Nursing Perception on Seclusion essay

Last Updated on 03/06/2023 by Sophia

Each person in the world adapts to various challenges differently from the other but some
are unable to cope with the challenges. This is as a result of mental disabilities that lead to the
development of destructive behaviors that may be dangerous to himself and others around him.
Mental disorders cause an inability to cope with various stress factors surrounding or internal to
the person leading to a mix of feelings, thoughts, and behaviors which are socially and culturally
considered as deviations from the norm (Happell, & Koehn, 2011). Different methods have been
developed by mental and psychiatric science to help in controlling destructive behaviors. Some
of these methods include medication and seclusion. Seclusion is faced by legal and ethical issues
as various organizations argue whether it is good or not (Abdel-Hussein & Mohamed, 2019). The
purpose of this study is to explore the patient’s perceptions of seclusion as a psychiatric method
of handling patients who are mentally unstable and could cause harm to others if not controlled.

Background

The seclusion approach is a method that is highly associated with the development of
psychiatric institutions. The method is involved in the development of emergency units and
environment therapy in psychiatric institutions where the patients with mental disorders are taken
care of when they become a danger to themselves and others (Aihw, 2020). Seclusion’s clinical
concept dictates that an inpatient gets retained in a bare room when there is a situation that may
develop to an emergency require to be contained first before other medical steps are taken.
Seclusion can therefore be defined as a retention of a patient at any given time of the day or night
in a separate unit or a room within the ward where there is limited movement (Abdel-Hussein &
Mohamed, 2019). Patients are not allowed to move out of the room until their mental condition is
calmed down and determined that they are no longer a danger to others and themselves.

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According to the United Kingdom National Preventative Mechanism, seclusion in a
health setting is defined as supervised detention and separation of a patient or resident from other
patients to an area where the individual is restricted from moving out due to immediate
inevitability duly so that a severe disturbance behavior can be contained to prevent a likely event
of the patient harming others. According to this organization, the isolation place does not matter
whether it is an enclosed room or the entrance remains open or closed as long as the patient
cannot move from that place (Mwcscot, 2019). In most cases, seclusion entails using a locked
door to the room but it is also considered in situations where the patient is physically blocked by
the care provider from exiting (Bowers et al., 2015). The room being used as a seclusion space
should be free of items that the patient may use consciously or unconsciously to cause injuries to
himself.
When a person isolates to his room in agreement to have access to some level of the
environment, the situation cannot be considered as seclusion. This person has the freedom to
avert the decision and go back to normal life. However, if his movement out of the room is
restricted and he cannot leave, the situation becomes a seclusion case (Mwcscot, 2019). In
psychiatric settings, this situation needs careful consideration when a patient request to stay in
isolation as it may not be a conscious decision. The resident should be put under observation
when in the room to assess the situation and determine whether he is doing that intentionally or
not (Abdel-Hussein & Mohamed, 2019). However, isolation of this nature is considered
beneficial to a person when he wants to engage in meditation in private which is a good way of
calming the mind.
Different countries have guidelines that are used in restraining mentally ill people in all
care settings. These guidelines are focused on the rights of the patient, risk involved, and

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limitations to freedom. Seclusion has specified guidelines whose applications are limited to
hospital environments (Bowers et al., 2015). There are scarce research and guidance on how
patients should be restricted from the freedom of movement in psychiatric hospitals as patients
have different mental conditions that behave differently and require to be handled differently.
For instance, a patient may be mentally ill and is only causing injuries to himself while another is
fighting others (Happell, & Koehn, 2011). Both patients require to be handled and secluded
differently. However, some people feel that mentally ill people or those with learning disabilities
and related conditions, should not be secluded as this affects their emotions and psychology.
Patients do not appreciate seclusion as they perceive it negatively due to infringement of
their freedom although the method brings positive outcomes, most patients feel that they are
being punished, dehumanized, and overpowered (Abdel-Hussein & Mohamed, 2019). The
caregivers may find it necessary to seclude these patients as it may be naturally beneficial to the
patient and others around him. Seclusion may cause traumatization of the patient leading to more
problems instead of the person recovering and hence the need to be careful not to cause panic
and unnecessary commotions.

