Skill List > Seclusion for Assaultive and Violent Behaviour (Mental Health)
Clinical Alert
Carefully review your organisation’s policies and procedures regarding the use of seclusion. Policies may vary based on local guidelines and interpretation of national regulations and standards of practice.

Elsevier Clinical Skills covers the principles of this procedure. You must follow local policies and procedures regarding technique, equipment used and documentation.
Authors:
Based on Mosby Nursing Skills
Adapted by: Neil Murphy BSc(Hons) MSc RMN; Naomi Sharples BSc MBA PGCE ProfDoc RMNH RMN
Updated by: Catherine Johnson RGN RMN
Last updated: September 2017

Learning Objective
After reading the skill overview, following up some of the references/web sites and completing the self-test quiz you should be ready to be assessed in practice in the skill of seclusion for assaultive and violent behaviour in mental health patients.

Introduction

The term seclusion is defined as the supervised confinement and isolation of a patient in a room, away from other patients, in an area from which the patient is prevented from leaving, where it is of immediate necessity for the purpose of confinment of severe behavioural disturbance which is likely to cause harm to others (Chapter 26.130 Department of Health 2015). Seclusion should be used only as a last resort after other interventions have been tried (such as de-escalation). It must not be used as a part of any care plan, a punishment, or a stand-in for a shortfall in staff numbers. If the person who needs seclusion is an informal patient, then this should indicate the need to reassess the status of the person and look at formal procedures. The act of secluding someone should be made clear in all documentation, highlighting the rationale for why it was needed and what else had been tried. 

Each Trust will have a clear seclusion policy that will highlight the timing of checks, the duration of any period of seclusion, and the essential paperwork that must be completed for any such decisions. There are some important adjuncts that may affect this, e.g., the person who is in seclusion may have been medicated or even have some minor injuries. As a consequence, consideration of observation and treatment options may need to factor in such variables.

Once someone is placed in seclusion their care plan should be amended and a clear explanation given of how their present needs are to be met. This will also need to be discussed in a multidisciplinary team meeting to establish how this action fits with the patient’s presentation. Documentation will be contemporaneous and needs to indicate the time for reviews in order to fit with local Trust guidelines and the Code of Practice (Department of Health 2015). Generally these indicate that an appropriately trained person reviews every 2 h with another person who was not involved in the seclusion, e.g. two Registered Mental Health nurses, and a doctor reviews every 4 h until a multidisciplinary team review is held. Following this there should be a medical review at least twice in every 24-hour period. 

The seclusion can be terminated by the person in charge of the ward, and they will then notify involved personnel of their decision and why it has been made. Involvement of senior clinicians where possible is indicated in the Code of Practice (Department of Health 2015).

Multidisciplinary education (training) regarding safely working with patients at risk for violent behaviour should include:

  • De-escalation techniques.
  • Personal safety techniques (including breakaway).
  • Understanding and role in the use of rapid tranquillisation.
  • Understanding and management of violence and aggression.

Cultural considerations

As it clearly states, seclusion will affect a person’s liberty and ability to engage in their normal cultural and spiritual activities. The need for safety outweighs all other rights although the use should be for as short a period as possible so the person can resume their normal activities and cultural practices as soon as possible.

Young people and seclusion

Seclusion can be a very traumatic event for anyone; however, it can have particularly adverse implications on the emotional development of a young person, especially for those with a history of trauma or abuse. Careful assessment must be carried out on an individual basis by an appropriately trained professional. Staff should ensure they refer to individual Trust policy relating to the care of young people. (Chapter 26.52 Department of Health 2015, NICE 2015).

Older people and seclusion

The procedure for older people is inherently similar to adult actions, but there are considerations to be made including: taking account of the individual’s age, physical and emotional maturity, health status, cognitive functioning and any disability or sensory impairment, which may confer additional risks to the individual’s health, safety and wellbeing in the face of exposure to physical restraint (Chapter 26.71 Department of Health 2015).

Patient and family education

  • Explain to the patient and their family why seclusion would be used.
  • Explain their rights and the option for alternative action.
  • Give clear, unambiguous advice on the need for seclusion and the process involved.

Preparation and safety

  • The decision to seclude someone is something that involves professional judgement and knowledge of the patient and the potential effect of their actions on themselves and others. It can be considered only if alternative actions have been tried first.
  • Ensure sufficient staff that are trained (in the Trust or to Trust policy) in the management of violence and aggression are available to deal with the needs of the seclusion process while still caring for and managing the other patients on the unit, with a member of staff coordinating the actions.
  • The availability of a seclusion room and a plan of action to carry out the procedure are imperative. A poorly organised plan could result in unnecessary actions and an escalation in the already stressful situation, hence increasing the risks to all. Staff involved in the various parts of the process and those not involved directly with the seclusion need to know what their role is.
  • The room used for seclusion needs to be lockable and be designed for such use. It must be heated, ventilated, and lit. It should contain furniture such as a bed, and should afford some level of privacy from other patients while allowing observation by staff. Although offering quietness, it should not be soundproofed and must have some way for the patient to draw attention to their requests.
  • Many universities and Trusts do not allow student nurses to be involved in seclusion, but you should check the policy agreed in your institution.

