Report to the DH Policy Research Programme
Len Bowers, City University
Diane Hackney, Independent User Consultant
Henk Nijman, City University and Radboud University
Angela Grange, Bradford Teaching Hospitals NHS Foundation Trust
Teresa Allan, City University
Alan Simpson, City University
Cerdic Hall, East London and The City Mental Health NHS Trust
Sophie Eyres, City University
November 2007
Department of Mental
Learning Disability
City University
London E1 2EA
Health
and
CONTENTS
ACKNOWLEDGEMENTS .................................................................................... 6
1. EXECUTIVE SUMMARY ................................................................................. 7
BACKGROUND................................................................................................... 7
AIMS .................................................................................................................... 8
METHODS ........................................................................................................... 8
FINDINGS.......................................................................................................... 10
The nature and purpose of acute inpatient psychiatry ...................................... 10
Multidisciplinary working in acute psychiatry ................................................. 11
The aftermath of Serious Untoward Incidents .................................................. 11
Adverse incidents, patient flow and workforce ................................................. 12
Prevention and Management of Violence and Aggression training................... 12
Junior staffing changes and the temporal ecology of incidents......................... 12
The three Psychiatric Intensive Care Units compared...................................... 13
Staff attitudes, ward structure, and conflict/containment.................................. 13
CONCLUSIONS ................................................................................................. 14
The working model of conflict and containment ............................................... 14
Methodological conclusions ............................................................................ 15
General conclusions and recommendations ..................................................... 16
2. INTRODUCTION AND METHODS ............................................................... 22
BACKGROUND................................................................................................. 22
Acute inpatient psychiatric care....................................................................... 22
Recent developments and history ..................................................................... 22
Conflict and containment................................................................................. 24
The working model .......................................................................................... 27
Rationale for the study..................................................................................... 30
STUDY AIMS..................................................................................................... 31
DESIGN.............................................................................................................. 32
SAMPLE............................................................................................................. 32
INSTRUMENTS AND DETAILS OF DATA COLLECTED............................... 33
Official statistics.............................................................................................. 33
Operational Philosophy and Policy Interview (OPPI)...................................... 35
Patient-staff Conflict Checklist – Shift Report (PCC-SR) ................................. 36
Attitude to Personality Disorder Questionnaire (APDQ).................................. 37
Ward Structure Questionnaire (WSQ).............................................................. 38
Patients' Perception of Staff Interview (PPSI).................................................. 39
Focus Group Handovers.................................................................................. 39
Additional questionnaires ................................................................................ 40
PROCEDURE ..................................................................................................... 41
DATA MANAGEMENT AND PROCESSING ................................................... 42
OTHER STUDIES AND EVENTS...................................................................... 43
ETHICAL ISSUES.............................................................................................. 44
3. DESCRIPTION OF WARDS AND HOSPITALS ........................................... 45
2
THE MENTAL HEALTH NHS TRUST .............................................................. 45
THE THREE HOSPITALS.................................................................................. 47
Refuge Hospital ............................................................................................... 48
Haven Hospital................................................................................................ 49
Shelter Hospital............................................................................................... 51
THE WARDS AT REFUGE HOSPITAL............................................................. 53
Manhattan ward .............................................................................................. 53
Thames ward ................................................................................................... 56
Victoria ward................................................................................................... 58
Millwall ward .................................................................................................. 61
Albert ward ..................................................................................................... 64
Refuge PICU ................................................................................................... 67
THE WARDS AT HAVEN HOSPITAL .............................................................. 70
Canary ward.................................................................................................... 70
Felstead ward.................................................................................................. 73
Empire ward.................................................................................................... 76
Deanston ward ................................................................................................ 79
Haven PICU .................................................................................................... 82
THE WARDS AT SHELTER HOSPITAL........................................................... 85
Metropolitan ward........................................................................................... 85
Capital ward.................................................................................................... 87
Prospect ward ................................................................................................. 90
Hoba ward....................................................................................................... 93
Shelter PICU ................................................................................................... 96
COMPARISONS BETWEEN WARDS............................................................... 99
DATA SOURCES FOR THIS CHAPTER ..........................................................101
4. BASELINE INTERVIEWS OF MULTIDISCIPLINARY WARD STAFF...103
INTRODUCTION..............................................................................................103
DATA AND ANALYSIS ...................................................................................109
THE NATURE AND PURPOSE OF ACUTE INPATIENT PSYCHIATRY .......112
Rationales for admission.................................................................................112
Inconsistency ..................................................................................................114
The function of acute care...............................................................................115
INTERPROFESSIONAL WORKING IN ACUTE PSYCHIATRY.....................119
Nurses on interprofessional working...............................................................120
Ward managers on interprofessional working.................................................122
Occupational therapists on interprofessional working ....................................125
Consultant psychiatrists on interprofessional working ....................................128
Interprofessional training ...............................................................................131
SERIOUS UNTOWARD INCIDENTS AND THEIR AFTERMATH .................131
Impact on morale............................................................................................132
Search for understanding................................................................................134
Managerial responses.....................................................................................136
Patient responses............................................................................................139
SUMMARY .......................................................................................................140
5. ADVERSE INCIDENTS, PATIENT FLOW, WORKFORCE VARIABLES,
TRAINING AND TEMPORAL ECOLOGY......................................................141
INTRODUCTION..............................................................................................141
3
DATA AND ANALYSIS ...................................................................................145
Adverse incidents............................................................................................145
PMVA training ...............................................................................................145
Staffing rotations ............................................................................................146
Analysis ..........................................................................................................146
ADVERSE INCIDENTS, PATIENT FLOW AND WORKFORCE.....................149
Serious untoward incidents.............................................................................150
All incidents (SUIs and others) .......................................................................151
PREVENTION AND MANAGEMENT OF VIOLENCE AND AGGRESSION
TRAINING ........................................................................................................152
Incident rates and fluctuations over time.........................................................152
Associations within four-week periods ............................................................153
Associations within weeks...............................................................................155
JUNIOR STAFFING CHANGES AND THE TEMPORAL ECOLOGY OF
ADVERSE INCIDENTS ....................................................................................156
Junior doctor rotations ...................................................................................156
Nursing student allocations ............................................................................156
Days of the week.............................................................................................157
Ward-round days ............................................................................................158
SUMMARY .......................................................................................................159
6. THE THREE PSYCHIATRIC INTENSIVE CARE UNITS COMPARED ..160
INTRODUCTION..............................................................................................160
DATA AND ANALYSIS ...................................................................................161
RESULTS ..........................................................................................................162
Refuge PICU ..................................................................................................166
Haven PICU ...................................................................................................167
Shelter PICU ..................................................................................................169
SUMMARY .......................................................................................................170
7. STAFF ATTITUDES, WARD STRUCTURE, AND CONFLICT AND
CONTAINMENT .................................................................................................171
BACKGROUND................................................................................................171
AIM ...................................................................................................................173
DATA ANALYSIS ............................................................................................174
FINDINGS.........................................................................................................175
The data .........................................................................................................175
Relationships between questionnaires.............................................................180
Staff WSQ and APDQ as precursors and/or consequences of conflict and
containment ....................................................................................................183
Patient WSQ as a precursor of conflict and containment ................................187
Patient interview (PPSI) scores as a precursors of conflict and containment ..188
SUMMARY .......................................................................................................189
8. DISCUSSION ...................................................................................................190
THE NATURE AND PURPOSE OF ACUTE INPATIENT PSYCHIATRY .......190
Bureaucracy ...................................................................................................190
Service provision levels: beds and staff...........................................................192
Other issues....................................................................................................193
Statement of purpose.......................................................................................194
4
INTERPROFESSIONAL WORKING IN ACUTE PSYCHIATRY.....................195
Model of interprofessional working ................................................................196
SERIOUS UNTOWARD INCIDENTS AND THEIR AFTERMATH .................201
Need for support systems and 'blame' .............................................................202
Defensive psychiatry and other outcomes........................................................203
ADVERSE INCIDENTS, PATIENT FLOW AND WORKFORCE.....................207
The effect of admissions ..................................................................................208
A feedback cycle of incidents ..........................................................................209
Regular, consistent, available staff .................................................................209
Implications....................................................................................................210
PREVENTION AND MANAGEMENT OF VIOLENCE AND AGGRESSION
TRAINING ........................................................................................................212
Impact of courses............................................................................................212
Alternative explanations .................................................................................213
JUNIOR STAFFING CHANGES AND THE TEMPORAL ECOLOGY OF
ADVERSE INCIDENTS ....................................................................................215
Decreased stress among patients at weekends.................................................216
Staff stress ......................................................................................................218
COMPARISON OF THREE PICUS....................................................................220
Ethnicity .........................................................................................................220
Differences between the PICUs.......................................................................221
STAFF ATTITUDES, WARD STRUCTURE, AND CONFLICT AND
CONTAINMENT...............................................................................................224
Model confirmation ........................................................................................224
Individual conflict and containment events .....................................................227
Patient evaluations of ward structure..............................................................229
LIMITATIONS ..................................................................................................231
9. CONCLUSIONS AND RECOMMENDATIONS ...........................................235
The working model of conflict and containment ..............................................235
Methodological conclusions ...........................................................................236
General conclusions and recommendations ....................................................237
10. REFERENCES ...............................................................................................243
APPENDICES ......................................................................................................257
APPENDIX 1: OPERATIONAL PHILOSOPHY AND POLICY INTERVIEW (OPPI) ........257
Baseline version .............................................................................................257
Follow up version ...........................................................................................260
APPENDIX 2: PATIENT-STAFF CONFLICT CHECKLIST – SHIFT REPORT (PCC-SR)264
APPENDIX 3: ATTITUDE TO PERSONALITY DISORDER QUESTIONNAIRE (APDQ).266
APPENDIX 4: WARD STRUCTURE QUESTIONNAIRE (WSQ).................................268
APPENDIX 5: PATIENTS' PERCEPTION OF STAFF INTERVIEW (PPSI) ....................270
APPENDIX 6: CONFIDENTIALITY GUIDELINES, 2/1/04 .........................................274
5
ACKNOWLEDGEMENTS
The authors wish to thank the clinical and administrative staff that helped the research
team obtain the data reported in this study; the staff of all disciplines who agreed to be
interviewed on a repeated basis, and filled out questionnaires that became increasingly
tiresome as they were repeated time after time.
We would also like to thank the many patients who have been involved with this
study, from those who were consulted in the early stages on the design of the
interviews, to those who later on agreed to participate in those interviews and/or who
filled out questionnaires.
Managers in the study Trust gave their full and enthusiastic support to this study,
making available data, encouraging staff to participate, and most importantly of all,
were keen to use the results to improve the services for the public. The research team
is most grateful.
The research upon which this publication is based has been supported by funding
from the Tompkins Foundation and the Department of Health. However the views
expressed in this publication are those of the authors and not necessarily those of the
funding bodies.
6
1. EXECUTIVE SUMMARY
BACKGROUND
The disturbed behaviour of acute psychiatric inpatients, and the way that behaviour is
managed, arouse considerable concern. Aggression can result in injuries, sometimes
serious, to other patients or to staff, causing staff absence and hampering the
efficiency of the psychiatric service. Absconding is linked to negative outcomes,
invokes time consuming bureaucratic procedures, disrupts treatment, and causes staff
anxiety. Self-harm or suicide attempts by patients also cause injuries and medication
refusal disrupts treatment, hinders patient recovery and extends length of stay. The
ways in which these behaviours are contained by staff are contentious and emotive,
and there is little evidence or agreement about their efficacy. Concerns have also been
raised that, in the UK, ethnic minority patients are subject to excessive coercion and
containment.
Patient behaviour that threatens the safety of themselves or others we term 'conflict',
and this includes aggression, absconding, use of non prescribed substances,
medication refusal, general rule breaking and resistance/obstruction of treatment. The
measures staff take to maintain safety we term 'containment', and this includes PRN
medication, coerced IM medication, manual restraint, seclusion, special observation,
etc. Our working model arising from previous research suggests that differences
between wards (and on the same ward from time to time) in conflict and containment
7
rates are determined by staff attitudes and behaviour, specifically positive
appreciation of patients, emotional self- regulation, and the provision of an effective
structure of rules and routines for patients.
AIMS
To assess the relationship between (i) nurses' positive appreciation of patients, nurses'
emotional self regulation, the effective structuring of the ward's rules and routine, and
(ii) rates of conflict and containment.
METHODS
A longitudinal study was conducted on 14 acute inpatient psychiatric wards and three
Psychiatric Intensive Care Units in a single NHS Trust. The study Trust served a
population of 650,000 in three inner London boroughs, each of which had high
proportions of ethnic minority residents (approximately 60%, compared to the
England and Wales average of 12%), and high levels of social deprivation (all fell
within the category of the 10% most deprived areas in the country).
Data were drawn from officially collected information on admissions, adverse
incidents, workforce deployment and training; researcher collected information
included end of shift reports from the wards, repeated interviews of patients, ward
managers and consultant psychiatrists, and repeated waves of questionnaires from
8
patients and ward staff. The study was undertaken in two phases, the first
retrospective and utilising officially collected data only (2002-04), the second
prospective and including both researcher and officially collected data (2004-06).
The study brought together four years of officially collected data on adverse incidents
on the wards and patient admissions/discharges; two years of prospectively collected
research data on conflict and containment on the wards, composed of approximately
15,000 end of shift reports, 119 patient interviews, 77 ward manager interviews, and
43 consultant psychiatrist interviews. In addition a number of questionnaires were
collected on a repeated basis throughout the study. Overall response rates for the
prospectively collected data were fair, with 45% of the potential total end of shift
reports collected. Precise estimates of response rates for other items are not possible
to provide, as numbers of staff in post fluctuated over time during the study. For
interviews of patients, a 93% response rate was attained, as replacements were
sampled for those patients who did not wish to participate. The same process could
not be used for staff as, for example, each ward had only one ward manager.
Nevertheless the response from ward managers was excellent, with only a few missed
interviews (96% reponse rate), whereas interviews with consultant psychiatrists were
much more difficult to obtain (46% response rate).
These data are complex, cover a large period of time, and can be analysed in many
different ways. In this report we present findings from qualitative, computer-aided
content analyses of the staff interviews; cross sectional time-series analysis of the
relationship between admissions, workforce deployment and officially reported
adverse incidents; cross sectional time-series analysis of the impact of staff attendance
9
on aggression management training courses and violent incidents on the wards; a
pooled cross sectional analysis of the relationship between day of the week, ward
rounds, and adverse incidents; a mixed method, multiple case comparison study of
psychiatric intensive care; a contrast analysis between patients who receive
psychiatric intensive care and those who do not using logistic regression; and a cross
sectional time-series analysis demonstrating the temporal relationships between staff
attitudes, ward structure, and incidents of conflict and containment.
MAIN FINDINGS
The nature and purpose of acute inpatient psychiatry
Patients are admitted because they appear likely to harm themselves or others, and
because they are suffering from a severe mental illness, and/or because they or their
family/community require respite, and/or because they have insufficient support and
supervision available to them in the community. The tasks of acute inpatient care are
to keep patients safe, assess their problems, treat their mental illness, meet their basic
care needs and provide physical healthcare. These tasks are completed via
containment, 24-hour staff presence, treatment provision, and complex organisation
and management.
10
Multidisciplinary working in acute psychiatry
Nurses, occupational therapists and ward managers valued being listened to and
having their professional knowledge and views considered and respected.
Relationships between nurses and OTs were generally positive; relations between
nursing and medical staff were sometimes positive but could be affected by
differences in styles and approaches of the consultant psychiatrists. Ward managers
worked to accommodate different consultant styles and were central to the successful
operation of the wards. Consultants spoke mainly of their relations with nurses of
which they were largely positive, although some would like nurses to take more
responsibility. Multidisciplinary working consisted of attempts to ensure harmonious
relations, good communications and mutual respect between disciplines. There was
little evidence of staff working alongside each other in a more integrated,
collaborative fashion.
The aftermath of Serious Untoward Incidents
Staff reported feelings of shock, depression, demoralisation, upset, loss, and grief,
followed by ruminations, guilt and anxiety. Levels of containment increased, as did
the focus on risk assessment. Processing of the emotional impact was hindered by the
pace of ward life, a lack of external support, and management investigations. Patient
responses were largely ignored. A few staff responded negatively, hindering service
improvements.
11
Adverse incidents, patient flow and workforce
Adverse incidents were more likely during and after weeks of high numbers of male
admissions, during weeks when other incidents also occurred, and during weeks of
high regular staff absence through leave and vacancy.
Prevention and Management of Violence and Aggression training
A positive association was found between training and violent incident rates. There
was weak evidence that aggressive incident rates prompt course attendance, no
evidence that course attendance reduces violence, and some evidence that update
courses trigger small short term rises in rates of physical aggression. Course
attendance was associated with a rise in physical and verbal aggression whilst staff
were away from the ward.
Junior staffing changes and the temporal ecology of incidents
The arrival of new and inexperienced staff on the wards was not associated with
increases in adverse incident rates. Most types of incidents were less frequent at
weekends and midweek. Incident rates were unchanged on ward-round days, but
increased rates were found on the days before and after ward rounds.
12
The three Psychiatric Intensive Care Units compared
Intensive care patients were more likely to be young, male, and suffering a psychotic
disorder, as compared to general acute ward patients. Caribbean patients were twice
as likely, and Asian patients half as likely, to receive intensive care (age, gender and
diagnosis controlled). There were large differences in service levels, staffing, team
functioning and adverse incidents between the three units. Various aspects of physical
security were important in preventing absconds.
Staff attitudes, ward structure, and conflict/containment
Greater ward structure was associated with more positive staff attitudes to patients.
The level of patient routine on wards predicted total conflict rates in the following
month. However higher levels of conflict led to reduced ward structure in the
following months, demonstrating a bidirectional relationship between the two. Also,
positive staff attitudes to patients were found to follow rather than precede conflict
rates. Greater use of containment was followed by more positive staff attitudes,
especially the use of intermittent observation. Quantitative data collected from patient
questionnaires was not related to outcomes or any other measures.
13
CONCLUSIONS AND LIMITATIONS
Strengths and limitations
A strength of this study was the in depth examination over time of conflict and
containment in a single NHS Trust. This design allowed the identification of potential
causal relationships in a way that other studies could not. However the restriction to a
single Trust can also be seen as a weakness, in that some aspects of the findings might
not be generalisable to services in other parts of the country, perhaps particularly less
socially deprived areas with more sparse minority populations. However much of the
study addresses problems that are common to acute in-patient psychiatry across the
country, and indeed internationally, and the causal pathways identified are likely to be
generalisable. In addition, this study is one of a pair that were undertaken at the same
time. The second study (The City-128 Study) is cross sectional and provides evidence
on generalisability from data drawn from 136 wards in 26 NHS Trusts. Together these
two studies provide a strong foundation for further work.
The working model of conflict and containment
Certain elements of this model were supported. The extent of a daily routine for
patients on the ward was found to be predictive of conflict rates, providing a strong
indication that structure is causal. Links were also found between positive attitudes to
patients and ward structure as measured by different scales, and the presence of
regular staff on the ward was found to be associated with lower incident rates.
