Reducing seclusion at Te Toka Tumai

Seclusion is profoundly untherapeutic and negatively impacts wellbeing. Worryingly, in Aotearoa New Zealand’s mental health system, this practice (along with other types of force) is used predominantly against Māori, creating equity issues.    

"Some people’s experiences suggest seclusion is like a form of torture. Many tāngata whaiora say it exacerbates suffering at a time when people are already at their lowest point,” Millar says.  

“In the rare instances when seclusion is used, we see it solely as a risk management tool and resort to it only when all other options have been exhausted. When it does occur, there’s a real acknowledgement people need to get out of it as soon as possible — for most whaiora in our care, that doesn’t exceed two hours.” 

Becoming less reactive, and more prevention-focused   

Te Toka Tumai recognised that seclusion wasn’t reducing workplace violence overall. While some thought it may help reduce the risk of imminent violence, feedback from tāngata whaiora and consumer advisors suggested that whaiora often felt increased resentment, frustration and anger after a seclusion episode, leading to a compromised rapport between whaiora and kaimahi (staff) providing care.  

To help turn the tide, the unit’s leadership team created a workplace violence prevention action plan and drew on a kete (toolkit) of staff and tāngata whaiora-focused key actions. These simple, yet highly effective tools and techniques were designed to improve wellbeing and address consistent feedback from tāngata whaiora about boredom and monotony contributing to dissatisfaction and sometimes, incidents happening.

For example, people in the unit’s care can now take part in various activities and programmes after hours, such as cultural groups, kapa haka, guitar lessons and baking classes. What’s more, both staff and whaiora found the simple, quick wins — like offering sensory modulation kits, sprucing up the environment or providing massage chairs — made a massive difference. Medication could also be used to reduce distress, but only through a best-practice, evidence-based model — not as the default option.
   
It’s hard to overstate the importance of services working together to reduce seclusion. The Zero seclusion initiative has opened the door for shared learnings on a national level, notes Millar. That’s why, for instance, Te Toka Tumai’s Charge Nurse for the Te Whetu Tawera Inpatient Unit's ICU (or intensive care unit) visited three other ICUs to discuss key insights and findings — what works and what doesn’t — all with the common goal to reduce the use of seclusion.

Millar says that when kaimahi wellbeing is poor or staff don’t feel valued, the evidence shows the standard of care can be compromised. For this reason, interested staff at the unit can benefit from a free mindfulness-based stress reduction course during their working hours (2.5 hours off every week on a Thursday) over a course of 10 weeks. In addition, they can also join psychologist-led meditation and reflection exercises twice a week.     

If seclusion occurs, the unit ensures the person who has been secluded, their whānau and staff are supported afterwards. It’s especially important that whānau are involved as soon as and whenever possible. The unit’s Kai Atawhai team provides specialist and round-the-clock cultural support to Māori whaiora, and there are also many Pacific nurses ensuring that Pacific whaiora receive culturally-appropriate care. In addition, all whaiora can benefit from peer support from people who have been through mental health challenges themselves.  

Putting someone in seclusion can also be very distressing for employees, which is why the unit’s leadership team has put an emphasis on staff wellbeing and a no-blame policy. After a seclusion event, there’s a follow-up process with kaimahi to help them diffuse and debrief.    

“Seclusion is unacceptable, but it’s still there, and if you have elected to use it after exhausting all other options — it needs to be a collaborative decision. That’s when we focus on what we can do so it doesn’t happen next time,” Millar says.

Millar acknowledges that reducing seclusion rates can be complex. Seclusion can be a tragic consequence of understaffing or not having the right resources to hand, such as parallel services to treat and manage substance use, separate detox units, clinicians with alcohol and other drug (AOD) experience or staff with sufficient experience to skillfully de-escalate whaiora with the most complex experiences.   
However, due to the psychological trauma it entails for the person needing care, it should always be the last resort.  
“When seclusion does happen, it is limited to a select and small group of people, presenting with high-risk behaviours that leave us unsure of the way forward,” says Millar.