Procedure

  1. The decision to use seclusion is generally made by a responsible clinician or the nurse in charge of the ward. If the decision has been made by the nurse in charge, then the patient’s doctor should be informed immediately.
    The doctor should attend a review of the patient within an hour of the seclusion. All actions need to be carefully recorded in the patient’s records.
  2. As with any patient that has received such attention, monitoring is on the whole directed under the Trust observation policy. Initial monitoring will be line of sight until reviewed by the doctor and then based on the acuity of risk. The minimum is every 15 minutes when in seclusion (Deprtment of Health 2015).
  3. Once seclusion is initiated, a personal care plan should be developed and records made that account for decisions to treat and act throughout the period. Further reviews will need to be recorded and also added to the patient’s records. Some Trusts utilise separate seclusion logs and files. Adherence to Trust protocol is essential.
  4. The actual procedure for moving a patient into the seclusion room varies from Trust to Trust. Only staff who have been trained by appropriately qualified personnel to carry out the procedure can be involved in seclusion. Staff who have not been trained are not insured to carry out seclusion duties (refer to local Trust agreed training policy). N.B. The patient may be restrained (according to Trust directives) and taken to the seclusion room. Once a person is placed in seclusion, the focus of care reverts to the Code of Practice (Department of Health 2015) and the agreed national directives.
  5. The patient must be involved where possible in the procedure and have their safety protected. The patient must be offered the opportunity to cease the behaviour causing concern and told that the staff will seclude them if it continues. Use clear, unambiguous language.
    Rationale –  This gives the patient every opportunity to cooperate with the request being made, to remove the need for the use of seclusion.
  6. Once in the room, establish the safety of staff and if necessary continue to restrain the patient. A risk assessment of all items the patient has taken into seclusion needs to be made.
    Rationale – Establish staff safety. Any items that may be dangerous to the patient or others will need to be removed. This will involve things such as spectacles and may in some circumstances involve some types of clothing. Alternative clothes that are safer should be offered e.g. tear proof clothing that can minimise ligature risks.
  7. Anything removed must be documented and kept safe.
    Rationale – Maintaining trust that things will be safe will help to allay anxiety that the patient may lose something they hold dear to them. It will also protect staff from accusations at a later date.
  8. If medication is used, it may be given at this time, but as with any action the patient must be notified and actions recorded.
    Rationale – Respects the patient’s right to be involved in their care. Accurate record of actions.
  9. Involve the patient where possible in the process with advice from the staff. If the patient remains aggressive and violent while the seclusion is being completed, staff should exit the seclusion room in the manner set out in the Trust's physical intervention policy (e.g. prevention and management of violence and aggression). 
    Rationale – Respects the patient’s right to be involved in their care. Staff and patient safety is maintained by following Trust format.
  10. If a patient is placed in seclusion and needs to be restrained while staff exit, where possible avoid the prone position. Patients must not be restrained in a way that deliberately impacts on their airway, breathing or circulation. 
    Rationale – The mouth and/or nose should never be covered and there should be no pressure to the neck region, rib cage and/or abdomen. Unless there are cogent reasons for doing so, there must be no planned or intentional restraint of a person in a prone position (whereby they are forcibly laid on their front) on any surface (Chapter 26.70 Department of Health 2015).
  11. If the patient remains violent, then the door should be locked initially and the patient advised.
    Rationale – To maintain staff and patient safety.
  12. Records of the seclusion should be continued and the doctor contacted, if not already there (see above).
    Rationale – Ensures a continuous and accurate record of actions. Demonstrates compliance in ensuring a doctor attends and reviews the patient within 1 h of seclusion.
  13. The patient should be reviewed according to the Code of Practice (Department of Health 2015) in the time frame outlined (see above).
  14. Food and drink should be provided regularly.
    Rationale – To give the staff an opportunity to observe the patient for changes in presentation, and to keep the patient hydrated and nourished should seclusion go on for a prolonged period.
  15. Toilet facilities must be offered and provided to protect where possible the dignity and cultural and spiritual needs of the patient.
    Rationale – A patient in seclusion still has human rights, and these should not be forsaken. Access to toilets and privacy, where possible, should be afforded.
  16. Contact by next-of-kin and visits from the family should be discussed.
    Rationale – The next-of-kin should be informed at the earliest opportunity (unless it has been agreed with them that they would not wish to be informed), and visits from family may need to be curtailed by the staff as the behaviour of the patient may place others in jeopardy. The opportunity for family to visit can often reduce violent behaviour and needs to be considered. The needs of the patient and the family have to be considered, and the opportunity to have and continue with a family life must be respected.
  17. Following the initial medical review within 1 hour of starting the seclusion, there must be a medical review a minimum of every 4 hours until a multidisciplinary team review is held (Chapter 26.131) then at least twice in every 24-hour period. At least one of these should be carried out by the patient’s Responsible Clinician (local arrangements for out-of-hours cover may provide for an alternative approved clinician to cover these responsible clinician reviews (Chapter 26.132 Department of Health 2015). Rationale – To comply with the Code of Practice (Department of Health 2015), which clearly outlines the conditions pertaining to seclusion. Ensures completion of the agreed Trust paperwork and that patient records are updated.
  18. If the patient has been given some rapid-acting tranquillisation medication, they may need to be nursed in the recovery position depending on its effect. Continuous observation is needed. Where possible, most Trusts prefer the observer to be of the same gender as the patient.
    Rationale – The patient may become unconscious and the recovery position is clearly the safest. The same gender reduces the chance of accusation of sexual inappropriateness and protects dignity.
  19. Staff entering the room must ensure that sufficient numbers of staff are available to keep the patient in seclusion and the staff entering the room must keep the door unlocked.
    Rationale – To administer care or ensure that the patient remains in seclusion. To prevent being  placed in danger by being locked in with the patient.
  20. Staff will need some form of alarm to summon further help should an incident occur in the seclusion room.
    Rationale – Staff will need sufficient support should the need to intervene in the seclusion room arise. They should enter only once it is safe and there are enough personnel to manage the incident.
  21. Terminating seclusion can be decided by the ward manager on the ward. Once the patient is safely able to leave the seclusion area, this should be done without delay.
    Rationale – This will avoid an unnecessary delay in ending the seclusion and potentially creating a further incident. It will also aid the patient in understanding that the seclusion was for the protection of self and others and not a punitive measure.
  22. All actions and reasons for actions are recorded in the appropriated records (see below).
    Rationale – A full record of events is documented and available to scrutiny.

