Nurses ' knowledge about psychiatric patient seclusion in Jordan

ةصلاخلا : ثحبلا ةیفلخ : ادیقت لقلأا تلاخادتلل نوبیجتسی لا نیذللا فنعلا ىضرم ىلع ةرطیسلل ھنودب وأ ضیرملا دییقت عم لزعلا مدختسی ىذلأا نم نیرخلآاو ضیرملا ةیامحلو . نم دحلا وأ ضفخ يف حاجنلا قیقحتل يساسأ رمأ لزعلا موھفمل نیضرمملا ةفرعم مھف نإ سا نیضرمملا يف ةلصلا تاذ لمعلا طغض نم ةیاقولاو ىضرملاب ةیانعلا ةیعون نیسحتو ھمادخت . ةساردلا فدھ : ئدابم عضو ىلعو ىفشتسملا يف نیدقارلا ىضرملل لزعلا مادختسا لوح ةیسفنلا ةحصلا يضرمم ىدل ةفرعملا مییقت لزعل ا مادختسلا ةیھیجوت . ةیجھنملا : ،ةمظنم ھبش ةلباقم تیرجأ نم تانایبلا عمجل يتاذلا ریرقتلا نایبتسا اھیف ثحابلا مدختساو ٢٠ يف ةضرممو ضرمم ةیسفنلا ةحصلا . لزعلا ةیلمع لحارم عیمجل نیضرمملل ةیصخشلا ةفرعملا لوح ةددعتم تارایخ عم دونب ةتس تنمضت . ةرتف تناك نیب ةساردلا ٨ و ٣٠ سرام نم ٢٠١١ . ماقملا يف ةیوئملا بسنلا تمدختساو ةباجلإا نم ةبسن ىلعأ ىلإ ةراشلإل ةساردلا هذھ يف لولأا لاؤس لكل ةحیحصلا . جئاتنلا ادج مھم ءارجإ وھو ، فنعلا ىضرمل ةیئیبلا تازفحملا نم دحلل مدختسی لزعلا نأ تحضوأ ةساردلا ةنیع فصن نأ نیضرمملل . ا نیضرمملل احضاو ریغ ناك لزعلا موھفم نأ ىلإ اضیأ جئاتنلا تراشأو نییسفنلا ىضرملا عم نولمعی نیذل . جاتنتسلاا : ةرطیسلاو ةطلسلل ةلیسوك ةطیسبلا تابارطضلاا يف ىتح ضیرملا لزعب اونمؤی ةیسفنلا ةحصلا يضرمم ھنأ ىلإ . تایصوتلا : نیرخلآا وأ درفلا ىلع رطخ كانھ نوكی امدنع طقف دیقتلاو لزعلا ةیلمع مدختست نأ . Abstract Back ground: Seclusion is used with or without restrain to confined violent clients who do not respond to less restrictive interventions and protect the client himself and others from harm. Understanding nurses' knowledge about seclusion is essential for the success in reducing or limiting its usage and improving the quality of patient care and prevention of work related stress in nurses. The study aimed to assess psychiatric nurse's knowledge about using seclusion for hospitalized patients &to establish a guideline for using for seclusion. Method: Semi-structured interview was conducted; the researcher use selfreported questionnaire to collect the data from 20 mentally health nurses. The questionnaire included seven items with multiplechoice options about personal knowledge of nurses throughout the seclusion process. Period of the study was between 8 and 30 of March 2011. Percentages were used primarily in this study to indicate the highest proportion of the proper answer for each question. Results: shows that half of the studied sample explained that seclusion used to reduce environmental stimuli for agitated patients, and it was very important for nurses. Results also indicated that the concept of seclusion was not so clear to the nurses who working with psychiatric patients. Conclusion: nurses believe in seclusion to be very necessary even in minor disturbance as a means of power and control. Recommendations: that using seclusion process and restraint should be used only when there is a risk or danger to the individual or others.


INTRODUCTION:
Seclusion is a measure used for managing aggressive or agitated psychiatric client and to promote site security in an emergency psychiatric situation (1).Seclusion is used with or without restrain to confined violent clients who do not respond to less restrictive interventions and protect the client himself and others from harm (2).Using of seclusion in mental health services is controversial, and recent Government policy in Australia has identified the reduction and, if possible, elimination of seclusion as a national safety priority because it affect the quality of care of psychiatric patient (3).However, seclusion is continuing to be a widespread measure used in psychiatric settings.Furthermore, the humanitarian, ethical and legal issues associated with the use of seclusion make it one of the most controversial management strategies available (4).Nurses as direct primary caregivers, are commonly involved in the initiation and management of seclusions (5), Nurses consider seclusion as emergency intervention (6) and should not be used against client in inappropriate & harmless behavior.Pasqual 1985 explained the importance of seclusion as a treatment by reducing environmental stimuli which allow patient to be calm down (7).Other researcher identified other interrelated principle for seclusion which are containment and isolation (8).Using seclusion was contributed to serious mismatch between the needs of the client and the way of using this treatment and in turn it affected client relationship with treatment team and contributed to a negative view of the treatment process which may cause major emotional trauma for the patient and the staff (9).Nurses' Attitude toward Seclusion survey was conducted in Australia with 123 nurses from eight mental health services (3).The results of survey revealed that participants recognized the negative impact of seclusion on consumers; however, they continue to support its usage, particularly in cases of threatened or actual violence against staff and other consumers.Nurses believed that seclusion was necessary, not punitive and a highly therapeutic practice that assisted patients to calm down and feel better.
Patients, on other hand, believed that seclusion was used frequently for minor disturbances and as a mean of staff exerting their power and control (9).Patients believed that seclusion was a punishment approach, and had little therapeutic value (10).Despite these important issues, little nursing research has sought to gain an understanding of the nurses' process regarding the use of seclusion in psychiatric settings.Its looks like the more professional nurses were involved in seclusion the more they believe in it (11).The implementation and evaluation of alternative approaches to the care of patients is necessary to reduce seclusion and introduce changes to practice.Understanding nurses' attitudes to seclusion is essential for the success in reducing or limiting its usage and improving the quality of patient care and prevention of work related stress in nurses.Knowing when to use this treatment and how considered as a major responsibility of the psychiatric nurses to protect patients and to get the therapeutic goal of that treatment

