“It’s the last resort’’ forensic mental health nurses experience on the use of seclusion; implications for use and elimination in clinical practice

ABSTRACT

Seclusion is one of the extreme measures of managing violence and aggression. Despite the evidence base for the effectiveness and therapeutic value of seclusion being limited, there arguably remains a compelling case for its use. This qualitative study aimed to explore forensic nurse’s experiences and perspective on the use of seclusion in clinical practice and establish: •What are the factors that influence and inhibit the use of seclusion? •What skills are required when caring for patients in seclusion? A purposive sample of 12 registered and non-registered nurses from a UK high-security hospital consented to engage in a focus group. Thematic analysis was used to interrogate the data. The results included two emerging themes: ‘Keeping everyone safe’ and ‘The challenges’, including the identification of binary oppositions. A rationale for the use of seclusion; it’s a last resort. Evidence of challenges to the therapeutic relationship and communication barriers. Findings illustrate the need to critically examine the practise of seclusion, accuracy of risk assessment, also to balance safety and security proportionately and ensure therapeutic value. The use of a daily dynamic risk assessment and staff relational training is recommended to improve communication and reduce excessive and prolonged use of seclusion

Summary

What is known on the subject

• Over the last decade, significant headway has been made across the globe in relation to reducing restrictive practices such as seclusion.

• Early intervention and staff confidence in managing violence and aggression have been identified as factors that influence the occurrence of seclusion.

  What the paper adds to the existing knowledge

• Findings support the necessity to utilise objective assessment routinely.

• The binary oppositions described within the presenting results are as relevant today as they were almost two decades ago when published by Mason (2002)

• This paper provides new knowledge on forensic nurses’ perception use of seclusion and draws attention specifically to the impact of the therapeutic relationship and communication challenges during a seclusion event.

  What are the implications for practice

• The provision of a daily dynamic risk assessment within nursing practice will effectively identify patients who are imminently at risk of engaging in violence and aggression and reducing excessive and/or prolonged use of seclusion.

• Staff development and development that includes relational skills training in how to manage complex relationships to improve positive communication and reduce the need for seclusion being required.

• The findings suggest the need for future research and senior managers and health-care professional leaders to gain a better understanding of the factors that influence the clinicians’ decisions in the use seclusion, in order to achieve long-term reductions in its use.

KEYWORDS:

• Binary oppositions
• staff perception
• forensic mental health
• seclusion
• risk assessment
• therapeutic relationship

Introduction

Restrictive practices such as seclusion should only be adopted as a last resort (Wilson et al., 2017), when all other interventions such as de-escalation, rapid-tranquilisation, and restraint fail (Kinner et al., 2017).

Seclusion is one of the extreme measures of managing violence and aggression and is defined by the compulsory confinement of a patient in a sparsely furnished room, and prevented from leaving (Department of Health, 2008).

The frequency and prevalence of seclusion use among mental health inpatient settings, specialists, and countries, is globally limited due to the variations in definitions and data collecting methodology (Al-Maraira & Hayajneh, 2019; Kuivalainen et al., 2017; Lepping et al., 2016). Data presented in 2020–2021 by NHS Digital (2021), p. 2021, reports 14,164 seclusion incidents. These figures do not represent the United Kingdom, only England, and are inclusive of seclusion incidents in Mental Health, Learning Disabilities and Autism Services. It would seem the report includes incidents with similar details, therefore questioning its accuracy, as it is not known whether they were authentic incidents or duplications.

To the best of our knowledge, there is no national database in the United Kingdom that includes or separates all four nations. This may change in Scotland’s forensic services as a consequence of the Independent Review into the Delivery of Forensic Mental Health Services. It identified key gaps in data collection and reported on the need to resolve this.

In contrast, Australian’s reporting system (Australian Institute of Health and Welfare, 2022) provides annual data on the frequency and duration of seclusion occurrences within specialist clinical areas. Australia reported 7.3 seclusion incidents per 1,000 bed days within acute specialised mental health hospitals in 2020–21, decreasing from 13.9 in 2009–10, with an average seclusion length of 5.2 hours (Australian Institute of Health and Welfare, 2022).

The continued use of seclusion by mental health nurses presents a significant challenge to the profession’s preferred narrative of patient ally and therapeutic agent (Ion et al., 2020). While it may be difficult to reconcile claims about recovery focused care in the context of a professional group which holds the power to detain, restrain, administer medication without consent, and seclude patients, the reality is, in the absence of an effective and practical alternative, these approaches are as much a part of the therapeutic tool kit for some inpatient mental health nurses as is talking therapy.

