Clinical Audit on Seclusion Use in Mental Health - Research Proposal Example

Clinical Audit on’ seclusion’ use in Mental Health Title: Study to evaluate the use of Clinical Audit on seclusion use in Mental Health. Research Hypothesis: to be negated or validated: Seclusion is inclined to do more harm than good to patients. Rationale: The rationale of this study is to determine whether due standards of care and regulatory norms are maintained during the process of restraint and seclusion and whether proper audit trails, regular reporting, are evident in fulfillment of policy guidelines and established procedures. It is also necessary that the audit plan, considering that written policy and procedure for seclusion, which is enunciated in the clinical guideline issued by the Chief Psychiatrist are being rigorously implemented and followed in the cases of individual patients. (Seclusion: Chief Psychiatrist’s Guideline, 2005, P.15). The technique of seclusion has been a matter of controversy in recent times since many believe that it does more harm than good, and seclusion of children could be a particularly harrowing experience, for such young people, considering the concomitant trauma and adverse feelings associated with it. Even in the case of adults, many consider it more as a punishment rather than a curative exercise, which it should not be. (Locke et al, P.5). Given such a scenario, the rationale needs to consider positive and negative aspects of seclusion and impact it could have on the patients’ psyche and social interactions. It is necessary that robust yet careful plans, procedures and documentation need to be done taking the attending doctors, nurses and chief physiatrists into confidence. This is because the assessment of seclusion needs to be constantly and intensively monitored for ensuring the health and welfare of the patients during the period of seclusion. Objectives: The purpose also envisage providing insight into decision-making used for the medical interventional strategy of seclusion and its aftermath, with respect to the mental state of patients and their reactions to such processes induced by psychiatrists and health care professionals for several reasons, which may not always be in terms of the best interests of the patients. It is also necessary that seclusion need to be carried out as enunciated by the conditions laid down in the Mental Health Act. (Industry occupational health and safety interim standards for preventing and managing occupational violence and aggression in Victoria’s mental health Services, 2004, P.29). Methodology: In the first phase of testing of hypothesis, the methodology of the study would be face-to-face interviews with a cohort of Fifty (50) respondents in a hospital setting in Western Australia, consisting of the following: 1. Fifteen (15) children in the age group of 9-12 years. 2. Thirteen (13) Adolescents in the age group of 13- 19 years. 3. Forty one (41) adults in the age group of 25-51 years. The method would be through personal interviews with Questionnaires, which the respondents would have to answer to the best of their abilities. Since the interviews are of confidential nature, the prior permission of the parents/guardians in the case of children and adolescents, (below 19) and attending relatives of adult patients in hospital needs to be done. The ethical consideration also has to be maintained in that the information gleaned from interviews/ questionnaires would be kept confidential except for medical and therapeutic use. Further, ethical considerations also demand that the disclosures made during the course of personal interviews, or from questionnaires would not prejudice the interests, or future of the patients in any way. In the second stage of the study, 50 attending psychiatrists would also be interviewed on their viewpoint on the matter under research study, with particular emphasis on the responses provided by the interviewees. In particular, the adherence to clinical audit standards laid down by law and hospital policies has to be maintained, and this should reflect in the interviews the persons who are responsible for issuing seclusion initiating and terminating orders. The matter of seclusion is a serious one, and it needs to taken up only as the last resort and must be used only for the minimum time required, for the safety of others who are in contact with the secluded patient. The questionnaire is so designed as to elicit the opinion of the respondents on the various issues connected with seclusion and how it is executed, and terminated as per the orders of the attending doctors or nurse. It is necessary that if a health care officer other than the attending doctor has issued the order for seclusion, it is imperative that this fact be immediately informed to the attending psychiatrist, or nurse for proper follow up action in the matter. The methodology for this study would rely on the following: 1. Personal interviews and questionnaire made to respondents. Semi structured, thematically organized interviews, which would be taped and transcribed with the permission of respondents. (Inpatients had mostly negative experiences of seclusion during short-term treatment in a mental health facility, 2001). 2. Interviews with health care professionals who are directly or indirectly connected with the treatment of patients and these processes. 3. Web searches for gaining information about this procedure. 4. Medical documents regarding restraint and seclusion available from Australia‘s Department of Health (DoH) and relevant Social Welfare units. 