Literature Search

Literature search entails a systematic and comprehensive search for all literature
materials that relate to the topic of interest. To be able to quickly identify the materials being
searched, it is necessary to first identify the research questions for the study before beginning the
search. This is then followed by identifying keywords and phrases. The research questions are as
follows:
1. What perception do patients have toward seclusion?
2. What are the effects of seclusion and restrain for patients with mental disorders?

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The keywords and phrases for the research were obtained from the research questions and
includes the following:
 Patient perception of seclusion
 Seclusion
 Psychiatry
 Mental disorders
 Experiences of seclusion
After identification of the research questions and the keywords, a search for the research
papers was conducted. This involved use of the research questions on the online libraries to
search for the articles. The keywords and phrases were also combined and searched on the
Google scholar, PubMed, MedLine and Embase, for scholarly medical articles and research
papers. From the search, identified records were sixty-two and after first screening of duplicates,
a total of twenty-four research papers were identified and contained information closely relating
to the study. The papers were analyzed for quality and relevance through reading the abstracts
and checking for the publication dates. Those papers that were more than five years old were
eliminated as they may contain information that has been rendered irrelevant by recent studies.
After the analysis of the literature materials, six papers were selected as they contained most of
the information being searched for. The entire process used the Preferred Reporting Items for
Systematic Reviews and Meta-Analysis (PRISMA) method to collect its data from various
databases as shown in diagram 1.

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PRISMA Protocol

Diagram 1: Inclusion exclusion flow chart (PRISMA)
Records identified through the
search on Google Scholar
database (n = 32)

Records screened for quality:

n = 16

Records excluded:
n = 12

Full-text records assessed for
eligibility:
n = 9

Full-text articles excluded with reason

n = 7

Final literature sample:
n = 6

Additional records identified
through other sources: PubMed,
MedLine and Embase (n = 30)

Records after duplicates removed:

n = 28

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The chosen literature information was then recorded in a table as shown below:
Author(s),
date and
country of
origin (A-Z)

Aim of study Methodology Main findings

Blair et al.
(2016)
America

The pilot study involves
an intervention design
meant to de-escalate the
seclusion and restraints
and then evaluate the
effectiveness of the said
program. The
intervention included use
of Broset Violence
Checklist, staff
education, and trauma
care.

The study was
conducted in one of
the largest urban
psychiatric facilities
with a bed capacity of
120 beds. Analysis of
the frequency and
duration of occurrence
of seclusion and
restraint incidents was
done. Descriptive
statistics was used.

From the statistical
data obtained, there
was a significant
inverse relationship
between the
intervention and
seclusion and time
spent on seclusion.
Where they both
registered a decrease.
Results indicated that
the intervention
improve the outcomes
and further use of it
will eventually lead to
lower seclusion and

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restraint episodes in the
facility and thus
making the patients
feel comfortable.

Goulet &
Larue (2017)
Canada

This study focused on the
ideal situation that results
in the use of seclusion
and restrain from the
perspective of the staff
and the patients within a
psychiatric ward.

A case study was used
where a 56-hr
immersion into
practice setting and
interviews were used.
A total of seventeen
staff and inpatients
were involved in the
study. three factors
namely staff, patient,
and environmental
characteristics were
considered in the
study.

Implicit (ward rules)
and explicit (hospital
procedures) were found
to influence seclusion
and restrain. Seclusion
was found to pose a
difficult experience for
the patients. Staff
safety feel was found to
be different among
members. The
environment setting in
the wards was termed
as unsafe to practice
seclusion.

Harahsheh
(2019)
Jordan

To clarify a all-inclusive
analysis related to using
seclusion among
mentally unstable

The study used a case
study of a thirty-seven
years old single man
who had been

There are specific laws
that prevent use of
seclusion. There are
many studies

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individuals and argue
many ideas which
focused on use or not use
seclusion among
mentally ill in-patients
from legal and ethical
dimensions, followed by
summary and an end.

involuntarily admitted
to a hospital with
depression and
psychotic behavior.
The individual became
aggressive and tried to
cause harm to others
in the ward forcing the
care providers to
seclude him

advocating for
minimization of
seclusion due to ethical
consideration.

