumers are often dissatisfied with the quality of care. There is thus an imperative to generate understanding of needs and experiences of both groups with a view to informing practice development. This article summarizes qualitative findings from a multimethod study undertaken in Australia, which surveyed and interviewed mental health nurses who had recent experience of caring for consumers in suicidal crisis in a hospital setting, and interviewed consumers who had recovered from a recent suicidal crisis. A framework was developed to guide the study and support ethical imperatives; in particular, the promotion of consumer well‐being. The findings highlight that therapeutic interpersonal engagement between nurses and consumers was central to quality care. This was particularly noted, as engagement could help reduce consumer isolation, loss of control, distress, and objectification of the delivery of potentially‐objectifying common interventions. Of concern, the results indicate a lack of therapeutic engagement from the perspective of both consumers and nurses. Recommendations to promote fuller therapeutic engagement are presented.     

Being strategic: utilising consumer views to better promote an expanded role for nurses in Australian general practice

Australian consumers have articulated their perceptions of the role of the nurse in general practice. Practice Nurses (PNs) and General Practitioners (GPs) have also highlighted the issues they believe currently and potentially impact on this role in Australia. This paper identifies and discusses the nexus between the consumers' perceptions and expectations and health professionals' issues. Data collected from focus groups and interviews in 2 Australian studies of consumer perception of nursing in general practice, are re-considered alongside findings reported in the Royal Australian College of General Practitioners and the Royal College of Nursing, Australia report; General Practice Nursing in Australia. Consumers, doctors and nurses working in general practices in Australia, raised similar issues. However, consumers considered these issues in relation to their health care needs, whereas the GPs and PNs tended to focus more on professional and structural tensions related to the current and potentially expanded role of the PN. Understanding consumer views vis-a-vis issues raised by PNs and GPs about the role of nursing in general practice provides direction for both professions to better work with consumers to enhance their understanding of what general practice services could be and how changes, like expanding the role of nurses, may bring about improvements in the health outcomes of consumers. Health professionals can benefit from reflecting on the experiences and expectations of consumers if they desire to make general practice services more responsive to individual consumer's needs and at the same time adopt a primary health care focus.     

Consumers in mental health service leadership: A systematic review

Contemporary mental health policies call for greater involvement of mental health service consumers in all aspects and at all levels of service planning, delivery, and evaluation. The extent to which consumers are part of the decision‐making function of mental health organizations varies. This systematic review synthesizes empirical and review studies published in peer‐reviewed academic journals relating to consumers in leadership roles within mental health organizations. The Cochrane Library, Medline, and PsycINFO were searched for articles specifically analysing and discussing consumers’ mental health service leadership. Each article was critically appraised against the inclusion criteria, with 36 articles included in the final review. The findings of the review highlight current understandings of organizational resources and structures in consumer‐led organizations, determinants of leadership involvement, and how consumer leadership interacts with traditional mental health service provision. It appears that organizations might still be negotiating the balance between consumer leadership and traditional structures and systems. The majority of included studies represent research about consumer‐run organizations, with consumer leadership in mainstream mental health organizations being less represented in the literature. Advocates of consumer leadership should focus more on emphasizing how such leadership itself can be a valuable resource for organizations and how this can be better articulated. This review highlights the current gaps in understandings of consumer leadership in mental health, including a need for more research exploring the benefits of consumer leadership for other consumers of services.     

Collaboration as a process and an outcome: Consumer experiences of collaborating with nurses in care planning in an acute inpatient mental health unit

This qualitative study explores inpatient mental health consumer perceptions of how collaborative care planning with mental health nurses impacts personal recovery. Semi‐structured interviews were conducted with consumers close to discharge from one unit in Sydney, Australia. The unit had been undertaking a collaborative care planning project which encouraged nurses to use care plan documentation to promote person‐centred and goal‐focussed interactions and the development of meaningful strategies to aid consumer recovery. The interviews explored consumer understandings of the collaborative care planning process, perceptions of the utility of the care plan document and the process of collaborating with the nurses, and their perception of the impact of collaboration on their recovery. Findings are presented under four organizing themes: the process of collaborating, the purpose of collaborating, the nurse as collaborator and the role of collaboration in wider care and recovery. Consumers highlighted the importance of the process of developing their care plan with a nurse as being as helpful for recovery as the goals and strategies themselves. The findings provide insights into consumers’ experiences of care planning in an acute inpatient unit, the components of care that support recovery and highlight specific areas for mental health nursing practice improvement in collaboration.     