5. Legal aspects impinging upon restraint and seclusion in terms of Mental Health Association: Code of Practice, the Mental Health Act and the DoH guidance and directives on this issue. Findings: The findings of the survey can be divided into two categories: one from the dealings with the respondents and next, from information gathered from the concerned mental health care professionals, (HCP) including nurses and medical officers responsible for segregations. Respondents: Most of the respondents felt that segregation was not a welcome process since it interfered with the dignity and freedom of the patients. Although it was in vogue, it was mainly done in order to lighten the work of nurses and ward boys, especially in the case of hospitals being overcrowded and the staff being unable to attend to patients. It is seen as working more towards the benefit of staff than of the patients. Most of them were of the considered opinion that it was a form of punishment, made them very uneasy, and discomfortable. They questioned the validity of this process and opined that it was designed to cause discomfort and stress levels for patients since the duration and nature of solitary confinement was not known. Normally, it meant that patient was kept in a closed room locked from outside, either with, or without restraint. (Chains). It was in the form of keeping patients in some form of temporary arrest, or imprisonment and its “sole aim is to contain severely disturbed behavior which is likely to cause harm to other.” (Seclusion Policy, 2005). Nearly 90% of the respondents felt that segregation should be used only on emergency when all Other means of control was inoperable. Also, it should only be for short duration and at the behest of recommendations from the Chief Psychiatrists. Nearly 80% of the respondents felt that they would not like to experience another solitary confinement. Nearly 86% felt that it should be used only in the case of violent or aggressive patients, who could not be controlled and whose behavior symptoms could be dangerous to others, and who needed to be locked up in order to prevent harm to others. However, it is only during the period of unrest that the process should be used and should be discontinued as soon as the patient returns to normal state. Nearly 89% felt that segregation did not serve any useful medical or curing purposes, and did not help improve the treatment settings nor contribute to a better health for patients. Most of the patients felt that it did not come within the purview of treatment or medical intervention but was just a physical technique to calm the situation and the perceived offender who had become over emotional and needed to be calmed down. The findings of the survey in the case of children have been more intense and poignant. For 86% of the children interviewed, the experiences had been harrowing and stressful. Moreover, experience solitary confinement had been very traumatic and most of them wanted to forget the experience and not be segregated again. Again coming to the adolescents, being older, they were able to express their inner turmoil over segregation more vividly and lucidly. They felt it needed to be done only for gross misbehavior and aggressive conduct, which could cause physical injuries to others, or could seriously vitiate and undermine the peace situation in the hospital settings. Being young and active, they felt that the process of segregation creates more ill will and aggressive behavior; in other words, it exacerbates turmoil and anxiety in hospital settings caused by patients’ unreasonable behaviors. A secluded person could more vent to his inner insecurities and anxieties, which could manifest in socially unacceptable methods like violence, self-harm and destruction of property and injuries to people. The degree of self-harm could be in terms of attempted suicide, injuring oneself by hitting one’s head against the walls or floors, and other manifestations of psychic and physical misbehavior. Nearly 88% of the respondents felt that seclusion was more for the benefit of attending staff rather than controlling patient conduct. In a crowded hospital setting just like the present one, with lower staff : patient ratio, seclusion is being viewed by many patients as a tool to circumvent individualized attention to patients, and allow attending staff to attend to critical patients and responsibilities. 79% of the interviewed respondents believed that seclusion deprives patients of social contacts and interfacing, which is important for the treatment and recovery of mental patients. About 70% felt that there was no major differences between seclusion as a medical tool and as a social process, since whenever behavior patterns entails risks of causing injury to others, attending doctors /nurses need to resort to seclusion to temporarily control the situation. Even in case of domiciled treatment, this process may need to be invoked, in case of aggressive patients. The main difference may be the use of required sedative injections that could also calm the patients during seclusion and make his conduct socially acceptable. Nearly 90% of the respondents felt that seclusion could used only for emergency purposes when Other avenues of intervention cannot be utilized. It also needs to be for the minimum period to avoid long term psychic injuries to secluded patients be closely monitored and controlled to avoid escalation of the problem and risk of self harm by secluded patients. According