Much work has been carried out to reduce some of the factors associated with primary triggers for restrictive practice. Safewards (Bowers et al., 2015) is one such initiative that shows promise, with numerous studies now showing evidence of a reduction in violence in acute and secure mental health inpatient settings (Fletcher et al., 2019; Kipping et al., 2019; Maguire et al., 2018). Despite this, and the obvious desire to throw off the image of custodialism, that seclusion and other associated restrictive practices are being adopted as punitive measures, entrenched deep within a macho culture continues to be used across mental health services (Mason, 2002).

Despite the limited evidence base for the effectiveness, safety, and therapeutic value of seclusion (Griffiths et al., 2018; Jalil et al., 2017), there is arguably a compelling case for its use in risk management (Khadivi et al., 2004; Loi & Marlowe, 2017; Mental Welfare Commission for Scotland, 2019). Its utility is more notable in hospital settings, particularly mental health services, and more prevalent within forensic clinical environments (Flammer et al., 2020; Maguire et al., 2021). There are conflicting reports examining patients experience of seclusion (Holmes et al., 2015; Larue et al., 2013), varying from beneficial, to harmful effects (Kinner et al., 2017). The arguments against seclusion are associated with the belief it is an outmoded custodial approach, thought to be out of keeping with patient centred and recovery focused care. It is also said to be harmful to the patient’s rehabilitation contributing to psychological trauma in a population where prevalence is already high (Askew et al., 2019; Hansen et al., 2022)

Consequently there is a growing international move, in countries such as Australia, Germany, Ireland, New Zealand, and United Kingdom, to reduce and eliminate its use (Kennedy et al., 2020; Kontio et al., 2012; Lau et al., 2020; Tully et al., 2021McKenna et al., 2017; Maguire et al., 2020). While this is a laudable ambition, its achievement is dependent on a range of factors including established therapeutic alternatives, patient acuity, staffing levels, skill mix, and physical environment (McKeown et al., 2019).

Mason et al. (2009) presents a binary set of related but opposing domains in Figure 1, with an interesting theory owing to the polarised tension that forensic mental health nurses endure on a daily basis. A relationship found between positive and negative issues that help describe a challenging area of nursing practice. To better understand how seclusion reduction might be achieved, the researchers examined the reasons for its use, intending to give insight on the process and address some of the issues voiced about its practice in general. They did this by exploring the experiences and perceptions of nurses who have been involved in a seclusion event in a high security forensic setting and discuss the complex interplay of the findings.

Figure 1. Binary construct (Mason, 2002).

Method

Aim

This qualitative study aimed to explore forensic nurse’s experiences and perspective on the use of seclusion in clinical practice by exploring;

• What factors influence and inhibit the use of seclusion?

• What skills are required when caring for patients in seclusion?

Setting

The setting was a high-security forensic service within the United Kingdom that provides a comprehensive assessment, treatment, and care management through a multidisciplinary team of health-care professionals of up to 140 male patients all detained under national mental health legislation patients.

Sample

A purposive sample (n = 12) was drawn from all wards across the setting and split into two focus groups, with six participants in each, based on their availability.

In an attempt to gather a variety of perceptions from those who regularly work with patients in seclusion, registered and non-registered (Health-Care Support Workers) nurses were invited to participate

For the purposes of this paper, the term nurse(s) is inclusive of registered and non-registered nurses.

Demographic details of the participants were collected and presented in Table 1

Table 1. Demographic détails of participants.

Details	Description	No of participants	Mean (SD)	Range
Age			38.4 (9.9)	21-52
Sex	Male	5
	Female	7
Professional status	Registered Nurse	7
	Non- registered nurse	5
Worked in high secure service	Number of Years		15.5 (8.9)	1-31
Worked in mental health	Number of Years		14.3 (9.24)	1-31

Procedure

Participants were recruited from one highly secure forensic mental health hospital with the following inclusion criteria: (1) directly involved in a seclusion event in the preceding six months (2) registered or non-registered nurse.

The sample was identified using the organisations electronic incident reporting system by extracting names of staff who had been directly involved in a seclusion event in the preceding six months (N = 27). Participants were recruited by an email invitation by the first author, which included the study aim, criteria for participation and focus groups dates. Focus groups were selected to allow for in-depth discussion, they lasted between 60 and 90 min and were facilitated by two members of the project team, and took place in a meeting room separate from the clinical environment. Consideration was given to the focus group questions to ensure they reflected the study aims. A discussion guide with questions and prompts was developed by both authors following consultation with key stakeholders working in the forensic mental health field presented within Table 2.