14
However evidence was found for several factors influencing conflict rates which were
not in the working model. Stress in the ward community as a whole (admissions, ward
rounds, weekdays, other incidents) seemed to be linked to incidents. The physical
security of Psychiatric Intensive Care Units was found to be important in reducing
absconding. And some aspects of training courses may actually exacerbate rather than
reduce conflict rates. Unpredicted by the working model, adverse incidents and
conflict levels led to an erosion of ward structure over time, demonstrating that
structure and conflict were in a reciprocal relationship.
Several predictions made by the working model were not substantiated by the findings
of this study. Instead of determining conflict and containment rates, staff attitudes to
patients were found to be products of those rates. More conflict led to more negative
attitudes. More containment led to better attitudes. In addition, the working model
predicted that better technical mastery in interpersonal skills would lead to better staff
attitudes and thereby to lower conflict, whereas in fact training courses incorporating
de-escalation skills did not have any impact.
Methodological conclusions
Data collected from patients was disappointing when analysed quantitatively.
Evidence for its validity and reliability was very poor. We conclude that there may be
serious limitations to the use to data generated in this way from acutely ill patients.
Such data may be too biased by the context within which it was collected, and/or the
topic of ward structure and rules one that elicited emotional reactions that obstructed
objective reporting by patients. The experience of being compulsorily detained under
15
mental health legislation may particularly have influenced patient responses, leading
to idiosyncratic variability in scale completion or responses during interviews.
General conclusions and recommendations
Although the management of inpatient care, and the administration of the patient's
care pathway, are both critical and important tasks, they do remove nursing and other
staff from direct patient contact and hinder the development of supportive
relationships with people in crisis.
•
A work analysis study should be conducted with a view to defining the right
staffing and modern technological resources to enable this work to be done at
maximum efficiency, and to identify unnecessary bureaucratic tasks for
elimination.
•
Psychiatric nursing professional bodies and organisations should be requested
to define core assessment and care documentation for acute inpatient
psychiatry with a view to eliminating redundant paperwork.
Nurse staffing levels and acute inpatient bed numbers are currently based on historical
factors and local traditions. The primary tasks of acute inpatient psychiatry are to keep
people safe, assess their mental state, treat their condition, meet their basic care needs
and provide physical healthcare. In order to provide an evidence base for staff and bed
resource investment:
•
The National Confidential Inquiry into Homicides and Suicides should be
requested to investigate the relationship between staffing levels, bed provision
and outcomes, controlling for levels of psychiatric need and morbidity.
16
•
Utilising a descriptive study of patient needs for safety, assessment, etc. the
ideal staffing mix of a ward should be defined by bringing together the
empirical data and professional judgment. Such an analysis should be
undertaken without bias due to professional 'turf' defence or potential cost
implications. It should then be trialled to assess its outcome.
•
In conjunction with this exercise, efficient working methods to provide safety,
assessment etc., should be devised, perhaps by the NHS Institute for
Innovation and Improvement, using methodologies similar to those used in the
'productive ward' and 'No delays (18 week wait)' exercises.
The absence of regular nursing staff, for whatever purpose, has been found to be
associated with raised adverse incident rates.
•
Wards should be fully staffed with a zero vacancy factor. For this to occur
adequate numbers of staff need to be trained, in the right localities (a
responsibility of the training commissioners, Strategic Health Authorities), and
Human Resource Departments need to promptly respond to resignations.
•
Wards should be managed to spread the demands of study and annual leave
evenly across the year.
•
Wards should have adequate regular staff numbers to enable the large number
of training courses required by government policy to take place without an
excessive cost in adverse incidents
Acute inpatient treatment may be considered to be overly dependent on medication
alone, with little evidence for the efficacy of anything else.
17
•
Research should be commissioned that investigates new psychosocial
treatments for the acutely mentally ill.
The tasks of acute inpatient care are to keep patients safe, assess their problems, treat
their mental illness, meet their basic care needs and provide physical healthcare.
•
Relevant University Departments (Psychiatry, Mental Health Nursing,
Occupational Therapy, Clinical Psychology) should review their curricula to
ensure that qualified professionals are equipped to contribute to these tasks.
•
NHS Trust training committees or responsible officers should review their
training to those staff involved in inpatient care to see that it supports staff in
these activities
•
Clinical Audit within NHS Trusts should address the implementation of best
professional practice in acute inpatient wards in relation to these activities.
Respectful communication between the different disciplines is a foundation and
primary requirement for collaborative interdisciplinary care for patients.
•
Trust management teams should identify any wards where this is not
occurring, and take effective action to resolve problems and require good
professional standards of working from all staff.
•
Engagement in relevant multidisciplinary training, with clear and appropriate
learning outcomes for all disciplines, should be required from all acute
inpatient staff.
Serious untoward incidents cause considerable distress for staff, and have the
potential to affect their practice and psychological equilibrium, sometimes for many
18
years. In order to reduce the risks for future incidents, and in order to fulfil their
responsibilities toward the health and safety of their staff, NHS Trusts should:
•
Psychologically prepare staff through a relevant training programme (this
could also usefully be incorporated in basic professional training).
•
After any SUI, provide psychological support to staff and teams via a suitably
qualified third party, at arms length from any necessary post incident
investigation.
Evidence was found for poor support of patients and few attempts to address their
needs in the immediate or longer term aftermath of an SUI:
•
NHS Trusts should ensure their SUI policy requires a debriefing of the patient
group, and that this is actually carried out. Extra staffing support to the ward
may be required to enable this to occur. Given other study findings this is
likely to reduce adverse incidents by other patients in the wake of an SUI.
•
Community practitioners should work with patients after discharge to resolve
any outstanding emotional issues relating to any SUI which may have been
witnessed. In order to do this they will need to engage with their patients
during admission and ask them about their experiences after discharge.
Stress in the patient community seems to be linked to higher conflict rates. High
numbers of admissions are associated with more incidents, as are incidents
themselves. Conflict erodes ward structure thus leading to more conflict. Weekdays
and the days before and after ward rounds have raised incident rates.
•
Ward staff should seek to promote a calm, quiet, relaxed, low stress ward
environment. This could be accomplished through noise reduction, decreased
19
hurry, a calm and confident demeanour, restrictions of visitors to the ward
(both other staff and patient visitors), prompt and caring control of disturbed
patients, and reassurance to other patients following incidents.
•
A trial should be conducted of the provision of extra staff to wards at times of
high stress (e.g. a surge in admissions or the occurrence of an officially
reported incident) to see if incident rates can be reduced.
Staff attendance on courses on the prevention and management of violent incidents
were not found to be associated in falls in adverse incident rates. The removal of
regular staff from the ward in order to attend lengthy courses was associated with
rises in incident rates. In addition, rises in violent incident rates were found following
attendance on follow-up update courses, apparently linked to such courses covering
solely manual restraint skills and ignoring the need to also update de-escalation skills.
•
Trust managers should confirm that the courses they run or purchase cover
both de-esclalation and manual restraint skills, especially the shorter refresher
courses.
•
Further research into the efficacy of such courses in reducing violent incident
rates is required.
•
Wards should be staffed in sufficient numbers of nurses so that cover remains
robust even when some personnel are away for training.
Of all ethnic minorities, Caribbeans were the most over represented in the Psychiatric
Intensive Care Units, whereas Asian patients were least likely to be cared for in this
secure environment. These figures have no clear or certain explanation. In addition
the provision of PICU care was hugely variable, even within the adjoining districts
20
served by a single NHS Trust. This was coupled with massive variations in adverse
incident rates.
•
Further research should be commissioned to specifically examine the
relationship between ethnicity and PICU care.
•
More research should be commissioned to determine what are the most
effective care configurations for patient safety and therapeutic efficacy. That
research will also need to further investigate the interface between the
psychiatric and criminal justice system, as they impact on PICU bed use, with
a view to defining appropriate and effective usage.
There is considerable scope for the further analysis of the dataset collected using
additional statistical techniques to explore relationships between variables.
•
In order to maximise the return on the NHS investment in this study, further
analysis should be commissioned.
21
2. INTRODUCTION AND METHODS
BACKGROUND
Acute inpatient psychiatric care
Acute psychiatric wards are an integral part of psychiatric services as a whole. They
are typically about 20 beds in size, and serve a specific locality. When a person is so
ill they can no longer be treated in the community, it is the acute ward that they are
admitted to. That admission might be because of a relapse of schizophrenia, or other
social crisis that necessitates residential treatment. These wards have beds for both
men and women, and admit only adults. The elderly, children, and those with some
specific mental illnesses, are served by other specialist psychiatric services.
Recent developments and history
Over the last 20 years, the focus of attention for policy makers and researchers has
been on the implementation and development of different models of community care
and the appropriate service configuration, standards, management and training to
make that successful. Most recently, interest has been on developing alternatives to
inpatient care, such as home treatment and crisis intervention teams. With the
collective gaze directed towards community services, inpatient facilities have faced a
demoralising combination of retrenchment and drift with little research, discussion or
development.
22
There has also been a determined effort to reduce bed numbers to an historical low.
The total number of psychiatric beds in England fell from 154,000 in 1954 to around
67,000 in the late 1980s, to just 32,400 in 2003-04, of which just over 13,200 were
acute care beds (Warner 2005), spread across roughly 550 acute psychiatric wards
(Ryan 2002, Garcia et al 2005). Consequently, since the early 1990s, bed overoccupancy has been a constant pressure (Greengross et al 1999). A recent national
survey of adult psychiatric wards in England reported average bed occupancy rates of
100% (Garcia et al 2005), at the very time when home treatment teams and crisis
resolution services were expected to reduce the demand for inpatient beds. The
continuation of such a level of occupancy prevents the provision of an effective,
quality service and leaves staff managing crises rather than providing care (Quirk &
Lelliott 2001).
National guidelines on acute psychiatric care were published in 2002, with the
acknowledgement that “too often acute inpatient services are not working to anyone’s
satisfaction” (Department of Health 2002 p3). A series of reports and studies
highlighting difficulties in acute care were enough to depress even the most
optimistic. Problems included deficits in leadership, clinical skills and risk
management (SNMAC, 1999); lack of nurse-patient interaction and therapeutic
activities (Ford, Duncan & Warner, 1998); a high level of chaos and crisis-driven care
(SCMH, 1998); a non-therapeutic, fearful climate with overworked staff (MIND,
2004); noisy wards with overly restrictive rules, lack of privacy or information about
treatment (Goodwin et al 1999); and a medicalised view of care and indifference to
civil rights (Walton 2000). In a questionnaire survey completed by over 400 members
23
of the mental health charity Mind, more than half the respondents said that acute
wards were un-therapeutic environments with a similar number saying that conditions
were bleak and had a negative effect on their mental health (Baker 2000). These are
all serious concerns and led the Mental Health Act Commission recently to wonder
“whether all inpatient mental health services provide their patients with acceptable
levels of security, care, or a sense of being treated as someone who matters” (MHAC
2005: p19).
The national guidelines on acute psychiatric provision provided the National Institute
for Mental Health (England) (NIMHE) with the task of restoring the therapeutic status
of acute inpatient wards and redefining their role within a comprehensive system of
care (Appleby, 2004). The purpose of acute wards was defined broadly as to provide a
“high standard of humane treatment and care in a safe and therapeutic setting for
service users in the most acute and vulnerable stage of their illness” (Department of
Health 2002, p5). Inpatient services should be used when it is not possible to treat and
support the person at home or in an alternative, less restrictive setting. However, the
philosophy, purpose and nature of the service provided were to be determined locally.
This reluctance to outline the purpose and function of acute inpatient services perhaps
reflects the uncertainty and disagreement about the current focus and future direction
of such services.
Conflict and containment
Admission to a psychiatric ward is often required to ensure the safety of the person
being admitted and of others. Consequently, patient and staff safety is a critical issue
24
for modern acute psychiatric services. The Ward Watch survey by mental health
charity Mind reported that 27% of respondents rarely felt safe in hospital and half of
recent or current inpatients reported being verbally or physically threatened during
their stay (Mind, 2004). The Royal College of Psychiatrists’ National Audit of
Violence, commissioned by the Healthcare Commission, found that a third of
inpatients had experienced violent or threatening behaviour while in care. This figure
rose to 41% for clinical staff and nearly 80% of nursing staff working in inpatient
units (Healthcare Commission, 2005b).
The National Patient Safety Agency analysed nearly 45,000 mental health incidents
reported to the National Reporting and Learning System from almost 80% of mental
health/combined trusts in England and Wales (NPSA 2006). A staggering 83% of
mental health patient safety incidents occurred in inpatient areas that received just
162,250 admissions out of more than a million people receiving mental health care
across the NHS in 2003/4. After accidents, the three most commonly reported
incidents were disruptive/aggressive incidents (10,467; 23%); self-harm (7,726; 17%);
and absconding (3,827; 9%); totalling nearly half of all reports. Almost all incidents
of aggression (9,591; 92%) occurred in inpatient settings and over half of all claims of
clinical negligence refer to incidents of self-harm or violent/disruptive behaviour. As
a result, the National Patient Safety Agency has identified acute psychiatric care as a
priority area for attention.
The Commission for Health Improvement (CHI) has expressed concern at the way
mental health trusts deal with safety issues and found problems with the quality of
hospital environments, staffing levels and skills and systems for preventing and
25
managing risk (CHI 2004). Action is being taken to improve the management of
aggression in the NHS as a whole by the Security Management Services via
standardised training in conflict resolution and a special programme in the prevention
and management of violence in mental health settings (Nyberg-Coles 2005). This
builds on clinical practice guidelines for the management of disturbed behaviour in
inpatient mental health settings, published by the National Institute for Health and
Clinical Excellence (NICE 2005). Inpatient care of Black and Minority Ethnic
patients (BME), especially in relation to disproportionate use of containment, is also
an issue of growing concern, as highlighted by the Count Me In census (CHAI 2005).
The census found that found that Black, African and Caribbean people are three times
more likely to be hospitalised with mental health problems than the rest of the
population, and that once in hospital, black men are 50% more likely to be secluded
and 29% more likely to be subject to physical control or restraint than white men.
Patients in mental health units and those recently discharged are also at high risk of
suicide (Meehan et al 2006). The National Suicide Prevention Strategy for England
includes actions targeting the reduction of suicide among people who are known to
mental health services (Department of Health 2002c) and since the late 1990s, there
has been a reduction in completed suicide by inpatients, largely through the removal
of ligature points. The latest available data shows a decline in inpatient suicides from
220 in 1997 (52 by hanging) to 170 in 2002 (38 by hanging), but a slight increase
again in 2003, with 179 completed suicides, 44 of which were by hanging (NCISH
2005).
26
Absconding by patients from acute psychiatric wards is another significant problem
with an estimated 35 to 39 absconds per 100 patients (Bowers et al 1999; Neilson et al
1996). The National Confidential Inquiry into Suicides and Homicides (Appleby et al
1999) found that 23% of psychiatric in-patients who died by suicide had absconded
from the ward at the time. While the majority of absconds pass with no harm being
caused and patients return by themselves, they still cause the staff a considerable
amount of anxiety and cause both psychiatric staff and the police a great deal of work.
The confidence of relatives and carers can also collapse when a patient leaves the
ward without the knowledge and agreement of the clinical team. The NPSA (2006)
highlighted the challenges faced by staff in its recommendations aimed at reducing
absconding, balancing the risk of service users leaving the ward without staff
knowledge against the need for fire safety and patients’ rights for access and exiting.
The working model
Our research so far has shown that there are enormous variations in the frequency of
these difficult behaviours between different wards. For example, some wards have 12
times more episodes of patients running away than do other wards, without any
obvious difference in the type of patients who are resident there (Bowers et al 2000).
We believe these variations exist, at least in part, because of differences in the ways
psychiatric nurses think and behave. Our previous research has involved systematic
interviews of large populations of staff and patients, plus wide ranging surveys of
staff attitudes and investigations of staff practices. These findings are now forming a
pattern (figure 1) that identifies three important factors in staff behaviour for the
production of low conflict, high therapy psychiatric wards (Bowers 2002). These are:
27
the positive appreciation of patients by staff; the ability of the staff to regulate their
own natural emotional reactions to patients; and the creation of an effective structure
(rules and routine) for ward life. We have further determined that these three
processes are dependent upon a range of factors, these being: (i) the psychiatric
philosophy of staff (how they see the nature of mental illness and their role in care
and treatment); (ii) their moral commitments (e.g. nonjudgmentalism, nursing
professionalism, humanism, honesty etc.); (iii) their use of cognitive-emotional self
management methods; (iv) their technical mastery (in interpersonal skills); (v)
teamwork skill (the achievement of cohesion, consistency, and mutual support, within
and across disciplinary boundaries); and (vi) organisational support (provision of
clinical supervision and learning opportunities). This working model suggests that
low conflict environments are not achieved through high levels of containment, but
through better staff attitudes and working practices. In fact, the use of restrictive
methods to manage aggression (e.g., seclusion) is sometimes contra-productive, as
such measures may affirm the distorted beliefs of the patient about being endangered
and make him or her more afraid of the ward team (e.g., Corrigan, Yudofsky & Silver,
1993). Clearly such an intensification of distorted cognitions will have a negative
influence on the therapeutic alliance, and a repetitive pattern (or vicious circle) of
violent behaviour, followed by the use of more restrictive measures may emerge
(Nijman, à Campo, Ravelli & Merckelbach, 1999).
28
Figure 1. The working model of staff factors in the generation of conflict and
containment.
Positive appreciation
Psychiatric
philosophy
Moral
commitments
Moral perception
in action
Compassion
Positive attitude
Positive impact
Cognitive-emotional
self management
Technical
mastery
Teamwork
skill
Emotional regulation
Suppression
High therapy
Emotional
equilibrium
Low conflict
Effective structure
Low containment
Routine-direction
Organisational
support
Objects
Conduct
More recent work (Bowers, Carr-Walker et al, 2006) has demonstrated the link
between these six factors and a positive attitude to patients (enjoying working with
them, feeling secure in their presence, being accepting of them, having a sense of
purpose in relation to caring for them, and being enthusiastic), improved work
performance, better perception of managers, lower stress and lower burnout. However
this recent work has been cross sectional, and the direction of causality remains open
to challenge. In addition, it is becoming clear that this working model of conflict and
containment, although well defined in terms of the team and individual, is less clear
about the organisational factors that are also critically important.
29
Rationale for the study
It is therefore essential to confirm and elaborate this developing model as well as test
its application in practice. One way to do this is to look at a number of wards and their
development over time. It will then be possible to see how naturally occurring
changes in the variables identified as important by the model, impact upon rates of
conflict on wards. Such changes as the appointment of new ward managers or
psychiatrists, the provision of leadership training for staff, implementation of new
models and philosophies, dynamics in the ward team, changes in local and national
policy like the proposed new mental health act, etc.
