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J Psychiatr Ment Health Nurs. 2023;00:1–12.
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1wileyonlinelibrary.com/journal/jpm
Received: 22 December 2022
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Revised: 17 August 2023
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Accepted: 30 August 2023
DOI: 10.1111/jpm.12979
ORIGINAL ARTICLE
Patient perspective on observation methods used in seclusion
room in an Irish forensic mental health setting: A qualitative
study
Shobha Rani Shetty1,2 | Shauna Burke1 | David Timmons1 | Harry G. Kennedy3,4,5 |
Mary Tuohy1 | Morten Deleuran Terkildsen6,7, 8
This is an op en access arti cle under the ter ms of the Creative Commons Attribution-NonCommercial-NoDerivs License, whi ch permits use a nd distribution in
any medium, provided the original work is properly cited, the use is no n-commercial and no modi ficat ions or adaptat ions are made.
© 2023 The Authors . Journal of Psychiatric an d Mental Health Nur sing pub lished by John Wil ey & Sons Ltd.
1Nationa l Forensi c Menta l Health Serv ice,
Centra l Menta l Hospit al, Dublin, Ir eland
2School of Nursing Midwifery an d Health
Systems, University Co llege Du blin (UCD),
Dublin, Ireland
3Forensic Psychiatry, Trinity College
Dublin , Dublin, Irela nd
4Forensic Psychiatry, Aar hus Universit y,
Dublin, Ireland
5Forensic Psychiatry, Universit y of Bari
‘Aldo Moro’, Dublin, Ireland
6Depar tment of Forensic Psychiatry,
Centre for Forensic Psychiatric Re search
and Devel opment (CerF), Aarhus
University Hospital Psychiatry, Aar hus N,
Denmark
7DEFACTUM, Central Denmark Regio n,
Aarhus N, Denm ark
8Depar tment of Clinic al Medicine, Faculty
of Health, Aarh us University, Aarhus N,
Denmark
Correspondence
Shobha R ani She tty, Mental Hea lth
Nursing, UCD School of Nursing
Midwife ry and Health Systems, Belfield,
Dublin Ireland.
Email: shobha.shetty@ucd.ie
Accessible Summary
What is known on the subject?
• Nurses‘ obser vation of patients in seclusion is essential to ensure patient safety.
• Patient observation in seclusion assists nurses in adhering to the requirements of mental
health legislation and hospital policy.
• Direc t obser vation and video monitoring are widely used in observing patients in seclusion.
• Coercive practices may cause distress to patient-staf f relations.
What the paper adds to existing knowledge?
• We add detailed information on specific observation methods in seclusion and compare them
from the perspective of patients.
• Nurses communicating with patients ensures relational contact and that quality care is pro-
vided to patients even in the most distressed phase of their illness.
• Providing prior information to patients on observation methods in seclusion and the need for
engaging patients in meaning ful activities, while in seclusion are emphasized.
• Observation via camera and nurses‘ presence near the seclusion room made patients feel
safe and gave a sense of being cared for in seclusion.
• Pixellating the video camera would give a sense of privacy and dignity.
What are the implications for practice?
• The overarching goal is to prevent secl usi on. However, when seclu sio n is used as a last re sort to
manage risk to others, it should be done in ways that recognize the human right s of the patient ,
in ways that are least harmful, and in ways that recognize and cater to patients‘ unique needs.
• A consistent approach to relational contact and communication is essential. A care plan must
include patient‘s preferred approach for interacting while in seclusion to support individual-
ized care provision.
• Viewing panels (small window on the seclusion door) are important in establishing two-way
communication with the patient. Educating nurses to utilize them correctly helps stimulate
relational contac t and communication during seclusion to benefit patients.
• Engaging patients in meaningful activities when in seclusion is essential to keep them con-
nected to the outside world. Depending on the patient‘s presentation in the seclusion room
and their preferences for interactions, reading newspapers, poems, stories, or a book chapter
aloud to patients, via the viewing panel could help ensure such connec tedness.
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SHETTY et a l.
1 | INTRODUC TION
A higher incidence of aggression and violence reported in foren-
sic mental health settings (Bowers et al., 2011; Dickens, Picchioni,
& Long, 2013; Trestman, 2017) validates the importance given to
risk assessment and risk management strategies in these settings.
An in-depth risk assessment, use of interpersonal techniques such
as de-escalation, physical interventions including physical restraints
and restrictive measures such as seclusion and rapid tranquilization
are availed by the health care professionals to prevent and manage
aggression and violence in forensic settings (Flammer et al., 2020;
Kennedy et al., 2020).
Seclusion refers to isolating the patient in a locked room, mon-
itored by staff using security cameras in the room and/or through
a small window on the seclusion door (Berg et al., 2023: Cullen
et al., 2018). Monitoring encompasses visually observing and com-
municating with the patient in seclusion.
In th e Re pub lic of Irela n d , t he Men t a l He alt h Com m iss i o n Rul es
(MHC, 2009, page 17 ) gover ning the use of seclu sion and mechan-
ical means of bodily restraint defines seclusion as ‘the placing or
leaving of a person in any room alone, at any time, day or night,
with the exit door locked or fastened or held in such a way as to
prevent the person from leaving’. While in seclusion, the patient
is put on direct observation by a registered mental health nurse
day and night and monitored by closed-circuit television (CCTV).