Patients' perceptions of seclusion: a qualitative investigation

Twelve patients receiving acute in-patient psychiatric care in Queensland, Australia, participated in semi-structured interviews to elicit their perceptions of seclusion. All respondents had experienced time in seclusion within the 7 days prior to interview. Interviews were audiotaped, transcribed and analysed using content analysis. Five major themes emerged: use of seclusion, emotional impact, sensory deprivation, maintaining control and staff-patient interaction. The prevailing negativity towards seclusion underscores the need for ongoing critical review of its use. In particular, the relationship between patient responses to seclusion and the circumstances in which seclusion takes place requires greater consideration. Interventions such as providing information to patients about seclusion, increased interaction with patients during seclusion, attention to privacy and effective debriefing following seclusion may help to reduce the emotional impact of the practice.     

Association of methamphetamine use and restrictive interventions in an acute adult inpatient mental health unit: A retrospective cohort study

The aim of the present study was to describe incidences of restrictive interventions and the association of methamphetamine use at an acute adult inpatient mental health unit in metropolitan Melbourne, Victoria, Australia. A total of 232 consecutive consumer admissions to the inpatient unit across a 3‐month period were described for illicit substance use and the use of restrictive interventions (seclusion, mechanical restraint, and physical restraint) prior to and during admission. Of all admissions, 25 (10.8%) involved consumers subjected to a restrictive intervention. Methamphetamine use was either self‐reported or detected by saliva test for 71 (30.6%) consumers. Following multivariate analyses, methamphetamine use (odds ratio (OR): 7.83, 95% confidence interval (CI): 2.33–26.31) and restrictive intervention in the emergency department prior to admission (OR: 8.85, 95% CI: 2.83–27.70) were significant independent predictors of the use of restrictive interventions after inpatient admission. Anecdotal observations provided by clinical mental health staff that consumers intoxicated with methamphetamine appear to require restrictive intervention more frequently than other consumers was confirmed with the results of the current study. As the state of Victoria in Australia is on a pathway to the elimination of the use of restrictive interventions in mental health services, clinicians need to develop management strategies that provide specialist mental health care using the least‐restrictive interventions. Although 26.8% of methamphetamine users were secluded after admission, restrictive interventions should not be the default management strategy for consumers who present with self‐report or positive screen for methamphetamine use.     

Factors associated with seclusion in a statewide forensic psychiatric service in Australia over a 2‐year period

Despite seclusion being described as one of the most ethically‐ and legally‐controversial management options available, it remains a widely‐used clinical strategy for managing disruptive, aggressive, and violent behaviour. This study sought to determine how frequently seclusion was used, the common characteristics of those secluded and not secluded, and the degree to which the Level of Service Inventory – Revised: Screening Version (LSI‐R: SV) could predict seclusion. The study was retrospective, covering the first 2 years of operation of a statewide forensic psychiatry hospital in Victoria, Australia. Data were collected from individual case files, electronic databases, and paper copies of records pertaining to violent incidents and episodes of seclusion. Eighty five (44%) of the 193 patients admitted during this period were secluded. Those secluded were significantly younger and had a more established psychiatric history. LSI‐R: SV scores were significantly and positively associated with being secluded. A statistical model containing three LSI‐R: SV items, along with age on admission and psychiatric history, achieved an area under the curve of 0.74. Seclusion is used on a regular basis in response to a range of different forms of aggressive behaviour of different severity. The LSI‐R: SV demonstrated moderate‐to‐good accuracy in predicting seclusion and warrants further research using detailed prospective methodologies.     