Longitudinal designs have never before been applied in this way. A comprehensive
search of CINAHL revealed no longitudinal ward studies in any speciality. A similar
search of PSYCHINFO (post 1984) revealed only one retrospective 21-year analysis
of admission data for a single child psychiatric ward. To the knowledge of the
authors, the only longitudinal studies previously carried out in the psychiatric field on
patient conflict have been hospital rather than ward based, and have been
retrospective and used officially collected data (see Bowers et al’s 1998 literature
review, or Noble and Rodger 1989 as an example).
This proposed study has a further significant benefit. We currently do not have a
natural history of variation in ward incident rates over time. This makes it problematic
to conduct quasi-experiments because there is a risk they may misidentify maturation
or random effects as due to the independently manipulated variables. Information on
incident rates by wards and its variability is also not currently available, making it
30
problematic to make accurate power calculations for intervention studies. Having this
background data is therefore an important step in mounting further intervention
studies.
This research forms part of an integrated and ongoing series of studies into conflict
and containment in acute psychiatric nursing, based at City University, including
multimethod exploratory research, interview studies, surveys, action research and
controlled trials. The programme has been ongoing for ten years, with many
completed and published studies. The ultimate aim of the programme is to discover
how best to accomplish high therapy, low conflict nursing.
STUDY AIMS
The main goal was to assess the relationship between (i) nurses' positive appreciation
of patients, nurses' emotional self regulation, the effective structuring of the ward's
rules and routine, and (ii) rates of conflict (patients' violence, verbal abuse,
absconding, etc.) and containment (nurses use of seclusion, restraint, special
observation, etc.).
Subsidiary goals were 1) to provide data on the natural variation in incident rates on
psychiatric wards over time, and 2) to specifically explore the impact of
interdisciplinary relationships on conflict and containment rates.
31
DESIGN
A retrospective and prospective longitudinal study, using continuous and repeated
measures (qualitative and quantitative).
SAMPLE
The sample included all fourteen acute psychiatric wards plus three psychiatric
intensive care units, belonging to an inner London Mental Health NHS Trust. These
were spread across three hospital sites. In mid-2003 one of the acute wards was
closed, so only some baseline and retrospective data was available for this ward. All
nursing staff on these wards, all consultant psychiatrists and other medical staff
working on these wards, all occupational therapists (where allocated to individual
wards), all participated in the study. All patients resident on these wards were also
part of the study.
Phase one of the study (retrospective) included the collation and analysis of official
data already collected covering 2002 to 2004. Phase two of the study (prospective)
included the collection of baseline interviews in late 2003 and early 2004, followed by
intensive data collection using repeated interviews and questionnaires from mid 2004
to mid 2006. Official data was also collated for phase two.
32
INSTRUMENTS AND DETAILS OF DATA COLLECTED
Data collected was both qualitative and quantitative, and came from a variety of
sources. An overview of the different waves and types of data collection during phase
two is provided in figure 2, which should be consulted in conjunction with the text.
Aug-06
Jun-06
Jul-06
Apr-06
May-06
Feb-06
Mar-06
Dec-05
Jan-06
Oct-05
Nov-05
Aug-05
Sep-05
Jun-05
Jul-05
Apr-05
May-05
Feb-05
Mar-05
Dec-04
Jan-05
Oct-04
Nov-04
Aug-04
Sep-04
Jul-04
Figure 2. Source of data and timings during phase two, excluding baseline interviews
Official data
Patients admission/disch
Adverse incidents
Workforce
PMVA training records
Research data
PCC-SR
Staff APDQ/WSQ
Patient WSQ
PPSI
OPPI (ward managers)
OPPI (psychiatrists)
Official statistics
These included data from;
(i) The Patient Administration System (PAS), the Trust's main system for collating
patient related statistics, and includes comprehensive data on all patients admitted.
This system was used to provide data on bed occupancy and patient characteristics by
ward, e.g. age, gender, ethnicity, diagnosis. This data covered the period April 2002 to
June 2006.
33
(ii) Data on adverse incidents are routinely collected by nursing reports, which are
entered on a proprietary computer system. We were provided with the dates and
wards of all incidents falling into the following categories: verbal abuse, property
damage, physical assault, self-harm, and absconding. Some of these incidents were
severe, requiring special investigation and report, and these were referred to as
‘serious untoward incidents’ (SUIs). An SUI was any incident where medical
treatment was required or death occurred, or where moderate to high financial loss, or
loss of reputation might occur. Managers, using guidelines from the National Patient
Safety Agency, decided whether an incident was counted as an SUI. One hospital
only commenced using the proprietary incident recording system in 2003 (week 36),
so for five wards in our sample this data is less comprehensive. For the remaining 9
wards data covering the full study period (April 2002 to June 2006) was available.
(iii) A rudimentary workforce information system was in use. Weekly returns from
ward managers were collated centrally, and covered staffing changes, vacancy rates,
bank and agency nursing utilisation, annual leave, study leave, sick leave, and number
of hours spent providing constant special observation. This data was available from
October 2003 to June 2006 for all study wards.
(iv) Mental Health Act information systems recording numbers of patients formally
detained and compulsorily treated under different sections of the Act were paper
based and operated by Mental Health Act Administrators in each of the three study
hospitals. Although returns of data were received starting November 2003, a large
time investment was required to secure this from the administrative staff concerned
(who had other responsibilities and duties), and the quality of the data was poor. This
was therefore abandoned in 2004 and none of this data was used in the analysis.
34
(v) Prevention and Management of Violence and Aggression (PMVA) training has
been given to all acute psychiatric ward staff in the study district for many years. A
team of two trainers provided the courses over the period of the study. Courses
consisted of either a five-day foundation course, or a one-day annual update. The fiveday course covered reporting under Health and Safety legislation; the role of personal,
environmental and organisational factors in violence reduction; responses to violence,
involving de-escalation, communication skills, problem solving and negotiation; and
the principles and practice of breakaway and restraint skills. Update courses covered
manual restraint skills only. Full training records for all wards, covering 2002 to early
2005, were made available by the current PMVA trainers. At time of writing, further
data has been requested to cover the rest of phase two, but has not yet been obtained.
Operational Philosophy and Policy Interview (OPPI)
This semi-structured interview, for use with the ward manager and consultant
psychiatrists, has two forms (Appendix 1). One is a baseline interview and covers the
general care philosophy of the subject, their concept of the purpose of acute inpatient
psychiatry, interdisciplinary relationships, team strengths and weaknesses, ward
structure, plans for changes in practice in the coming six months. The second form of
the interview is as a follow up, intended to be repeated every six months, looking
retrospectively at any changes over the past six months in terms of the
multidisciplinary team, patients treated, exceptional events; then again asking about
plans for changes over the six months to follow.
35
Baseline interviews were conducted with 16 ward managers, 17 F grade nurses, 14
Occupational Therapists, during autumn 2003, representing a full response rate from
those categories. Subsequent interviews with ward managers were collected in four
further waves at roughly six-month intervals, with the first wave conducted between
Dec 2004 and Feb 2005, and the last between May and July 2006. Response rates
remained very good and 61 follow up interviews (77 in total) were conducted with
ward managers. Consultant psychiatrists were more difficult to recruit to the study. In
the first baseline interviews in 2003 only nine agreed to participate, although two
worked with each acute ward and one with each psychiatric intensive care unit
(making a potential pool of interviewees of 31, although some posts were vacant at
different times and/or covered by temporary staff). Large amounts of time were
invested trying to recruit them again in autumn 2004, resulting in 19 interviews. For
the nine previous participants these were follow-up interviews, for others the baseline
interview was conducted. Given the workload involved in recruiting for and actually
obtaining these interviews (many were cancelled at the last minute), the frequency
was curtailed to annual, and a final wave of an additional 15 interviews was
completed between Feb and Mar 2006. The total number of consultant psychiatrist
interviews obtained was 43.
Patient-staff Conflict Checklist – Shift Report (PCC-SR)
The shift report version of the Patient-staff conflict checklist (PCC-SR Appendix 2)
checklist was used to log the frequency of patient conflict behaviours (e.g. self-harm,
absconding, violence, medication refusal) either attempted or successful, and the staff
containment measures used to maintain safety (e.g. intermittent special observation,
36
constant special observation, seclusion, physical restraint etc.) and was compiled
using strict definitions at the end of every nursing shift. An inter-rater reliability check
using PCC scoring of medical and nursing case note entries has demonstrated a
satisfactory kappa of 0.69 (Bowers, Douzenis et al 2005), and validation against
official records has shown a significant association between total conflict scores and
total adverse incident rates by week (Bowers, Flood, Brennan et al 2006). In order to
achieve compatibility with another parallel study, for part of the two-year data
collection period wards used a variant of the PCC-SR, containing severity scores for
self-harm incidents, as an alternative to the usual PCC-SR counts of incidents. Staff
on all the wards were trained in the use of the PCC-Sr and provided with a handbook
to refer to for definitions of different types of events.
A total of 15,006 PCC-SRs were returned by the 16 wards, representing an overall
response rate of approximately 45%. Response rates by ward varied from 18 – 84%.
Attitude to Personality Disorder Questionnaire (APDQ)
This is a 37 item, five factor (enjoyment, security, acceptance, purpose and
enthusiasm) scale that assesses staff attitude to personality disorder (Bowers & Allan
2006, Appendix 3). Its psychometric properties are good, with a Cronbach Alpha of
0.94, and a six month test-retest reliability of 0.66 (intra-class correlation coefficient).
Higher scores on this scale are related to the positive appreciation of patients, the
capacity for emotional self-regulation of the member of staff, and the capacity to
implement structure effectively.
37
Six waves of questionnaires were collected from staff at roughly four-month intervals.
The mean number of APDQs per ward per wave (excluding waves with no returns)
was 4.61 (sd = 2.62), with 11 of the 96 possible ward waves having no returns.
Ward Structure Questionnaire (WSQ)
This new instrument completed piloting immediately prior to this study (Appendix 4).
It was constructed based upon three previous qualitative projects in the City
University conflict and containment programme, involving interviews with over 150
staff, 30 patients and more than seven months in total of fieldwork observation in
acute psychiatric settings. The items describe rules and routines for patient conduct,
and the enforcement of those rules, and subjects are asked to indicate the frequency
with which these apply on their ward. The questionnaire is for use with both patients
and staff, and provides four scores:
•
Rules – the overall number of common rules for patient conduct in operation
on the ward.
•
Communication – the degree to which these rules are communicated to
patients and new /temporary staff, and are known by everyone.
•
Routine – the extent of a daily routine for patients
•
Value – the degree to which the implementation of rules and routine by the
staff reflects the values of equality, honesty, and courage.
Six waves of questionnaires were collected from staff at roughly four-month intervals.
The mean number of WSQs per ward per wave was 4.79 (sd = 2.71), with 12 of the
96 possible ward waves having no returns. Four waves of questionnaires were
38
collected from patients. The mean number of WSQs per ward per wave was 2.16 (sd
= 0.7), with one of the 64 possible ward waves having no returns.
Patients' Perception of Staff Interview (PPSI)
This semi-structured interview (Appendix 5) was developed as part of this project by
the User Consultant, via a process of brainstorming questions related to staffs' positive
appreciation of patients, their emotional self-regulation, and production of an effective
structure. The brainstorming process involved users, the research team and the
steering group. An agreed schedule was then piloted with some volunteers, before a
final agreed format was obtained.
Four waves of interviews were collected, with the intention of completing two per
ward for each wave. Patients were chosen at random form those available on the ward
at the time of data collection, subject the assessment of the nurse in charge that they
were fit to participate and their signed informed consent. Two per ward per wave was
the maximum that could be collected given the resources available. A total of 119
interviews were ultimately completed, representing 93% of the target total. The
majority of these (but not all) were conducted by the service user consultant.
Focus Group Handovers
These took place every six months, and involved feedback to the ward staff of
summaries of the data they had collected, plus data from the official recording
39
systems, with mean values from other wards in the study. Those attending were asked
for their explanations of variations, and open discussion of the study results took
place. As well as providing a form of respondent validation, these meetings provided
further information and data aiding in the interpretation of results.
However ultimately only two rounds were held, one in Jan – Feb 2005, and another in
Aug – Oct 2005. Thereafter it became impossible to collect the data at the same time
as keeping up with data inputting and analysis in order to produce the feedback
reports on which the focus groups were based. Delays in getting access to official data
compounded this problem. By the close of the project, 31 of the 64 planned focus
groups had been held.
Additional questionnaires
All the wards in this study completed the questionnaire set from another parallel
research study (City 128), on a 'once only' basis. These were:
Ward Atmosphere Scale (WAS, Moos 1974). This scale measures 10 different
dimensions of the atmosphere and ideology of a ward, is a self-report questionnaire
composed of 100 statements about the ward, each requiring a true or false answer.
The subscales of the WAS reflect aspects of relationships, treatment and maintenance
systems within the ward. Three of these relate to ward structure. ‘Order and
organisation’ reflects how important order and organisation are in the program and
includes statements about planned activities, general tidiness and punctuality.
‘Program Clarity’ reflects the extent to which patients know what to expect in their
daily routine and the explicitness of rules, and includes statements about the
40
predictability of staff availability, decision making and communication about
treatment.. ‘Staff control’ reflects the extent to which staff use measures to keep
patients under control, and includes items about punishments and obedience.
Maslach Burnout Inventory (MBI, Maslach & Jackson 1981). This scale is widely
used and validated in studies of workplace stress and morale, within and outside
healthcare settings.
Multifactor Leadership Questionnaire (MLQ, Bass & Avolio 1995). This scale
assesses the quality of ward leadership, and is a well validated and reliable scale
widely used to assess transformational and transactional leadership.
Team Climate Inventory (TCI, Anderson & West, 1999). Multidisciplinary team
cohesion was assessed using this scale, which has been used in multiple health service
studies, including psychiatric settings (Community Mental Health Teams and wards),
and is derived from a large and well-known programme of work in this area.
PROCEDURE
All wards were first recruited into the study, with a full explanation being given to
their staff about the nature of the project and what it was designed to accomplish.
Baseline interviews (OPPI) were conducted with multidisciplinary ward staff in order
to establish a profile of: the history and character of the wards over the past few years;
and the nature and character of the geographical locality they serve. Existing sources
of information about wards were also identified over this period (e.g. information on
admissions collected for NHS purposes, mental health act usage, personnel data,
incident data) and mechanisms devised for this to be brought together on a regular
41
basis for analysis in a single database. This information was also obtained
retrospectively for the previous few years. Ward’s participating in the study received
training in the use of the PCC-SR and then started using it to submit data. During this
preparatory phase, the Patients’ Perception of Staff Interview (PPSI) was developed
and subsequently piloted, under the leadership of the User Consultant.
Follow up interviews (OPPI) then commenced with all consenting Consultant
Psychiatrists with acute beds, and all ward managers. Waves of patient interviews also
commenced, with two randomly chosen consenting patients from each ward
interviewed by the User Consultant, or when unavailable, a researcher, using the
previously developed schedule (PPSI). After the interview the same patients were
asked to complete (and aided if necessary) the WSQ. This package of data collection
measures was repeated on a six-month cycle.
Also at the commencement of the study, all multidisciplinary staff attached to the
study ward were asked to complete and submit two questionnaires, the Attitude to
Personality Disorder Questionnaire (APDQ) and the Ward Structure Questionnaire
(WSQ). This package of data collection measures was repeated on a four-month
cycle.
DATA MANAGEMENT AND PROCESSING
Official data were assembled, collated, and checked for integrity in a single MS
Access relational database created for the study. Questionnaires (including PCC-SRs)
42
were scanned for data entry using SNAP survey software, with all high scores and
outliers checked against the originals. Data was then exported and matched/merged
with other questionnaires utilising data management features of both SPSS and MS
Access. SPSS and STATA were both used to conduct the final statistical analysis.
OTHER STUDIES AND EVENTS
Four of the sixteen wards in this study were randomly selected to take part in a
national cross sectional study of conflict and containment, the City 128 study of
observation and outcomes, led by the same research team. All wards in this study
therefore completed the City 128 dataset (which overlapped and was compatible), but
only the data from the four randomly selected wards, covering a period of six months,
were utilised in the City 128 study analysis.
Three wards in this longitudinal study participated in the 'City Nurse' study during
2004 (Hoba, Prospect and Empire wards). This study allocated specialist nurses to the
wards in order to reduce levels of conflict and containment. Reference is made to this
in the presentation of findings at appropriate places.
Also during 2004-2005 data was being collected on the study wards for the
EUNOMIA project. This included interviews with patients about their compulsory
admission to hospital and the completion of several questionnaires.
43
Many other events occurred in the Trust, including some changes of senior
management, and changes in policy related to conflict and containment. These are
also referred to where relevant to the findings.
ETHICAL ISSUES
The study was approved by the Local Research Ethics Committee. Hospital and ward
names have been replaced by a consistent set of pseudonyms used in this report and in
all publications from the study. Particularly difficult issues arose relating to
confidentiality and the limits of data collection, as a number of members of the
research team had other and additional roles within the study Trust, such as
membership of various committees. Additional confidentiality guidelines were
therefore produced, and these were approved by the study steering group (Appendix
6).
44
3. DESCRIPTION OF WARDS AND HOSPITALS
THE MENTAL HEALTH NHS TRUST
The top-level organisational unit of the study was a Mental Health NHS Trust. Trusts
are locally based units on the National Health Service in the UK, and provide hospital
and community health services to defined populations, in conjunction with local
government social services departments and independently organised primary care
services (e.g. General Practitioners, Dentists, Pharmacists etc.), and Acute Trusts
providing physical health care. Mental Health NHS Trusts cover varying sizes of
population, from the small (just under 250,000) to large (e.g. 1.7 million), with larger
Trusts running from multiple bases and hospitals.
The study Trust served a population of 650,000 in three inner London boroughs, each
of which had high proportions of ethnic minority residents (approximately 60%,
compared to the England and Wales average of 12%), and high levels of social
deprivation (all fell within the category of the 10% most deprived areas in the
country, Office of the Deputy Prime Minister, 2004).
Just prior to phase two of the study (July 2004) a new Director of Nursing
commenced working for the Trust, and the Trust was awarded 'two stars' in the
national NHS assessment and ranking process – an improvement from the previous
rating of 'one star'. Throughout the study the same Chief Executive led the Trust.
During 2004-2005 Home Treatment Teams were expanded to cover the whole area
45
served by the Trust, and community mental health services changed from a locality
based service to one tied to GPs (i.e. Community Mental Health Teams worked with
patients registered with specific GPs, rather than patient living in specific locales).
New policies on bed management and special observation were introduced during the
study period, and in December 2005 discussions commenced about a new nursing
management structure, primarily for the wards, although its introduction did not
commence until after the study data collection ceased.
Figure two shows the frequency of total conflict and total containment across the
Trust during the phase two. As not all wards commenced the study during the first
month (and not all ceased data collection during the same month), and sometimes
small numbers of PCC-SR returns for part months were made that may not be
representative, the values for the first and last months can be biased. However the
graph shows there was a decline in conflict over the first six months, followed by a
fairly static picture for the remainder of the study.