The legally binding MHC Rules Ireland (2009 page 10) defines di-
rect observation in seclusion as the ‘ongoing observation of the
patient by a registered nurse who is within sight and sound of the
• More focus should be placed on providing communication training to nurses to strengthen
their communication skills in caring for individuals in challenging care situations.
• Patient education is paramount. Providing prior information to patients using a co-produced
information leaflet might reduce their anxiety and make them feel safe in the room.
• When using cameras in the seclusion room, these should be pixelated to maintain patients‘
privacy.
Abstract
Introduction: A lack of research investigating the specific role that various observa-
tional techniques may have in shaping the therapeutic relations in mental health care
during seclusion warranted this study.
Aim: The aim of the study was to explore patients’ experience of different methods of
observation used while the patient was in seclusion.
Method: A retrospective phenomenological approach, using semi-structured inter-
views, ten patients’ experiences of being observed in the seclusion room was inves-
tigated. Colaizzi’s descriptive phenomenological method was followed to analyse the
data.
Results: Communicating and engaging patients in meaningful activities can be
achieved via the viewing panel. The camera was considered essential in monitoring
behaviour and promoting a sense of safety. Pixelating the camera may transform pa-
tient view on privacy in seclusion.
Discussion: The mental health services must strive to prevent seclusion and every
effort should be made to recognise the human rights of the patient. The study reveals
numerous advantages when nurses actively engage in patient communication during
the process of observation.
Implications for Practice: Different observation methods yield different benefits;
therefore, staff education in using these methods is paramount. Empowering the pa-
tient with prior information on seclusion, engaging them in meaningful activities and
proper documentation on patient engagement, supports the provision of individual-
ised care in seclusion.
KEYWORDS
camera, communication, mental health nurse, observation, safety, seclusion, seclusion room
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SHETTY e t al.
seclusion room at all times but is outside the seclusion room’. The
MHC Rules further permit the continuous observation of the pa-
tient after 1 h which incorporates the patient being directly ob-
served by nurses through the viewing panel (a small window on
the seclusion door fitted with a curtain/blind from outside). The
nurse can also view the patient via a CC TV mon itor locate d within
sight and sound of the seclusion room. The nurse communicates/
interacts with the patient via the viewing panel and a written re-
cord of the patient s' behaviour is made ever y 15 min.
Direct observation and video monitoring are used internation-
ally in observing patients in seclusion to improve patient safety. It
also assists nurses in adhering to the requirements of mental health
legislation and hospital policy. Another method of observing is via
ceiling-fixed, wide-angled anti-ligature mirror which is less invasive.
Observation involves a nurse allocated to care for a patient for a
specified period to ensure the patient's safet y (Ray & Allen, 2015).
In almost all cases, the reason for seclusion is imminent serious
violence to others while violence to self is possible, therefore, con-
stant observation of patients is essential.
2 | RATIONALE
Current forensic mental health research underlines a need to study
how to balance care and custody in forensic mental health practices
in ways where the promotion and sustainment of strong care rela-
tions are realized while risks posed by patients are managed accord-
ingly (Mann et al., 2014; Terkildsen, Kennedy, et al., 2022; Terkildsen,
Vestergaard, et al., 2022).
For nurses working in recovery-orientated secure settings, how-
ever, the use of explicit power (in the form of risk management strat-
egies) has been depicted in literature as providing nurses with a role
marred by a specific ambivalence (Martin & Street, 2003; Terkildsen,
Kennedy, et al., 2022; Terkildsen, Vestergaard, et al., 2022). On th e on e
han d, they are to eng age pat ie nt s in reha bi litative pr ac tice s. Such prac-
tices are dependent on strong therapeutic/care relations (Terkildsen,
Kennedy, et al., 2022; Ward, 2013; Clarke et al., 2016) with patients
in which power is sought more symmetrically distributed (Mann
et al., 2014 ). Conversely, and as seen above, studies reveal that a cru-
cial component of the nursing role also involves the prevention and
management of aggression and violence to en su re the saf et y of the pa-
tient, other patients, staff, and society in general (Dickens, Piccirillo, &
Alderman, 2013). When other preventive measures are unsuccessful,
these strategies may include seclusion as a last resor t when a patient
is at imminent risk of harming others (Chieze et al., 2019; Council of
Europe: Committee for the Prevention of Torture, 2017; Men tal Hea lth
Commission Ireland, 2014; Power et al., 2020).
Current research on using seclusion in mental health has demon-
strated diverse experiences of seclusion practices for the therapeutic
relationship between patients and staff. These experiences may range
from patients experiencing support and safety (Ezeobele et al., 2014;
Iversen et al., 2011) to experiences of being in a situation of neglect
and lack of care (Askew et al., 2019; Hansen et al., 2022; Holmes
et al., 2015; Ntsaba & Havenga, 2008) and nurses' feelings of delivering
extra care via seclusion (Holmes et al., 2015). Feeling a connec tion to
staff and having relevant access to communication between patients
and staff during seclusion has, however, commonly been underlined as
a salient condition that may help promote strong patient–staf f relation-
ships that ameliorate the adverse effects of seclusion (Berg et al., 2023,
Ezeobele et al., 2014, Askew et al., 2019). Moreover, it is commonly
agreed the physical environment may promote or inhibit such contact
and communication, and thereby draw correlations between the layout
and function of seclusion rooms and their instrument s and the possibil-
ities for achieving desirable patient–staff relational outcomes (Askew
et al., 2019 ; Hansen et al., 2022; Holmes et al., 2015).
