The Health Quality & Safety Commission recently announced that our mental health and addiction quality improvement team will work alongside Te Pou , the national KPI programme and DHB mental health and addiction services to achieve the aspirational goal of Zero seclusion: towards eliminating seclusion by 2020.
Seclusion has many negative consequences. It causes physical and psychological harm to those who experience it and, anecdotally, to the staff who participate in or observe it. It also has an impact on other consumers who observe it. Seclusion contravenes basic human rights and does not align with modern, evidence-based, high-quality care. In mental health and addiction services, its elimination is inevitable.
For us, eliminating seclusion by 2020 is an aspirational goal, rather than a target. Some people have asked us why we are taking this approach.
Factors and drivers
Seclusion is predominantly a response to a complex range of issues relating to both the individual and the service.
To eliminate seclusion, we have to find appropriate and therapeutic ways to better address a number of factors like:
- extreme distress
- aggression, threats of violence or actual violence to property or staff, or unpredictable violent behaviour
- anxiety or fear of being harmed.
There are also several drivers influencing or contributing to seclusion. These include:
- the influence of alcohol, others drugs or substances on individuals (intoxication and drug-induced behaviours)
- the way people are greeted and assessed as they enter services
- referral and admission protocols from other services
- the number of people admitted within a time period (intensity of individuals admitted) and the number of individuals in the unit (occupancy)
- environmental resources in the unit/hospital and community
- number, capability and skill mix of staff.
These factors and drivers are not in the direct control of any one individual, organisation, or even system. To set a target and hold someone to account for something they cannot fully control can lead to unhelpful responses, such as compliance in name only, too specific a focus and data doubts or manipulation.
Aspirational still means achievable
An aspirational goal focuses the mind on breakthrough thinking. It encourages us to look at new ways of doing things that build on gains already made. At the same time, it maintains the urgency of the eventual elimination of a practice we know causes harm.
We believe the aspirational goal of zero seclusion by 2020 is achievable, but we absolutely acknowledge it is a ‘stretch goal’.
Practical steps to eliminating seclusion
To eliminate seclusion, we will monitor key factors and contributing drivers, set clear expectations and specific measures, and undertake data collection/analysis. We will need to make adjustments as we go, so each provider can follow a pathway towards eliminating seclusion that is effective and sustainable for them.
After all, when you say to someone ‘We want to get to zero’, people have a right to say ‘Actually, I’m not sure I can do that’. While that is a really important conversation to have, we need to turn the conversation from ‘Why we can’t’ towards ‘Why we should’. Most importantly, we need to ask, ‘What do we need to do to achieve this goal, and who can help us?’
We will be supporting teams to focus on the drivers and processes behind this goal, to develop higher-quality, evidence-based alternatives to seclusion that work for consumers and providers. We’ll use tools like the Six Core Strategies © to do this, as well as quality improvement methodology and co-design principles. Over time, we expect to see further drops in seclusion rates and the eventual elimination of the practice.
In the words of Mersey Care NHS Trust chief executive Joe Rafferty, an aspirational goal ‘… helps you move from where you are, to somewhere outrageously different!’
Co-authors: Dr Janice Wilson, chief executive, Richard Hamblin, director of health quality intelligence, and Shaun McNeil, national consumer engagement advisor mental health and addiction – all Health Quality & Safety Commission.