Table 2. Discussion guide.

Area of Focus	Semi structured questions
A brief overview of research project and study aims.	As well as a discussion on knowledge, perception, workplace incidents, audit, and workplace culture
Perception	How do people feel about seclusion in general?
	In your opinion, is it realistic to practise without seclusion? In what way?
Barriers	In your opinion, what are the main challenges to reducing seclusion?
Skills	What kind of skills are important when nursing a patient in seclusion?
Early intervention	What early intervention or prevention of aggression strategies are available to assist reduce seclusion?
	In your opinion, how successful are they?
Recommendations	If you had a magic wand, what would be the one thing you would change/remove or introduce to reduce seclusion in clinical practice?

Data analysis

The authors adopted Braun and Clarke (2006) six-step framework analysis, employing inductive and deductive techniques. For data management, the authors used NVivo (release 1.0) software (https://www.qsrinternational.com/nvivo/home) to organize and structure the data.

In step one, two authors independently read through each interview line, selecting terms and phrases that were relevant to the study objectives, creating the second step, data codes. The first author completed stage three using the NVivo programme software, using an iterative approach to group participant words and statements into each of the separate data codes. These were then reviewed and refined in step four by the first author and reviewed independently by the second author for coherence and fit with the data. In step five, a third member of the project team reviewed the analysis and data set providing additional comment which led to further amendments. In the final stage, all authors met to review and agree the resultant analysis (Klenke, 2016).

Rigor and trust worthiness

Focus groups were conducted by two members of the research team. This enabled one to facilitate the group while a second observed, made notes and acted to ensure all participants had an opportunity to contribute. Interviews were recorded and transcribed verbatim by an independent transcriber. The analysis provided draws on the full data set and utilised the approach describe above. Each participant received a copy of their transcribed interview for accuracy checking, including the analysis (Klenke, 2016); and invited for their feedback. This encouraged the researchers to draw conclusions about the relationship between the participants’ perspectives and the researcher’s illustration of them (Tobin & Begley, 2004).

Ethical considerations

The study was approved by the internal research committee. All potential participants were provided with written information about the study, including that their participation was voluntary. They were given seven days to consider their engagement, after which they were asked to complete a consent form if they wished to be involved. All participants consented to recording of focus group sessions and the use of anonymised extracts in any subsequent outputs.

Results

The analysis revealed eight sub categories presented in Table 3, further collapsed into three categories and finally two overarching themes; ‘Keeping Everyone Safe’, describes participant views on the purpose of seclusion and ‘The Challenges’ describes the difficulties these nurses faced when trying to achieve this.

Table 3. Results.

Sub categories	Categories	Final Themes
Patient Safety- avoiding prolonged restraint	What is it we are trying to achieve.	“Keeping everyone Safe”
Responsibility – recording and monitoring
Care and Compassion- least restrictive approach	How are we trying to do that.
Relational Skills-Maintain therapeutic Relationship
Struggle to communicate- door of MSR	These are the challenges we face when doing it	“The Challenges”
Staff confidence- getting it right
Subjective risk assessments- inconsistences
Atmosphere- everyone’s on edge

Theme 1. keeping everyone safe

The first theme describes the participant’s reflections on what they are aiming to accomplish when the decision is made to seclude a patient. The focus is on patient safety and the safety of others in the clinical setting. This took place in the challenging context in which anger, violence, and unpredictability were a feature of the day-to-day milieu.

‘Every day we are dealing with complex violent and sometimes unpredictable patients, the majority who don’t want to be here and don’t know how to communicate other than be violent. When a patient’s angry – especially if the anger is directed towards you – then they certainly don’t see you as a person, they don’t see that nurse- patient relationship. They just see the target and they just point that aggression towards you.’ (P8).

Participants agreed that seclusion was a last resort used when there was significant concern about the safety of patients or others in the clinical environment. It was drawn on when approaches such as de-escalation, pharmacological intervention or restraint failed to decrease patient arousal and when there appeared to be no change, or an escalation in the level of crisis.

That’s what’s key for me, because you don’t go into seclusion just willy-nilly you have to go in because of the extreme danger, because we’ve got to the point that you’ve ran out of options and it’s still not safe for anyone to be in prolonged contact with this individual. So it’s the last resort (P6).