However, despite the emphasis on understanding the interac-
tion between the physical design and the psychological function of
seclusion practices, instruments and rooms as well as the potential
for fostering communication and connection between patients and
staff, there has been a lack of research investigating the specific role
that various obser vational techniques and instruments may have
in shaping these therapeutic relations in mental health care during
seclusion. Therefore, a gap exists that, if further studied, may help
develop future seclusion practices that promote strong patient–staff
therapeutic relationships and ensure the safety of patients and staf f
remains an unexplored area in the field.
This study aims to fill this gap, by exploring the patients' experi-
ences of different observation methods in seclusion and their influence
on the ir con nec tio n an d re lat io ns to st aff, by pat ien ts in an Irish fore nsic
mental health hospital, in order to inform future seclusion practices.
Integrating patient perspectives in the development and implementa-
tion of such ment al health practices are impor tant to ensure their fu-
ture success (Terkildsen, Vestergaard, et al., 2022, Kontio et al., 2010).
3 | METHODS
3.1 | Study design
A retrospective phenomenological approach was used in this study.
Phenomenology helps describe the meaning of participant's expe-
rience both in terms of what was experienced and how it was ex-
perienced (Teherani et al., 2015). The retrospective design allowed
participants to reflect on their past experience and establish mean-
ings to their experiences. Nonetheless, retrospective studies are
sometimes criticized for relying on participants' memories of events
from the past (Cohen et al., 2011).
The SRQR (Standards for Reporting Qualitative Research: A
Synthesis of Recommendations) checklist (O'Brien et al., 2014) was
used to guide the reporting of the study.
3.2 | Researcher characteristics and reflexivity
Interviews were c arried out by the first and the second author, who
have no clinical contac t with the participants. Both authors are
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SHETTY et a l.
qualified mental health nurses and have experience in conducting in-
terviews. The interviewers separately maintained a reflective diary
after every interview. Reflective diary enables the researcher to
write down observations or assumptions made during the inter view
(Wojnar & Swanson, 2007). Reflexivity was maintained by discuss-
ing any assumptions, among two researchers who carried out the
interviews and with other researchers in the team who are experts
in phenomenolog y to minimize researchers' bias if any.
3.3 | Setting
This study was conducted in one forensic mental health hospital that
had 97 inpatients at the time of data collection. There were eight
wards categorized into three clusters, that is, acute (one female and
two male wards), medium (three male wards) and rehabilitation and
recovery (two male wards) clusters. A structured pathway of care
allows patients to move from acute to medium to rehabilitation and
recovery clusters based on their clinical presentation and risk as-
sessment. The female ward provided care to patients in all three
clusters. Patients were above 18 years and may have a minimum
length of stay of 6–7 years in the forensic mental health service. The
acute wards utilized seclusion as a last resor t in managing patients
who were at risk to others. In this study, patients in medium secure
wards/category we re selected wit h the perception that patient s fur-
ther on their pathway of care can better reflect on their experience.
3.4 | Sampling strategy
This study was carried out in July 2021 and only those participants
who were admitted to the service in the past 5 years were included.
Out of 43 patients in the medium secure units/category, 23 were
admitted to the service in the past 5 years. Purposive sampling
technique was used to select the participants. The inclusion criteria
included:
• Patients in Medium Secure units/category
• Patients admitted to the hospital in the last 5 years (since 2016)
• Has experience of being nursed in seclusion room.
Exclusion criteria
• Patients in acute wards
• Patients who were admitted to the hospital for more than 5 years.
• Patients who were admitted in the past 5 years and had no expe-
rience of being nursed in the seclusion room.
The first and the second authors sent an invitation letter to all
23 patients meeting the inclusion criteria in three male medium se-
cure wards and one female ward. Both researchers are known to pa-
tients as teaching faculty in the service. Those who were interested
in participating in the study contacted the researchers by sending
an expression of interest form via an internal post-system. The first
and the second author met all interested participants to provide a
participant information sheet and a copy of the consent form. Seven
days later, if they were still interested, a date, time and venue were
arranged for a semi-structured interview. The consultant psychiatrist
was informed of patients' participation in the research. All 10 partici-
pant s wh o sh ow ed an in te re st in par tak in g we re inc lu ded in the st ud y.
3.5 | Ethical considerations
Ethical permission was sought from the Audit, Research and Ethics
committee in the ser vice (Approval Ref No: AUD/18062021/SR).
An informed consent was obtained from each participant prior to
conducting the interview. Confidentiality of the participant was
maintained by carrying out the interview in the board room, away
from the wards. Inter views were conducted by two researchers, not
involved in the patient care. There were no other staff members pre-
sent. A num er ic al cod e wa s assigned to all recordings and all ide nt if i-
able data were removed from the transcript to maintain anonymity.
The participant information sheet detailed that they could withdraw
from the study at any time with no effect on their care.
3.6 | Data collection method
Data were collected using semi-structured interviews by the
first and the second author. Face-to-face semi-structured inter-
views helps gather personal experiences from the key inform-
ants (DeJonckheere & Vaughn, 20 19). Open-ended questions and
prompts were used in the interview which lasted approximately
30 min. Table 1 provides the semi-structured interview guide.
Wri t te n conse nt was ta ke n, an d the aim and ob jec tives of the stu dy
was reiterated at the beginning of the interview. The inter views
were recorded using T-pro app.
3.7 | Data analysis
Colaizzi (1978) descriptive phenomenological method with distinc-
tive seven step framework for rigorous analysis was used in this
study. This framework depends on rich first-person accounts of ex-
perience (Meyers, 2019). Initially, the researchers read and re-read
the transcripts to become familiar with the data. There were sev-
eral statements indicating patients' views on the seclusion room.