46
Figure 1. Mean total conflict and total containment events per shift (by PCC-SR)
across the Trust by month, commencing August 2004 (month 8) and finishing July
2006 (month 31)
Total conflict
7.00
Total containment
6.00
Value
5.00
4.00
3.00
2.00
1.00
8.00 10.00 12.00 14.00 16.00 18.00 20.00 22.00 24.00 26.00 28.00 30.00
9.00 11.00 13.00 15.00 17.00 19.00 21.00 23.00 25.00 27.00 29.00 31.00
month
THE THREE HOSPITALS
The Trust provided its acute inpatient services at three different hospitals, each of
which served a different London borough. Each hospital had several wards most of
which in turn served smaller localities and worked in association with specific
community mental health teams serving the same localities, as well as with borough
wide community services such as home treatment teams and assertive community
treatment teams.
47
Refuge Hospital
This hospital, built in the early 1990s, consisted of a unit within the grounds of a
larger district general hospital providing acute medical care, although the two were
organisationally distinct. The study wards at this hospital included four locality based
acute admission psychiatric wards, one small female only ward, and a male
psychiatric intensive care unit. The borough to which this hospital provides services
was the resident location for a wide range of the different ethnic minority groups, the
largest of which were Black African, Black Caribbean, and White Other. Even these
national census based groupings mask a multiplicity of different ethnic backgrounds.
This hospital had the highest ratio of acute beds to population, with a resident
population of 2,038 per bed. During phase two there were changes to the management
team and the introduction of a well-regarded Modern Matron. Home treatment and
assertive community treatment teams had been in existence in the borough for over a
year before phase two of the study commenced. Wards at this hospital (with the
exception of the PICU) were locked at the discretion of the nurse in charge, so at
times they were open and at other times locked. Security guards were available at a
main reception desk, but nearly all incidents were managed by nurses. CCTV was
only utilised in video entry phones to the wards.
Figure two shows total conflict and containment rates over phase two of the study at
Refuge Hospital. It shows that there was some decline in conflict over the first six
months, followed by a period of relative stability. In comparison to the other two
hospitals, Refuge had particularly low levels of containment use, and little variation in
its use from month to month.
48
Figure 2. Mean total conflict and total containment events per shift (by PCC-SR) at
Refuge Hospital by month, commencing August 2004 (month 8) and finishing July
2006 (month 31)
Hospital: Refuge Hospital
Total conflict
8
Total containment
7
6
Value
5
4
3
2
1
0
8.00 10.00 12.00 14.00 16.00 18.00 20.00 22.00 24.00 26.00 28.00 30.00
9.00 11.00 13.00 15.00 17.00 19.00 21.00 23.00 25.00 27.00 29.00 31.00
month
Haven Hospital
This hospital was built in the 19th Century and was originally a workhouse. The
environment was generally of a poor quality and not fit for purpose. At the time of the
study a new replacement hospital was being built on another site, but had not yet
opened and plans for the move were repeatedly delayed during the study period. The
study wards at this hospital included four locality based acute admission psychiatric
wards, and a psychiatric intensive care unit. During phase one an additional acute
admission ward, acting as a collective first point of entry, had been in operation, but
closed during summer 2003. All hosting a large variety of ethnic minority
communities, the borough served by Haven Hospital was dominated by one group:
49
Bangladeshi. Even after the ward closure, this hospital had almost, but not quite as
high a bed to population ratio as Refuge Hospital: Haven Hospital had a resident
population of 2,361 per bed. During phase two this hospital had a consistent
management team until early summer 2006, when the director left and was replaced.
A home treatment team had been started in this borough in April 2003, but was
expanded to cover the whole borough in autumn 2004, at which point an assertive
community treatment team was also initiated.
Wards at this hospital (with the
exception of the PICU) were locked at the discretion of the nurse in charge, so at
times they were open and at other times locked. No security guards or CCTV were
available and all incidents were managed by nurses.
Figure 3 shows total conflict and containment rates over phase two of the study at
Haven Hospital. It shows that there was a steep decline in conflict over the first six
months, followed by a period of relative stability. In comparison to the other two
hospitals, Refuge had particularly moderate levels of containment use, and these
might have risen slightly towards the close of the study.
50
Figure 3. Mean total conflict and total containment events per shift (by PCC-SR) at
Haven Hospital by month, commencing August 2004 (month 8) and finishing July
2006 (month 31)
Hospital: Haven Hospital
Total conflict
8
Total containment
7
6
Value
5
4
3
2
1
0
8.00 10.00 12.00 14.00 16.00 18.00 20.00 22.00 24.00 26.00 28.00 30.00
9.00 11.00 13.00 15.00 17.00 19.00 21.00 23.00 25.00 27.00 29.00 31.00
month
Shelter Hospital
This was the newest of the three hospitals, being built in the new millennium and
opened in 2002. The study wards at this hospital included four locality based acute
admission psychiatric wards, and a psychiatric intensive care unit. The borough to
which this hospital provided services had the highest proportion of ethnic minority
residents, and was home to significant numbers of virtually all ethnic minority groups
in the UK, none of which dominated in terms of numbers. This hospital had the
lowest number of beds proportional to the population (approximately a third less than
the other two hospitals), with a resident population of 3,297 per bed. During phase
two this hospital had a consistent management team with no major changes. A home
51
treatment team was initiated in February 2005. Wards at this hospital (with the
exception of the PICU) were unlocked to patients leaving. Those coming in to the
wards had to ring a bell or use a key, those exiting simply had to push a green button
to release the door lock. The system utilised meant that for any one acute ward to be
locked, all had to be locked. In May 2005, the system was altered so that all wards
were locked both to entry and exit during the night shift. Neither CCTV nor security
guards were available, and all incidents were managed nurses.
Figure 4 shows total conflict and containment rates over phase two of the study at
Shelter Hospital. Unlike the other two hospitals, there was no high rate of conflict to
start with and no decline in conflict over the first six months. Both conflict and
containment levels were relatively static over the whole period of the study, however
containment appeared to have been used at a higher frequency overall in this hospital.
52
Figure 4. Mean total conflict and total containment events per shift (by PCC-SR) at
Shelter Hospital by month, commencing August 2004 (month 8) and finishing July
2006 (month 31)
Hospital: Shelter Hospital
Total conflict
8
Total containment
7
6
Value
5
4
3
2
1
0
8.00 10.00 12.00 14.00 16.00 18.00 20.00 22.00 24.00 26.00 28.00 30.00
9.00 11.00 13.00 15.00 17.00 19.00 21.00 23.00 25.00 27.00 29.00 31.00
month
THE WARDS AT REFUGE HOSPITAL
Manhattan ward
This 19-bedded mixed gender acute admission psychiatric ward served an area with a
large Caribbean population, and significant orthodox Jewish community.
The largest four ethnic categories of patients were: British (32%), White other (17%),
African (16%), Black other (12%). This ward had one of the highest proportions of
male patients (61%) and older patients (36 years and over, 55%).
53
Staffing and incidents: A second consultant psychiatrist started working on the ward
from August 2004. After covering two wards during 2004, the ward manager was
changed in March/April 2005. Otherwise, nurse staffing was fairly stable during
2005-6, but there were several changes of OT during 2005. Good relations with HTT
and AOT were reported in 2005. Numerous SUIs (Serious Untoward Incidents, see
Chapter 4) were reported throughout the study period, including several attacks on
staff, two ward-related suicides and several absconds in late 2005. A patient attacked
several staff during December 2005.
The response rate of Manhattan ward over the study period is displayed in figure 5.
After the first few months, this ward had a fairly static response rate of roughly 50%.
Figure 5. Manhattan ward: Response rate in numbers of PCC-SRs returned per month
Ward: MANHATTAN
100
Value No of PCCs
80
60
40
20
0
9.00 11.00 13.00 15.00 17.00 19.00 21.00 23.00 25.00 27.00 29.00
10.00 12.00 14.00 16.00 18.00 20.00 22.00 24.00 26.00 28.00 30.00
month
54
When measures were taken in late 2004 and early 2005, Manhattan ward was
particularly strong in terms of leadership (MLQ 'Transformational leadership' and
'Outcomes of leadership'), structure (WAS 'Programme Clarity' and 'Staff Control'),
and team functioning (TCI 'Support for Innovation' and 'Vision').
Total conflict and containment rates are depicted in figure 6, and show that after high
levels of conflict in the first two months, this ward remained static at about three
conflict and one containment event per shift.
Figure 6. Mean total conflict and total containment events per shift (by PCC-SR) on
Manhattan ward by month, commencing August 2004 and finishing July 2006
(standardised to 20 beds)
Ward: MANHATTAN
Total conflict
12
Total containment
10
Value
8
6
4
2
0
30.00
29.00
28.00
27.00
26.00
25.00
24.00
23.00
22.00
21.00
20.00
19.00
18.00
17.00
16.00
15.00
14.00
13.00
12.00
11.00
10.00
9.00
month
55
Thames ward
This 20-bedded mixed gender acute admission psychiatric ward served an area with
both a working and middle class population. There were several large deprived
council estates, with a fairly stable population, in close proximity to the hospital. The
population was about half Black British, also with Serbs, Turks, and a small
Vietnamese population. There were a few trendy rich areas, but many dangerous
deprived areas comprising this inner city, vibrant, cosmopolitan area.
The largest four ethnic categories of patients were: British (36%), White other (16%),
Caribbean (13%), Black other (12%). This ward also had one of the highest
proportions of older patients (36 years and over, 53%).
Staffing and incidents: The Ward manager left in October 2003 after five years in
post. An acting ward manager was appointed from Oct 2003 to October 2005, but left
in February 2006 when the ward was managed by the Modern Matron. A new
consultant psychiatrist joined a well established consultant in March 2004. A
permanent OT was appointed late in 2004 and left early 2006. Nurse shortages, bed
pressures and variable relations with the HTT were reported throughout study.
Protected therapeutic time was introduced and increased throughout 2006. In July
2004 a drug administration error led to staff suspension. No major SUIs were reported
but one patient caused disruption though stealing late 2004/early 2005, and in late
2005 a patient overdosed on the ward.
56
The response rate of Thames ward over the study period is displayed in figure 7, and
shows that with the exception of one month with a very poor response (March 2005),
this ward's response gradually climbed until it was making full returns for the final six
months of the study.
Figure 7. Thames ward: Response rate in numbers of PCC-SRs returned per month
Ward: THAMES
100
Value No of PCCs
80
60
40
20
8.00 10.00 12.00 14.00 16.00 18.00 20.00 22.00 24.00 26.00 28.00 30.00
9.00 11.00 13.00 15.00 17.00 19.00 21.00 23.00 25.00 27.00 29.00
month
When measures were taken in late 2004 and early 2005, Thames ward staff tended to
be highly supportive of the use of containment methods (ACMQ 'Efficacy',
'Acceptability', 'Dignified' and 'Safe for patients').
Total conflict and containment rates are depicted in figure 8, and show that after high
levels of conflict in the first month, this ward remained static at about three to four
conflict events per shift and one containment event every other shift.
57
Figure 8. Mean total conflict and total containment events per shift (by PCC-SR) on
Thames ward by month, commencing August 2004 and finishing July 2006
(standardised to 20 beds)
Ward: THAMES
Total conflict
12
Total containment
10
Value
8
6
4
2
0
30.00
29.00
28.00
27.00
26.00
25.00
24.00
23.00
22.00
21.00
20.00
19.00
18.00
17.00
16.00
15.00
14.00
13.00
12.00
11.00
10.00
9.00
8.00
month
Victoria ward
This 13-bedded female only acute admission psychiatric ward served the whole
hospital locality, and took the most vulnerable as well as the most disturbed female
patients from other wards at the same hospital.
The largest four ethnic categories of patients were: white British (24%), African
(22%), White other (17%), Black other (14%). Patients on this ward were generally
58
younger than on most other wards, with the majority (60%) being 35 years of age or
younger.
Staffing and incidents: A new ward manager started in May 2003 following several
changes of leadership and a serious incident on the ward, and took on joint
management of the ward and Mother and Baby Unit in March 2005. One permanent
consultant psychiatrist was on the ward throughout the project. The OT changed in
late summer 2004 and again in June 2006. Protected therapeutic time was introduced
late in 2005. The study period was marked by number of highly disruptive,
disinhibited and sometimes aggressive patients, especially June-Oct 2004, JuneSeptember 2005 and early 2006. An attempted hanging took place in May 2005.
The response rate of Victoria ward over the study period is displayed in figure 9, and
shows that after a steep climb to a maximal response rate of about 66%, this ward's
response gradually declined to just under 50%.
59
Figure 9. Victoria ward: Response rate in numbers of PCC-SRs returned per month
Ward: VICTORIA
100
Value No of PCCs
80
60
40
20
0
8.00 10.00 12.00 14.00 16.00 18.00 20.00 22.00 24.00 26.00 28.00 30.00
9.00 11.00 13.00 15.00 17.00 19.00 21.00 23.00 25.00 27.00 29.00
month
When measures were taken in late 2004 and early 2005, Victoria ward staff had
particularly negative attitudes towards personality disordered patients (APDQ
'Enjoyment', 'Acceptance', 'Purpose', and 'Enthusiasm'), and low on ward structure
(WAS 'Programme Clarity' and 'Staff control') and team functioning (TCI 'Participant
safety' and 'Task orientation').
Total conflict and containment rates are depicted in figure 10, and show a level but
sharply fluctuating course in both total conflict and containment, averaging out at
about four conflict and two containment events per shift (after adjustment for bed
numbers).
60
Figure 10. Mean total conflict and total containment events per shift (by PCC-SR) on
Victoria ward by month, commencing August 2004 and finishing July 2006
(standardised to 20 beds)
Ward: VICTORIA
Total conflict
12
Total containment
10
Value
8
6
4
2
0
30.00
29.00
28.00
27.00
26.00
25.00
24.00
23.00
22.00
21.00
20.00
19.00
18.00
17.00
16.00
15.00
14.00
13.00
12.00
11.00
10.00
9.00
8.00
month
Millwall ward
This 18-bedded mixed gender acute admission psychiatric ward served a small inner
city catchment area with lots of refugees and economic migrants, and few white
middle class with stable family backgrounds. There were significant numbers of
Caribbeans living in the area, and the ward also served significant numbers of the
homeless.
61
The largest four ethnic categories of patients were: British (32%), African (17%),
Caribbean (17%), White other (12%). This ward had one of the highest proportions of
patients with a primary diagnosis of schizophrenia (35%).
Staffing and incidents: Two new consultant psychiatrists and the ward manager were
appointed in 2002. This ward took part in the City Nurse project 2003-2004. Tensions
in the nursing team, high nurse turnover and disjointed input from OTs and
psychology were apparent throughout study. Numerous allegations of staff abuse
against patients were made in late 2003, early 2004 and in spring 2005 required police
involvement. In the autumn of 2004, there was one attempted hanging on the ward
and two patients committed suicide post-discharge. Early 2005, a patient absconded
and committed suicide. Several extremely challenging, medically complex and
aggressive patients were on the ward at numerous stages throughout the study, with
one disruptive patient on the ward from April 2004 to Jan 2006 eventually stabbing a
nurse. During the spring of 2005 one patient threatened to kill a nurse and another was
found to be dealing drugs on the ward.
The response rate of Millwall ward over the study period is displayed in figure 11,
and shows that after an initial start at about 50%, rates declined to about 25% by the
close of the study. In between there were several isolated months where the ward
stopped collecting data, and only energetic encouragement from the research team
resulted in further submissions.
62
Figure 11. Millwall ward: Response rate in numbers of PCC-SRs returned per month
Ward: MILWALL
100
Value No of PCCs
80
60
40
20
0
8.00 10.00 12.00 14.00 16.00 18.00 20.00 22.00 24.00 26.00 28.00 30.00
9.00 11.00 13.00 15.00 17.00 19.00 21.00 23.00 25.00 27.00 29.00 31.00
month
When measures were taken in late 2004 and early 2005, Millwall ward was poor in
team functioning (TCI 'Support for innovation', 'Vision' and 'Task orientation').
Total conflict and containment rates are depicted in figure 12, and show a sharply
fluctuating course with an underlying trend towards increased conflict (possibly
containment also to a lesser degree), averaging out at about eight conflict and one
containment events per shift (after adjustment for bed numbers). This was a
substantially higher conflict rate than other wards at the same hospital.
63
Figure 12. Mean total conflict and total containment events per shift (by PCC-SR) on
Millwall ward by month, commencing August 2004 and finishing July 2006
(standardised to 20 beds)
Ward: MILWALL
Total conflict
12
Total containment
10
Value
8
6
4
2
0
31.00
30.00
29.00
28.00
27.00
26.00
25.00
24.00
23.00
22.00
21.00
20.00
19.00
18.00
17.00
16.00
15.00
14.00
13.00
12.00
11.00
10.00
9.00
8.00
month
Albert ward
This 18-bedded mixed gender acute admission psychiatric ward served an area with
high levels of social distress. The population comprised of about half white, and a
third Black British, many of whom were third wave immigrants from West Africa.
There was also a stable population of Turkish Muslims, Kurds, Hassidic Jews, plus
some 'yuppie' families and an expanding black and white middle class. One area of
the sector was totally Bed & Breakfast and homeless accommodation. The population
was highly mobile, with high deprivation, poor education, and high levels of drug use.
64
The largest four ethnic categories of patients were: white British (26%), Other white
(22%), Caribbean (16%), African (11%). This ward had one of the highest
proportions of male patients (62%), older patients (36 years and over, 54%), and
patients with a primary diagnosis of schizophrenia (36%).
Staffing and incidents: A consultant psychiatrist of ten years and two respected
locums covered the ward during the period of the study. The ward manager was
appointed in January 2003 and left two years later, followed shortly by an experienced
charge nurse. A new ward manager was appointed in March 2005. New OTs joined
the ward in June 2004 and April 2006. In December 2005, the ward was re-located to
refurbished, more spacious premises with 18 single bedrooms. On New Years Day
2003, a nurse was assaulted by a relative on the ward. Between March and August
2004 there were regular patient assaults on staff. In October the ward manager was
stabbed by a patient. There were serious self-harming incidents in the spring of 2004
and March 2005. Very disruptive patients requiring extensive nursing attention were
evident throughout May to September 2005. The locum consultant was assaulted in
January 2006. A drug administration error in the summer of 2005 led to serious
disciplinary measures. In March 2006, a patient died on the ward of dehydration.
The response rate of Albert ward over the study period is displayed in figure 13, and
shows that this ward had a poor response rate throughout the study, for the first half of
the period averaging at about 25% and then rising for the remainder of the study to
30%.
65
Figure 13. Albert ward: Response rate in numbers of PCC-SRs returned per month
Ward: ALBERT
100
Value No of PCCs
80
60
40
20
0
10.00 12.00 14.00 16.00 18.00 20.00 22.00 24.00 26.00 28.00 30.00
11.00 13.00 15.00 17.00 19.00 21.00 23.00 25.00 27.00 29.00
month
When measures were taken in late 2004 and early 2005, Albert ward staff had
particularly negative attitudes to personality disordered patients (APDQ 'Enjoyment',
'Purpose' and 'Enthusiasm'), but were amongst the least burnt out (MBI 'Emotional
exhaustion' and 'Personal accomplishment'), and ward structure was high (WAS
'Order and organisation' and 'Programme clarity').
