Restricted accessReview articleFirst published online 2026
Contributors to seclusion use in adult mental health inpatient units across organization for economic cooperation and development countries: A systematic literature review
The use of seclusion remains a controversial practice in psychiatric care, raising human rights concerns.
Objective
To synthesize and analyse evidence on factors contributing to the use of seclusion in adult mental health inpatient units across countries within the Organization for Economic Cooperation and Development (OECD).
Methods
A comprehensive literature search was conducted following the PRISMA guidelines, with focus on studies published until 28th February 2025, which reported on use of seclusion or similar restrictive practices in adult psychiatric inpatient units. The Covidence tool was used for full-text screening, data extraction, and initial quality assessment.
Results
The review identified complex interactions among factors influencing seclusion, with variation in findings related to patient demographics and clinical characteristics, staff attributes, and ward conditions. Organizational and political factors were less frequently examined; however, available evidence suggested progressive policy frameworks were associated with lower seclusion rates.
Conclusion
This review highlights the need to reconceptualise seclusion practices, advocating an integrated approach that incorporates socio-cultural and policy-level interventions alongside patient and staff factors. Further research is needed to inform policy and practice on seclusion use in adult mental health settings across OECD countries.
CarronMASaadH. Treatment of the mentally ill in the pre-moral and moral era: a brief report. Jefferson Journal of Psychiatry2012; 24(1), 1. https://doi.org/10.29046/jjp.024.1.001
2.
Paradis-GagnéEPariseau-LegaultPGouletMH, et al.Coercion in psychiatric and mental health nursing: a conceptual analysis. Int J Ment Health Nurs2021; 30(3): 590–609. https://doi.org/10.1111/inm.12855
3.
SavageMKLeppingPNewton-HowesG, et al.Comparison of coercive practices in worldwide mental healthcare: overcoming difficulties resulting from variations in monitoring strategies. BJPsych Open2024; 10(1): e26. https://doi.org/10.1192/bjo.2023.613
4.
FaissnerMBraunE. The ethics of coercion in mental healthcare: the role of structural racism. J Med Ethics2024; 50(7): 476–481. https://doi.org/10.1136/jme-2023-108984
5.
BuschABShoreMF. Seclusion and restraint: a review of recent literature. Harv Rev Psychiatr2000; 8(5): 261–270.
MulunehZBChavulakJLeeDA, et al.Variations in definitions used for describing restrictive care practices (seclusion and restraint) in adult mental health inpatient units: a systematic review and content analysis. Soc Psychiatr Psychiatr Epidemiol2025; 60(1): 1–24. https://doi.org/10.1007/s00127-024-02739-6. Epub 2024 Jul 30.
8.
OECD. New benchmark for mental health systems: tackling the social and economic costs of mental ill-health. In: OECD health policy studies. OECD Publishing, 2021.
9.
LinkhorstTBirkelandSFGildbergFA, et al.Use of the least intrusive coercion at Danish psychiatric wards: a register-based cohort study of 131,632 first and subsequent coercive episodes within 35,812 admissions. Int J Law Psychiatr2022; 85: 101838. https://doi.org/10.1016/j.ijlp.2022.101838
10.
BelaynehZChavulakJLeeDA, et al.Prevalence and variability of restrictive care practice use (physical restraint, seclusion and chemical restraint) in adult mental health inpatient settings: a systematic review and meta-analysis. J Clin Nurs2024; 33(4): 1256–1281. https://doi.org/10.1111/jocn.17041
11.
BaggioSKaiserSHuberCG, et al.Effect of coercive measures on mental health status in adult psychiatric populations: a nationwide trial emulation. Epidemiol Psychiatr Sci2024; 33: e35. https://doi.org/10.1017/S2045796024000416
12.
HennessyBHunterAGrealishA. A qualitative synthesis of patients’ experiences of re-traumatization in acute mental health inpatient settings. J Psychiatr Ment Health Nurs2023; 30(3): 398–434. https://doi.org/10.1111/jpm.12889
13.
MubayiwaGCJosephBGilbertJ, et al.Nurses’ perspectives on the proposed seclusion elimination in mental health wards. Int J Ment Health Nurs2024; 33(6): 2145–2156. https://doi.org/10.1111/inm.13375
14.
The Royal Australian and New Zealand College of Psychiatrists (RANZCP). RANZCP: position statement 61: minimizing and, where possible, eliminating the use of seclusion and restraint in people with mental illness. RANZCP, 2021.
15.
KuosmanenLMakkonenPLehtilaH, et al.Seclusion experienced by mental health professionals. J Psychiatr Ment Health Nurs2015; 22(5): 333–336. https://doi.org/10.1111/jpm.12224
16.
Victoria Department of Health. Chief Psychiatrist’s guideline and reporting directive on restrictive interventions under the mental health and wellbeing act. The Victorian Government, 2022.
17.
Organization for economic cooperation and Development (OECD). Better policies for better lives. Organization for Economic Co-Operation and Development, 2025.
18.
PageMJMcKenzieJEBossuytPM, et al.The PRISMA statement: an updated guideline for reporting systematic reviews. 2020. BMJ2021; 372: 71. https://doi.org/10.1136/bmj.n71
19.
