What influences the use of seclusion? A cross-sectional study of forensic mental health nurses in a UK high secure hospital
| Date | 16 July 2024 |
| Pages | 201-218 |
| DOI | https://doi.org/10.1108/JFP-05-2024-0022 |
| Published date | 16 July 2024 |
| Subject Matter | Health & social care,Criminology & forensic psychology,Forensic practice,Sociology,Sociology of crime & law,Law enforcement/correctional,Public policy & environmental management,Policing,Criminal justice |
| Author | Lindsay Tulloch,Helen Walker,Robin Ion |
What influences the use of seclusion? A
cross-sectional study of forensic mental
health nurses in a UK high secure hospital
Lindsay Tulloch, Helen Walker and Robin Ion
Abstract
Purpose –Incidents of violence and aggressionare a regular occurrence within adult forensic mental
health inpatientsettings and often lead to the use of restrictive practices suchas seclusion. Such events
are frequently attributed to the complexity of the patients. Research commonly focuses on patient’s
characteristics and their association with seclusion use. Less attention has been centred on forensic
mentalhealth nurses’ attitudes to seclusionand the association of nursing staffcharacteristics.
Design/methodology/approach –A cross-sectional survey was undertaken using a standardised
questionnaire,‘‘Survey of Nurses’ Attitudes to Seclusion’’.Responses were received from n¼147 nurses
at a high secureforensic mental health hospitalin the UK.
Findings –Key findings indicatethat most participants believed seclusionshould remain part of clinical
practice. A correlation was identified between forensic mental health nurses’ attitudes to seclusion use
and their characteristics:gender, age range, educationallevel and experience.
Practical implications –This paper presents novel information on seclusion reduction opportunities
through modifiable workforce factors such as gender-sensitive rostering and staff training and
development. Furthermore, recruitment and retention strategies should beprioritised so forensic mental
healthis perceived as an attractive career anda safe workplace.
Originality/value –The paucityof research in this area has prompted calls for further researchto explore
nursingstaff characteristics and seclusion use.This is particularly important now due to the currentglobal
difficultyin the recruitment and retention of mental healthnurses.
Keywords Attitudes, Seclusion, Views, High secure, Mental healthnurses, Staff characteristics
Paper type Research paper
Introduction
Seclusion is best defined as the separation of a patient from their peer group within a
defined room or area from which they are not permitted to leave to manage behavioural
disturbances (Council of Europe, 2017). Its use is only justified as a last resort when de-
escalation and all other preventative strategies have beenexhausted and there continues to
be concern of harm to others if no action is taken [McKeown et al.,2019;World Health
Organization (WHO), 2020].
Adult forensic mental health inpatient settings (AFMHIS) are volatile environments that are
populated with acutely mentally unwell and high-risk offenders with a history of significant
violent offences (Barr et al.,2019). Forensic mental health nurses (FMHN) who work in these
settings must perform a dual role of preserving the safety of patients and others and
maintaining a therapeutic nurse–patient relationship (Hui, 2017).
It is reported that almost all mental health nurses have been assaulted while on duty at
some point, and this occurs at a much higher rate within forensic mental health (Renwick
Lindsay Tulloch is Lead
Nurse, The State Hospital,
Carstairs, UK. Helen Walker
is Head of School at the
Forensic Network,
Lanarkshire, UK. Robin Ion
is an Independent Scholar,
Nursing, UK.
Received 13 May 2024
Revised 15 June 2024
Accepted 16 June 2024
DOI 10.1108/JFP-05-2024-0022 VOL. 26 NO. 4 2024, pp. 201-218, ©Emerald Publishing Limited, ISSN 2050-8794 jTHE JOURNAL OF FORENSIC PRACTICE jPAGE 201
et al.,2019). It is, therefore, unsurprising that fear in the workplace is an issue that is
encountered on a daily basis (Jalil et al.,2017). Fear of assault can impact the clinician’s
ability to establish and maintain therapeutic nurse–patientrelationships, as well as influence
nurses’ attitudes and clinical decision-making regarding the use of restrictive practices
such as seclusion (Muir-Cochraneet al.,2018).
Seclusion is primarily adopted in mental health inpatient settings, although its use is more
prevalent in AFMHIS, where there is increased evidence of patient restlessness, aggression
and violence (Maguire et al., 2019).It has become a controversial ethical challenge due to a
lack of supporting evidence of its effectiveness, safety, utility in clinical risk management
and therapeutic value (Jalil et al.,2017). It was condemned by the Ashworth Inquiry
[Department of Health (DoH) 2008] in the 1990s and declaredinhumane and tantamount to
torture in 2013 by the United Nations “Reportof the Special Rapporteur on torture and other
cruel, inhuman or degrading treatment or punishment” (Mendez, 2013). For this reason,
international efforts have focused on reducing the use of seclusion through the introduction
of legislative guidance and models of care such as Six Core Strategies and open-door
psychiatry (Bowers et al.,2015;W. Haugom et al.,2019;Lau et al., 2020;Maguire et al.,
2021). Nonetheless, reports of seclusion practices being adopted across the globe
perpetuate a culture of control and coercion(Ion et al.,2020).