Haugom et
al. (2019)
Norway

The study aimed at
identifying the measures
that staff use in
psychiatric settings
assess and determine
cases of seclusion and the
ethical challenges
attributed to it.

The study analyzed
149 detailed cases of
seclusion from fifty-
seven psychiatric
wards in Norway
using a descriptive and
exploratory approach.
Qualitative content
analysis method was
used in data analysis.

There are ethical
challenges in treatment
and control during
seclusion. Staff desire
to provide the best
treatment during
seclusion and they
understand that being
loyal to a treatment
plan is important. Staff
feel that most patients
are negative towards
seclusion.

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Newman &
Fogg, (2018)

The objective of the
study is to determine the
impact that training has
on staff on reducing the
rate of inpatient seclusion

The study involved a
90-minute training of
the staff in 2015 and
also used surveys to
collect data for
measuring several
secondary outcomes.

The study found that
seclusion rates reduced
from a six-month
intervention with an
average of 2.95 hours
of seclusion for every
1,000 patient hours to
0.29 seclusion hours
for the same number of
patients

Schneeberger et
al, (2017)

The study focused on
aggression and violence
for psychiatric patients
under locked and open
door techniques in
various hospitals in
Germany.

The study analyzed
data from seventeen
hospitals and the
records were from
1998 to2012. Data was
analyzed for
participants who were
on open, partially open
and closed door policy
in the facilities.

The study found that
the there was no
significant effect for
the open versus locked
door policy in the
analysis of aggressive
behavior in treatment.
Seclusion and restraint
were found to be less
likely for hospitals with
open door policy.

Appraisals and Findings

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Blair et al. (2016) conducted a pilot study in one of the mental hospitals in an urban area
as a move to reduce seclusion and restraints in the psychiatric hospital. The authors understood
that in psychiatry, one of the biggest challenges is the management of violent and aggressive
behavior in the patients. The most common method of handling such inpatients is restraint and
secluding the individual so as not to cause harm to self and others. They came up with an
evidence-based intervention program that would engage the staff in a training process to educate
them. The components of the program included Broset Violence Checklist (BVC), mandatory
training of the staff on crisis intercession and trauma care, regular rechecks on the care giver’s
need for seclusion and restraint of patients, and environmental development. All these
components were required to be fulfilled by the end of the pilot study to evaluate its efficiency
and possible application on a large scale.
The study was approved by the Institution Review Board and got partial funding from its
research committee. The baseline data obtained was from incidents that occurred the previous
year from December 2008 to September 2009 before the beginning of the program and the total
sample size was 3884. The sample size for the study was 8029 and was collected from October
2010 to September 2012. Comparison of the frequency and duration each event was done
between the study sample and the baseline data. Chi-square was used to compare the incidents
while the t-test compared the durations. The results indicated that the intervention led to a
significant decline in the rate of seclusion events from 9.2 to 4.4 per 100 cases. The rate of
restraints also declined by 6% during the study period. The intervention results were found to be
consistent with those of previous reports on seclusion and restraints. The study concluded by
recommending further studies to be done to determine whether the intervention program