to 89% of the respondents, including young people who were part of this study, the alternative arrangements that could be used could be in terms of Negotiating with the patient. Eliminating power blocks that could be source of problem. Efforts by the attending team to de-escalate the situation through physical methods. Medication and psychological therapies. Inducing relaxation techniques to the patient. Any other medical or psychiatric intervention that could de-escalate the situation. Deliberations with attending mental care nurses and doctors: It is now necessary to get the feedbacks from the attending Chief Psychiatrists, attending doctors and other health care professionals regarding seclusion and its needs. Of the doctors interviewed, nearly 91% felt, that though unpleasant, seclusion is the only available alternative for violent behavior that could result in death, or risk of injuries to people in the hospital milieu. By locking up the patient in solitary confinement with regular monitoring and medical examination, the risk of injuries to others could be alleviated, if not eliminated. Therefore, “The examination shall include a physical and mental status examination, risk assessment and the need for continuing seclusion.” (Victoria’s Mental Health Services, 2007). Another benefit of seclusion could be seen in terms of better patient management for his own safety and risk of self-harm. When combined with restraints (chaining) and if necessary, medication, the risks of future intense psychotic attacks could be avoided. Nearly 98 % of the doctors confirmed that seclusion was being carried out in terms of MHA and Australian DoH Guidelines and the Hospital’s own Rules and Regulations. Proper and up-to –date audit trails are being maintained and are subject to scrutiny from officials of the Government Health Department officials. Individualized records pertaining to reason for seclusion, time frame of process, initiating, attending and releasing health care professionals, and the Medical information, including Discharge Reports of patients are available. All doctors confirmed that relevant particulars in Seclusion Register (MHA 31) are being maintained according to law and subjected to government inspections. Nearly 75 % of the attending psychiatrists believed that seclusion was a necessary intervention to arrest risk of injuries to others. Although they felt that it need to be restricted only, up to desired levels and time frames, the risk of secluded patients undergoing a relapse, could not be ruled out. Seclusion, in their opinions, was not a punishment but a deterrent, or insurance against future misconduct. It needs to be long enough to reform the patient, and yet short enough to be effective and safe for the patient and his relatives, etc. According to 84% of attending psychiatrists and nurses, the fact that seclusion is a safe and efficient process is evident from the fact that marked improvements in behavior patterns of secluded patients, including conduct, interaction, personality traits and mannerisms have considerably improved in nearly a majority of the patients who had undergone seclusion. Interpretations: The above study has confirmed the continuing controversy that surrounds use of seclusion method. On the one hand, the medical profession finds it an effective tool for controlling undesirable behavior patterns among mental patients in this hospital setting, on the other, it is seen that the patients themselves are vehemently against it, primarily due to physical, psychological and physiological damages this could cause the patients, especially children. The writer is of the considered belief that, although a lot would depend upon the surroundings milieu and the degree of harm or damages, a particular hostile patient is capable of causing, it would be desirable to use other interventionist programs like use of sedatives, restraint, counseling or mediation to deal with seclusion. Conclusions: This stems from the fact that it is believed that isolation and solitary confinement could leave a permanent impact upon the psyche and intellectual capabilities of such patients, which could not only delay his recovery process, but could also be the breeding grounds for future mental derangements. Thus, it needs to be fully justifiable, and needs to be convincing to the attending doctors and nurses, including the Chief Psychiatrists. The facts consider the high degree of aggressive misconduct being meted by the patients, and the fact that no other intervention could be suitably efficient or effective to mitigate these events. Under such circumstances, the only available option would be to have the patient restrained and/or secluded. This is being done in the best interests, not only of the other patients, and attending staff, but also benefiting the patient himself/herself. In the event this intercession is not resorted to, the harm and damages may be incalculable and would be the risk and responsibilities of the attending health care professionals. Matching of the current literature with the study: The final diagnosis with regard to the study matches with that of established facts. This reinforces the fact that “The research on the use of seclusion with children or adults provides evidence that the experience actually may cause additional trauma and harm. There is no research to support a theoretical foundation for the use of seclusion with children. Evidence has been building for more than 30 years that the practice of seclusion does not add to therapeutic goals and