Total conflict and containment rates are depicted in figure 14, and show wide
fluctuations over time. Some of the highest and lowest peaks and troughs are in
months with extremely low response rates, and therefore are probably not
representative. Nevertheless this ward clearly had a high rate of conflict to begin with,
which then later declined.
66
Figure 14. Mean total conflict and total containment events per shift (by PCC-SR) on
Albert ward by month, commencing August 2004 and finishing July 2006
(standardised to 20 beds)
Ward: ALBERT
Total conflict
12
Total containment
10
Value
8
6
4
2
0
30.00
29.00
28.00
27.00
26.00
25.00
24.00
23.00
22.00
21.00
20.00
19.00
18.00
17.00
16.00
15.00
14.00
13.00
12.00
11.00
10.00
month
Refuge PICU
This 15-bedded male only psychiatric intensive care unit served the whole hospital
locality, and took the most disturbed male patients (with occasional exceptions) from
other wards at the same hospital. There were therefore 5.9 acute beds for every PICU
bed in this district, and a population of 14,000 per PICU bed. Demographic profiles of
patients on the three PICUs are presented in a subsequent chapter, however this PICU
had particularly low numbers of patients from an Asian background.
67
Staffing and incidents: The ward manager had been in post five years at the start of
study, but was suspended in summer of 2004 pending investigation of a drug
administration incident. An acting ward manager covered the ward from July 2004 to
February 2005, when the manager returned. Some staff tensions and changes occurred
in the following summer. The ward OT of three years and his assistant left in the
summer of 2004, with a replacement OT only, starting in January 2005. Protected
therapeutic time was introduced one day a week in February 2006. Only isolated
incidents were reported during the study: in September 2003 a patient cut his wrists
on the ward with a razor and two patients were found using ‘crack’ cocaine. In
October 2004 a patient made a formal complaint following a restraint episode. In
early 2005, a nurse was punched several times by a patient. In March 2005, a ‘near
miss’ suicide was reported and in November 2005 a patient absconded from the ward.
The response rate of Refuge PICU over the study period is displayed in figure 15, and
shows that this ward started with a 50% response rate, but this declined to very low
levels by the end of the study period.
68
Figure 15. Refuge PICU: Response rate in numbers of PCC-SRs returned per month
Ward: REFUGE PICU
100
Value No of PCCs
80
60
40
20
0
9.00 11.00 13.00 15.00 17.00 19.00 21.00 23.00 25.00 27.00 29.00 31.00
10.00 12.00 14.00 16.00 18.00 20.00 22.00 24.00 26.00 28.00 30.00
month
When measures were taken in late 2004 and early 2005, Refuge PICU staff were low
in burnout (MBI 'Emotional exhaustion', 'Depersonalisation' and 'Personal
accomplishment') and tended to approve strongly of containment (ACMQ 'Safe for
staff', 'Safe for patients', and 'Prepared to use').
Total conflict and containment rates are depicted in figure 16, and show a fairly static
picture with relatively low rates of conflict (four to five per shift) and high rates of
containment (about five per shift). Other general acute wards at the same hospital
have higher rates of conflict than this PICU. Note the scale of the PICU graphs has
been altered to facilitate comparisons across PICUs.
69
Figure 16. Mean total conflict and total containment events per shift (by PCC-SR) on
Refuge PICU by month, commencing August 2004 and finishing July 2006
(standardised to 20 beds)
Ward: REFUGE PICU
Total conflict
30
Total containment
25
Value
20
15
10
5
0
31.00
30.00
29.00
28.00
27.00
26.00
25.00
24.00
23.00
22.00
21.00
20.00
19.00
18.00
17.00
16.00
15.00
14.00
13.00
12.00
11.00
10.00
9.00
month
THE WARDS AT HAVEN HOSPITAL
Canary ward
This 18-bedded mixed gender acute admission psychiatric ward served an area with
one notorious council estate with a reputation for drug problems. There was a large
Bangladeshi community, one small affluent area, and small Vietnamese, Somali and
West Indian communities. Most patients were from impoverished, overcrowded living
conditions.
70
The largest four ethnic categories of patients were: white British (40%), Bangladeshi
(26%), African (10%), Caribbean (5%). This ward had one of the highest proportions
of older patients (36 years and over, 55%), and patients with a primary diagnosis of
schizophrenia (44%).
Staffing and incidents: A new consultant was appointed in October 2004 and another
in August 2005, making three in total. During 2005 and 2006 the ward regularly
admitted patients under numerous consultants across the hospital. In July 2006, the
consultant for the new Early Intervention Service also began to admit patients to the
ward. The ward manager had been in post for over six years at the start of the study
but was removed in June 2006, pending inquiry into a patient suicide. OT input was
affected by sickness and temporary appointments during 2004 and 2005. In March
2006 a new ward OT was appointed. A psychologist had input from October 2005.
Protected Therapeutic Time was introduced in March 2006. Serious assaults against
staff occurred in early 2003, summer 2004, April 2005 and October 2005. Suicides
took place on the ward or shortly after discharge in August 2003, early 2005 and
December 2005.
The response rate of Canary ward over the study period is displayed in figure 17, and
shows that this ward started with a good 66% response rate, but this declined to about
25% by the end of the study period.
71
Figure 17. Canary ward: Response rate in numbers of PCC-SRs returned per month
Ward: CANARY
100
Value No of PCCs
80
60
40
20
0
8.00 10.00 12.00 14.00 16.00 18.00 20.00 22.00 24.00 26.00 29.00
9.00 11.00 13.00 15.00 17.00 19.00 21.00 23.00 25.00 28.00 30.00
month
When measures were taken in late 2004 and early 2005, Canary ward staff did not
score particularly high or low on any questionnaire.
Total conflict and containment rates are depicted in figure 18, and show an initial high
conflict rate of about four per shift, which declines to two and rises back to three by
the end of the study period. Containment shows a slight upwards trend, and averages
about two events per shift.
72
Figure 18. Mean total conflict and total containment events per shift (by PCC-SR) on
Canary ward by month, commencing August 2004 and finishing July 2006
(standardised to 20 beds)
Ward: CANARY
Total conflict
12
Total containment
10
Value
8
6
4
2
0
30.00
29.00
28.00
26.00
25.00
24.00
23.00
22.00
21.00
20.00
19.00
18.00
17.00
16.00
15.00
14.00
13.00
12.00
11.00
10.00
9.00
8.00
month
Felstead ward
This 18-bedded mixed gender acute admission psychiatric ward served an area with a
mixed population, generally working class, high unemployment, with some pockets of
affluence. There was a significant Bengali population, mostly first generation.
Somalis were in two groups, post war refugees, and children of those in the Merchant
Navy. A few refugees from former Yugoslavia also lived in the district. Substance
misuse was a significant factor for many patients.
73
The largest four ethnic categories of patients were: white British (58%), Bangladeshi
(10%), White other (9%), Black other (7%). This ward had one of the highest
proportions of male patients (68%) and older patients (36 years and over, 52%).
Staffing and incidents: Very stable, long-standing ward management, nursing
establishment and same two consultant psychiatrists throughout study. Well served by
occupational therapy staff. City’s Anti-absconding intervention introduced and
maintained from November 2003. Activities co-ordinator introduced and activities
available seven days a week from February 2005. Protected Therapeutic Time
introduced in February 2006. Patient deaths occurred on the ward or at home in April
2004, June 2004 and two in September 2004. Few serious assaults were reported
during the study although two patients assaulted staff in early 2005 and a patient
threatened to kill staff in the spring of 2005.
The response rate of Felstead ward over the study period is displayed in figure 19, and
shows that this ward quickly climbed to a full response rate, which was sustained for
the whole study period with the exception of a fall to 50% around Christmas 2005.
74
Figure 19. Felstead ward: Response rate in numbers of PCC-SRs returned per month
Ward: FELSTEAD
100
Value No of PCCs
80
60
40
20
0
9.00 11.00 13.00 15.00 17.00 19.00 21.00 23.00 25.00 27.00 29.00 31.00
10.00 12.00 14.00 16.00 18.00 20.00 22.00 24.00 26.00 28.00 30.00
month
When measures were taken in late 2004 and early 2005, Felstead ward had strong
leadership (MLQ 'Transformational leadership' and 'Outcomes of leadership') and
staff disapproved strongly of containment method use (ACMQ
'Efficacy',
'Acceptability', 'Dignified', 'Safe for staff', 'Safe for patients', and 'Prepared to use').
Total conflict and containment rates are depicted in figure 20, and show an initial very
high conflict rate of about eight per shift, which soon declined to two to three.
Containment is static at just under two events per shift.
75
Figure 20. Mean total conflict and total containment events per shift (by PCC-SR) on
Felstead ward by month, commencing August 2004 and finishing July 2006
(standardised to 20 beds)
Ward: FELSTEAD
Total conflict
12
Total containment
10
Value
8
6
4
2
0
31.00
30.00
29.00
28.00
27.00
26.00
25.00
24.00
23.00
22.00
21.00
20.00
19.00
18.00
17.00
16.00
15.00
14.00
13.00
12.00
11.00
10.00
9.00
month
Empire ward
This 18-bedded mixed gender acute admission psychiatric ward served an area that is
socially deprived, with high unemployment and substance use problems, and a mixed
ethnicity population including Bangladeshis and Somalis. There were difficulties with
language, education and reliance on welfare benefits. A big sector, sparsely populated
because there were many offices and industrial areas.
76
The largest four ethnic categories of patients were: white British (57%), Bangladeshi
(15%), African (6%), White other (6%). This ward had one of the highest proportions
of male patients (77%), younger patients (35 years and under, 72%), and a low
proportion of patients with a primary diagnosis of schizophrenia (27%).
Staffing and incidents: This ward has a history of extremely unstable medical and
nursing leadership, which continued throughout the study with constant changes of
consultant psychiatrists and four changes of ward manager. The ward also hosts a
consultant psychiatrist for homeless people and from April 2004, the Assertive
Community team, both of whom admit to the ward.
Turnover of nursing staff
appeared high and was amplified by several suspensions. There was limited input
from psychology and a locum OT. The ward took part in the City Nurse project 20042005 but this was terminated prematurely. Serious attacks on staff took place in early
2004 and 2005. Patient suicides involving the ward were reported in autumn 2004,
April, May and June 2005 and March 2006. Numerous incidents of self-harm,
aggression and drug use were also reported.
The response rate of Empire ward over the study period is displayed in figure 21, and
shows that this ward quickly climbed to a 66% response rate, but that this collapsed in
June 2005 when the then Ward Manager was moved to a different post. Empire ward's
engagement with the study was thereafter minimal and sporadic.
77
Figure 21. Empire ward: Response rate in numbers of PCC-SRs returned per month
Ward: EMPIRE
100
Value No of PCCs
80
60
40
20
0
8.00
10.00 12.00 14.00 16.00 18.00 22.00 24.00 26.00 28.00
9.00
11.00 13.00 15.00 17.00 19.00 23.00 25.00 27.00
month
When measures were taken in late 2004 and early 2005, Empire ward staff did not
score particularly high or low on any questionnaire.
Total conflict and containment rates are depicted in figure 22, and show an initial very
high conflict rate of about eight per shift, which then decreased by half, only to rise
again. Containment shows a significant increase in the latter part of the period.
78
Figure 22. Mean total conflict and total containment events per shift (by PCC-SR) on
Empire ward by month, commencing August 2004 and finishing July 2006
(standardised to 20 beds)
Ward: EMPIRE
Total conflict
12
Total containment
10
Value
8
6
4
2
0
8.00 10.00 12.00 14.00 16.00 18.00 22.00 24.00 26.00 28.00
9.00 11.00 13.00 15.00 17.00 19.00 23.00 25.00 27.00
month
Deanston ward
This 20-bedded mixed gender acute admission psychiatric ward served a highly
populated area, very ethnically mixed, with large groups of Bangladeshis and
Somalis, but also former Yugoslavian refugees, working class Caribbeans and whites,
and a mix of others. Housing was of a low standard and cramped, and the area was
generally impoverished.
79
The largest four ethnic categories of patients were: white British (46%), Bangladeshi
(26%), Black other (8%), African (4%). This ward had particularly low numbers of
male patients (52%), and high numbers with a primary diagnosis of schizophrenia
(40%).
Staffing and incidents: Deanston had two consultant psychiatrists at the start of the
study, which increased to four by the summer of 2005. This ward had no stable
nursing management in the year or two prior to the study but appointed a new ward
manager in January 2004. High turnover and suspension of nurses culminated in
serious staff shortages in 2005, matched by a number of temporary and agency OTs.
Protected therapeutic time was introduced in December 2005. Patient or visitor
attacks on staff were reported in June and November 2004, April and May 2005 and
in May 2006. Suicides or serious attempted suicides linked with the ward were
reported in March 2003, August and September 2004. Increased drug use amongst
patients was observed in 2005.
The response rate of Deanston ward over the study period is displayed in figure 23,
and shows that this ward had a modest response rate of just under 50% throughout the
project.
80
Figure 23. Deanston ward: Response rate in numbers of PCC-SRs returned per month
Ward: DEANSTON
100
Value No of PCCs
80
60
40
20
0
8.00 10.00 12.00 14.00 16.00 18.00 20.00 22.00 24.00 26.00 28.00 30.00
9.00 11.00 13.00 15.00 17.00 19.00 21.00 23.00 25.00 27.00 29.00
month
When measures were taken in late 2004 and early 2005, Deanston ward staff had
particularly positive attitudes to personality disordered patients (APDQ 'Security',
'Purpose' and 'Enthusiasm') but poor team functioning (TCI 'Participant safety',
'Support for innovation' and 'Vision').
Total conflict and containment rates are depicted in figure 24, and show an initial very
high conflict rate of about ten per shift, which then decreased by half, only to rise
again. Containment was static at about two events per shift.
81
Figure 24. Mean total conflict and total containment events per shift (by PCC-SR) on
Deanston ward by month, commencing August 2004 and finishing July 2006
(standardised to 20 beds)
Ward: DEANSTON
Total conflict
12
Total containment
10
Value
8
6
4
2
0
30.00
29.00
28.00
27.00
26.00
25.00
24.00
23.00
22.00
21.00
20.00
19.00
18.00
17.00
16.00
15.00
14.00
13.00
12.00
11.00
10.00
9.00
8.00
month
Haven PICU
This 9-bedded mixed gender psychiatric intensive care unit served the whole hospital
locality, and took the most disturbed patients from other wards at the same hospital.
There were therefore 8.2 acute beds for every PICU bed in this district, and a
population of 21,780 per PICU bed. Demographic profiles of patients on the three
PICUs are presented in a subsequent chapter, however this PICU had a particularly
high number of Bangladeshi and a low number of Black African patients.
82
Staffing and incidents: The consultant psychiatrist was a long-standing member of the
PICU team but between September 2003 and August 2005, the ward manager position
changed five times. Other input was provided by two different psychologists and an
occupational therapist. Protected Therapeutic Time was introduced in February 2006.
Serious attacks on staff were reported in February and August 2003, June 2004, April,
May and December 2005 and several times in June 2006. Patient suicides linked to
the ward were reported in September 2003 and the summer of 2005. Absconds
occurred in February 2003, several times in both the spring and summer of 2005 and
in November 2005.
The response rate of Haven PICU over the study period is displayed in figure 25, and
shows that this ward had a very high response rate that gradually declined throughout
the project.
Figure 25. Haven PICU: Response rate in numbers of PCC-SRs returned per month
Ward: HAVEN PICU
100
Value No of PCCs
80
60
40
20
0
9.00 11.00 13.00 15.00 17.00 19.00 21.00 23.00 25.00 27.00 29.00 31.00
10.00 12.00 14.00 16.00 18.00 20.00 22.00 24.00 26.00 28.00 30.00
month
83
When measures were taken in late 2004 and early 2005, Haven PICU staff did not
score particularly high or low on any questionnaire.
Total conflict and containment rates are depicted in figure 26, and show a sustained
high conflict rate of about ten per shift, possibly with a rising trend. Containment was
static (or possibly rising also) at about five events per shift. Note the scale of the
PICU graphs has been altered to facilitate comparisons across PICUs.
Figure 26. Mean total conflict and total containment events per shift (by PCC-SR) on
Haven PICU by month, commencing August 2004 and finishing July 2006
(standardised to 20 beds)
Ward: HAVEN PICU
Total conflict
30
Total containment
25
Value
20
15
10
5
0
31.00
30.00
29.00
28.00
27.00
26.00
25.00
24.00
23.00
22.00
21.00
20.00
19.00
18.00
17.00
16.00
15.00
14.00
13.00
12.00
11.00
10.00
9.00
month
84
THE WARDS AT SHELTER HOSPITAL
Metropolitan ward
This 15-bedded mixed gender acute admission psychiatric ward served an area with a
large transient population. Fifty per cent of people were non-white, and there were
high numbers where English was not the first language. Lots of refugees coming from
all over the world live in the area, with benefit problems and homelessness.
The largest four ethnic categories of patients were: white British (31%), Black other
(15%), African (10%), Pakistani (6%). This ward had a particularly low proportion of
male patients (55%), and patients with a primary diagnosis of schizophrenia (26%).
Staffing and incidents: One permanent consultant psychiatrist was joined by a second
in December 2004, replacing a locum consultant. The experienced ward manager
associated with the ward prior to its move to Shelter was replaced by an acting ward
manager in April 2005 and another in February 2006. The OT changed several times
during the study and a psychologist left in October 2005, to be replaced in March
2006. Staff tensions and difficulties were reported throughout 2004 and 2005.
Disruptive and aggressive patients were on the ward at Christmas 2004 and 2005.
Drug-related aggression was reported on the ward between in early, mid and late
2005. Serious assaults on staff were reported in November 2005 and June 2006. A
ward–related suicide occurred in September 2005.
85
The response rate of Metropolitan ward over the study period is displayed in figure
27, and shows that this ward had a good response rate that immediately declined, but
that data collection was reinvigorated in June – September 2005, thereafter again
slowly declining.
Figure 27. Metropolitan ward: Response rate in numbers of PCC-SRs returned per
month
Ward: METROPOLITAN
100
Value No of PCCs
80
60
40
20
0
8.00 10.00 12.00 14.00 16.00 18.00 20.00 22.00 24.00 26.00 28.00
9.00 11.00 13.00 15.00 17.00 19.00 21.00 23.00 25.00 27.00 29.00
month
When measures were taken in late 2004 and early 2005, Metropolitan ward staff were
low on burnout (MBI 'Emotional exhaustion', 'Depersonalisation' and 'Personal
accomplishment'), had particularly good team functioning (TCI 'Participant safety',
'Support for innovation' and 'Task orientation') and tended to approve strongly of
containment (ACMQ 'Efficacy', 'Acceptability', 'Safe for staff', 'Safe for patients', and
'Prepared to use').
Total conflict and containment rates are depicted in figure 28, and show sharply
fluctuating rates of conflict for the first few months, followed by a levelling off, then
86
a gradual increase. Containment was fairly static with the exception of a single spike
in June 2005.