A conscious decision was made to separate these statements and
they were excluded from this analysis. Significant statements were
identified and labelled to formulate meanings. At this stage many
themes arose from the analysis that were clustered into main
themes. Based on these themes, a full and inclusive description of
the phenomenon was written. We then structured the themes and
descriptions to capture patient s' experience of obser vation. The last
step in Colaizzi's (1978) seven steps is seeking verification from the
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SHETTY e t al.
participants. This step was not followed as the participants were not
interviewed for a second time.
4 | RESULTS
Ten patients, eight male and two female patients who had experi-
enced seclusion in the last 5 years participated in the study. All the
participants reported that they were aware of being observed by
nurses while they were in the seclusion room. Analysis of data using
Colaizzi's (1978) framework generated the themes given in Table 2.
Participants were asked to describe their experience of being
observed in the seclusion room via two methods: direct observation
using a viewing panel and a camera in the room. Further, their view
on the use of a mirror in the room for observation was also explored.
Participants experience and views on each of these methods of ob-
servation is described here.
4.1 | Viewing panel communicated human
connection, comfort and reassurance
a. Promoting connections in seclusion
Patients considered nurses being present and communicating via
the viewing panel promoting a sense of human connection. They had
a sense of being seen and valued the interaction with nurses.
Participant 5 acknowledged ‘… because they (nurses) checking in
on you and you (the patient) see a live person.… they (nurses) might
say he llo to you (the patient)… they (nur ses) might make some cont ac t
with you that way…it makes you (the patient) feel good like you're
still alive like you're human being, yeah… there was contact… human
cont act’.
b. Relieving the sense of isolation
Nurses communicating with patients via the panel gave a sense
of hope and a feeling of relief that the nurses were still there if
needed. The quote below from participant 10 highlights patients'
lack of information on seclusion. They underlined how they would
benefit from prior information to reduce the sense of being left
alone in the seclusion room.
‘…I thought they (nurses) were going off and they
weren't coming back at one stage because it (felt) so
long… I was psychotic and I thought they had left me
in there on my own, …they came back, and I was happy
then …I prefer (staff coming to) the window to be hon-
est with you because I'm still connected to the world’
(P10).
c. Fostering reassurance and comfort
The viewing panel provided an oppor tunit y to communicate with
nurses thus promoted a sense of comfort and being treated indi-
vidually. Talking to patients in seclusion and just being there outside
the seclusion room was comforting and reassuring to the patients.
TAB LE 1 Semi-structured Interview Guide.
Q1: Were you aware t hat you were being observed in seclusion?
Q2: What was your thoughts on being observed in seclusion room?
Prompts: 1. Why did you think that way?
2. At that time, how did you feel about being obser ved?
3. What was difficult?
4. Now, when you look back at that time in seclusion, what is your
view on registered nurses obser ving patients in seclusion?
Q3: We would like to explore your experience of different methods
used for observation in seclusion. How do you describe your
experience of staff observing you via the viewing panel while
you were in seclusion?
Q4: What was your experience of staff observing you via a camera
in seclusion room?
Q5: The images on the camera can be pixelated (blurred). What are
your views on this?
Prompts: 1. Why do you think that way?
2. What are your concerns?
Q6: There is another option that involves the use of a mirror where
the nurses would look at the mirror that would reflect an image
of the room without looking at you directly. What is your view
on this method for observation?
Q7: Given a choice, which are the following you would have
preferred when you were in seclusion?
Choices: 1. Not observed at all
2. Be observed directly or using camera
3. Using video camera
4. Video c amera with pixellation
Q8: Drawing from your experience and understanding, overall what
is your preferred method of observation?
TAB LE 2 Themes and subthemes identified from the analysis.
Themes and subthemes
1. Viewing panel communic ates human connection , comfor t and
reassurance
a) Promoting connections in seclusion
b) Relieving the sense of isolation
c) Fostering reassurance and comfor t
d) Engaging in meaningful activities
2. Camera for monitoring behaviour, recognizing emergencies and
ensuring safety
a) Monitoring patients' mental health
b) Recognizing medic al emergencies
c) Promotes a sense of safety and being cared for
d) Pixellating the c ameras for privacy and dignit y
3. Mirror as an aid
4. The viewing panel and camera as preferred methods of
observation
5. Obser vation portrays a sense of caring
6. Observation is for patients' safety
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Participant 9 described ‘…talking to a staff mem-
ber, making sure I been heard and listen to …it was
reassuring…just talking to me…by being nice…was
reassuring’.
d. Engaging in meaningful activities
Patients regarded nurses reading newspapers via the viewing panel
as a meaningful ac tivit y that kept them connected with the outside
world.
Participant 10 enthusiastically shared ‘… nurses com-
ing to the door was helpful, (mentioned a nurse) came
to the door, she used to read the newspaper to me
because we weren't allowed newspapers or books or
anything (inside the seclusion room)…nurses reading
the newspaper occupies your time …something to
do…’.
4.2 | Camera for monitoring behaviour, recognizing
emergencies and ensuring safety
Patients perceived the camera in seclusion room as a method of ob-
servation to monitor behaviour, recognize emergencies and promote
safety. Patients highlighted the use of a camera as an imperative
continuous support/aid for nurses to carry out their role.
a. Monitoring patients' mental health
Participant 1 recalled an incident while they were in the seclusion
room and how staf f were able to intervene immediately, highlighting
the value of observation via camera. Other patients reported useful-
ness of camera in preventing self-harm.