AIM OF THE STUDY:
The study aims to identify psychiatric nurse's knowledge about using seclusion for hospitalized patients.

METHODOLOGY:-
Twenty mentally health registered nurses working in psychiatric hospital in Amman were recruited for this study Semi-structured interview was conducted, the researcher use self reported questionnaire to collect the data from the participants.The questionnaires included six items with multiple choice options about personal knowledge of nurses about seclusion process.Questionnaires items were extracted from related literature and the area of question were. 1) Benefits of seclusion 2) Necessary of seclusion to nurses 3) Causes of seclusion 4) Seclusion as a treatment or punishment 5) Uses of restraint 6) Time for terminating seclusion

STATISTICAL ANALYSIS:
Descriptive statistics as percentages were used primarily in this study to indicate the highest proportion of the proper answer for each question.This table shows that half of the studied sample (50%) reported that the reason for using seclusion was to reduce environmental stimuli, while only 10% of the studied sample indicated that they had fear from other patients to become agitation.
Very important for me 16 80 2.
Not so important 4 20 Total 20 100 The majority of the nurses (80%) founded that seclusion was very important for nurses while the other (20%) they said it's not important( table 2).
Refuse to eat or drink 0 0 4.
Refuse to sleep 0 0 Total 20 100 Table (3) shows that 65% of nurses believed that violence and destruction are the major causes for secluded patient.The results also shows that 80% of participants reported that seclusion was used as a treatment, while for other (20%) for them it was a form of punishment (Table 4).About the fifth question numbers of nurses showed (40%) that they terminate seclusion when patients become controlled, while the remaining nurses (60%) were relied on patient responses to the nurses' orders or to doctors' orders.

Table ( 4) seclusion as a treatment or punishment
Asking about feelings of nurses during seclusion, results shows that majority of nurses (90%) reported that they feel very sad and they found huge difficulties when they put patients into seclusion rooms.

DISCUSSION:
Findings about the importance of seclusion as a management were similar to other studies (6&7).Nurses found seclusion as important and necessary action for agitated patients, although it should be the last choice especially after using psychotropic treatment and mental status exam by nurses.This study showed that nurses had knowledge deficit and little training about how to deal with agitated patients before reaching violence level, which indicated the importance of training and education for nurses to limit the use of seclusion.Nurses who considered seclusion as a treatment for violence and destruction they admitted many difficulties which encounter that treatment especially its effect on patient's relation with their staff, in spit of that they founded necessary for controlling patients behavior, While the other nurses used it as a punishment which makes a sense of why it causes emotion distressing for both patients and nurses as the other researcher found (9).Using seclusion as punishment makes it out of its goals and some times deterioration to the patient's mental health (12).The results indicated that nurses depended for terminating seclusion either on doctors orders which means that they didn't had the authority or when patient ready to response to the health professional's ordered which indicated that they punished their patient and this contributed to major emotional trauma for the patient.Findings indicated that seclusion may provide effective means for preventing injury and reduce agitating behavior it can also have a serious deteriorating effect on patient.Need for modifying the institutional culture surrounding seclusion and transforming nursing practices to reduce or prevent seclusion treatment should be done in our hospitals.

CONCLUSION:
Findings of the study do combine to conclude that nurses had knowledge deficit and little training about how to deal with agitated patients.The concept of seclusion was not so clear to the nurses who working with psychiatric patient especially the therapeutic affect of that treatment.Results of the present study also concluded that nurses believed in seclusion to be very necessary even in minor disturbance as a means of power and control.

RECOMMENDATION:
The researcher recommended the following: 1-Using the seclusion process and restraint only when there is a risk or danger to the individual or others and no other safe and effective intervention is possible.2-Seclusion and restraint should never be used: (1) as a threat; (2) as punishment; (3) for control; (4) as a substitute for active treatment; (5) because of low staffing levels; or (6) as a convenience for staff.3-Mental health programs should establish safe therapeutic environments that reduce and eliminate the need for seclusion and restraint.4-Training for staff in prevention and early intervention techniques should be ongoing.5-Only staff that has been adequately trained should use seclusion and restraint.Staff should be trained in the use of physical holds, restraint equipment, in the need to check and document vital signs, and in other essential practices surrounding seclusion and restraint.6-Communicating with patient during seclusion is very important to decide if the patient out of his problem to terminate seclusion.7-Most of the investigator emphasizes gradual release and involve the other mental health team in the care of the patient focusing on initiating a trusting relationship between staff and patient which is defined as understanding pat's feelings and attitudes.8-The decision to terminate the seclusion treatment should be done by the nurse and the other health professional because initiating the treatment done by observing agitated patient and decided to but him in seclusion.