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      Reducing conflict and containment rates on acute psychiatric wards: The Safewards cluster randomised controlled trial

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          Abstract

          Background

          Acute psychiatric wards manage patients whose actions may threaten safety (conflict). Staff act to avert or minimise harm (containment). The Safewards model enabled the identification of ten interventions to reduce the frequency of both.

          Objective

          To test the efficacy of these interventions.

          Design

          A pragmatic cluster randomised controlled trial with psychiatric hospitals and wards as the units of randomisation. The main outcomes were rates of conflict and containment.

          Participants

          Staff and patients in 31 randomly chosen wards at 15 randomly chosen hospitals.

          Results

          For shifts with conflict or containment incidents, the experimental condition reduced the rate of conflict events by 15% (95% CI 5.6–23.7%) relative to the control intervention. The rate of containment events for the experimental intervention was reduced by 26.4% (95% CI 9.9–34.3%).

          Conclusions

          Simple interventions aiming to improve staff relationships with patients can reduce the frequency of conflict and containment.

          Trial registration

          IRSCTN38001825.

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          Most cited references39

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          Safewards: a new model of conflict and containment on psychiatric wards

          Delbert L Bowers (2014)
          Accessible summary Rates of violence, self-harm, absconding and other incidents threatening patients and staff safety vary a great deal by hospital ward. Some wards have high rates, other low. The same goes for the actions of staff to prevent and contain such incidents, such as manual restraint, coerced medication, etc. The Safewards Model provides a simple and yet powerful explanation as to why these differences in rates occur. Six features of the inpatient psychiatric system have the capacity to give rise to flashpoints from which adverse incidents may follow. The Safewards Model makes it easy to generate ideas for changes that will make psychiatric wards safer for patients and staff. Abstract Conflict (aggression, self-harm, suicide, absconding, substance/alcohol use and medication refusal) and containment (as required medication, coerced intramuscular medication, seclusion, manual restraint, special observation, etc.) place patients and staff at risk of serious harm. The frequency of these events varies between wards, but there are few explanations as to why this is so, and a coherent model is lacking. This paper proposes a comprehensive explanatory model of these differences, and sketches the implications on methods for reducing risk and coercion in inpatient wards. This Safewards Model depicts six domains of originating factors: the staff team, the physical environment, outside hospital, the patient community, patient characteristics and the regulatory framework. These domains give risk to flashpoints, which have the capacity to trigger conflict and/or containment. Staff interventions can modify these processes by reducing the conflict-originating factors, preventing flashpoints from arising, cutting the link between flashpoint and conflict, choosing not to use containment, and ensuring that containment use does not lead to further conflict. We describe this model systematically and in detail, and show how this can be used to devise strategies for promoting the safety of patients and staff.
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            A tutorial on count regression and zero-altered count models for longitudinal substance use data.

            David Atkins, Scott Baldwin, Cheng Zheng … (2013)
            Critical research questions in the study of addictive behaviors concern how these behaviors change over time: either as the result of intervention or in naturalistic settings. The combination of count outcomes that are often strongly skewed with many zeroes (e.g., days using, number of total drinks, number of drinking consequences) with repeated assessments (e.g., longitudinal follow-up after intervention or daily diary data) present challenges for data analyses. The current article provides a tutorial on methods for analyzing longitudinal substance use data, focusing on Poisson, zero-inflated, and hurdle mixed models, which are types of hierarchical or multilevel models. Two example datasets are used throughout, focusing on drinking-related consequences following an intervention and daily drinking over the past 30 days, respectively. Both datasets as well as R, SAS, Mplus, Stata, and SPSS code showing how to fit the models are available on a supplemental website.
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              The antecedents of violence and aggression within psychiatric in-patient settings.

              C. Papadopoulos, J. Ross, D. Stewart … (2012)
              To systematically review the types and proportions of antecedents of violence and aggression within psychiatric in-patient settings. Empirical articles and reports with primary data pertaining to violence and aggression within adult psychiatric in-patient settings were retrieved. For each study, prospective antecedent data were extracted. The extracted antecedent data were thematically analysed, and all higher-level themes were meta-analysed using rate data. Seventy-one studies met the inclusion criteria, from which 59 distinct antecedent themes were identified and organised into nine higher-level themes. The higher-level antecedent theme 'staff-patient interaction' was the most frequent type of antecedent overall, precipitating an estimated 39% of all violent/aggressive incidents. An examination of the staff-patient interaction themes revealed that limiting patients freedoms, by either placing some sort of restriction or denying a patient request, was the most frequent precursor of incidents, accounting for an estimated 25% of all antecedents. The higher-level themes 'patient behavioural cues' and 'no clear cause' also produced other large estimates and were attributed to 38% and 33% of incidents overall. This review underscores the influence that staff have in making in-patient psychiatric wards safe and efficacious environments. © 2012 John Wiley & Sons A/S.
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                Author and article information

                Contributors
                Len Bowers
                Journal
                Journal ID (nlm-ta): Int J Nurs Stud
                Journal ID (iso-abbrev): Int J Nurs Stud
                Title: International Journal of Nursing Studies
                Publisher: Pergamon Press
                ISSN (Print): 0020-7489
                ISSN (Electronic): 1873-491X
                Publication date PMC-release: 1 September 2015
                Publication date (Print): September 2015
                Volume: 52
                Issue: 9
                Pages: 1412-1422
                Affiliations
                [a ]Institute of Psychiatry, King's College London, De Crespigny Park, London SE5 8AF, United Kingdom
                [b ]Royal College of Psychiatrists, 21 Prescot Street, London E1 8BB, United Kingdom
                [c ]City University London, Northampton Square, London EC1V 0HB, United Kingdom
                Author notes
                [* ]Corresponding author at: PO Box 30, Section of Mental Health Nursing Institute of Psychiatry, De Crespigny Park, London SE5 8AF, United Kingdom. Tel.: +44 020 7848 5323; fax: +44 020 7848 0458. len.bowers@ 123456kcl.ac.uk
                [1]

                Service User and carer Group for Research, led by Professor Simpson, hosted by City University, London.

                Article
                Publisher ID: S0020-7489(15)00160-1
                DOI: 10.1016/j.ijnurstu.2015.05.001
                PMC ID: 4518134
                PubMed ID: 26166187
                SO-VID: 8ba3b5c9-e12d-4b5b-87d5-05b9cfe5a53e
                Copyright © Crown Copyright © Published by Elsevier Ltd. All rights reserved.
                License:

                This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

                History
                Date received : 24 February 2015
                Date revision received : 30 April 2015
                Date accepted : 3 May 2015
                Categories
                Subject: Article

                ScienceOpen disciplines: Nursing
                Keywords: absconding,inpatient,psychiatry,rapid tranquillisation,restraint,seclusion,self harm,special observation,violence
                Data availability:
                ScienceOpen disciplines: Nursing
                Keywords: absconding, inpatient, psychiatry, rapid tranquillisation, restraint, seclusion, self harm, special observation, violence

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