A Qualitative Synthesis Exploring the Potential Role for Mental Health Occupational Therapists Working with Patients in Seclusion

Figures & data

Figure 1. Illustrating Kielhofner’s (2002) model of human Occupation.

Table 1. Search inclusion and exclusion criteria and justifications.

Include	Exclude	Justification
Service users with personal experience of seclusion. or long-term segregation.	Alternate settings where service users may be secluded, such as prisons or detention centers.	Seclusion may be experienced differently and for reasons other than mental illness.
Service users aged 13 and over.	Service users under 13.	Secure mental health services provide care from adolescent onwards. All research examining qualitative data from forensic and non-specialist mental health inpatient hospitals will be included.
Mental health hospital and secure/forensic settings.	Specialist settings such as dementia care or neurological mental health.	Seclusion may be experienced and researched differently in these settings, this review intends to focus on the experience of seclusion by mental health inpatients, clinicians and carers. Extending the inclusion criteria to include additional settings is beyond the remit of this synthesis.
Clinicians with direct experience of caring for or working with patients while in seclusion.	Clinicians experience that does not reflect on the experience of seclusion.	In order to expand and triangulate the results, qualitative data from clinicians with experience of working with patients in seclusion will be included.
Carers of service users who have cared for people experiencing seclusion	Carers of service users that have not been secluded.	The sensitive nature of the research topic may mean that service users are too unwell to ethically participate. Therefore, carers views will be included.
Papers published between 2007 and 2020	Sources published prior to 2007	Due to the lack of contemporary research in this area, as suggested in the pilot search, the publication date was extended to 2007. This is in line with the year of the most recent update to the Mental Health Act (2007), despite this it was necessary to further widen the search to incorporate research from other nationalities due to lack of UK based research.
Peer reviewed qualitative research papers	Reports, grey literature, unpublished research	Due to time constraints and this review being completed by one researcher, only peer reviewed, published research was considered. The peer review process ensured the quality of papers selected.
Qualitative primary research	Quantitative research, existing literature reviews	Primary research was selected to avoid repetition and ensure originality. Qualitative research will examine patient experience of seclusion and is best suited to answering the research question.
Research from journals based in: U.K, Europe, The USA, Australia and Canada	Journals from other geographical locations	Due to lack of UK based research, the inclusion criteria were expanded to include countries listed by the British Journal of Occupational Therapy as associated journal countries of publication (RCOT, 2021) Additionally, European articles will be considered due to similar healthcare viewpoints between Europe and the UK.
Published in English language	Publications not in English language	Financial and time constraints preventing translation.
Patient, carer and staff views and experiences of seclusion and segregation that could have implications for occupational therapy practice. Current occupational therapy interventions for patients in seclusion/segregation..	Qualitative data that does not have implications for occupational therapy practice.	Ensures data answers research question.

Figure 2. PRISMA (2009) Diagram illustrating the screening process.

Table 2. Overview of papers selected for synthesis.

Paper	Author and Year	Title	Aim	Design	Context	Sampling	Participant information	Data collection	Analysis Method	CASP Score
1	Brophy et al. (2016)	Consumers and Carer perspectives on poor practice and the use of seclusion and restraint in mental health settings: results from Australian focus groups.	Expand literature base looking at seclusion in multiple jurisdictions.	Focus groups	Five focus groups conducted in Australian cities: Brisbane, Perth, Shepparton, Sydney and Melbourne	Convenience sample	Group one, family members of secluded patients − 29 female and 7 male participantsGroup two, patients with experience of seclusion − 13 males and 17 femalesAge 20 – 70+	Researchers: mental health practitioner alongside research lead and team.Recordings and transcription.	General inductive approach.Theming	18
2	Konito et al. (2012)	Seclusion and Restraint in Psychiatry: Patients’ Experiences and Practical Suggestions on How to Improve Practices and Use Alternatives	Gain insight into patients’ experiences and ideas for seclusion practice improvement. To aid consideration of alternatives to seclusion. Inform education and training providers.	Descriptive qualitative approach. Open ended focused interview questions.	Interviews conducted in two psychiatric hospitals in Finland	Purposive sample	30 patients aged 20–64 that met the inclusion criteria and gave consent.Mixture of male and female participants.	Researchers: professional researchers with background in nursing.Interviews Transcribed verbatim	Inductive content analysis	24
3	Holmes et al. (2015)	Experiencing Seclusion in a Forensic Psychiatric Setting: A Phenomenol-ogical Study	Understand the experience of seclusion. Inform nursing staff of the impact of seclusion.	Modified Interpretative Phenomenol- ogical Analysis (IPA) Semi-structured interviews	Interviews conducted in one Canadian psychiatric inpatient facility	Purposive sample	13 participants made up of patients with experience of seclusion and nurses working in the singular psychiatric facility. Gender split not discussed.	Separate researchers for patients and nurses interviews.Interviews digitally recorded.	Content analysis principles used to code and theme data.	20
4	Askew et al. (2020)	Being in a Seclusion Room: The Forensic Psychiatric Inpatients’ Perspective	Better understand the lived experience of seclusion. Expand the knowledge base around patients’ psychological needs during seclusion.	Interpretative Phenomenol-ogical Analysis (IPA)	Interviews conducted in one English medium secure forensic hospital across three wards. Interviews conducted on the wards in a private room.	Combination of convenience and purposive sampling	7 patients with experience of seclusion who met the inclusion criteria and gave consent.	All interviews conducted by lead researcher. Interviews recorded and transcribed.	Systematic analysis following analysis guidelines. Second researcher reviewed coding and themes prior to publication	17
5	Allikmets et al. (2020)	Seclusion: A Patient Perspective	Appraise the use of seclusion from the patients’ perspective.	Questionnaire to assist structured face to face interview	Interviews conducted in one English hospital with a psychiatric intensive care unit	Purposive sampling	14 male patients with experience of seclusion aged 18–65 that met inclusion criteria and gave consent	Pilot questionnaire followed by questionnaire including open and closed questions	Systematic coding, analysis and theming following a framework.	19
6	Holmes et al. (2004)	The mentally ill and social exclusion: a critical examination of the use of seclusion from the patient’s perspective	Using patient experience to adapt and challenge current nursing care.	Heideggerian phenomeno-logical research framework	One Eastern Canadian psychiatric unit	Purposive sampling	6 patients, male and female with experience of seclusion that met the inclusion criteria	Non-directive interviews with two open ended questions and subsequent secondary questions	Coding, theming and categorizing following a framework	23
7	Ezeobele et al. (2014)	Patients’ lived seclusion experience in acute adult psychiatric hospital in the United States: a qualitative study	To explore and describe the patients’ lived seclusion experience	Qualitative phenomeno-logical design	One large (250 bed) acute psychiatric hospital in South-western USA	Purposive sampling	20 patients, male and female, aged 19–53 with experience of seclusion that met the inclusion criteria.	Advanced psychiatric nurses conducted semi-structured interviews with open ended questions.	Coding, theming and categorizing following a framework.	23