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strategies can be generalized and be used on a large scale and have the same reduction effect on
seclusion and restraint.
Goulet and Larue (2017) conducted a case study that focused on understanding the
situations that lead to the use of seclusion and restraints as understood by patients and staff in a
psychiatric facility. The study was prompted by the fact that there are many seclusion and
restraint reduction intervention programs that have been verified to be efficient recently.
However, the prevalence of seclusion and restraints remain high. According to the authors, many
research studies have shown seclusion and restraint use to have severe physical damages to the
patient. These damages include injuries, discomforts and deaths in some cases. Psychological
consequences include stress, fear, anxiety and a sense of neglect. For the staff, studies show that
they are faced with fear, stress, guilt, and injuries when handling aggressive and violent patients.
The authors used an instrumental case study that used a participatory approach.
The case study was from an adult mental care facility with 420 beds in Montreal. The
study focused on one unit that held twenty-seven patients. The researchers used convenience
sampling for the patients and staff. Multiple data sources were used to get information about the
case study. Interviews that were recorded, were transcribed into texts and read multiple times to
get the relevant information required. Interviews from patients required deeper analysis as the
information provided could be considered as not reliable due to their mental status. The study
used QDA software for data analysis and it provided 1,004 segments. Tables were used to
present the data from the analysis. The results were categorized based on patient and staff
perceptions. Patients considered seclusion and restraints as a difficult experience in their
emotions. They felt uncomfortable being subjected to the mistreatment. Staff feared their jobs as
they felt that they could lose their lives as the patients’ violent behaviors are unpredictable. The

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hospital protocols were not highly talked about but the ward rules were discussed as this is where
patients interact with their care providers. The study had a limitation of a small sample size. The
study recommends the need for enhanced communication between patients and the staff before
and after episodes of seclusion and restraint. The authors also recommend that intervention
programs to address the roles that patients should play in case of the event occurrence.
Harahsheh (2019) conducted a study on the use of seclusion on patients with aggressive
behaviors in a psychiatric facility. His study used a case study approach to analyze the best ways
to use seclusion for aggressive patients and the different options available that determine whether
or not to use seclusion legally and ethically. The case study involved a thirty-seven years old
man called Sami who had been hospitalized with mental-related health complications. The
patient was aggressive and tried to harm others warrantying restraint and seclusion to avert the
impending danger to other patients in the ward. The author presents arguments of the case based
on legal and ethical components. From a legal perspective, Harahsheh notes that every patient
including those in psychiatric wards has a right not to take any treatment including seclusion
which is also a form of treatment. However, there is a loophole in law as there are no laws that
prevent the use of seclusion of patients in psychiatric facilities.
Internationally, seclusion is considered as an emergency measure that care providers use
on mentally ill patients to prevent them from causing harm to themselves and others when they
turn aggressive. However, how it is conducted is not governed by any policies making
psychiatrists manhandle the patients inappropriately. Many interventions and policies have been
formed and implemented to minimize the use of seclusion on mentally ill patients in psychiatric
facilities. They aim at enhancing ethical considerations that protect these patients from physical
and psychological abuse. The author does not support the use of seclusion for mentally unstable

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individuals in the health facilities. He recommends education to the staffs, enhanced
communication between them and the patients, and train them on de-escalation measures. Also,
the staff should be taught on pharmacological education to use antipsychotic drugs instead of
seclusion and restraints.
Haugom et al. (2019) researched the ethical challenges that seclusion induces in mentally
unstable patients in a psychiatric facility in Norway. The study aimed to evaluate how caregivers
in psychiatric facilities assess and describe the ethical issues associated with seclusion in the
country. According to the authors, the Norwegian description of seclusion as a form of
intervention for the psychiatric patients in the facility wards which is a progression of milieu
therapy. There has been a high number of seclusions in Norway as 2017 there were 2517
reported cases. This study was part of a project that aimed at developing knowledge on and
efficient seclusion approaches that can be used by the psychiatrists when handling mentally
unstable patients. The authors used detailed accounts of events of seclusion that occurred in the
facilities through a descriptive and exploratory method.
Data collection was done using a semi-structured form that was sent to sixty-four
psychiatric wards in Norway. The form required the staff to provide a written narrative of the
seclusion measures used in these facilities. The psychiatrists who participated in the study were
required to have adequate information concerning the patients and be cooperative with the ward
staff. Patients whose information was provided were either subjected to seclusion in the ward
isolation room or other isolated places. Data analysis was done using the Graneheim and
Lundman’s method focusing on the subject and situation. To ensure that ethical considerations
were upheld, patient information remained anonymous in the study. the study found a strong
relationship between the treatment method and control measures used in seclusion and ethical