‘… I think it's (cameras) necessary, because I remem-
ber one incident, I was punching myself in the stom-
ach (in seclusion)…I think it's necessary to have the
camera…they're (nurses) able to come in there calm
me down and it's necessary because you can harm
yourself, they (nurses) can monitor your behaviour…’
(P1).
b. Recognizing medical emergencies
Recognizing medical emergencies were frequently mentioned as
a benefit of having a camera in the seclusion room in terms of re-
sponding to an adverse event and acting quickly.
Participant 3 stated ‘… in case there is an emergency
or something… in case something wrong with meds
(medication side effects) or emergency like some-
thing to do with your hear t or stroke or something you
know’. Furthermore, participant 7 added ‘…someone
(in seclusion room) could be taking a fit or something
…staff can see that through camera and come straight
in …’.
c. Promotes a sense of safety and being cared for
Camera-assisted observation was perceived by participants as an
additional resource that promoted a sense of safety. There was an
expectation to be cared for in seclusion, and they believed that the
camera assisted the nurses in doing so.
Participant 2 said ‘…because the person could hur t
themselves or harm themselves, they need to be
observed and looked after, that is the reason for
it (camera) isn't it? you're in seclusion…so people
(nurses) need to keep you safe, so you won't do
anything’.
d. Pixellating the cameras for privacy and dignit y
The researchers further explored participants' views on cameras in
the seclusion room being pixelated. Participants expressed a lack of
control over observation via camera hence they felt pixelating the
cameras would promote a sense of privacy and dignity in the situa-
tio n. The ir perception of ca me ra recording in di ca ted a lack of knowl-
edge of being c ared in seclusion.
Participant 1 stated ‘I prefer it (camera image) blurred.
It's for anonymity… it be better if it's blurred on the
recording because you don't know who's going to see
it… I wasn't well so I was acting inappropriate, so I
needed to be out of the situation… I think from my
own personal point of view I need the camera blurred
because when you're so sick you could do anything…
you want your privacy respected especially in the toi-
let area….I am sure that's (pixellation) good for your
dignity….certain standard of privacy, because you
are a human being and you're at your lowest and you
need it (dignity)…’.
4.3 | Mirror as an aid
Participants were further asked about their views on the idea of
using a mirror in seclusion room for observation. Par ticipants had a
lack of experience with this method of observation and thus did not
perceive mirror as their preferred method for observing patients in
the seclusion room.
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SHETTY e t al.
P3 described mirror as far-fetched ‘… I don't know… it's (mirror
used for observation) a bit far-fetched…far-fetched like camera like a
mirror, why not just look at someone instead of using a mirror you
kn ow ’.
However, participant 8 expressed that mirror may be used if the
patient was very dangerous where other method of observation was
not appropriate.
‘…no not for me no not unless someone was really,
really dangerous’
(P8).
Similarly, participant 6 agreed by saying ‘ … I suppose it is acceptable
when you think about it… it just there as an aid to make sure you're
ok, I don't see why that's a problem’.
4.4 | The viewing panel and camera as preferred
methods of observation
Par tici pa nt s were asked whic h method th ey woul d recom mend for ob-
servation of patients in seclusion room. Seven out of ten participants
preferred direct observation using a camera and the viewing panel.
One of the par ticipants stated ‘… I had a horrible time
when I was in there my mind went against me and I
think there should be camera. I think there should be
one to one as well. I think both … everyone's set of cir-
cumstances are different… my opinion is there should
be both…’
(P10).
Further, participant 5 listed three benefits of using both the camera
and the panel for observation. They included safety of the patient,
early recognition of deterioration and timely intervention.
‘…I prefer both (camera and the panel), just to be on
the safe side…sometimes you (patient) not even know
you're hurting yourself …so staf f can come straight
to you…the benefits is one, you (patient) know that
you're safe, two you (patient) know that if you do
someth ing you're watched an d they (nurses) will come
and help you and three, you know that you won't
do stuff (harming oneself) because you are being
watched, that makes yourself good for yourself any-
way. Some people don't be thinking when they're in
there (seclusion room)’.
4.5 | Observation portrays a sense of caring
Further, participants were asked if there was a choice of nurses not
observing patients in the seclusion room, would they have preferred
that. Almost all of them said that they prefer to be observed via one
or the other method when in seclusion.
Participant 9 explained observation by nurses meant someone
caring for patient s.
‘…I would have preferred to be observed…it gave me
reassurance…to make me feel that someone cares
about me…I think it 's important to be obser ved’
(P9).
Participant 2 claimed patients being not observed in seclusion is
dangerous to the patients.
‘…that would be dangerous for the patient because
they need to obser ved nearly all the time because of
the suicide risk so the camera is necessary’
(P2).
4.6 | Observation is for patients' safety
Almost all participants expressed the view that nurse's observation
in the seclusion room is essential to ensure patients' safety and an
underpinning theme of acceptance emerged. Participants consid-
ered observation as both a preventative and safety measure. Being
observed by nurses made patients feel safe in seclusion even though
they did not know what was going on outside.
‘I didn't mind being obser ved….I thought it (observing)
is good because I didn't really know what was going
on outside, but I knew I was safe you know and I
knew they (nurses) were safe because obviously they
(nurses) were looking after you (patient)’
(P5).