is in fact a method to control the environment instead of a therapeutic intervention.” (Finke, 2001). Validation or negation of hypothesis: Based on the above paper, the hypothesis that seclusion could cause more harm than good has been validated. JOANNA BRIGGS INSTITUTE CLINICAL AUDIT TEMPLATE HEALTH SERVICE AUDIT TOPIC: REF NO: Audit Objectives: Rationale: Audit Team: AUDIT DEFINITIONS CLINICAL GUIDELINE: AUDIT INDICATOR 1: 1: 2: 2: 3: 3: References: SIGNATURE: DATE: AUDIT INDICATORS 1. Structure Process Outcome S1- P1- O1- S2- P2- O2- S3- P3- O3- S4- P4- O4- 2. Structure Process Outcome S1- P1- O1- S2- P2- O2- S3- P3- O3- S4- P4- O3- 3. Structure Process Outcome S1- P1- O1- S2- P2- O2- S3- P3- O3- S4- P4- O4- SIGNATURE: DATE: AUDIT CRITERIA AUDIT ACTIVITY FINDINGS AND COMMENTS COMPLIANCE Achieved Expected 100% 100% AUDIT CRITERIA AUDIT ACTIVITY FINDINGS AND COMMENTS COMPLIANCE Achieved Expected 100% 100% HEALTH SERVICE AUDIT TOPIC: REF NO: SUMMARY OF AUDIT FINDINGS AND ACTION PLAN: 1: Identified Problems: Action: Responsibility and Expected Date: 2: Identified Problems: Action: Responsibility and Expected Date: 3. Identified Problem: Action: Responsibility and Expected Date: SUMMARY OF AUDIT FINDINGS AND ACTION PLAN CONTINUED .. 4: Identified Problem: Action: Responsibility and Expected Date: 5: Identified Problem: Action: Responsibility and Expected Date: CONCLUSIONS AND OUTCOMES OF AUDIT ACTIVITY: SIGNATURE DATE Questionnaire: nurses and health care professionals 1. Whether strict adherence and application of the documented policy and procedures regarding the mode of seclusion is being carried out? 2. Whether proper records and accurate entries of each occurrence of seclusion is available which fulfills the degree of care, consideration and compassion which is needed for the treatment of mental health patients? 3. Whether the clinical records that deals with seclusion briefs about procedural requirements? 4. Whether individualized records are maintained to cover the preliminary medical assessment, forecasts options, risk evaluation and such other important matters required for this? 5. The reason(s) why the patient needs to be secluded? 6. Whether it is combined with restraint “ 7. Perceived duration of seclusion? 8. Whether this seclusion is a mode of punishment or retribution? 9. Whether details of the physical estimation and medical reports of the patient justify seclusion? 10. How has the patient responded to seclusion process? 11. The need for any changes in the procedures to be rationalized? 12. Whether Seclusion Register (MHA 31) has been provided within 20 days of the occurrence and it provides the following: (a) Why the seclusion was made. (b) Person who initiated the seclusion. (c) Person who kept the seclusion. (d) Time frame of seclusion and reasons for any variation or postponement in medical examination of the patient for purpose of seclusion decision. Questionnaire: Respondents 1. Do you feel that seclusion should be used only as a last resort? 2. Do you feel that seclusion should only be for short period emergencies only? 2. How do your rate your own seclusion? 3. Why was it necessary to have you secluded? 4. How long did your seclusion last? 5. Do you feel better or worse after seclusion? 6. If need be, would you agree to undergo seclusion in the future? 7. Do you feel seclusion is undertaken because of shortage of working staff? 8. Do you feel seclusion does more harm than good? 9. Do you feel that there is no difference between seclusion as a medical tool and as a social Process? 10. What are your personal feelings about seclusions? 11. Do you personally feel that seclusions needs to be dispensed with at the earliest, nor not? 12. If you do not favor seclusions, what other medical processes or interventions would you prefer? Why? Reference Seclusion: Chief Psychiatrist’s Guideline: Seclusion - Clinical Audit, (2005). P.15. Retrieved Jun 15, 2008, from http://www.health.vic.gov.au/mentalhealth/archive/cpg/cpg_seclusion_final.pdf Locke, Linda., Williams, Angelina., & Barker, Paul. Policy for the use of locked doors, intensive nursing areas and seclusion: 7.Seclusion, P.5. Retrieved Jun 15, 2008, from http://www.cambsmh.nhs.uk/documents/Clinical/Policy_on_Seclusion_and_Locked_Doors.pdf?preventCache=23%2F06%2F2006+11%3A47 Industry occupational health and safety interim standards for preventing and managing occupational violence and aggression in Victoria’s mental health Services: Interventions in clinical practice for managing violence: Seclusion: (2004). State Government of Victoria. P.29. Retrieved Jun 15, 2008, from http://www.health.vic.gov.au/mentalhealth/ohs/ohs-standards.pdf T, Meehan., C, Vermeer, & C, Windsor. Inpatients had mostly negative experiences of seclusion during short-term treatment in a mental health facility, (2001). Evidence Based Nursing. Retrieved Jun 15, 2008, from http://ebn.bmj.com/cgi/content/extract/4/2/62 Seclusion Policy, (2005). Northamptonshire Healthcare. Retrieved Jun 15, 2008, from http://www.northamptonshire.nhs.uk/NHT/related/Policies/Clinical_Policies_Committee_(CLP)/CLP027.pdf Victoria’s Mental Health Services: Seclusion October 2006, (2007). Victorian Government Health Information. Retrieved Jun 15, 2008, from http://www.health.vic.gov.au/mentalhealth/cpg/seclusion.htm Finke, Linda M. (2001). Use of Seclusion is not Evidence-based Practice, The Journal of child and adolescent psychiatrist nursing, BNET. Retrieved Jun 15, 2008, from http://findarticles.com/p/articles/mi_qa3892/is_200110/ai_n8993463/pg_4 Read More