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issues. Staffs were found to be eager to administer good treatments to the psychotic patients
during seclusion. Patients did not appreciate being subjected to seclusion as they felt that it
dehumanized them. Since the staffs have to take control of an aggressive and violent patient, the
treatment approach raises ethical dilemmas. The use of semi-structured forms limited the study
as they are not robust. The study had the potential for biased information from these forms. The
authors recommended more research to assess the different forms of seclusion, approaches and
environments.
Newman & Fogg, (2018) carried a research project that focused on the effects that staff
training intervention has on the rate of seclusion within an adult patient psychiatric ward. This
study was carried out in an 18-bed adult psychiatric facility within a 300+ bed regional hospital
in Oregon. The researchers took eighty-eight staff and put them under the training. This was part
of an eight-hour mandatory unit. This was a paid skills day and the participants were made aware
through verbal and written notice. The participants were required to join the training on a willing
basis and their personal details were not required so as to maintain anonymity. Data collection
involved the use of monthly HBIPS-3 patient seclusion rates and anonymous staff survey. From
the study, the researchers identified that the average seclusion hours per 1,000 patient hours was
at 2.95 before the training. After the training, the seclusion rate reduced significantly to a rate of
0.29. From the anonymous survey, it was identified that the trained staff members had gained
knowledge, some change in attitude, and de-escalation skills.
Schneeberger et al, (2017) carried out a study to determine aggression and violence in
psychiatric hospitals in Germany. The study focused on the open versus closed door policy in
dealing with behavioral treatment for psychotic patients. The researchers conducted the research
on twenty-one psychiatric hospitals where they analyzed one of seventeen hospitals with open

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policy. Here they analyzed 68,135 record and obtained data for the study. For those without open
policy, the study analyzed 246,195 records from one of the four hospitals. In total, 314,330
records from 1998 to 2012 were analyzed by the researchers. Data was also analyzed on the basis
of hospitals that practiced full open, partial, and full locked policy in their wards when dealing
with aggressive and violent psychiatric patients. The type of hospital and ward was determined
using generalized linear mix-effect model.
The outcomes of the data analyzed from the study indicated that there was no significant
difference between open and locked policies for controlling aggressive and violent patients.
Hospitals that practiced locked policy were found to engage more restraints and seclusion as
compared to those with an open policy for handling patients with aggression. There was no
difference in the type of aggression demonstrated by psychiatric patients for both types of
hospitals. Due to minimal use of interventions to control aggression, open policy hospitals were
found to significantly reduce aggression.

Implementation

Many intervention programs have been developed and implemented in psychiatric
settings as identified by Harahsheh. However, the negative impact seclusion has on psychotic
patients continue to occur. These programs are meant to make seclusion and restraints more
pleasant to the patients and secure. The success of these intervention has been achieved but after
the enrolment, they are quickly forgotten and the staff resume the usual methods of restraining
aggressive patients. This can be eliminated if there were better strategies developed to do a
follow-up. After educating the caregivers and the patients, a special committee needs to be
formulated and be mandated to regularly check on how aggressive cases are handled and
secluded without causing much harm physically and psychologically to the patient. This will

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make violent patients calm as they will not feel intimidated or their rights violated. A follow-up
protocol should be made a policy to ensure that every staff in psychiatric facility handles the
patient appropriately.
When mentally ill patients are taken into seclusion by force due to violent and aggressive
behaviors, they tend to become more aggressive making it hard for the staff to work with them.
According to Haugom et al. (2019), the patients become distressed and develop anxiety.
Effective communication between the psychiatrist and the patient enhances control of the
situation and may minimize the need to seclude the patient as he will calm down. The caregivers
require to be trained on ethical methods of handling violent and aggressive behaviors and trauma
developed after seclusion. Mentally ill patients have been found to have a minimal instance of
seclusion when their care providers are close to them and communicate with each other.
Therefore, they should minimize the aggressive handling of the patients as this may also cause
injuries to them as they work. Seclusion should be considered as the last option in the case of a
violent mental patient.
In most cases, the care providers to the mentally unstable patients are faced with an
ethical dilemma when they are handling aggressive patients. These patients have a right to refuse
any treatment and seclusion just like any other patient. If the staff were to adhere to this law, they
would endanger other patients in the wards and themselves from this aggressive and violent
psychotic patient. If they seclude the patient, they will be breaking the law but securing other
patients and themselves. The problem with handling the patients is that there are no policies to
guide how they should be treated when they are aggressive and violent. When an episode occurs,
the workers do not have time to determine the ethical dilemmas involved as a lot can happen
within a short time causing more harm than expected. It is upon the staff to decide as quickly as