Table 3. CASP scores of papers selected for synthesis.

Author and Paper number	Research Design	Recruitment Strategy	Data Collection	Researcher Relationship/ Bias	Ethical Issues	Data Analysis	Statement of Findings	Research Value	Score
Brophy et al. (2016)	3	3	2	2	1	2	3	2	18
Konito et al. (2012)	3	3	3	3	3	3	3	3	24
Holmes et al. (2015)	3	3	3	2	3	2	3	1	20
Askew et al. (2020)	3	3	3	1	2	1	2	1	17
Allikmets et al. (2020)	3	3	2	1	1	3	3	3	19
Holmes et al. (2004)	3	3	3	3	2	3	3	3	23
Ezeobele et al. (2014)	3	3	3	2	3	3	3	3	23

Table A1. llustrating development of research question using SPIDER.

SPIDER mnemonic	To be included in literature search
Sample	Service users aged 12 and over with experience of seclusion or long-term segregation in a mental health hospital OR clinicians with lived experience of working with this client group.
Phenomenon of interest	Patient experiences of seclusion and the role occupational therapists could have working with this client group.
Design	Primary qualitative research, e.g., Focus groups, phenomenological interviews
Evaluation	Not applicable
Research type	Qualitative

Table

Author(s)/Year	Journal	Article	Reason for Exclusion
Wright et al. (2020)	International Journal of Mental Health Nursing	‘“Why didn’t you just give them PRN?”: A qualitative study investigating the factors influencing implementation of sensory modulation approaches in inpatient mental health units’	Study exclusively focused on nurses’ perspectives, limited generalizability to occupational therapy practice, no qualitative patient data included.
West et al.  (2017)	Australian Occupational Therapy Journal	An evaluation of the use and efficacy of a sensory room within an adolescent psychiatric inpatient unit’	No qualitative results collected.
Wood et al.  (2019)	Psychology & Psychotherapy: Theory, Research & Practice	‘The role of psychology in a multidisciplinary psychiatric inpatient setting: Perspective from the multidisciplinary team’	Focus on MDT working, not seclusion as experienced by the service user. Little content around the literature review topic.
Sustere, and Tarpey (2019)	Journal of Forensic Psychiatry & Psychology	Least restrictive practice: its role in patient independence and recovery	Minimal qualitative information on the topic of seclusion. Does not answer the research question.
Estrella et al. (2019)	Occupational Therapy in Mental Health	Exploring the Experiences of Individuals With Serious Mental Illness in a Modified Treatment Mall: Centralized Off-Unit Programing With Extended Hours, a Mixed Methods Study	Seclusion not practiced within the service examined in the article
Wiglesworth and Farnworth (2016)	Occupational Therapy International	An Exploration of the Use of a Sensory Room in a Forensic Mental Health Setting: Staff and Patient Perspectives	Mixed methods study where the qualitative element does not include information on seclusion experience/the impact of sensory room on seclusion.
Tully et al. (2016)	CNS Spectrums: The International Journal of Neuropsychiatric Medicine	Innovation and pragmatism required to reduce seclusion practices	Quantitative data – not appropriate for literature review.
O’Connell et al. (2010)	International Journal of Forensic Mental Health	Time Use in Forensic Psychiatry: A Naturalistic Inquiry into Two Forensic Patients in Australia	Patients included in the study had not experienced seclusion.
Sutton et al. (2013)	International Journal of Mental Health Nursing	Optimizing arousal to manage aggression: A pilot study of sensory modulation	Not appropriate for literature review as the article does not include experience of seclusion. Useful for discussion around potential for OT
Goodman et al. (2020)		Barriers and facilitators to the effective de-escalation of conflict behaviors in forensic high-secure settings: a qualitative study	Data collected does not answer research question

