Improvements to seclusion practices empower patients at Forensic Psychiatric Hospital

​The use of seclusion rooms in adult psychiatric settings has been an ongoing topic of discussion, debate and review. Since 2019, a quality improvement initiative at the Forensic Psychiatric Hospital (FPH) has focused on reducing the number seclusion days per year and improve patient safety overall.

The results to date are positive—a 27 per cent decrease in patient days in seclusion and a 90 per cent decrease in Code White reports of violent behaviour in seclusion rooms.

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“Seclusion is not something we as care providers like to use as an intervention,” said Neeta Nagra, director of interprofessional practice, Forensic Psychiatric Services. “This project supports a more patient-centred approach. Given the severity and complexity of the illnesses among our patients, seclusion facilities will always need to be available and utilized but as this project has shown, there is room for other therapeutic and trauma-informed interventions to support de-escalation."

What is seclusion?

Seclusion is an intervention that involves containing a patient in a safe, secure room, without a free exit. It is intended for use only in instances where a patient is at immediate risk of harming themselves or another person, and should be used for the shortest duration possible.

A 2019 study by Swiss researchers published in Frontiers in Psychiatry supports this, noting seclusion should only be used as a last resort, that patients should be given an opportunity to take part in decision making whenever possible, and their preferences should be taken into account by care providers.

Unlike solitary confinement or isolation in prison settings, seclusion is not a punitive measure or to be used for extended periods. Unlike isolation, seclusion also gives patients access to care providers, the ability to communicate what they feel they need to support their stabilization, and the opportunity come out of seclusion as early as is safe.

Quality improvement for seclusion

Previously, seclusion was used more frequently and clients were secluded for longer than necessary, according to Nagra. She explains that as new evidence becomes available, greater focus is being placed on patient-centred and trauma-informed care.

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“There are two things happening simultaneously with this quality improvement project,” said Nagra. “We’re committed to being more trauma-informed. Our interdisciplinary teams are working with patients to develop personalized comfort plans that help them and their care teams with stabilization, and nurses are more committed to implementing those interventions. In the past, treatment was based on what the care provider thinks is best, whereas now the patient identifies via their comfort plans what works for them."

"It empowers patients and makes things easier for the nurse. Really, it’s win-win.” - Neeta Nagra

Moving away from the use of seclusion as a lower-level intervention involves not only a change in practice, but also in culture. Health care providers in psychiatric settings rely on seclusion to keep at-risk patients safe. Shifting this mindset to one where alternative interventions are prioritized has been an important part of the project.

“The biggest thing we worked on is supporting staff in using other interventions available so they still feel empowered to do their work. We wanted to make sure staff understand that moving away from seclusion as a lower-level intervention is not a barrier to providing care, but rather an opportunity to better support patients through other approaches," said Peter Parnell, interim provincial executive director of Forensic Psychiatric Services. "Change is difficult but for most part, staff understand the evidence and principles behind us utilizing alternatives. The team has been great at working with patients to identify and implement comfort plans so situations do not escalate needlessly. It’s actually strengthening the therapeutic relationship between patients and care teams.”

The future of seclusion improvement – gathering patient experience

The next phase of the quality improvement project involves getting feedback from patients on their experience with seclusion at FPH.

“We are currently determining the factors we want to measure so we can assess how this patient-centre approach is working for patients,” said Neeta. “We are working in collaboration with patient and family groups at the hospital to get patient input. Based on this input, we will create a survey for patients at FPH who have experienced seclusion, and incorporate their feedback into our care.”