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possible the steps to take to control the situation. However, clear and elaborate guidelines need to
be implemented so that this dilemma is eliminated and the workers can do their job
appropriately.
Collection of information about the perception that patients have towards seclusion is a
difficult task as you are dealing with people who are not mentally fit. They are likely not to
provide the expected answers leading to a lack of reliable data. The easiest way to get the data is
through engaging the staff who have adequate knowledge about the patients to provide the
information. This means that the information is from a second source and hence subject to bias.
Some staff may lie to hide the actual feeling of the patients towards being restrained and
secluded as they do not want to be seen as the ones causing the trauma. This is a major problem
towards implementing a good intervention that will minimize cases of seclusion. The developed
program is likely to have loopholes due to the bias of the provided information. More research is
required to ensure that more data is collected and then compared to determine the actual situation
in most facilities so that a comprehensive policy can be made.
Since most patients do not like to be placed under seclusion, more methods of controlling
aggressive and violent mental patients should be advocated for. Researchers continue to develop
antipsychotic drugs that are rapid-acting to lower the aggression and calm the situation. Many
facilities only employ the use of isolated rooms where the aggressive patient is secluded from the
others and this increases pressure and distress in the individual. After calming down, most of the
psychotic patients develop trauma due to staying isolated from others. They develop fear and
when there is a recurrence, the violence is more severe and may result in deaths as indicated by
Goulet and Larue (2017). The staff should be educated on these drugs ass advocated by

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Harahsheh in his study, to ensure that the mentally ill and aggressive patients are treated
immediately and they calm down.
The biggest challenge that this study faced was that there exist very few studies that deal
with mentally ill patient perception of seclusion in psychiatric settings. Both the past and recent
studies are few making the knowledge pool in this field inadequate. It was difficult to get recent
research papers as most of the available ones are past ten years which could make their result
irrelevant to the current situation. Most research work has been done on the non-mentally ill
patients leaving this area undiscovered. From the literature materials used in this study, all the
researchers recommended further research in different areas. The health sector should encourage
more researchers to venture into psychiatry and seclusion so that different problems can be
identified and better policies formulated. Having a better understanding of how aggression and
violence occurs can help care providers and researchers to find alternative solutions to handling
psychotic patients instead of using seclusion which is considered an unfavorable to them.

Conclusion

Seclusion is a critical move that care providers are required to take when some aggressive
and violent mentally sick patients in a psychiatric ward become a danger to themselves ad to
others. It entails restraining the patient and placing him in a separate room where movement is
restricted. According to some studies, the method should be the last solution in handling an
aggressive patient as it has physical and psychological impacts. There are issues raised on how
these patients should be secluded as there exist no specific guidelines. According to law, a
mentally ill person has equal rights as any other patient. Therefore, the person is entitled to the
freedom of accepting or rejecting any form of treatment. This means that the patient can decide
to reject being secluded and the right is respected. However, there is no policy guide as to how

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an aggressive patient should be handled. According to staffs working in psychiatric wards,
mentally sick inpatients do not want to be secluded. They feel mistreated and their rights denied
leading to anxiety, distress and panic. After the incident calms down, most of these inpatients are
reported to experience trauma from the ordeal. Different intervention programs have been tested
and proven to be effective but seclusion cases have not changed. I recommend the development
of policies and follow-up teams that will ensure that the guidelines are followed and the patients
receive appropriate care. Also, there is a need for more research work to be done to ensure that
the psychiatric department is analyzed well for the easier formulation of policies. Mentally ill
patients are equally humans and deserve to be treated with the most humane way possible
regardless of the temperament they exhibit.

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