Table

Study Number/Author/ Publication Year	Strengths	Limitations
1. Brophy et al. (2016)	Examined experience of both carers and patients meaning better triangulation. Study took place across four Australian locations, increasing variety of participants. Ethical approval and method guided by advisory group Independent researcher assisted in analysis. Results well evidenced with quotes.	Although advisory group could have positively influenced the ethical standards, having prior patients contribute to the method could also result in bias. Focus groups conducted in English but had wide variety of nationalities taking part – potential for language barrier. No clear explanation of informed consent. No plan for debrief/how to manage distressed participants. No recommendations for future practice/research. Little acknowledgement of limitations Reduced generalizability outside of Australia
2. Konito et al. (2012)	Ethical approval Detailed information re. consent and right to withdraw. Clear explanation of method and rationale. Researchers had appropriate background in psychiatric care. Clinical evaluation of participants wellbeing before interview increased ethical standards. Data analysis performed by separate researchers to minimize risk of bias Thorough results section well supported by quotes. Steps to minimize bias clearly illustrated. Implications for future research and practice well defined.	Interviews conducted a short duration after seclusion, could be distressing for participants. Setting was two hospitals in Finland, potentially reducing generalizability. Only patient views taken into account, suggesting increased risk of bias.
3. Holmes et al. (2015)	Examines experience of both patients and nurses, triangulating data and reducing bias. Clear methodology and explanation of the different methods used for nurses and patients. Ethical approval received. Informed consent gained and detailed. Illustrated separate plans for nurses and patients, should a participant become distressed, showing regard for patient welfare. Clear results section supported by quotes.	Setting was one Canadian hospital, appearing to reduce generalizability. Method of analysis briefly explained. No clarification on researcher experience or whether the researchers were known to the participants. No discussion of researcher bias. Minimal recommendations for future research or implications for practice. No discussion of limitations.
4. Askew et al. (2020)	Ethical approval received. Consideration of ethical sampling technique well evidenced. Topic guide informed by service users, suggesting resulting topics were more patient centered. Consideration of duration since last seclusion, 28 days means patients had time to recover before being interviewed.	Small sample (n = 7) from one hospital, resulting in less data for analysis and reducing generalizability. No discussion of right to withdraw or plan for managing potential distress. Relatively minimal data presented, unclear how themes were drawn from data. No identification of areas for future research/practice. No data collected from other participant groups, i.e., nurses, carers to provide balance, and as such, the discussion does not include the potential benefits of seclusion.
5. Allikmets et al. (2020)	Clear explanation of consent process and justification of data excluded from publication. Mental health qualified staff conducted interviews to ensure participant welfare, and bias taken into account. Informed consent and right to withdraw explained. Thorough discussion of bias and methods used to reduce bias. Discussion around implications for future practice and research, both in the country of research taking place (UK) and worldwide, for both people experiencing seclusion, and healthcare staff. Comprehensive discussion of limitations of the study.	Ethical approval deemed not required, although similar studies have had ethical committee approval. Participants interviewed over a period of four months, but no reference is made to potential for fluctuations in mental health impacting the research, or to regaining consent. Small sample (n = 10) of male adult participants from one hospital, resulting in less data for analysis and reducing generalizability to other locations, ages and genders. Using a structured interview format may have reduced the amount of data collected.
6. Holmes et al. (2004)	Participants were both male and female, ensuring representation of views from both genders. Informed consent received. Clear, appropriate explanation of research method and data analysis.	Setting was one Canadian psychiatric hospital and the sample was small (n = 6) resulting in less data for analysis and reducing generalizability to other locations. Nursing notes and care plans for patients accessed but no discussion of consent gained for this. No discussion of potential for researcher bias, however researchers were not involved in care of participants. Only patient data collected, no triangulation of data via additional participant groups. Acknowledgement of the sensitive nature of the research, but no plan for participant debrief or managing the potential for distress. No identification of areas for future research/practice.
7. Ezeobele et al. (2014)	Participants (n = 20) were both male and female, ensuring representation of views from both genders. Informed consent received and evaluated by psychiatrists. Ethics committee approval received, right to withdraw clearly detailed. Discussion around how confidentiality was maintained. Methods of bias reduction discussed, including utilizing an additional, neutral researcher. Patient welfare considered, researchers had nursing backgrounds but were not care providers for the participants. Clear explanation of data collection and analysis process. Clear discussion of limitations of study. Implications and suggestions for future practice and research clearly outlined.	Participants were from one psychiatric hospital in the USA, reducing generalizability to other nationalities. Only patient data collected, no triangulation of data via additional participant groups.

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