The findings show that nurses obser ving patient s in seclusion com-
municated a sense of safety, being cared for, and a connection with
the external world.
5 | DISCUSSION
This study explored forensic mental health patients' opinions and
experience of being observed in the seclusion room, using three
methods, the viewing panel, a camera and the use of a mirror. All
ten participants accepted that observation in seclusion was primarily
being used for patient's safety.
In forensic mental health, seclusion may be seen as a necessary
intervention to ensure the safety of the individual patient, other
patients in the ward and the forensic mental health staff (Harpøth
et al., 2022; Kennedy et al., 2020). Patients in forensic mental health
wards are often admitted for extended periods (Uhrskov Sørensen
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8
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SHETTY et a l.
et al., 2020), making their social life and care and treatment regime
highly dependent on strong patient–staff relations. Utilizing seclu-
sion measures does, however, underline the custodial role of foren-
sic mental health staff (Martin & Street, 2003; Terkildsen, Kennedy,
et al., 2022; Terkildsen, Vestergaard, et al., 2022), and this role
could prevent close patient–staff relationships, promote negative
relational experiences and thereby act counterproductive to the in-
dividual patient's recovery process (Mann et al., 20 14; Marshall &
Adams, 2018).
The seclusion of patients is often accompanied by nega-
tive experiences (Ezeobele et al., 20 14). Several other studies
have reported patients expressing a feeling of neglect and lack
of care while in seclusion, ultimately portraying a lack of ther-
apeutic connection and relation (Askew et al., 2019; Hansen
et al., 2022; Holmes et al., 2015; Meehan et al., 2000; Ntsaba &
Havenga, 2008). However, strong patient–staff relational contact
during seclusion may ameliorate such adverse effects. According
to Iversen et al. (2011), Steinert et al. (2013), Møllerhøj and Os
Stølan (2018) and Kontio et al. (2012), acknowledging that well-
known and caring staff is closeby if needed, and having contact
with them may greatly promote feelings of support and safety.
Conversely, lacking contact with staf f during seclusion may lead
to feelings of isolation, solitary confinement, and sensory depriva-
tion, which may cause irritabilit y, mood swings and extreme bore-
dom (Meehan et al., 2000). Though the experiences of patients in
our study resonate with existing studies, we argue that our focus
on the observational techniques applied during seclusion provides
a cr iti cal sp ri ngb oar d to hel p fur ther un d er s tan d and he lp pro mote
relational connectedness between staff and patients, thereby alle-
viating the adverse effects described as having been experienced
when going through a session of seclusion. Specifically, our study
demonstrates how the specificities of observational techniques
and th ei r app li cation may he lp supp or t the possibility of uph ol ding
a crucial patient–staff therapeutic relationship that is often seen
as severely hindered during seclusion sessions.
Our study demonstrates that even though seclusion was ulti-
mately experienced as a custodial practice that radically reduced
personal autonomy, we found that desirable therapeutic effects
were promoted by using viewing panels and cameras as obser vation
techniques. More concretely, our study showed being aware that a
nurse was outside the seclusion room monitoring either via viewing
panel or via camera promoted feelings of having a relational connec-
tion to staff and ultimately provided patients with a sense of safety.
However, though both provided a sense of presence, viewing panels
and cameras did yield substantially critical differences in patients'
experiences, which needs to be included to guide future seclusion
practices. According to Berg et al. (2023), staff needs to tailor com-
munication with patients in seclusion in ways that accommodate
their unique needs to promote more positive seclusion experiences.
Our study supports these insights by Berg et al. (2023) but argues
that different observation techniques may provide very different
possibilities for how such tailored communication between staff
and patients may unfold. As demonstrated through the experiences
of our patients, we argue that viewing panels may be specifically
well suited to uphold and promote communication because they,
according to patients, permit ted the staf f to easily communicate in-
formation (i.e. by staff reading newspapers or books), which in turn
became experienced as providing engagement, hope and a connec-
tion to reality in circumstances when patients may be experiencing
psychotic symptoms.
Mo reov e r, ac c o rding to Tulloch et al . (2022) an d Be r g et al. (2023),
good communication between staff and patient s in seclusion creates
the basis for a strong patient–staff connection. Focusing on observa-
tional techniques, we argue that different observational techniques
during seclusion provide very different possibilities (if any currently)
for upholding especially non-verbal forms of staff–patient commu-
nication. Our study highlighted that many par ticipants (eight out of
ten) preferred the additional observation via viewing panel because
it promoted hope through therapeutic two-way communication.
Though overall acknowledged as an acceptable form of observa-
tion, the patients did not attribute the same experiences of having
two-way verbal and non-verbal communication between staff and
patients when using cameras. Using cameras as an observation
method was mainly experienced as a method of providing securit y.
According to Varpula et al. (2020), enhanced camera surveillance in
the seclusion room that covers multiple angles may assist nurses in
being more aware of patient activities in the seclusion room. For ex-
ample, cameras can also help identify subtle safety hazards in the
clinical setting needing management (Yanes et al., 2016).
Moreover, cameras in seclusion rooms can be a valuable method
to let nurses know when patients are ready to come out of seclusion
(Holmes et al., 2015). Despite providing staff and patients with an
imparted sense of safety for the patients, especially in recognizing
medical and psychiatric emergencies, our study underlined adverse
effects experienced by patients. As demonstrated in our study, sev-
eral participants experienced the use of cameras as equated to less
direct personal contact with nurses compared to viewing panels.