Comparison of instructor‐led versus peer‐led debriefing in nursing students

Despite its widespread support, the most effective simulation‐based debriefing method has little evidence to support its efficacy. In this study, we compared the effect of peer‐led and instructor‐led debriefing among nursing students. The study was conducted with a non‐equivalent control group using a pretest–post‐test design. A convenience sample of third‐year nursing students was used for the study, where 65 students enrolled in a 2‐week clinical placement rotation were randomly assigned to the instructor‐led group or peer‐led group. The quality of cardiopulmonary resuscitation skills, satisfaction with simulation, and quality of debriefing in the peer‐led group were compared to those in the instructor‐led group. Group differences at each testing interval were analyzed using independent t‐test. Nursing students in the instructor‐led debriefing group showed better subsequent cardiopulmonary resuscitation performance, more satisfaction with simulation experience, and higher debriefing scores compared to the peer‐led group. From our study, instructor‐led debriefing is an effective method in improving skills performance, inducing favorable satisfaction, and providing better quality of debriefing among nursing students.     

Patient concerns about seclusion: developing a leaflet

Seclusion continues to be used as a last resort in many acute in-patient mental health facilities, hence, mental health nurses must consider a range of strategies to improve seclusion practice. This article reviews selected literature to glean relevant information to provide to patients regarding seclusion protocols, rationales, and aims. Some postseclusion debriefing, nurse education, and organizational monitoring issues are also briefly discussed. The provision of supplementary written patient information about seclusion processes has the potential to decrease patient anxiety and fear. This initiative involves collaboration with consumer consultants to creatively develop effective solutions to some long-standing patient-identified problems associated with the experience of seclusion.     

Patient Concerns About Seclusion: Developing a Leaflet

Seclusion continues to be used as a last resort in many acute in-patient mental health facilities, hence, mental health nurses must consider a range of strategies to improve seclusion practice. This article reviews selected literature to glean relevant information to provide to patients regarding seclusion protocols, rationales, and aims. Some postseclusion debriefing, nurse education, and organizational monitoring issues are also briefly discussed. The provision of supplementary written patient information about seclusion processes has the potential to decrease patient anxiety and fear. This initiative involves collaboration with consumer consultants to creatively develop effective solutions to some long-standing patient-identified problems associated with the experience of seclusion.     

Doing what we can,but knowing our place: Being an ally to promote consumer leadership in mental health

Consumer participation in all aspects of mental health services is clearly articulated as an expectation of contemporary mental health policy. Consumer leadership has been demonstrated to be beneficial to mental health services. Barriers to implementation have limited the realization of this goal. In this discursive paper, we argue that non‐consumers who support consumer partnerships and leadership (known as ‘allies’) have an important role to play in facilitating and supporting consumers in leadership roles. Allies currently have more potential to influence resource allocation, and might be viewed more credibly by their peers than consumer leaders themselves. We call for allies to ensure their role is one of support and facilitation (doing what they can), rather than directing the content or speaking on behalf of the consumer movement (knowing their place). In the present study, we address the importance of allies for the consumer movement. It proposes some ‘rules of engagement’ to ensure that allies do not intentionally or otherwise encroach on consumer knowledge and expertise, so that they maintain the important position of supporting consumers and facilitating the valuing and use of consumer knowledge, expertise, and ultimately, leadership.     

Consumer sexual relationships in a Forensic mental health hospital: Perceptions of nurses and consumers

The management of consumer‐related risk is paramount in a secure forensic mental health facility. However, the consequent risk aversion presents a major barrier to consumers forming sexual relationships in a manner that is open and accepted. Investigation of the views of nurses working in forensic mental health settings on this topic is limited, and even more so for consumers of services. This qualitative exploratory study was undertaken to elicit the views of consumers and nurses about forming sexual relationships within this long‐term and secure setting. Individual in‐depth interviews were conducted with 12 nurses and 10 consumers. The benefits of, and barriers to, sexual relationships was identified as a major theme, and these findings are the focus of this paper. Nurse responses included the subthemes ‘supportive factors’ and ‘potential dangers’, reflecting their qualified support. Consumer responses included the subthemes ‘therapeutic’, ‘feeling normal’, ‘restrictions and barriers’, and ‘lack of support and secrecy’. The importance of sexual relationships was clearly articulated, as was the difficulties in forming and maintaining them within the forensic setting. More open discussion about this commonly‐avoided issue and the education of nurses and other health professionals is required.