Figure 28. Mean total conflict and total containment events per shift (by PCC-SR) on
Metropolitan ward by month, commencing August 2004 and finishing July 2006
(standardised to 20 beds)
Ward: METROPOLITAN
Total conflict
12
Total containment
10
Value
8
6
4
2
0
29.00
28.00
27.00
26.00
25.00
24.00
23.00
22.00
21.00
20.00
19.00
18.00
17.00
16.00
15.00
14.00
13.00
12.00
11.00
10.00
9.00
8.00
month
Capital ward
This 18-bedded mixed gender acute admission psychiatric ward served a very mixed
area with all sorts of people, Asian, Caribbean, white, refugees with money and
accommodation problems, owner occupiers and council tenants.
87
The largest four ethnic categories of patients were: white British (37%), African
(21%), Pakistani (7%), Black other (7%). This ward also had a particularly low
proportion of male patients (55%), and patients with a primary diagnosis of
schizophrenia (22%).
Staffing and incidents: This ward has two consultants but two changes in postholder
occurred in October 2003 and September 2005. The ward manager had been in post
three years at the start of the project and remained throughout the study. This ward
took part in the City Nurse Project between 2003 and 2004, ending in August. New
psychologists joined the ward in September 2004 and May 2005. Few serious
incidents were reported during the study, although staff were assaulted in August and
September 2005 and a worrying abscond occurred in July 2006.
The response rate of Capital ward over the study period is displayed in figure 29, and
shows that this ward had a modest response rate with one interval of six months
having a very low level of data returns.
88
Figure 29. Capital ward: Response rate in numbers of PCC-SRs returned per month
Ward: CAPITAL
100
Value No of PCCs
80
60
40
20
0
9.00 11.00 13.00 15.00 17.00 19.00 21.00 23.00 25.00 27.00 29.00 31.00
10.00 12.00 14.00 16.00 18.00 20.00 22.00 24.00 26.00 28.00 30.00
month
When measures were taken in late 2004 and early 2005, Capital ward staff had
particularly good team functioning (TCI 'Participant safety', 'Support for innovation',
'Vision' and 'Task orientation'), and strong negative views about the use of
containment compared to other wards (ACMQ 'Efficacy', 'Acceptability', 'Safe for
staff' and 'Safe for patients').
Total conflict and containment rates are depicted in figure 30, and show a rather static
and low level of conflict, in the presence of a fairly continuous modest rate of
containment events.
89
Figure 30. Mean total conflict and total containment events per shift (by PCC-SR) on
Capital ward by month, commencing August 2004 and finishing July 2006
(standardised to 20 beds)
Ward: CAPITAL
Total conflict
12
Total containment
10
Value
8
6
4
2
0
31.00
30.00
29.00
28.00
27.00
26.00
25.00
24.00
23.00
22.00
21.00
20.00
19.00
18.00
17.00
16.00
15.00
14.00
13.00
12.00
11.00
10.00
9.00
month
Prospect ward
This 18-bedded mixed gender acute admission psychiatric ward served an area with
numerous ethnic minorities, very diverse, with high numbers of asylum seekers. Many
patients on the ward had no right to remain in the UK. A sad population,
predominantly working class, with high levels of depression and suicidal ideation.
90
The largest four ethnic categories of patients were: white British (44%), African
(18%), Caribbean (10%), Black other (7%). This ward had a relatively low proportion
of male patients (57%).
Staffing and incidents: Prospect ward suffered an SUI shortly after opening. One of
the two consultants had been associated with this ward for seven years, the other just
over one year. A new ward manager started in January 2004 following a number of
SUIs on the ward. A significant turnover of nursing staff followed and again in the
summer of 2004. The ward took part in the City Nurse project between October 2005
and January 2006. The ward manager moved on in May 2006 to be replaced by an
acting ward manager. The ward was provided with temporary or no OT cover for long
periods of time, until the appointment of a ward OT in September 2004, who was
replaced in March 2006. A structured programme of activities was introduced in June
2005. Few serious incidents were reported and absconding was significantly reduced
following a several absconds in 2004. In autumn 2004, several drug using and
aggressive patients were on the ward. In December 2005 a patient on leave committed
suicide.
The response rate of Prospect ward over the study period is displayed in figure 31,
and shows that this ward had a good response rate with one interval of two months
having a very low level of data returns.
91
Figure 31. Prospect ward: Response rate in numbers of PCC-SRs returned per month
Ward: PROSPECT
100
Value No of PCCs
80
60
40
20
0
9.00 11.00 13.00 15.00 17.00 20.00 22.00 24.00 26.00 28.00 30.00
10.00 12.00 14.00 16.00 18.00 21.00 23.00 25.00 27.00 29.00
month
When measures were taken in late 2004 and early 2005, Propsect ward staff had high
levels of burnout (MBI 'Emotional exhaustion' and 'Depersonalisation') and negative
views about the use of containment (ACMQ 'Efficacy', 'Acceptability', 'Dignified'
'Safe for patients' and 'Prepared to use').
Total conflict and containment rates are depicted in figure 32, and show a rather high
level of conflict, with one large 'spike' in June 2005 (which may not be accurate as it
is based on the same month with the lowest response rate – in this case only 4 PCCSRs). Containment rates on this ward were generally high, at about four events per
shift.
92
Figure 32. Mean total conflict and total containment events per shift (by PCC-SR) on
Prospect ward by month, commencing August 2004 and finishing July 2006
(standardised to 20 beds)
Ward: PROSPECT
Total conflict
12
Total containment
10
Value
8
6
4
2
0
30.00
29.00
28.00
27.00
26.00
25.00
24.00
23.00
22.00
21.00
20.00
18.00
17.00
16.00
15.00
14.00
13.00
12.00
11.00
10.00
9.00
month
Hoba ward
This 15-bedded mixed gender acute admission psychiatric ward serves a multiethnic
but predominantly Asian area with, lots of temporary accommodation and asylum
seekers. A deprived area with lots of multiple occupancy rooms, and a highly mobile
population. People come and go, from other parts of the UK as well as internationally.
There was high deprivation, lots of drugs and alcohol abuse, poor quality council
accommodation, high levels TB, HIV and other physical health problems. A large
Tamil and south Indian population resided in the area.
93
The largest four ethnic categories of patients were: British (30%), African (13%),
Indian (11%), Pakistani (8%). This ward had a relatively low proportion of patients
with a primary diagnosis of schizophrenia (23%).
Staffing and incidents: Hoba ward was marked by several SUIs shortly after opening,
which led to staff dismissals and suspensions in the spring of 2003. A new ward
manager was appointed in February 2003. One consultant psychiatrist had a long
association with the ward. The second consultant post was filled by a succession of
short-term and locum doctors and psychology input was sporadic throughout the
study. OT staff made a major contribution to the ward and changed only in September
2005 and July 2006. This ward took part in the City Nurse project between 2004 and
2005 and started a pilot of Protected Therapeutic Time in May 2005. Disturbing wardrelated murders took place in the spring of 2003 and in February 2004. A suicide and
attempted suicide were also reported in early 2004. Very few serious incidents were
reported in 2005 and 2006.
The response rate of Hoba ward over the study period is displayed in figure 33, and
shows an early climb to a very good response rate, followed by a slow decline over
the two-year period.
94
Figure 33. Hoba ward: Response rate in numbers of PCC-SRs returned per month
Ward: HOBA
100
Value No of PCCs
80
60
40
20
0
9.00 11.00 13.00 15.00 17.00 19.00 21.00 23.00 25.00 27.00 29.00 31.00
10.00 12.00 14.00 16.00 18.00 20.00 22.00 24.00 26.00 28.00 30.00
month
When measures were taken in late 2004 and early 2005, Hoba ward staff did not score
particularly high or low on any questionnaire.
Total conflict and containment rates are depicted in figure 34, and show a high level
of conflict and containment, both of which gradually decline.
95
Figure 34. Mean total conflict and total containment events per shift (by PCC-SR) on
Hoba ward by month, commencing August 2004 and finishing July 2006
(standardised to 20 beds)
Ward: HOBA
Total conflict
12
Total containment
10
Value
8
6
4
2
0
31.00
30.00
29.00
28.00
27.00
26.00
25.00
24.00
23.00
22.00
21.00
20.00
19.00
18.00
17.00
16.00
15.00
14.00
13.00
12.00
11.00
10.00
9.00
month
Shelter PICU
This 8-bedded (became 10-bedded in January 2005) mixed gender psychiatric
intensive care unit served the whole hospital locality, and took the most disturbed
patients from other wards at the same hospital. There were therefore 8.2 acute beds
for every PICU bed in this district, and a population of 30,500 per PICU bed.
Demographic profiles of patients on the three PICUs are presented in a subsequent
chapter, however this PICU had the most evenly balanced ethnic profile of the three,
with all major categories present in equal numbers.
96
Staffing and incidents: The consultant psychiatrist was in post from March 2003 until
May 2005, when he was replaced by three locums until a new consultant started in
November 2005. The ward manager was seconded elsewhere in January 2003 and
replaced by an acting ward manager for 18 months. For about six months there was no
ward manager until a new appointment in March 2005. OT and psychology provision
was variable. Patient attacks on staff occurred throughout most of 2004, culminating
in two serious assaults in the autumn of 2004. This led to significant staff sickness and
departures over the next six months. The summer of 2005 saw more violent incidents
on the ward. New staff arrived in February 2006 but between February and May 2006,
a violent patient caused serious disruption, with a major incident in March requiring
police assistance and causing injuries to several staff members.
The response rate of Shelter PICU over the study period is displayed in figure 35, and
shows a low response rate, followed by a continuous, lurching decline over the twoyear period.
97
Figure 35. Shelter PICU: Response rate in numbers of PCC-SRs returned per month
Ward: SHELTER PICU
100
Value No of PCCs
80
60
40
20
0
9.00 11.00 13.00 15.00 17.00 19.00 21.00 24.00 26.00 28.00 30.00
10.00 12.00 14.00 16.00 18.00 20.00 22.00 25.00 27.00 29.00
month
When measures were taken in late 2004 and early 2005, Shelter PICU staff had very
positive attitudes to personality disordered patients (APDQ 'Enjoyment', 'Security',
'Acceptance', 'Purpose' and 'Enthusiasm'), but were experiencing poor leadership
(MLQ 'Transformational leadership' and 'Outcomes of leadership').
Total conflict and containment rates are depicted in figure 36, and show low but
fluctuating levels of conflict and containment. Because of the low response rate,
values for some months are based on very low numbers of PCC-SRs. Note the scale
of the PICU graphs has been altered to facilitate comparisons across PICUs.
98
Figure 36. Mean total conflict and total containment events per shift (by PCC-SR) on
Hoba ward by month, commencing August 2004 and finishing July 2006
(standardised to 20 beds)
Ward: SHELTER PICU
Total conflict
30
Total containment
25
Value
20
15
10
5
0
30.00
29.00
28.00
27.00
26.00
25.00
24.00
22.00
21.00
20.00
19.00
18.00
17.00
16.00
15.00
14.00
13.00
12.00
11.00
10.00
9.00
month
COMPARISONS BETWEEN WARDS
The following figures present comparative total conflict and containment rates by
ward, averaged out across the whole of phase two of the project. Whilst they
illuminate some differences, they can also mislead, as a ward that is high in conflict to
begin with and low at the end will appear as mid-range in these bar charts.
99
Figure 37 shows rates of conflict events by ward, and figure 38 rates of containment.
Two of the three PICUs are distinctive in terms of the high levels of containment use,
but only one displays a very high conflict rate. The other two PICUs are not
distinguishable from the acute admission wards. Several of the acute admission wards
exceed some of the PICUs in their levels of conflict. Levels of conflict on the ward
appear to be only partly related to containment use. Whilst for some wards both at
equal levels (e.g. Canary ward, Victoria ward, Prospect ward, Haven PICU), for
others containment is low but conflict high (e.g. Deanston ward, Millwall ward,
Albert ward) or the opposite (e.g. Capital ward, Refuge PICU, Shelter PICU).
Figure 37. Mean total conflict events per shift (by PCC-SR) by ward, between August
2004 and July 2006 (standardised to 20 beds)
Mean Total Conflict/20 beds
10.00
8.00
6.00
4.00
2.00
0.00
U
C
PI
R
TE
U
EL
C
PI
SH
E
G
U
U
EF
C
R
PI
EN
AV
H
N
TA
BA
LI
O
H
PO
O
R
T
ET
M
EC
SP
O
PR
AL
IT
AP
C
T
R
BE
AL
L
AL
W
IL
M
IA
R
TO
C
VI
ES
AM AN
T
TH
AT
H
AN
M
E
R
PI
N
EM TO
S
N
EA
D
AD
TE
LS
FE
Y
AR
AN
C
Ward
100
Figure 38. Mean total containment events per shift (by PCC-SR) by ward, between
August 2004 and July 2006 (standardised to 20 beds)
Mean Total containment/20 beds
6.00
5.00
4.00
3.00
2.00
1.00
0.00
U
C
PI
R
TE
U
EL
C
PI
SH
E
G
U
U
EF
C
R
PI
EN
AV
H
N
TA
BA
LI
O
O
H
P
O
R
ET
T
M
EC
SP
O
PR
AL
IT
AP
C
T
R
BE
AL
L
AL
W
IL
M
IA
R
TO
C
VI
ES
AM AN
T
TH
AT
H
AN
M
E
R
PI
N
EM
O
ST
N
EA
D
AD
TE
LS
FE
Y
AR
AN
C
Ward
DATA SOURCES FOR THIS CHAPTER
Population details for the district have been taken from 2001 census data. Details of
patient ethnicity, gender and diagnosis are drawn from the study Trust's official
records of admissions and discharges in the financial year 2003-2004. Cameo
descriptions of ward catchment areas are drawn from multidisciplinary staff OPPI
interviews conducted in late 2003 and early 2004. PCC-SR data was collected from
all wards continuously between August 2004 and July 2006. Questionnaire
comparisons are drawn from a range of questionnaire collected from all staff over
101
during late 2004 and early 2005. Events occurring on different wards and in the Trust
during the study are from OPPI follow-up interviews of Ward Managers and
Consultant Psychiatrists.
102
4. BASELINE INTERVIEWS OF MULTIDISCIPLINARY
WARD STAFF
INTRODUCTION
Modern acute inpatient psychiatry in the UK is beset by problems. A series of recent
reports have highlighted difficulties such as: deficits in leadership, clinical skills and
risk management (Standing Nursing and Midwifery Advisory Committee 1999); lack
of nurse-patient interaction and therapeutic activities (Ford et al 1998); a high level of
chaos and crisis-driven care (Sainsbury Centre for Mental Health 1998); and a climate
of fear, untherapeutic conditions and overworked staff (MIND 2004). These concerns
have been echoed in several research studies. A survey of over a hundred inpatients
by Goodwin et al (1999) identified problems with noise, overly restrictive rules, lack
of privacy and lack of information about treatment. Walton (2000) collated the
feedback of 160 trainees who carried out a period of observation in 22 acute
psychiatric wards. She identified a lack of therapeutic direction on the wards with
nothing for patients to do; an avoidance of social factors in the generation of mental
disorders coupled with a medication-centred view of care; and indifference to
patients’ civil rights.
For some time the focus of attention of policy makers and researchers has been the
implementation of community care and the appropriate service configuration,
standards, management, training, etc., to make that successful. Research has largely
103
concentrated on that area, examining and evaluating different models of care (e.g.
Assertive Community Treatment, Priebe et al 2003). Attention which has been given
to inpatient psychiatry has focused on its replacement with community services (e.g.
partial hospitalisation, Wesson et al 2001, or home treatment, Marks et al 1994).
However no service has been able to do without acute inpatient beds at all, and wards
have been left to drift with little research, discussion or development.
Coupled with the research and policy focus on community care, there has been a
failure to articulate or assert the positive role that acute wards play within the full
spectrum system of modern psychiatric services. It is, unfortunately, not easy to do
that. Each of the professions involved in psychiatry has differently accented
perceptions of acute psychiatry and their role within it. Additionally, there are many
different models of treatment competing for attention, including a multitude of
psychotherapies, with little empirical evidence to guide the choices of professionals
working in the field. To add further complexity, the basic philosophy of psychiatry,
and the nature of mental illness are disputed issues, leading to further lack of clarity
(Bowers 1998). When attempts are made to define the role of acute inpatient care,
there is often further confusion between the endeavour to state what acute care should
or could be, and what it is. It is therefore not surprising that recent UK government
guidance avoids attempting to provide a statement of the core tasks of acute
psychiatry, instead suggesting that each service develops this for itself (DH 2002, p
10).
Multi-disciplinary teams (MDTs) have become a key feature of modern health and
social care with a number of benefits anticipated (Leathard, 1994; Gorman, 1998).
104
More integrated healthcare teams produce better patient outcomes (determined by the
setting and aims of the service), greater continuity of care, consistent communications
with patients and family, and shared team knowledge and skills (Firth-Cozens, 1998;
West, 1999; Miller, Freeman & Ross, 2001). Teams with clear, shared objectives,
higher levels of member participation and communication, greater emphasis on
quality and support for innovation are more effective and host healthier, calmer staff
(Borrill, West, Shapiro & Rees, 2000). But attempts to establish MDT working in
health settings have faced numerous difficulties, with the potential benefits often not
realised (Leathard, 1994; West & Poulton, 1997). Barriers include communication
difficulties, power imbalances, interpersonal and interprofessional conflict, and
organisational factors (Firth-Cozens, 1998); costly, time-consuming consultation,
additional administration, differing leadership styles, and inequalities in status and
pay (Leathard, 1994).
MDTs are acknowledged as essential in the provision of community mental health
services (Department of Health, 2002; Onyett, 2002) and there is some limited
evidence that team approaches addressing health and social care needs are superior to
that of individual practitioners (Burns, et al., 2001; Simmons, et al., 2001; Burns &
Lloyd, 2004; Huxley, et al., 2003). But community team functioning is often
constrained by inter-professional rivalry and suspicion and the failure to establish
respect, trust and participative safety (Simpson, 2004); defensive role protectionism
(Norman & Peck, 1999; Brown, Crawford & Darongkamas, 2000; Miller & Freeman,
2003); and poor leadership (Onyett, 2002). More positively, Bowers’ (2002) study of
nurses working in high security psychiatric hospitals reported that teamwork skills
supported the development of positive attitudes towards difficult and challenging
105
patients and reduced the potential for conflict. These skills included the sharing with
colleagues of both positive and negative feelings towards patients, sharing the burden
of care, and the development of a consistent approach in relation to rules and routines
for patient conduct. Effective communication through regular face-to-face meetings
facilitated by good leaders may be key components of successful collaboration and
teamwork in psychiatry (Liberman, Hilty, Drake & Tsang, 2001).
