use of seclusion is not evidence-based practice, The

Journal of Child and Adolescent Psychiatric Nursing, Oct-Dec 2001 by Finke, Linda M

TOPIC. Published articles on the use of seclusion in psychiatric care.

PURPOSE. To present the argument that the use of seclusion in the psychiatric care of children is not evidence-based practice.

SOURCE. Review of the scientific study literature of the last 30 years on the use of seclusion.

CONCULSION. The scientific evidence available illustrates that the use of selcusion with children is not therapeutic and is, in fact, harmful to patients.

Search terms: Isolation, Seclusion, solitary cofinement

In ancient Greece, those who behaved in what was deemed an inappropriate manner were exiled from society. It is said that this form of sanction was viewed as such a horrible punishment that Socrates chose to drink poison rather than suffer such banishment, a form of isolation or seclusion. The same conclusion can be drawn from the use of solitary confinement in the penal system. Throughout history, the worst punishment deemed possible in prisons is seclusion/solitary confinement. In psychiatric care, patients who behave inappropriately are placed in seclusion. Perhaps the only thing different in psychiatric care is that we call seclusion therapeutic.

The use of seclusion remains common practice in psychiatric care (Lendemeijer & Shortridge-Baggett, 1997). The purpose of this article is not to repeat the numerous reviews of the literature on seclusion that have been conducted (Brown & Tooke, 1992; Fisher, 1994; Lendemeijer & Shortridge-Baggett; Sailas & Fenton, 2000) but to present the case that the use of seclusion in the psychiatric care of children is not evidence-based practice. This article will further document that the research has found seclusion to be harmful to patients and not related to positive patient outcomes.

Discussions of restraints and seclusion frequently pair the two interventions as though they are closely linked. Moreover, the literature often speaks of both as if they are the same intervention. The use of restraints in psychiatric settings has received wide discussion, and there has been some reluctant change in practice. The use of seclusion as an intervention has received less attention but needs the same scrutiny. This is especially true when the use of seclusion is implemented with children, a particularly vulnerable population. This article summarizes the available literature on the use of evidence-based seclusion practices.

Definitions

Seclusion. The definition of seclusion can vary, but usually the term refers to some form of isolation. The isolation may occur in a locked, bare room or it may take place within the confines of a patient's room. It may entail a requirement to sit in a chair or involve serving a time-out period (Miller, 1986). Seclusion also means some form of involuntary or voluntary confinement (Lendemeijer & Shortridge-Baggett, 1997). Timeout rooms are considered seclusion by most authors (Landau & MacLeish, 1988). Landau and MacLeish also state that the legal definition of seclusion in most states equates with isolation. For the purposes of this paper, a broad definition of isolation is used that includes all forms of isolation, including being sent to one's room or time-out.

Evidence-based practice. According to Brown (1999), evidenced-based practice involves the critical review of research findings to evaluate their usefulness in patient care. Ingersoll (2000) further contends that evidenced-based nursing practice is theory-driven, research-informed decision making. It follows that the use of seclusion in psychiatric care would need to be theory based and supported by research findings to be deemed evidence-based practice.

Seclusion and Research Findings

Numerous articles in the literature theorize and present philosophies about the need for seclusion with psychiatric patients. The majority are not supported in any way with research. Further, most of the research that has been conducted on the use of seclusion has been chart reviews that record the demographics of patients or count the documented use of seclusion. Few research studies are available that incorporate a methodology that includes some kind of rigor able to support generalized conclusions. Such methodological rigor could include control groups or even measured patient outcomes. Sailas and Fenton (2000) conducted a review of 2,155 citations from 1974 to 1999 and found not one controlled study of seclusion. The published research also does not have a theoretical foundation. No attempt has been made to connect theory with research methodology when studying seclusion.

Child-Related Research

To add to the concern about methodology, the majority of the research examining the use of seclusion in the psychiatric setting has been done with adult patients. Little research has examined the use of seclusion with children; therefore, clinicians are left in part to draw conclusions from studies of adult patients.

Miller (1986) is one of the few researchers who have examined the use of seclusion specifically with children. His definition of seclusion ranged from use of a locked isolation room, to sitting on a chair, to being sent to one's room. The 40 children included in the study, ranging in age from 5 to 13, were asked to draw and comment about seclusion or time-out. The pictures they drew that portrayed people did not seem to convey the concept of children gaining self-control while in seclusion, but rather conveyed punishment, where the child was crying and pleading for help. The children's descriptions of seclusion also included feeling very afraid and abandoned.