Concern for the safety of everyone, including the patient, also motivated the decision to use seclusion;

To maintain their safety, everybody’s safety because it could be other patients in the ward. So, you’ve ran out of options and got to the fact that you and others on duty sometimes might be safer nursing the patient behind a door, because they are not calming down and are so aggressiveTo maintain their safety, everybody’s safety because it could be other patients in the ward. So, you’ve ran out of options and got to the fact that you and others on duty sometimes might be safer nursing the patient behind a door, because they are not calming down and are so aggressive (P11).

Staff were acutely aware of the need to balance the risks presented by the patient against the potential consequences of prolonged physical and increasing levels of chemical intervention, here seclusion was seen as a safer option, but also one which took account of the need to consider the patient’s dignity and privacy at a very distressing point;

‘It’s maybe, in the short term, the safest way to manage the violent patient because you can’t restrain him for hours and you also can’t keep giving him IM meds that puts his body under even more pressure. So, what other options are there? Rolling about the day room floor or in a side room”, (P7).

Safety continued to be the priority when a seclusion was initiated, this involved participants careful descriptions of observing, recording, and monitoring of the secluded patient to ensure that the person was cared for and that was accurately conveyed to the wider team:

‘During the whole seclusion time, the patient is being continually checked on by us. It’s about observing how they say things, their body posture, what position they are sitting or lying in’ (P11)

Staff recognised that to do this effectively, the staff member should be someone who knew the patient well. This is made clear in the extract below which also indicates that the observing nurse should also be thinking about how to help bring seclusion to an end.

“There’s no point in having somebody who doesn’t know the patient outside his door when maybe 30 yards away you’ve got the key worker sitting for instance, it’s very important to have a good insight in to obviously why the patients there and obviously the skills to get him back out’ (P2).

There was also an awareness that an episode of seclusion had the potential to resonate across the ward and beyond those directly involved:

‘It’s not just about that particular patient, it’s much wider than just the secluded patient’ (P6),

‘You’ve got other people who are on the ward dealing with other patients who might well have questions or be dealing with an aftermath of a traumatic incident, so we’ve got those people to think of as well’ (P1).

Theme 2. The challenges

The second theme captures the perspectives of the participants on the challenges presented by seclusion.

The challenges and difficulty of accurately determining the degree of risk presented was acknowledged. In this setting, decisions about risk were based on professional judgement and a degree of subjectivity:

‘People have different kinds of views on the risks presented (P1) ‘, some might think something is a risky behaviour and others might not, (P2), ‘whether you are a stranger to the ward or have been nursing that patient for a while to know what is risky or not’ (P7).

The potential for error led some to worry that they might make the wrong decision.

‘ … shame faced and worried about doing the wrong thing, should we seclude or not to seclude?’ (P9).

‘The nurse in charge’s neck is on the line, it’s a big risk’ (P5).

For some, this was reflected by a preference to avoid being the decisionmaker:

‘In my view, it would hopefully be somebody else that will make the decision instead’ (P5).

The struggle to effectively communicate with a patient once in seclusion was acknowledged by all participants. While the seclusion door acted as a protection from violence, it was also a source of tension and frustration for the secluded patient and secluding nurse.

‘If they’re not talking very loudly that can become an irritation for some people when you’re having to constantly ask to repeat stuff because you’re not sure what they’ve said’ (P1). ‘It’s difficult, it’s not an ideal situation for the patient, but it’s also not what we want either, you’re really limited to what you can do through a door’ (P4).

In the extract below, the challenge of communicating with a hostile patient is outlined by Participant 11:‘Well I think the most important factor is that it’s very difficult to maintain the therapeutic relationship but it depends on the patient if you have a very hostile and aggressive patient that’s through the other side of the door that doesn’t want to communicate with you. (P11). Although participants were clear that seclusion was an intervention of last resort and that its initiation was an attempt to maintain safety, they were also acutely aware that others might perceive their actions as punitive and questionable.

‘I think certain staff in the hospital see it as some sort of draconian of punishment but it’s not, it’s just making everybody safer especially for the person that’s behind the door’ (P9),

‘Yeah, I also think others think we’re being punitive by shutting him away, although actually it’s better because their violence is escalating and sometimes it’s the only option to get him out of the situation’ (P7).