Acute inpatient psychiatric care depends on collaboration between different
professionals within the hospital and with community teams and services (Herrman et
al., 2003). But service users have cited the lack of multidisciplinary input into
inpatient treatment programmes and poor interprofessional communication as a
concern (Department of Health, 2002). The Policy Implementation Guide for acute
psychiatric care in England identified the need for an increased MDT approach
towards risk management and recommended increased collaboration between nurses
and medical staff in particular (Department of Health, 2002). Multi-disciplinary
solutions are also being sought to ease the pressures faced by overburdened
psychiatrists (National Steering Group, 2004). Currently, however, there is still a lack
of research related to multidisciplinary teamwork in inpatient mental health settings.
The risk of serious untoward incidents in acute inpatient psychiatry is small, but
appreciable and ever present. The inpatient suicide rate in England is 0.14%, or one
for every 714 admissions (Powell et al 2000). The number of suicide attempts exceeds
the number of completed suicides by a factor of ten (i.e., 2700 attempts versus 240
suicides in The Netherlands; Brunnenberg & Bijl, 1998). The figure for homicides by
inpatients is 9 per year in England and Wales (Department of Health 2001). Violent
106
incidents are, however, fairly common on acute inpatient wards. Nijman et al (2004)
report a mean rate across Europe of 9.3 per patient year, although a large majority of
these involve verbal abuse and property damage, rather than actual physical assault.
Absconding (elopement) by patients is also common, although negative outcomes are
not. Bowers et al (1999, 2003) report an absconding rate of 6.1 per patient year,
although many of these are not officially reported as such, and only 3.6% result in any
kind of adverse outcome.
In the UK, a serious untoward incident (SUI) in psychiatric services is generally
considered to be any incident where medical treatment was required or death
occurred, or where moderate to high financial loss, or loss of reputation might occur.
The National Patient Safety Agency (NPSA, 2006) defines a 'patient safety incident'
even more broadly as any unintended or unexpected incident which could have or did
lead to harm for one or more patients receiving National Health Service funded care.
An SUI is similar to a 'sentinel' event in the USA, as defined by the Joint Commission
on the Accreditation of Healthcare Organizations (JCAHO, 2005), which is "an
unexpected occurrence involving death or serious physical or psychological injury, or
the risk thereof." Both JCAHO and the NPSA mandate Root Cause Analysis for the
investigation of such incidents. Root Cause Analysis is a systematic approach to the
identification of underlying reasons behind errors and mistakes which has been
widely used in industrial and other settings (Rooney and Vanden Heuvel, 2004). In a
Root Cause Analysis, detailed data is collected about the sequence of events, which is
then analysed using a variety of diagrammatic tools such as “cause-and-effect”,
“interrelationship” and “current reality tree” (Doggett 2004). This causal analysis is
directed towards identifying the reasons why the identified causes existed, proceeding
107
step by step until the “root causes” (those that if changed will prevent future incidents
throughout the organisation) are recognized.
Little (1992) describes three stages in staff responses to suicide; disbelief and fear of
further suicides, turmoil and exhaustion, followed by growth or prolonged disability.
These contrast with the stages described by Bartels (1987) of shock, recoil (guilt,
shame, anger, depression, self-doubt), and a search for meaning; a pattern confirmed
by Cotton et al (1983). There is a significant literature on staff responses to attempted
suicide (e.g. Main 1957, Maltsberger et al 1974) most of which stems from the
psychoanalytic tradition and suggests that such patients are rejected and avoided by
staff, possibly increasing suicide risk (Morgan and Priest 1991). Only two papers on
the effects of homicide on staff could be located. One (Turns and Gruenberg 1973)
found no impact on the use of containment (increases in transfers to closed wards or
tranquilliser use, decrease in home leaves and discharges). A similar result was
reported more recently by Bowers (2006), although an increase in staff leaving the
service was found. There is a plentiful literature on the impact of less severe patient
violence on staff, although most of this relates specifically to staff who have been
victims of attacks, and not to vicarious violence witnessed occurring to other staff or
to patients. Ryan and Poster (1989) report that staff suffer from post traumatic stress
disorder, and Baxter et al (1992) reporting that half of nurses consider it can take
several months to recover emotionally. In interviews of nurses about absconding by
patients, Clark et al (1999) found emotional reactions primarily of anxiety and fear of
blame.
108
This chapter addresses these linked topics: the purpose of acute inpatient psychiatry,
the roles and teamworking of different professionals within the system, and the
impact of serious untoward incidents on staff. We draw upon the baseline OPPI
interviews to present what professionals working in acute inpatient psychiatry said
they did and how they saw their (and each other’s) roles and contributions. Through
this we sought to arrive at a systematic and clear statement of the nature and purpose
of acute inpatient psychiatry, as it operates in the UK in the present day, and to
describe multidisciplinary teamwork as it operates to deliver to those goals. We also
present what they had to say about the impact of serious untoward incidents on their
wards.
DATA AND ANALYSIS
Subjects included multidisciplinary staff (n = 47) in the study NHS Trust, composed
of Ward Managers (n = 13 [0]), F Grade mental health nurses (n = 14 [0]),
Occupational Therapists (n = 11, [3]) and Consultant Psychiatrists (n = 9, [15]).
Numbers in the square brackets are of those who declined to participate, or did not
respond to an invitation to do so. Staff from 14 acute psychiatric wards were included,
and all Ward Managers, Occupational Therapists and Consultant Psychiatrists were
approached and asked to participate. Where there was more than one F Grade nurse
on a ward, the person first contacted was asked to participate. The interviews were
conducted from October to December 2003.
109
The duration of current experience in post on the study ward at the time of being
interviewed is shown in Table 1. Consultant Psychiatrists had the longest experience
as they tended to stay in the same post, whereas nurses moved through jobs as they
got promoted or moved between wards. The staff group interviewed who had the
shortest duration of experience were Occupational Therapists. However considerable
variation can be seen within the figures.
Table 1. Duration (in years) of experience on current ward at time of interview
Ward
Consultants Managers
Refuge Hospital
Albert
Manhattan
Millwall
Thames
Victoria
Haven Hospital
Canary
Deanston
Empire
Felstead
Old Belgate
10.00
1.25
13.00
4.00
2.50
11.00
F grade
nurses
Occupational
Therapists
0.50
3.00
1.50
5.00
0.25
2.00
4.00
3.00
4.50
2.00
0.50
1.50
1.25
2.00
1.25
6.00
0.25
10.00
1.25
4.00
3.00
1.50
2.75
0.75
2.00
1.00
0.25
0.25
0.25
Shelter Hospital
Capital
Hoba
Metropolitan
Prospect
5.00
1.50
7.00
1.00
0.50
7.00
0.25
7.00
0.25
5.00
6.00
Mean
6.14
2.81
3.27
6.00
1.48
Interview transcripts were imported into qualitative data analysis software (QSR N6)
and basic factual coding completed (e.g. ward, profession, etc.). All interviews were
then read by three researchers, who each created ideas on analytic categories and
priorities and then met to agree a strategy for coding. As a preliminary step,
interviews were coded to the broad topic areas of the structured interview questions.
110
For the findings reported in this paper, interviewees’ responses about who was
admitted to their wards and what their problems were, were first reread and then
coded into different categories, resulting in the analysis presented under ‘rationales
for admission’ below. Material about the philosophy of care and treatment was then
tackled in a similar way, resulting in the analysis presented in the first paragraph of
‘the production of acute care’. Finally, questions about the roles of different
professionals were categorised into, initially, a large number of different tasks.
However as coding proceeded, it became apparent that these tasks could be grouped
together under the four overarching means by which acute care is made to happen. All
coding followed this iterative procedure where the finest grained categories were used
at first, then were progressively merged into broader domains as commonalities
became
apparent.
Interviewees’
responses
about
multidisciplinary
and
interprofessional working were read and re-read and key themes identified and coded
for each professional group interviewed. Following further discussion of these themes
by the research team, additional coding and analysis led to the identification of overarching explanatory themes, and the development of a working model of
multidisciplinary teamworking. A serious untoward incident was considered to be
whatever interviewees mentioned in response to questions about whether there had
ever been a serious incident on the ward. This did not necessarily match the local
definition of SUI for all respondents, although all SUIs as defined by Trust policy
were mentioned in response to this question. Once an incident had been identified by
the subject, they were asked follow up questions on the impact and consequences.
Throughout these analyses, although expert consensus was used to identify and define
themes, the application of those themes and all coding of the texts to them was
completed with QSR N6.
111
THE NATURE AND PURPOSE OF ACUTE INPATIENT PSYCHIATRY
Rationales for admission
(a) Risk
Most admissions were reported to be emergencies or in response to crises. Most often
those emergencies were related to assessments that patients were a risk to themselves
or others. The two most frequently cited reasons for admissions were:
1. Risk of harm to self. This incorporated such things as self-harm, parasuicide, selfneglect, vulnerability, suicidal ideation, suicidal talk, and suicide attempts.
2. Risk of harm to others. Words such as ‘endangering others’, ‘homicide’, ‘harming
others’, ‘risk to the public’, ‘homicidal ideas’, ‘threats to kill’, ‘homicidal feelings’
and ‘violent behaviour’ were used in this context.
(b) Lack of social support
The degree of risk that resulted in an admission is not considered to be the same for
every patient. What matters as well as the degree of risk is the social support available
to the patient outside hospital in the community. People who are totally bereft of
support, completely alone and/or without resources are more readily admitted. The
responses of several interviewees emphasised that admission was a ‘last resort’, and
that community psychiatric services and teams were strongly geared towards keeping
people out of hospital and treating them in the community as far as possible. This was
considered to be the function of Community Mental Health Teams, Home Treatment
112
Teams, and Assertive Community Treatment Teams. Over occupancy of ward beds
was another factor leading to only the most severe and emergency cases gaining
admission. However, as one respondent remarked, this huge emphasis on keeping
people out meant that when an admission did have to occur, it could be seen in a
negative light, as a failure.
(c) Need for respite
Safety was far from being the only reason for admission to an acute psychiatric ward.
Respite, in different ways, was another. This could mean respite for the patient from
stressful living conditions outside the hospital. Alternatively, it could mean respite for
the patient’s relatives, neighbours, or local community. In this regard interviewees
spoke of patients sometimes being a ‘burden to their relatives’ or causing their family
to be ‘at their wits end’. Occasionally it is the wider local community that develops
concerns or anxiety about patient’s bizarre or difficult behaviour, leading to an
admission to provide respite for them.
(d) Acuity
The acuity of the patient’s mental illness was the other major rationale for admission.
They spoke of patients being ‘relapsed or in an acute phase’, ‘acutely ill’, ‘severely
mentally disordered’, ‘very unwell’, in ‘acute crisis’, ‘thoroughly psychotic’, and
‘incredibly high’. Mention of these facts was often linked to statements about risk,
usually affirming that the risk was because of the acuity of the mental illness. A
corollary of being admitted for acute mental disorder linked with risk is that a
function of admission is to treat patients’ mental disorder. All interviewees were
asked what were the main psychiatric conditions they had on their wards, and most
113
answered: psychotic disorders, schizophrenia, paranoia, mania, bipolar affective
disorder, depression and personality disorder, in that order. Many went on to add that
these presentations were commonly triggered or exacerbated by alcohol or illicit drug
use, and they estimated that a quarter to a half of their admissions had some form of
substance use co-morbidity. Personality disorders were referred to as being admitted
in smaller numbers than people with psychoses, and opinions varied on the utility or
benefits of such admissions.
Inconsistency
The routes by which patients are admitted to acute wards are multifarious, with a wide
range of different professionals, teams and agencies involved. All of the following
were mentioned as, at certain times and in certain places, initiating, facilitating or
undertaking the admission of a patient: Community Psychiatric Nurse; Senior House
Officer (preparing to be GPs as well as career psychiatrists); Senior Registrar;
Consultant
Psychiatrist;
Emergency
Clinic;
Crisis/Home
Treatment
Team;
Community Mental Health Team; Police; Accident and Emergency Liaison Team. As
a result, some professionals feel that who gets admitted is not under their control. This
kind of statement was made by several nurses, however even the Consultant
Psychiatrists felt their control over who appeared on the ward could be limited, with
one saying he had very little control, as most admissions came via other routes.
In these interviews, there was little agreement about what constituted an inappropriate
admission, with several groups of clients or problems that the majority of staff felt
were acceptable work for acute inpatient psychiatry being rejected by other
114
interviewees. Examples included differences over the role of psychiatry in public
protection, the precise level of risk necessitating admission, and the utility of
admitting patients with drug problems or personality disorders.
The function of acute care
Five themes were found in answers to questions about the treatment and management
of patients, indicating the objectives of acute care:
To keep patients safe, expressed as ‘keeping safe’, ‘making sure they are safe’,
‘keeping the ward safe’ and similar phrases.
To assess the nature, type and extent of patients’ problems, and patients’ response to
treatment, expressed as ‘assessment’ or ‘making a diagnosis’.
Provide treatment for patients’ mental illness, for example medication.
Meeting and addressing patients’ basic self care deficits and needs, for example
‘feeding them’ or ‘attending to personal hygiene’.
Providing physical healthcare and treatment, including diagnostic procedures, and the
care and treatment of chronic conditions.
The interviews revealed four processes by which these objectives are achieved:
(a) Containment
The means by which patients are kept safe are diverse. Interviewees spoke about the
use of sedating medication, de-escalation, and physical restraint in the case of patients
who posed a risk to others. For those who were at risk of harming themselves they
spoke, for example, of restrictions on the items patients could have with them,
115
observation and searching of their property. Respondents mentioned the need for
constant assessment and reassessment of risk so that these activities would be
appropriately titrated to the precise degree of risk posed by the patient concerned.
Many of these protective actions were therefore individually applied, with, for
example, some patients being allowed freely off the ward whereas others were
detained within its boundaries for a time.
(b) Presence and presence+
A very large number of interviewees, of all professions, spoke about the need to be
with patients, spend time with them, in order to do their work. Medical staff spoke
about ‘seeing people every week’ and conducting ‘mental state assessments’. For the
occupational therapists, time was spent with patients in running groups, or in
assessment of everyday living skills. Presence was therefore a means of conducting
assessments and delivering treatment. However it was the nurses who spoke about
being with patients the most, reflecting that they are at hand 24 hours a day, seven
days a week.
That presence was the main method by which nurses contributed to the assessment of
patients’ problems and the outcome of treatment. Whilst engaged in a huge variety of
different activities with patients, they would be interacting with them and observing
their reactions and behaviour, then communicating these to the rest of the team. The
actual treatment of patients also demanded the presence of nurses with them (e.g. the
giving out of medication) as did many containment activities previously described,
plus the provision of physical health care and dealing with the self care deficits of
patients. In fact, it was via the continuous presence of nurses that such things could be
116
adequately delivered, as without 24-hour presence they could not be done at all (e.g.
ensuring a patient ate a decent lunch as well as ensuring he had a good night’s sleep;
or, effectively preventing self-harm).
However, nurses generally meant more than this when they spoke about being with
patients, perhaps encapsulated by the word ‘presence+’. They had different ways of
expressing what they meant. They used words like ‘friendly’, ‘rapport’ and ‘caring’,
with one ward manager strongly declaring that ‘psychiatry isn’t done in the office,
psychiatry is done outside where the patients are’. For some nurses this was about
‘welcoming’ patients and treating them ‘like family’, whereas for others this was
about ‘getting to know them’ or getting a good understanding of them through
constant contact’. Yet others spoke of ‘engagement’ with patients, developing a
‘relationship’ with them, expressing ‘respect’, ‘building up trust’, or developing a
partnership through ‘empowerment’ and the provision of ‘support’. Thus such
presence+ merged into therapeutic relationships and therapeutic treatment in its own
right, or could be seen as providing the best possible opportunity for them to occur.
(c) Treatment provision
A variety of different treatments were mentioned, but the greatest prominence was
given to medication. The medical staff spoke of prescribing it, the nursing staff of
administering and monitoring it, and both spoke of the valuable support and advice
they received from pharmacists. Medication was generally the first thing mentioned
by interviewees when asked what treatment was given to patients on the acute ward,
and was seen as the means by which patients’ mental illness was resolved and
behaviour brought under control. Some also described the use of sedating medication
117
to manage aggression and arousal. The use of medication was thus central to the task
of acute psychiatry. Other physical treatments like ECT and drug detoxification were
rarely mentioned.
For nurses, the next most frequently mentioned treatment was presence+, referred to
in this context as a ‘therapeutic relationship’ characterised by a listening to and
hearing of patients’ distress, problems, and feelings about themselves, their current
admission, and their treatment. A variety of psychotherapeutic approaches were
mentioned as being used with patients by different professions, including: art therapy,
music therapy, psychodrama, counselling, behavioural programmes, psychoeducation, social skills training, and cognitive behaviour therapy. At one end of the
spectrum these psychotherapies merged into descriptions of community meetings
linked to vague ideas of the ward as a semi-self-governing therapeutic community. At
the other end of the spectrum these activities shaded into rehabilitation and training in
life skills.
(d) Management, organisation and co-ordination
The activities of the acute wards were supported by an array of professionals of
different types, and by a hugely complex organisational and administrative machine.
Getting and keeping things organised took a great deal of time and effort from
everyone involved. The work was highly necessary, and it was clear that without it,
the whole function of the ward would quickly grind to a complete halt.
Admission and discharge of patients were themselves, largely organisational and
administrative procedures, requiring complex advance arrangements involving
118
transport, treatment, handovers from community staff to hospital staff (and vice
versa), and stressful juggling of bed vacancies between wards involving transfers of
other patients or discharges in order to make way for more urgent cases. Once the
patient was in hospital, Mental Health Act documentation and procedures had to be
carried out, the necessary organisational records maintained, benefits and financial
needs attended to, fresh accommodation secured for discharge, the family’s needs for
information attended to, among a multitude of other administrative and organisational
tasks, many involving securing and timetabling visits from other necessary specialist
staff (e.g. home treatment team, assertive outreach, specialist addiction unit,
psychologists, art therapists, etc.). The multidisciplinary team were heavily involved
in making the system as a whole work to the benefit of patients, and expressed this as
‘co-ordination’, ‘general management’, being a ‘bridge’ or a ‘link’ between the
patient and everybody involved, ‘bringing everything together’. This task involved
‘chasing up’ various resources and other professionals, ‘making referrals’,
‘explaining’ things to the patient, ‘communicating’ and ‘providing information’.
INTERPROFESSIONAL WORKING IN ACUTE PSYCHIATRY
The key professional staff on the 14 acute wards studied were mental health nurses,
ward managers, psychiatrists and occupational therapists (OTs). When asked about
input from other disciplines on the wards there was mention of healthcare assistants,
domestic and administrative staff, psychologists, art therapists, pharmacists, modern
matrons, patient advocates, housing advisors and staff from assorted community
teams. This vast array of professionals and other visitors passing through reflects the
119
congested reality of acute wards (Quirk et al. 2004), but it was widely agreed that
nurses provided the bulk of care, treatment and ward management, with regular
support from doctors and OTs. Consequently, this paper focuses primarily on the
relationships between these key personnel. All illustrative quotes are identified with
coded ward names to maintain confidentiality.