Veritas Health Innovation, Melbourne, Australia. Covidence systematic review software. Veritas Health Innovation, 2025. https://www.covidence.org.
CullenAEBowersLKhondokerM, et al.Factors associated with use of psychiatric intensive care and seclusion in adult inpatient mental health services. Epidemiol Psychiatr Sci2018; 27(1): 51–61. https://doi.org/10.1017/S2045796016000731
22.
DoedensPMaaskantJMLatourCHM, et al.Nursing staff factors contributing to seclusion in acute mental health care - an explorative cohort study. Issues Ment Health Nurs2017; 38(7): 584–589. https://doi.org/10.1080/01612840.2017.1297513
KirkpatrickH. A descriptive study of seclusion: the unit environment, patient behavior, and nursing interventions. Arch Psychiatr Nurs1989; 3(1): 3–9.
26.
KrücklJSMoellerJImfeldL, et al.The association between the admission to wards with open-vs. closed-door policy and the use of coercive measures. Front Psychiatr2023; 14: 1268727. https://doi.org/10.3389/fpsyt.2023.1268727
27.
LaiJJuryALongJ, et al.Variation in seclusion rates across New Zealand’s specialist mental health services: are sociodemographic and clinical factors influencing this?Int J Ment Health Nurs2019; 28(1): 288–296. https://doi.org/10.1111/inm.12532
28.
O’MalleyJEFramptonCWijnveldA-M, et al.Factors influencing seclusion rates in an adult psychiatric intensive care unit. J Psychiatr Intensive Care2007; 3(2): 93–100. https://doi.org/10.1017/s1742646407001124
29.
TullochLWalkerHIonR. What influences the use of seclusion? A cross-sectional study of forensic mental health nurses in a UK high secure hospital. J Forensic Pract2024; 26(4): 201–218. https://doi.org/10.1108/jfp-05-2024-0022
Van de SandeRNoorthoornENijmanH, et al.Associations between psychiatric symptoms and seclusion use: clinical implications for care planning. Int J Ment Health Nurs2017; 26(5): 423–436. https://doi.org/10.1111/inm.12381
32.
BeamesLOnwumereJ. Risk factors associated with use of coercive practices in adult mental health inpatients: a systematic review. J Psychiatr Ment Health Nurs2022; 29(2): 220–239. https://doi.org/10.1111/jpm.12757
33.
DoedensPTer RietGVermeulenJ, et al.Influence of nursing staff characteristics on seclusion in acute mental health care—a prospective two-year follow-up study. Arch Psychiatr Nurs2021; 35(5): 491–498. https://doi.org/10.1016/j.apnu.2021.07.003
34.
JanssenWNoorthoornELingeRV, et al.The influence of staffing levels on the use of seclusion. Int J Law Psychiatr2007; 30: 118–126. https://doi.org/10.1016/j.ijlp.2006.04.005
35.
HøyerGDrangeH. Utviklingen av tvangsmiddelbruk i norske psykiatriske institusjoner [changes in the use of compulsory measures in Norwegian psychiatric institutions]. Tidsskr Nor Laegeforen1994; 114(5): 585–588.
36.
PatelRChesneyECullenAE, et al.Clinical outcomes and mortality associated with weekend admission to psychiatric hospital. Br J Psychiatry2016; 209(1): 29–34. https://doi.org/10.1192/bjp.bp.115.180307
37.
HansenACHazeltonMRosinaR, et al.Exploring the frequency, duration and experience of seclusion for women in a forensic mental health setting: a mixed-methods study protocol. BMJ Open2021; 11(6): e044261. https://doi.org/10.1136/bmjopen-2020-044261
38.
JungferHASchneebergerARBorgwardtS, et al.Reduction of seclusion on a hospital wide level: successful implementation of a less restrictive policy. J Psychiatr Res2014; 54: 94–99. https://doi.org/10.1016/j.jpsychires.2014.03.020
39.
HochstrasserIVoulgarisAMollerJ, et al.Reduced frequency of cases with seclusion is associated with “opening the doors” of a psychiatric intensive care unit. Front Psych2018; 9: 57. https://doi.org/10.3389/fpsyt.2018.00057
40.
GillNSParkerSAmosA, et al.Opening the doors: critically examining the locked wards policy for public mental health inpatient units in Queensland Australia. Aust N Z J Psychiatr2021; 55(9): 844–848. https://doi.org/10.1177/00048674211025619
41.
WayBBBanksSM. Use of seclusion and restraint in public psychiatric hospitals: patient characteristics and facility effects. Hosp Community Psychiatry1990; 41(1): 75–81. https://doi.org/10.1176/ps.41.1.75
42.
BoumansCEEggerJIBoutsRA, et al.Seclusion and the importance of contextual factors: an innovation project revisited. Int J Law Psychiatr2015; 41: 1–11. https://doi.org/10.1016/j.ijlp.2015.03.001
43.
Victorian Government, Melbourne, Australia. The Royal Commission into Victoria’s Mental Health System (RCVMHC). Final report, 2021.
44.
Department of Health, Victorian Government, Melbourne, Australia. Safer Care. Framework for reducing restrictive interventions. Last updated on 28 05 2025.