Regardless of intent, these participants were aware that the act of seclusion would change the atmosphere of the ward. Thus, while safety may have been the rationale for the intervention, its impact on others was sometimes seen as chilling.

‘It kinda sends a wee shudder through the day room, you see it on everyone’s face, especially those who are more vulnerable getting affected by it’ (P3).

‘It lasts for the whole time they are in seclusion; you could cut the atmosphere with a knife’(P1).

Discussion

The distinction between necessity, convenience, and the point of ‘last resort’ was unclear. Questions raised how consistency was achieved in practice and how staff were able to defend the use of seclusion even for the shortest time possible. This finding is in keeping with the work of Price et al. (2018) who acknowledge practises such as seclusion are used on a regular basis and outside the concept of necessity to uphold safety of the clinical environment. The paradox between safety and therapy and the emotive feelings that arise, reinforce the presenting challenges of forensic mental health nurses. This reported difficulty that the participants describe resonates with Mason’s et al. (2009) binary construct theory, where opposing views emerge, based on related experiences.

The focus was on ‘use’ of seclusion not ‘abuse’ of power in order to keep everyone safe. This is in line with national (Nursing & Midwifery Council, 2018) and international (ICN 2012) guidance for nurses, which requires practise that prioritises the individual and promotes safety. It was also emphasised that seclusion was a last resort. While the use of last resort arguments as a justification for seclusion has been questioned by McKeown et al. (2019), participants in this study were consistent that the use of seclusion, when all other options had been exhausted.

The need to feel in control is at its greatest within high secure clinical settings Mason’s et al. (2009) and the introduction of alternative solutions to seclusion present questions of practicality in a high-acuity, high-complexity patient population (Barr et al., 2019). The participants perception was that seclusion sometimes felt safer than other restrictive practices. One alternative solution acknowledged by the participants was prolonged restraint with intra muscular medication, identifying this could continue for hours and the patient’s body could be placed under even more pressure; is this strategy really more acceptable than seclusion?

The shared experiences of the participants highlighted the need to critically examine the accuracy of risk assessment. They reported their assessment of risk were based on professional judgement, reflecting that ‘people have different kinds of views on the risks presented’ P1. Accurate assessment of risk is one of the key tasks of mental health nurses (Maguire et al., 2019), this is an area that requires attention and further consideration. The implications of inconsistent assessments can result in an unreliable, underestimation or exaggeration of presenting risks, ensuing inappropriate, excessive, or prolonged use of seclusion (Loi & Marlowe, 2017). The Broset Violence Check-list (Woods & Almvik, 2002) and the Dynamic Appraisal of Situational Aggression (Ogloff & Daffern, 2006) are brief structured risk assessments argued to be effective risk management tools, that identify patients who are imminently at risk of engaging in aggressive or violent behaviour and recommended by the National Institute for Clinical Excellence (NICE) (National Institute for Health and Clinical Excellence (NICE) 2015. These tools also improve clinical decision-making, and encourage least restrictive approaches to care (Van de Sande et al., 2011). Nurses who work in volatile and unpredictable environments, often fear for their safety and take a more restrictive approach to violent and aggressive care management (Barr et al. (2019) This is echoed by Happell et al. (2012), who reported in their sample of clinicians managing violent and aggressive incidents quickly reached their threshold of last resort. Although the findings of this study do not fully support these assertions, the participants described a dual opposition (Mason et al., 2009), what sounded like being locked in a fearful and worsening situation, however confident in their approach; ‘you’ve got to the fact that you and others on duty sometimes might be safer nursing the patient behind a door’ P11.

The participants described the challenging conditions under which seclusion was employed, and it seems appropriate to characterise it as unique and unlike any other kind nursing procedure. They questioned the phrase ‘nursing’ a patient in this circumstance, in what they ascribe a procedure that feels tainted in the eyes of their colleagues; ‘some staff in the hospital see it as a sort of draconian punishment’ P9, with themselves as custodians, carrying the threat of force and restriction. The commonly voiced denunciation and the troubled relationship with the decision of its use, make it feel like an act for which they should apologise for, subsequently they felt ‘shame faced and worried about doing the wrong thing’ P9.

The use of seclusion involves a multi-disciplinary team of professionals; however, it is nurses that are typically charged with carrying it out and carry the burden; ‘it’s a big risk’P5. All health-care professionals have their own registering body and provision of conscientious objection, however is it reasonable for mental health nurses to endure a troubling conscience, in a complexed challenging crisis, where they feel they have no other option? This perception is underpinned within the binary opposition (Mason et al., 2009) ‘use and abuse’, through this polarised perception that their skills and competencies are being analysed as either effective or worthless based on their decision to seclude or not seclude. This domain highlights the emotive tensions and feelings of resentment amongst the participants in a situation that is described as worsening, with an inevitable decline in the staff–patient relationship.

