Elsevier

International Journal of Law and Psychiatry

Volume 32, Issue 6, November–December 2009, Pages 408-412
International Journal of Law and Psychiatry

Seclusion: The perspective of nurses

https://doi.org/10.1016/j.ijlp.2009.09.011Get rights and content

Abstract

Knowledge of how nurses experience the process of secluding a patient can be useful in improving the quality of patient care and in the prevention of work related stress in nurses. This study describes personal experiences of nurses throughout the seclusion process. The emotions which came to surface in semi-structured interviews with 8 nurses were categorized in three main themes (Tension, Trust and Power) and a stress response curve was identified in the seclusion process, with specific feelings in each phase. Feelings denied in former studies such as feeling superior, anger and disgust were found in the interviews in this study.

Introduction

Seclusion as an intervention, subsequent to an aggressive incident or disruptive patient behaviour, is subject to much study and debate. Recent studies question its therapeutic necessity and effect. Beside this, legal and ethical issues dominate the discussion on reducing the use of seclusion and interventions and primarily aim at change of attitude and therapeutic culture.

Far less is known about the perception of the participants in the seclusion process. Even though best practice protocols favour a systematic evaluation of the seclusion with the team, as well as with the patients and their family members, few studies focus on experiences and emotions of those involved.

A Dutch study into the experience of patients (Hoekstra, Janssen and Lendemeijer, 2004) showed seclusion to be a stressful, often traumatising event. Clinical practice suggests that nurses also experience stress and negative emotions to some extent. Describing the perception and experience of nurses while secluding a patient is the main objective of this current study. The willingness and need to discuss emotions with colleagues and others is studied, to understand with whom and how nurses share their feelings subsequent to a seclusion incident.

Section snippets

The Use of Seclusion

By professionals seclusion is often seen as an effective intervention to restrain aggressive behaviour, as well as to protect ward security and atmosphere (Nijman et al., 1999, Lendemeijer, 2000). Seclusion is applied frequently in the Netherlands: one study showed seclusion is used in 25% of the situations, within a sample of 1000 admitted patients (Stolker, Nijman, & Zwanikken, 2004), a figure confirmed in a more recent nationwide study (Janssen et al., 2008). However, international studies

Objectives and main questions of this Study

This study focuses on nurses' feelings prior to, during and subsequent to a seclusion incident. The following questions will be addressed:

  • 1

    Which feelings do nurses recall concerning seclusion incidents?

  • 2

    How do these feelings interrelate, and what determinants can be identified?

  • 3

    To which extent do nurses feel a need for and to which extent do they allow sharing these feelings?

Method

Because of the explorative nature of the study a qualitative design using the Grounded Theory was chosen. (Glaser and Strauss, 1967, Morse and Field, 1998). This method focuses on the development of theory out of daily practice, by means of theoretical sampling and saturation. Theoretical sampling is the acquisition of data from literature, text sources and interviews, in the process of developing a conceptual framework. Theoretical saturation refers to the point where no new items arise from

Overall outcome

Eight subjects were interviewed, 4 male and 4 female. Their age varied between 24 and 56 years, job experience within mental health care between 3 and 27 years. Team members all had higher vocational training, either as a nurse or as a social worker. The interviews were performed in four subsequent months in 2005, with a time frame of two to three weeks between interviews, allowing analysis in between. Responders were asked not to discuss the content with fellow workers. Interview time varied

Discussion

In the current study a qualitative technique was used to explore nurses' feelings experienced during the seclusion process. As opposed to pre-structured surveys, this technique facilitates the investigation of perceptions and emotions. Following an open interview technique based on the grounded theory, this study revealed a number of general themes, also known from literature. Because many of the themes are supported by literature, it is plausible these perceptions will be recognised by many

Conclusion

Little is known about the experience and perceptions of nurses in the seclusion process. Feelings denied in former studies such as feeling superior, anger and disgust do arise from the interviews in this study. Tension, trust and power were identified as main themes. The tension increase corresponds with physiological stress response curves. The role of nurses during the seclusion process, but also being the person most concerned with the daily care of the patient, determine experienced

References (29)

  • W.A. Janssen et al.

    The use of seclusion in the Netherlands compared to countries in and Outside Europe

    International Journal of Law and Psychiatry

    (2008)
  • W.A. Janssen et al.

    The influence of staffing levels on the use of seclusion

    International Journal of Law and Psychiatry

    (2007)
  • Abma T., Widdershoven G., Lendemeijer B. (2005). Coercion and urge in psychiatry, the quality of limiting measures....
  • M. Belnaves et al.

    Introduction to quantitative research methods: An investigative approach

    (2001)
  • E.J. Betemps et al.

    Length of time spent in seclusion and restraint by clients in 82 VA Hospitals

    Hospital and Community Psychiatry

    (1992)
  • E.J. Betemps et al.

    Hospital characteristics, diagnoses and staff reasons associated with use of seclusion and restraint

    Hospital and Community Psychiatry

    (1993)
  • E. Broers et al.

    Strijd in de werkrelatie. Een interactionele visie op agressie tussen patiënt en verpleegkundige

    Maandblad Geestelijke Volksgezondheid

    (1997)
  • J. Corbin

    Basics of Qualitative Research: Techniques and Procedures for Developing Grounded Theory

    (2008)
  • J.P.C. Cangas de

    Nursing staff and unit characteristics: do they affect the use of seclusion?

    Perspectives in Psychiatric Care

    (1993)
  • J. Dekker

    Stones as bread

  • Special Admissions in Psychiatric Hospitals act

    (1994)
  • A. Gaillard

    Stress, productivity and health

    (2003)
  • A. Gerlock et al.

    Factors associated with the seclusion of psychiatric patients

    Perspectives in Psychiatric care

    (1983)
  • B.A. Glaser et al.

    The discovery of grounded theory: Stategies for qualitative research

    (1967)
  • Cited by (23)

    • Ethical consideration on use of seclusion in mental health services

      2020, International Journal of Nursing Sciences
    • Coercion and power in psychiatry: A qualitative study with ex-patients

      2019, Social Science and Medicine
      Citation Excerpt :

      Some participants hypothesized that mental health workers were afraid of them and therefore treated them as an object. Anxiety is common when professionals are confronted with aggression and coercion (Brophy et al., 2016; VanDerNagel et al., 2009; Wilson et al., 2017). Further research is needed to investigate the link between de-subjectivation and anxiety.

    View all citing articles on Scopus
    View full text