Conflict and containment in psychiatry

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Conflict and containment in psychiatry

• Len Bowers,
• Professor of Psychiatric Nursing
• City University, London

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Where I come from

• Population 59 million
• 8 belong to an ethnic minority African,
  Caribbean, South Asian (and Turkish)
• Secular only 38 believe in God
• 1.8 million Muslims
• Famous for industrial revolution, empire,
  scientific advances, slave trade, football,
  colonialism, generally interfering with everyone
  else, etc.

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Psychiatry in the UK

• Countrywide state funded psychiatric hospitals
  started in 1840s
• Steady growth in size till WW2
• Decreased in size thereafter, with initiation of
  community care
• Closure of large old asylums, coupled with move
  of staff into community teams

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Springfield hospital
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Typical unit now

• Psychiatric unit within the grounds of a general
  hospital
• Short stay admission wards only
• Sectorised each ward serves a locality
• Some specialist services elderly, children,
  adolescents, forensic

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c75,000 local population
Community mental health team
Acute ward 20 beds 20 nurses
Crisis team
Assertive outreach team
Residential care
Admissions for Risk (self/others) Assessment Trea
tment Physical care
More than 500 wards like this in England alone
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Perceived problems

• 200 inpatient suicides every year
• Inter-patient sexual harassment and assaults
• Violence to staff, occasionally serious
• Absconding
• Over-occupancy in some places
• 15 staff vacancy rate
• High staff turnover
• Blame culture
• Quality of care

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Psychiatric nurses in the UK

• Three year direct entry training at University
  Diploma or Degree level
• 66 female
• Modal age group 30-39 years (30)
• Acute in-patient wards 50/50 qualified and
  unqualified nurses
• Minimum starting salary for a qualified nurse is
  19,683 (46,452 TL)

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What in-patient nurses do

• Prevent and manage patients harming themselves
  and others through 24/7 supervision and
  containment
• Contribute to assessment of mental state,
  diagnosis, self-care capability, etc.
• Deliver treatment, mainly medication, but also a
  program of patient activities
• Assist with self-care and deliver physical health
  care
• Care management and liaison

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Post-basic and in service training (examples)

• Prevention and management of violence and
  aggression
• Medication management
• Risk assessment
• Psychosocial interventions, family work, CBT and
  other therapies
• Dual diagnosis
• Further academic courses masters, doctorates

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Conflict and containment research at City
University

• Conflict violence, aggression, absconding,
  medication refusal, rule breaking, drug/alcohol
  use, etc.
• Containment security policies, manual
  restraint, seclusion, special observation,
  coerced IM medication, etc.
• 12 years, gt 2 million (5 million TL) grant
  income, gt 50 publications, many projects

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Evaluations of different containment methods
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Physical restraint
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PRN medication
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Net bed
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Mechanical restraint
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Time out
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Straightjacket
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Methods

• Collected Attitude to Containment Methods
  Questionnaires (ACMQ)
• 1,226 staff (mostly nurses and HCAs) and 1,361
  patients on 136 wards completed the
  questionnaires
• Patients chosen randomly, 10 per ward, and were
  assisted by a research assistant when necessary

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Acceptability of containment
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More containment

• PRN meds, time out and intermittent observation
  the most acceptable to patients
• Mechanical restraint not acceptable, but here
  staff were more extreme in their rejection than
  patients
• Experience of observation improved patient
  ratings, experience of seclusion or coerced IM
  medication had the opposite effect
• Staff approved more of those methods they had
  used
• Male staff approved more of containment in general

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Conclusions and questions

• Patients and staff comprehensively reject
  mechanical restraint
• Intermittent observation is highly acceptable (as
  well as being associated with lower self-harm)
• The nature of that connection might therefore
  also be through respectful valuing of patients
• We need to avoid coerced IM medication and
  seclusion wherever possible (but how?)
• Do we have a gender related problem with male
  staff?

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Absconding
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Absconding exploratory study

• Profiled the absconder (175 absconders and 159
  controls)
• Young
• Male
• Schizophrenia
• Medication refusal
• Previously absconded
• Reasons for absconding (62 patient interviews)
• Bored
• Frightened of other patients
• Feel trapped and confined
• Household responsibilities
• Miss relatives and friends
• Worried about security of home and property
• Reasons for and patterns of absconding defined an
  anti-absconding strategy

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Absconding reduction

• Before and after study of five acute wards
• Overall a significant 25 reduction in absconding
  achieved
• Door locking decreased
• Preparation of handbook, workbooks, poster, cards
• 15 wards completed an audit, 3 months before and
  after measures
• 25 decrease in absconding

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Tompkins Acute Ward Study
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Methods

• Longitudinal study
• 4 years official data on admissions, workforce
  deployment, adverse incidents
• 2 years prospectively collected data repeated
  interviews, questionnaires, and measure of
  conflict and containment
• More than 300 interviews and 15,000
  questionnaires

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Adverse incidents

• Findings
• Incidents associated with each other
• Surges in admissions precipitate incidents
• Days before and after ward rounds
• Weekends 20 fewer incidents
• Same patients
• Consume staff availability
• Increase uncertainty

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Staffing resources

• Findings
• Attendance on 5-day prevention and management of
  violence course is associated with more incidents
  on the ward
• Total staff absence in related to a greater
  number of adverse incidents
• Regular staff absence reduces support or
  stability of the ward atmosphere, leading to
  incidents

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Patients feelings of safety and security
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Method

• Interview schedule created by a service user
  consultant in combination with various user
  groups
• Topic patients feelings of safety and security
  on the ward
• A patient was randomly chosen for interview on
  every other ward, until a total of 60 was reached
• Interviews taped, transcribed and analysed to
  themes

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Findings

• Two-thirds felt no threat from other patients,
  and just under half found staff to be supportive
  and able to keep them safe
• The greatest day-to-day irritation was petty
  thieving
• Intimidation and bullying occurred, mainly for
  cigarettes and money
• There was a strong culture of patients helping
  each other, which was highly valued led to
  discharge grief (suicide risk?)
• Patients who denied they had a need to be there
  saw nothing positive about any aspect of their
  stay

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Working model 1
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Peace on the wards

• Low conflict and high therapy environments
• Low rates of violence, abuse, self-harm,
  absconding, rule breaking, etc.
• Low containment use, i.e. less seclusion,
  sedation, observation, security measures,
  restraint, etc.
• Greater therapeutic activity and interaction
• Positive impact on staff

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Three key processes

• Positive appreciation
• Emotional self regulation
• Effective structure

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Foundations

• Psychiatric philosophy
• Moral commitments
• Emotional self-management
• Technical mastery
• Teamwork skill
• Organisational support

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www.citypsych.com

• Research reports
• Details of our research programme
• List of published research papers
• Masterclass video clips on acute psychiatric
  nursing
• A short story about inpatient care
• Details of the international internet
  psychiatric-nursing mailing list
• Availability of anti-absconding package
• Further information L.Bowers_at_city.ac.uk