The participants described the maintenance of a therapeutic relationship as difficult in a seclusion environment, recalling that there was very little they could ”do through a door” P4, articulating what sounded like the seclusion door became an unhelpful wedge between the nurse and the secluded patient. Indeed, there is evidence contained in many publications relating to the power struggle of a secluded patient (Ezeobele et al., 2014; Sibitz et al., 2011). However, a method designed to reduce risk of harm to others seemed to create a sense of powerlessness for all, resulting in a combined feeling of success and failure; success of feeling safer but failure to effectively and therapeutically communicate. This challenging and complex relationship between the secluded patient and nurse is not often complimentary (Jalil, 2020). The study results emphasise the need for positive communication between the nurse – patient relationships as this could help to minimise the negative effects of seclusion.

Exploring patient experiences was out-with the focus of this study, however the participants acknowledged that patient care was disrupted, the therapeutic relationship was tested and the experiences of trauma leading to seclusion were evident. Recognising and responding effectively to trauma is central to the role of a mental health nurse and is congruent with a contemporary movement towards trauma-informed care (Sweeney et al., 2018). This was noted in their articulation of crisis events in realising the violent trauma of an incident ‘sends a wee shudder through the day room’ P3 and its effect on everyone in the clinical environment ‘you could cut the atmosphere with a knife’ P1.

This finding reinforces the need to maintain a therapeutic environment free of aggressive tension and threats of violence. When staff and patients are trapped in a negative spiral of transference and countertransference, this can prove dangerous for patients with a history of violence and aggression (Busch & Shore 2000) and a standard countertransference response from staff, is with fear, anger and frustration (Mason, Coyle, & Lovell 2008). It is therefore essential that this is addressed, as it can negatively influence patient–staff interactions and decision-making.

Recently, post-incident reviews incorporating staff, patients, and carers as part of seclusion and restraint reduction programmes, such as the Six Core Strategies; founded on preventative and trauma-informed concepts and are generally effective methods of reducing the frequency and duration of seclusion incidents (The Australian College of Mental Health Nurses, 2019; Maguire et al., 2012).

Limitations

The study used a qualitative design consisting of 12 participants, the findings cannot therefore be generalised to the wider forensic mental health population. The inclusion criteria attempted to reduce recall bias by limiting those eligible to participate to those involved in a seclusion experience within 6 months. It is possible those out with this time frame could have provided a varied and further perspective on the study. The results do, however, provide new knowledge to the existing literature in this field. The study did not consider potential differences based on experience of registered versus non-registered nurses or experience of seclusion. Future research should therefore consider influencing factors of nursing staff characteristics.

Conclusion

The binary oppositions described within the presenting results are as relevant today as they were two decades ago when published by Mason (2002) and continue to reinforce the complexities that forensic mental health nurses experience. They reinforce the paradox between the concept of safety and therapy and the emotive questions they arouse emphasising the challenges; principally the protection of the therapeutic alliance and the significance of critically examining practise of seclusion and preventative work to reduce its use, in particular the presence of a robust and dynamic risk assessment tool, and trauma informed care. Staff development programmes that encompass relational skills training in how to manage complex relationships could help to encourage and improve positive communication and reduce the need for seclusion. Future research and post-incident debrief must therefore include patient experiences and carers expectations, which may provide useful insights to investigate and unravel the factors that influence the use of seclusion in dynamic clinical environments.

Acknowledgments

The authors would like to thank all of the participants for their contributions, without whom this would not have been possible.

Disclosure statement

The study discloses a novel illustration of Forensic Nurses’ perception on the use of seclusion. The natural complexities described by the participants, being entwined within opposing views, based on related experiences, forced into a dual role, articulate their struggle to preserve safety and endurance to practice with care and compassion.

The findings offer the recommendation of a robust and dynamic risk assessment tool to be adopted within nursing practice. What is more, the protection of the therapeutic alliance. Given the high scrutiny use of seclusion, the findings are likely to be of interest to professionals within mental health settings.

Data availability statement

The authors confirm that the data supporting the findings of this study are available within the article and available from the corresponding author upon reasonable request.