Therefore, we argue that the sole use of a camera during seclusion
may inhibit vital patient–staff connections by hindering interactions
and preventing effective verbal and non-verbal communication.
Moreover, relying solely on cameras during seclusion may create
an atmosphere of detachment from the outside world. According to
Varpula et al. (2022), more vigilant observation and video observa-
tion with two-way communication to prevent adverse events may be
called for. We agree but infer that though CCT V cameras may assist
when observing patients during seclusion, it is crucial to supplement
such technologies with the use of direc t forms of observation, for
example, viewing panels, to support patient–staff communication
further and thereby reap the therapeutic benefits and counter the
mentioned adverse outcomes, that is, feelings of detachment.
Using videos for observation may, however, raise other concerns
that may not be salient when viewing panels are used. Though pro-
viding safety, the participants in this study tended to link privacy
inside the seclusion room with maintaining a person's dignity. Here,
cameras were perceived as giving rise to specific concerns about
the relationship between staff and patients. As seen in our study,
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9
SHETTY e t al.
using cameras could compromise privacy and underlined a need to
ensure that staff does not capture a patient in a potentially undig-
nified situation when using cameras in the seclusion room. Such
experiences linking infringing on patients' privacy due to the pres-
ence of a camera in the room have been documented in previous
studies (Department of Health, & Human Services, Australia, 2018;
Martinez et al., 1999). Following the patients in our study, we argue
that such breaches in privacy are crucial to address in the devel-
opment of future seclusion practices and specifically recommend
pixellating the camera as a positive remedy to maintain dignity and
privacy in seclusion.
Participants' view on using a mirror reflects their lack of experi-
ence with such measures for observation in a seclusion room. This
method requires further exploration. While seclusion is used as a
last resor t in managing aggression and violence, the study findings
identif y nurses' role in engaging in therapeutic care to patients using
the obser vation panel and the camera. This study offers new insight
into patients' experiences in a forensic setting of obser vations in
seclusion.
As underlined in the CHIME-S framework (Connectedness,
Hope and Optimism, Identity, Meaning, Empowerment, Safety and
Securit y) for forensic mental health patient s proposed by Senneseth
et al. (2022), providing safety and security is an essential compo-
nent of the recovery process. This leads us to state that though, ul-
timately, viewed as a custodial practice; seclusion practices do not
necessarily need to stand in opposition to the recovery process if
conducted according to patients' perspectives and needs. As seen
in this paper, we argue that obser vation techniques during seclusion
are instrumental in accommodating the needs of patient s but argue
that care should be taken when deciding how to observe, as diverse
forms of observation such as viewing panels, cameras and mirrors
yield ver y different potentials for such accommodation.
The authors acknowledge that retrospective studies have the
limitation of depending on participants' memory of their experience.
However, due to patients' clinical presentation at the time of seclu-
sion and from an ethical perspective, it was not possible to interview
patients while they were in seclusion.
5.1 | What the study adds to existing research
Previous studies (Askew et al., 2019, 2020; Ezeobele et al., 2014;
Larsen & Terkelsen, 2014) have captured patient experiences of
seclusion, however, none of these studies compared the influence
of different observational techniques may have for patients' experi-
ences. This study explicitly compared and discussed the implications
of using specific observation methods in seclusion seen from the
perspective of patients.
A recent video obser vation study by Varpula et al. (2022) iden-
tified hazards in seclusion room based on video recordings of the
room. It is evident from our study that camera in the room is es-
sential in managing safety and security of the patient. However, the
presence of camera may also be seen as compromising patients'
privacy and dignity. Hence, we recommend pixellating the video
camera. Moreover, cameras may be experienced as hindering two-
way relational contact with staff.
The need for communicating with the patient in seclusion was
a recurring theme in this study. Providing prior information to pa-
tients on observation methods in seclusion and the need for engag-
ing pat ie nt s while in seclusion were emphasiz ed . Tulloch et al. (2022)
highlighted the importance of nurses' communicating with patients
to minimize the negative effects of seclusion. We demonstrated
the highly important role that different modes of observation may
have for patient-staff connection and communication and, that the
patients in seclusion can be engaged in meaningful activities using
different communication tools. Observation is to ensure patient's
well-being through communication and engagement and not mere
‘looking at’ a patient.
5.2 | Implications for practice
Findings from this study highlighted the need for continued focus
am o ng men t a l hea lth nu rse s in pr ovi din g rel ati ona l ca re and su ppor t
for patients in seclusion. Communication is the key to ensuring a
human connection in isolation. Enquiring about patients' well-being
from outside the door and reading aloud news, poems or anything
that they are interested in, was repor ted as engaging in meaning-
ful activity that helps overcome their anxiety, fear and boredom to
an extent. This is an example of providing individualized care for
patients in seclusion. Hence, encouraging nurses to document the
communication methods used with patients in seclusion would en-
courage continuity in care. In this regard, communication training
and relational skills training for mental health nurses to manage
challenging care situations are recommended (Tulloch et al., 2022).
Irrespective of the obser vation method we have demonstrated
that a lack of information on seclusion among patients was evident in
this study. Hence, to further develop future seclusion interventions
in ways that promote relational care should work, a co-produced
information leaflet may be made available to patient s on seclusion
highlighting the different methods of obser vation used in the seclu-
sion room. Thus, providing accessible information to patients might
reduce their anxiety and make them feel safe in the room. However,
not all observation methods provide equal possibilities for promot-
ing and sustaining relational contact and communication between
patients and staff. For mental health nurses' future practices, we
argue that viewing panels may be important if nurses become edu-
cated to utilize them correctly because they help stimulate relational
contact and communication during seclusion to benefit patients.