Background
While seclusion data is regarded as an essential metric for evaluating care delivery (Barr
et al., 2022a,2022b), attempts to understand the scale of its use are hampered by
inconsistencies in standardised data collection, data interpretation and data reporting
across and within countries (Barr, 2023). As a result, there has been an increased call for
standardised definitions of seclusion and data collection to report on the frequency and
prevalence of use among mental health and AFMHIS internationally (Al-Maraira and
Hayajneh, 2019). To the best of our knowledge, the four nations of the UK do not have a
standardised national reporting database that captures the prevalence of seclusion use
within AFMHISs. This contrasts with Australia, which can report and examine the rate of
seclusion use in forensic mental health inpatient settings and published a troubling
threefold increase in the incidenceof seclusion use from 2008 to 2020 (Barr et al.,2023).
Research suggests that mental health nurses impact the incidence rate and persistent use
of seclusion (Barr et al.,2019;Happell and Koehn, 2010). This,however, is not unexpected,
considering nurses spend the most time with patients and play a significant role in
determining whether or not to secludea patient in the face of violence and aggression (Barr
et al., 2022a,2022b). Given the caring nature of the nursing profession, it seems
unreasonable to suggest that nurses cause aggression. Nevertheless, there are reports of
nurses’ attitudes and practices contributing to inpatient aggression and use of seclusion
(Bregar et al.,2018;W. Haugom et al.,2019), particularly when patients perceive their
attitudes and behaviour as beingcustodial or abusive (Tomlin et al.,2020).
Nursing staff characteristics, including gender, age, level of ed ucation and level of
experience, have been the focus of studies within acute and AFMHIS, although the findings
are inconsistent (Doedens et al.,2021). Research conducted in the acute m ental health setting
suggests that male nurses are more likely to adopt coercive measures (Hap pell and Koehn,
2010) and that seclusion use decreases with the presence of female nurses (Morrison and
Lehane, 1995;Doedens et al.,2021). A further study by Barr et al. (2022a,2022b) established
no significant correlation between nurses’ gender and seclusion use. H owever, they did
establish that registered nurses on duty contributedto higher rates of seclusion use.
A recent systematic literature review demonstrated the paucity of research on nurses’
characteristics and their influence on seclusion in the AFMHIS setting (Barr et al., 2022a,
2022b). This review identified only three studies examining nurses’ characteristics and
PAGE 202 jTHE JOURNAL OF FORENSIC PRACTICE jVOL. 26 NO. 4 2024
Get this document and AI-powered insights with a free trial of vLex and Vincent AI
Get Started for FreeStart Your Free Trial of vLex and Vincent AI, Your Precision-Engineered Legal Assistant
-
Access comprehensive legal content with no limitations across vLex's unparalleled global legal database
-
Build stronger arguments with verified citations and CERT citator that tracks case history and precedential strength
-
Transform your legal research from hours to minutes with Vincent AI's intelligent search and analysis capabilities
-
Elevate your practice by focusing your expertise where it matters most while Vincent handles the heavy lifting
Start Your Free Trial of vLex and Vincent AI, Your Precision-Engineered Legal Assistant
-
Access comprehensive legal content with no limitations across vLex's unparalleled global legal database
-
Build stronger arguments with verified citations and CERT citator that tracks case history and precedential strength
-
Transform your legal research from hours to minutes with Vincent AI's intelligent search and analysis capabilities
-
Elevate your practice by focusing your expertise where it matters most while Vincent handles the heavy lifting
Start Your Free Trial of vLex and Vincent AI, Your Precision-Engineered Legal Assistant
-
Access comprehensive legal content with no limitations across vLex's unparalleled global legal database
-
Build stronger arguments with verified citations and CERT citator that tracks case history and precedential strength
-
Transform your legal research from hours to minutes with Vincent AI's intelligent search and analysis capabilities
-
Elevate your practice by focusing your expertise where it matters most while Vincent handles the heavy lifting
Start Your Free Trial of vLex and Vincent AI, Your Precision-Engineered Legal Assistant
-
Access comprehensive legal content with no limitations across vLex's unparalleled global legal database
-
Build stronger arguments with verified citations and CERT citator that tracks case history and precedential strength
-
Transform your legal research from hours to minutes with Vincent AI's intelligent search and analysis capabilities
-
Elevate your practice by focusing your expertise where it matters most while Vincent handles the heavy lifting
Start Your Free Trial of vLex and Vincent AI, Your Precision-Engineered Legal Assistant
-
Access comprehensive legal content with no limitations across vLex's unparalleled global legal database
-
Build stronger arguments with verified citations and CERT citator that tracks case history and precedential strength
-
Transform your legal research from hours to minutes with Vincent AI's intelligent search and analysis capabilities
-
Elevate your practice by focusing your expertise where it matters most while Vincent handles the heavy lifting
