Policies and procedures governing seclusion are “very stringent” and staff already do their best to avoid the practice, says delegate, Luke Muller.
Luke Muller works in Cumberland Hospital’s acute mental health ward and on the admission desk where he triages presentations. He has 15 years’ experience in mental health nursing.
“There are strict criteria – you can’t just throw a patient into seclusion for a minor reason, such as yelling at someone or threatening to harm someone,” he says.
“Seclusion is almost always reserved for patients whose behaviour poses a real threat to the safety of other patients and staff.
“Sometimes the only way you can safely manage certain patients is to isolate them from other people while they are at the height of their psychotic episode or whatever it is they are experiencing.
“However, putting someone who is suicidal into a seclusion room might put them at even greater risk of self-harm.
“In such cases it is far better to increase the level of observation, sit with them and engage with them and use other strategies to manage their behaviour.”
Luke says the number of patients put in a seclusion room after admission is relatively low.
“Most seclusions are for people taken directly from the street into a seclusion room.
“Often they have been detained by police who are unable to use the strategies and techniques we have to calm people down and prevent them from harming others.
“They come to us at crisis point. The medication they are using – if any – is not helping and seclusion is the safest place to be.
“They are not yet in a state that allows us to have a cup of tea and a chat with them and get them talking about their problems.”
Banning seclusion would create problems
Luke says a ban on the use of seclusion would result in worse outcomes for both patients and nurses.
“Any open and broad review into how we can do things better is welcome so long as it’s not designed to reach a predetermined result such as closing seclusion down.”
He says patients are not secluded in order to make life easier for staff.
Strict monitoring requirements for secluded patients only add to nurse workloads, he points out.
“The requirements for documentation mean that a lot of your clinical time is spent making notes and ticking charts, which means less time available to engage with patients.
“We are always stretched for staff. If we had more staff on the wards we could spend more time building rapport with patients.
“One positive result would be that patients would be less likely to escalate to the point where they had to be put into seclusion.”
Insufficient staffing also cuts the time available to mentor new graduate nurses.
“A lot of our staff are retiring after working at the hospital for decades. They have a lot of knowledge and have built a lot of rapport with our patients, many of whom are in and out due to the revolving door syndrome.
“We are getting an influx of new staff, which is great to see but they get a short orientation package before being thrown in at the deep end.”
Observation demands can be ‘unachievable’
The NSWNMA wants the mental health review to consider how better staffing and use of new technology could improve restraint and observation of patients.
Failure to accurately observe patients correctly has had fatal consequences, says the NSWNMA submission to the review into mental health services.
“The association strongly advocates that all staff comply with state and local policy at all times to ensure best possible client outcomes,” it says.
“The Association acknowledges there have been situations where failure to accurately observe patients correctly has resulted in poor and on different occasions, fatal consequences.”
It says nurses have warned that due to the number of patients requiring observation and the physical layout and design of some units, the required frequency of observations (every 10 or 15 minutes) is “unrealistic and in some cases unachievable”.
On the issue of restraint, the submission says a sufficient number of restraint-trained nurses are required to be able to implement a restraint procedure safely.
“Mental health units have minimum staffing overnight and need to rely on trained staff to come from other areas before a minimum complement for restraint is available.
“This can impact on the feeling of vulnerability that staff feel when managing a high-risk client.”
The submission says staff try not to wake clients due to the detrimental effects of poor sleep on clients’ mental state.
They also are reluctant to disturb clients at night when nursing numbers are lowest, “due to the fear of aggression and violence that could result”.
The Association suggests the review look at the use of technology to help monitor clients overnight.
This could include instruments to measure breathing and movement and electronic wristbands that monitor pulse.