Ongoing care, monitoring and support

  • In addition to the above process, once a person has been placed in seclusion the process is generally similar in all Trusts. Most abide by the guidelines from the Mental Health Act Code of Practice (Department of Health 2015) and implement clear observational policies. These wil be based on individual risk assessments dependent upon the presentation of the secluded individual and their history.
  • Where possible patients should be cared for in their normal clothes, and meals and drinks offered at the times that they would normally be offered. Toilet facilities are best integrated into the seclusion area. For prolonged seclusions, care of personal hygiene will become problematic because the patient needs to be able to care for their hygiene and this will include the opportunity to shower or bathe. In certain cultures, this needs careful consideration as to timing and frequency.
  • When patients are secluded, the staff should assess whether sensory problems (hearing or visual problems) exist. If so, these problems are addressed including whether related items are made available when risk level permits.
  • Reviews are organised frequently and all conversations and discussions recorded. In prolonged seclusions a clear justification should be recorded repeatedly and necessary steps for the patient’s welfare explored. If the patient is not detained on a section of the Mental Health Act 2007 (Department of Health 2007), then this must be considered. Although the courts in the UK accept that seclusion is a necessary part of mental health treatment, there will become a point where human rights are brought into question with extensive use of seclusion.
  • Having a member of staff close to the seclusion room will maintain the opportunity for dialogue with the patient as they wish. A clear record is required throughout as this will then influence the decision making of team discussions and seclusion reviews.

Documentation and reporting

There are a range of documents that must be considered when using seclusion. Supplementary documentation (dependent on Trust) that underpins the process includes:
  • Observation policy.
  • Rapid tranquillisation policy.
  • Policy for management of violence and aggression.
  • Reference to National Institute for Health and Clinical Excellence (2015), NG10.
  • Policy for incident management and searching patients.
  • Documentation for the duration of the seclusion.
  • Document to initiate seclusion and record that the room has been checked to make certain it is lit, ventilated, heated, furnished with a bed, has a clear observation view, and that locks work.
  • Staff observation, charts, and documentation:
    • staff observation chart must be written legibly and note the patient’s food, drinks, medication, and clinical presentation
    • staff visiting the room must write in the patient’s records why they visited and the outcome of their visit
    • if seclusion is to be terminated, then a risk assessment is completed.
  • All review forms must be completed within the time frame of the appropriate guidelines of the Code of Practice (Department of Health 2015).
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