The use of camera for observation appears more useful in the early
identification of emergencies. However, lack of direct two-way con-
tact may mean mental health nurses lose a vital possibilit y for sus-
taining relational contact with patients during seclusion. Moreover,
understanding of video recording and an apprehension who will be
watching the video further strengthens the need for providing infor-
mation to patients.
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10
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SHETTY et a l.
The presence of a camera in the room may affect how patient s
view their privacy and dignity maintained in seclusion room. Camera
may be considered invading privacy and dignity especially when
using the toilet facility. Based on our findings, we recommend men-
tal health services to consider pixellating the camera to give a sense
of privacy to patients in seclusion.
All forms of observation described in our study depend on edu-
cation to reap their potential benefits. In the field of mental health
nursing, our study therefore underlines a paramount need for fu-
ture educat ion on obser vation tools and met hods to promote re cov-
ery-orientated service.
The overarching goal for all mental health services is to prevent
seclusion however when seclusion is used as a last resort to manage
risk to others, it should be done in ways that recognize the human
rights of the patient, in ways that are least harmful, and in ways that
recognize and cater to patients' unique needs.
For future research, the perspectives and experiences of mental
health nurses comparing observational methods would be relevant.
The profes sional pe rsp ective might usefully include th e advantages of
CCTV for improved observation of blind spots, the advantages of re-
cording CCTV for future insight-related work and for monitoring best
pr act ice s fo r leg al comp lia nce, au dit , tra ining and qu al ity mana gem ent .
6 | CONCLUSION
This study explored Irish forensic mental health service users' experi-
ence of being observed in the seclusion room. Participants recom-
mend the use of both the viewing panel and camera in the room for
observation. Participants viewed observation in seclusion as essen-
tial . Whi le th e us e of the vi ew ing pane l fo r obs ervati on co mm uni c at ed
human connection, comfort and reassurance, the camera provided a
sense of safety especially in emergencies. There were mixed reactions
to use of a c amera for observation. Concerns were raised about pa-
tients' privac y and dignity in the seclusion room. Pixellating the cam-
era seemed acceptable to participants in assuring privacy and dignit y.
A third method, the use of mirror was seen as an aid for observation.
We believe that the study findings have several implications
for mental health practice. A key finding from this study is the
importance of communication with patients be it before, during
or after the seclusion. A co-produced information leaflet on ob-
servation methods in seclusion rooms may empower patients in
this regard. While in seclusion, nurses may make use of different
plans of action to interact with patients. Presence of nurses out-
side the seclusion room also communicates comfort and securit y.
Using both the viewing panel and camera for interaction and ob-
servation is essential.
7 | RELEVANCE STATEMENT
This study strengthens the necessity for nurse–patient communica-
tion during seclusion from the patients' perspective. While ever y
mental health service must strive to prevent coercive practices,
in some challenging situations, seclusion may be used as a last re-
sort. Hence, continuous observation is essential in ensuring patient
safety, to give a sense of caring and to intervene in emergency
situations. Direct observation may be carried out using a viewing
panel (a small window on the seclusion door) and/or via the cam-
era. Communicating and engaging patients in meaningful activities
ensures individualized care in seclusion. It is evident that patient s
reported feeling safe and cared for, in nurses' presence and inter-
action. Hence, nurses must be afforded further training opportuni-
ties to enhance their communication skills in challenging situations.
Educating patients in some of the care practices is paramount to
reduce their anxiety thus helping them cope better in such situa-
tions. Technology is useful in aiding nurses to enhance their obser-
vation however care must be taken to protect the human rights of
the patients. Basic rights such as their right to privacy and dignity
can be achieved by pixelating the camera in the seclusion room.
This study further supports preventing coercive practices in mental
health settings and promoting patient involvement in their care and
treatment.
AUTHOR CONTRIBUTIONS
SRS and SB conducted the interviews and wrote and developed the
manuscript. MDT, DT, HGK and MT critically reviewed the manu-
script. All authors approved the final manuscript, confirmed they
met the authorship criteria and agreed with its content. The authors
report no conflic t of interest.
ACKNO WLE DGE MENTS
This study was fully supported by the National Forensic Mental
Health Service, Central Mental Hospital, Portrane, Ireland. Open ac-
cess funding provided by IReL.
DATA AVA ILAB ILITY STATE MEN T
Data available on request due to privacy/ethical restrictions.
ETHICS STATEMENT
This study has ethical permission from the Audit, Research & Ethics
Committee, National Forensic Mental Health Service, Ireland
(Approval Ref No: AUD/18062021/SR).
ORCID
Shobha Rani Shetty https://orcid.org/0000-0001-9196-1381
Shauna Burke https://orcid.org/0000-0002-6001-7651
Harry G. Kennedy https://orcid.org/0000-0003-3174-3272
Morten Deleuran Terkildsen https://orcid.
org/0000-0002-0974-3164
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How to cite this article: Shetty, S. R., Burke, S., Timmons, D.,
Kennedy, H. G., Tuohy, M., & Terkildsen, M. D. (2023).
Patient perspec tive on observation methods used in
seclusion room in an Irish forensic mental health setting: A
qualitative study. Journal of Psychiatric and Mental Health
Nursing, 00, 1–12. http s://doi.org/10 .1111/jpm.12979
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