Nurses on interprofessional working
(a) Valuing cohesion
Nurses valued cohesion within the nursing team, identifying things like supporting
each other through difficulties, expressing disagreements but still getting along, or
coming in at late notice to cover for a colleague. They appreciated similar unity with
other colleagues. Many nurses spoke of positive relations with other disciplines and
recognised this as an important component of an effective ward. Good communication
between disciplines was seen as important and included passing on information and
addressing tensions. Nurses saw themselves as playing a key role liaising between the
different professions and patients, often explaining or clarifying issues in order to
achieve cohesion.
(b) Continuity of care
The nurses valued the involvement of occupational therapists, largely through the
provision of group activities on the wards, and there was recognition of the
opportunity to learn from one another by taking part in these activities, which
enhanced continuity of patient care.
120
… you’ve got the OT, yeah, who does a fantastic job really. She's one of the strong
pinnacles of the management team really, yeah. She does all the early assessments;
she did everything, all the activities that is expected and everything like that. And also
the good thing about it [is] that the staff is involved in even the OT things because it, to
help us to understand what's happening really, so and the added strength that it gives
you an idea about what she is doing and then how you can utilise what is done by the
OT. [Manhattan Nurse]
One nurse regretted that the OT was ‘not valued’ or treated as a ‘full professional’
within the ward team [Hoba Nurse], but interdisciplinary tensions were largely
notable by their absence.
(c) Responsive and respectful
In their interactions with medical staff, nurses appreciated psychiatrists that were
available to provide advice and information, responded to requests to see patients and
supported nurses to manage the ward. Nurses also valued highly those consultant
psychiatrists who sought and considered the views of nurses and attempted to work
collaboratively in a manner that suggested professional respect.
So the medical team works quite in hand with us really … doctors here sort of very
much appreciate your views and we give our opinion just as much as anybody else.…
we do appreciate that level of togetherness. [Manhattan Nurse]
Unfortunately, nurses on some wards identified the lack of professional respect as a
significant barrier to effective multidisciplinary work.
(d) Developing constructive relationships
121
Changes in consultants and regular rotation of junior psychiatrists caused disruption,
with nursing staff having to help doctors learn and adapt to the routines of the ward,
particularly when they were relatively new to psychiatry. But it was acknowledged
that in helping these trainee psychiatrists, they could benefit from the constructive
relationships that emerged. Some nurses thought that positive relationships with the
medical staff developed despite the expectations some doctors had of nurses.
I think a lot of doctors are trained to believe that nurses aren't particularly intelligent
and that they don't have a particular body of knowledge of their own, but I think
generally speaking most doctors find us not just helpful, but quite intelligent, and on
a[n equal] level with them. [Felstead Nurse]
Ward managers on interprofessional working
(a) Accommodating consultants
Ward managers spoke predominantly of their interactions with consultant
psychiatrists. There were at least two consultants associated with each ward and
according to the ward managers and psychiatrists interviewed, there appeared to be
little contact or dialogue between the psychiatrists. Consequently, most negotiations
over bed management, admissions, discharges and the management of the ward took
place between the medics and the ward manager. Different psychiatrists often had
different styles and approaches, so it fell to the ward managers to negotiate these with
other members of the MDT. Consequently, most ward managers saw their role as
accommodating or adapting to these differences.
I say to the staff always, look we have people, learn from different people, different
ways because the person wants to work this way, he has got his reasons for doing it
122
that way, work with that way. There's no point saying 'no' you should work the other
way, because they are different, they have their own way. [Canary Ward Manager]
This same ward manager spoke of ‘making it easy’ for the psychiatrists and ‘not
harassing them’. Nurses were required to adapt to the style of the particular
consultant, not change that doctor’s behaviour. One example concerned the Care
Programme Approach (CPA), the case management policy that underpins mental
health service provision in the UK (Simpson, et al. 2003). One consultant requested
that CPA documentation was completed and made available at all ward rounds and
would not proceed without it. The other ward consultant was less insistent about the
level to which the CPA was adopted. As a result, nursing staff produced different
CPA documentation depending on which psychiatrist the patient was seeing.
I think we've all come to know what to expect from each consultant and I think the
patients themselves as well are aware, you know, that there are different consultants
who practise very differently, that their decision-making processes are very different
from each other and that is… We just accommodate that, which actually makes it more
dynamic and diverse. [Albert Ward Manager]
But the diverse approaches of the two or more consultants could cause problems, with
nursing staff sometimes feeling more comfortable with one than the other, particularly
around issues such as risk management and discharge decisions.
(b) Listening to and respecting nurses
As with the staff nurses, another key issue for the ward managers was whether other
disciplines listened to and respected the views of the nursing team. On some wards,
the consultant psychiatrists were respected for their clinical expertise and knowledge
123
and for how they managed certain patients, but the often disrespectful way in which
they interacted with the nursing staff caused difficulties. Only rarely were there
tensions with other disciplines.
I think he thinks I'm a bit of chewing gum on his shoe … he's one of those gentlemen
who what he says, that's it. … And he will write letters and complain to us and even
though he might be here he'll still write a letter… he's very good, he is very good, but
sometimes the staff get frustrated. [Metropolitan Ward Manager]
Even where there was evidence of professional respect, some ward managers were
aware that they seldom worked in a truly interprofessional fashion.
… they don't work that collaboratively. … they kind of act as oracles and, you know,
they do ask the nursing team and they do respect us as a group of professionals but it's
very much they come in, do their little bit, give a bit and kind of wander off again.
[Empire Ward Manager]
More collaborative approaches were appreciated, such as when consultants worked
with nurses to manage bed shortages or when members of assertive outreach teams
worked in partnership with ward staff.
(c) No power
Many ward managers believed that they and the nursing staff had little or no real
power when it came to decision-making over particular admissions and discharges or
whether to transfer patients to an intensive care unit. The nurses could present
arguments, advise and facilitate but ultimately, even where they felt they had a good
124
relationship, the doctors would ‘pull rank’ or make the final decision in a manner that
appeared arbitrary; “you know God has spoken” [Prospect Ward Manager].
Occupational therapists on interprofessional working
(a) Listening and respecting
Occupational therapists spoke of generally positive relationships on the ward,
especially between themselves and nursing staff. Again, having one’s professional
expertise and views acknowledged and considered contributed to the existence of a
team ethos.
…my opinion's always asked on a situation and you know, the work that I do is
appreciated so I do feel like I'm part of the team in that and, you know it's quite good
coming out of ward rounds feeling that you've, you've had, your inputs been recognised
and it's needed as well so yeah, so I think the strengths are that you know, the team
does feel like a team . [Albert OT]
Many OTs spoke of medical and nursing colleagues having a “lack of mutual
respect” [Deanston OT]. The perceived insensitive attitudes of some consultant
psychiatrists towards their colleagues, patients and families were remarked upon and
were seen to impair interprofessional relationships.
(b) Facilitating understanding
It could take time for interprofessional relationships to become established. OTs
spoke about having to explain and facilitate an understanding of their role and what
they could offer but that this was rewarded by constructive interactions.
125
The consultant I've known for over a year now and it’s taken me a long time to find a
working relationship with her, but I have done now. … it's taken a long time for me to
promote what I do to her, so that she understands and appreciates what I do... we've
got there, but its been difficult. [Manhattan OT]
One OT spoke of the need for each profession to have an awareness of the different
pressures each faced and an understanding of the philosophy that underpinned what
each was doing. It was deemed important that each person explain the thinking behind
their decisions and actions so that confusion and misunderstanding could be
minimised.
So there's a misunderstanding of my role often, I mean that's part of my role, to kind of
promote and educate about what I do.
I think, I think it's just we need more
communication between the team. [Thames OT]
(c) Participating
Experiences of being involved in multidisciplinary meetings and decision-making
varied widely, depending on which ward team, manager or psychiatrist the OTs
worked with. Many spoke positively of their experiences and acknowledged that
medical staff often used multi-disciplinary team meetings to collate information from
the other disciplines to produce agreed treatment plans.
I'm really impressed with the medical team because it's not kind of dictatorial, they're
not like well you know, we're going to do this, this and this, when they sit down and it's
a team decision ultimately they ask the nursing team and the OT team [Albert OT]
126
A smaller number described difficulties they experienced in trying to participate in
multidisciplinary settings and of being excluded from communications. As a result
they were sometimes not informed of key information about a patient or important
events, including incidents of violence.
Usually it's fed back by gossip lines, like very unprofessionally fed back, it's always
‘whispers’, unless I go back to the notes where it's written quite objectively. If it's one
of my patients, of course, I have an active interest in it. [Empire OT]
Some spoke of being “out of the loop” [Thames OT], as their time was divided
between the OT department and the ward. They felt on the periphery of the team, not
fully included or involved, with psychiatrists and nurses more established as team
members. Communication and joint decision-making was improved on wards that had
introduced joint planning meetings.
I think something that has changed recently which I think is really good, … there's a
nine o'clock handover as well which is for all the other members of the team who don't
work to a shift pattern, so I'll go, the OT assistant will go, there'll be the two Senior
House Officers will go to it, there'll be the psychologist there. That's a daily thing. And
I think it really does make a difference. [Hoba OT]
(d) Group activities
Some OTs referred explicitly to national policy recommendations that there should be
increased multidisciplinary input into therapeutic programmes (Department of Health
2002). This had led to the recent introduction of a programme of group activities
across the wards, facilitated by OTs. Staff had different ideas and views about
127
collaboration in the running of these groups and it was a source of concern for some
OTs that nurses were not always suitably qualified and skilled for such activities.
nurses say, I want to do this group, I want to do this group and they've actually set up
a group without thinking about, you know, continuity, without thinking about whether
their shift pattern allows the continuity, without any thought about boundaries, so the
group's starting at three, and they turn up at quarter to three, without any assessment
of person's needs or skills or whether that person can tolerate being in that group.
[Hoba OT]
Despite these concerns, there existed recognition of the value of nurses becoming
involved in group therapies and of opportunities for different professions to advise,
support and learn from one another.
Consultant psychiatrists on interprofessional working
(a) Positive relations
Many of the consultant psychiatrists in this study acknowledged the central role that
nurses played in acute psychiatry.
Well, I mean they [the nurses] do most of the work to be honest. … they run the ward
as far as I'm concerned. [Canary Consultant]
Most spoke very positively of their relations with nursing staff and thought that,
generally, the nursing staff were happy with them and that any disagreements were
usually sorted out amicably. Most consultants said they consulted regularly with
nurses about key decisions and some valued the views of the ward manager and other
128
nurses about medical students and exchanged concerns about particular nurses with
the ward manager.
A small number spoke of being the team leaders in acute psychiatry, whilst
recognising the important contributions others made. One explained that “doctors
have a training that teaches them to respond quickly and decisively” and to focus on
the “most important issues” [Albert Consultant]. As such, they were the natural
leaders of the MDT.
Doctors are by nature the leaders in multi-professional teams … if the consultant is not
actively involved in the ward, it ain't [gonna] work. Nothing's gonna work.
[Metropolitan Consultant]
A few spoke of working with different disciplines but most spoke only of their
relationships with nurses. Ward rounds were the main forums at which consultants
were involved in multidisciplinary discussions but some wards had introduced extra
weekly MDT management meetings to which all professions were invited. Some
acknowledged occasional disagreements but insisted that these were openly discussed
and resolved without bitterness.
I mean every now and again people disagree with the way we're managing something
but they're very, you know we'll talk about it, there won't be any kind of antagonism or
anything, so it's a nice atmosphere…. [Canary Consultant]
However, it was acknowledged that not all consultants had such positive relationships
and some medical colleagues with different approaches and styles could find
themselves in conflict.
129
(b) Taking more responsibility
One consultant wanted nurses to provide more detailed information about patients.
Another believed that inpatient care was largely a nursing activity and wanted to see
nurses taking more of a leadership role. He spoke of trying to encourage the nursing
team to become more involved in decision-making and to take more responsibility,
but suggested this was proving difficult.
often I feel that they're asking me to feed them with what to do next and I personally
want people to be creative and actually come to a view about the patient themselves
rather than behave as if they don't know what's going on with them, they want me to tell
them what to do. [Empire Consultant]
He went on to say that he was often pushed to operate in a more formal and dictatorial
style than he preferred and believed there was a lack of professional confidence and
pride in nursing that would allow relationships to be more egalitarian and functional.
The failure of nurses to accept more responsibility fed interprofessional tensions.
(c) Valuing the ward managers
The majority spoke warmly and positively of the ward managers and acknowledged
their centrality in creating a constructive ward team and culture. They had a key role
in identifying, attracting and retaining good staff, which then allowed a stable team.
They managed stressful, complex situations and the performance and development of
a disparate staff group and often brought a wealth of knowledge and understanding
about patients. Several spoke of how the ward manager took a lot of pressure off the
consultants by ensuring that things like bed management issues were dealt with. This
significantly lessened the potential for tensions between different medical staff and
130
ward managers were frequently recognised as providing an essential component of the
senior leadership team on the ward that allowed a consistency of approach to develop.
Interprofessional training
All interviewees were asked about training they had attended or that had made an
impact on the operation of the ward. It was apparent that there was little in the way of
joint training or development. Nurses were required to attend a vast array of
mandatory and other training. OTs attended courses that addressed individual
professional development needs, organised by the OT department and not involving
other professions. Consultant psychiatrists rarely mentioned training that they had
attended. Each profession appeared to know little or nothing about any training
undertaken by other ward staff. There were a couple of occasions when uniprofessional training was acknowledged to have improved interprofessional working,
such as when nurses had attended sessions on brief solution-focussed strategies.
Developments such as shared staff meetings, team information notice boards and
shared training sessions involving both nurses and OTs were identified as helping
develop a team ethos.
SERIOUS UNTOWARD INCIDENTS AND THEIR AFTERMATH
All interviewees spoke about serious untoward incidents when asked. Between them
they identified 39 incidents: 11 completed suicides, 5 attempted suicides, 2 homicides,
3 natural deaths, 7 serious absconds (elopements), 4 assaults, 1 alleged rape, 1
131
attempted rape, 3 serious threats, 1 accidental injury and 1 self harm incident. In
addition to these incidents affecting patients, they spoke about 2 incidents of alleged
staff misconduct, and one staff completed suicide. By no means had all of the
incidents taken place on the ward – many had not. Neither was the perpetrator always
an inpatient at the time – if they were known by the ward staff there would still be a
certain amount of impact. And those effects endured for long periods of time.
Although many of the incidents we were told about had occurred during the year
preceding the interviews, a substantial number were far more distant in time, with
some being 2 or 3 years ago, and one having taken place ten years previously.
Nevertheless, it was clear that these incidents, although distant in time, were still
having an influence on practice in the present.
Impact on morale
The emotional effect of the less severe of these incidents was largely restricted to the
wards where they occurred. However the more severe incidents, particularly those
involving deaths, had effects across the hospital where they occurred. On several
occasions interviewees told us about events on other wards that had had an effect on
theirs.
Interviewees spoke of the depression and demoralisation of the ward team that could
occur following an SUI, with one Consultant Psychiatrist saying "the atmosphere on
the ward was very sombre for a while", and another saying "people were rather
numbed and troubled by it and so the staff lost their zest". Several of the nurses spoke
about these events having a large negative impact on morale. However often linked
132
with these statements were comments about the driving force of the ward routine and
the needs of other patients, new patients, and how that necessity to focus on current
problems forced the staff to get on with things, preventing them from dealing with
their feelings about the SUI. The ward "has to carry on producing the goods
irrespective" in the words of one ward manager.
People are always talking about it for a little while afterwards if something like that's
happened. Because the ward is so hectic it's hard to, people might sometimes feel a bit
guilty about not moving on, because, I remember when this guy died on the ward,
somebody needed a bed and the bed area hadn't been cleared and I think it was a bit of
a respectful thing to maybe leave it just for a day or so. But they're under so much
pressure that they had to get it cleared. (Occupational Therapist)
After SUIs in which patients died, people also spoke about their sense of upset, loss
and grief. These feelings were particularly acute when the patient had been known for
some time, or the team had a real commitment to them, with one ward manager
saying "she was so well known to us, she was almost like a member of the family, it
definitely hit me so hard that", and another:
Well we had an SUI, when a patient killed themselves and that had a hell of an impact
on the nurses. The patient had been with us for quite a while, and it's like all of us
including the doctors, obviously everybody domestic, everybody, and it was first
admission, you just had a soft spot for him, and everybody was really concerned about
him, and everybody was basically involved in his care, and every week he got seen,
every ward round he got reviewed and so on. Then he started looking a bit brighter, a
bit more hope for the future, he went home for [leave]. The day he killed himself, he
133
was talking to me, it was the first time I'd seen him looking so bright, and then about
less than ten hours later we heard he'd just died, and that was just like, the impact it
had on everybody on the ward, we couldn't understand why it happened. (Ward
Manager)
Others also commented that SUIs came as a shock, were unexpected, and more
devastating because of that. This sense of shock went across the board for all types of
events – staff were definitely shocked by deaths, however they were also shocked by
attempted suicides, violent assaults, and by allegations of misconduct by a member of
the team.
Search for understanding
Hard on the heels of feelings of shock, grief and depression came ruminations about
whether anything could have been done to prevent the incident from occurring. Such
ruminations were frequently mixed with tentative feelings of guilt and dismay, with
the events rehearsed and alternatives explored and rejected. At the time of the
interviews some of these circular thoughts had become a well-worn track.
We had a serious self-harm on the ward, somebody who had a history of self-harm, …
were in a one to one position but it didn't work out because some people resent being
under one to one observation. And we tried to use options, can we give her more space,
or do we do it whether she likes it or not? But those were the difficult situation and I
think, on reflection, sometimes we have to take complete control of people's care,
sometimes to prevent an incident, but on the other hand, you always have to balance it,
134
what is definitely the best interest for the patient as well. And the thing is it is difficult
to get that balance right. I, we only don't get it right sometimes. (Ward Manager)
Others spoke of wishing they could have done more, wondering whether they could
have acted differently, or of reassuring themselves that there was nothing else they
could have done. Some spoke of feeling guilty just because someone had died, whilst
also fully knowing there was nothing they could have done. Sometimes mixed in
with these feelings were a sense of general stress, heightened anxiety, and specific
fears. In relation to violent incidents and threats, the anxiety was about the future
behaviour of the assaultive or threatening patient, with an Occupational Therapist
commenting "It made me feel quite unsafe on the ward for a little while after, a little
bit nervous". For absconds, there was anxiety about what the patient might do while
away from the ward, "for an hour and a half when I was phoned on the Saturday, you
know your career flashes in front of your eyes, and you think if he was to go and kill
himself, that would be it, and you feel quite exposed and vulnerable." In relation to
other incidents, primarily those involving deaths, the anxiety was about the reaction of
managers and the public, "people were scared, people were shocked I think people
were afraid that they were then going to be criticised or blamed". Other spoke about
the feeling that their practice would be inspected, and that their professional
registration might be under threat.
It devastated the team because we had a dreadful management structure that it was, the
blame culture was overwhelming. I just had to go the mortuary to identify him, the
very same day senior managers came, trying to blame somebody, all different staff.
When something happens, it doesn't matter who's fault it is, you're under scrutiny, as
an individual, as a practitioner, as a human being. (Ward Manager)
135
Several spoke about a continuing anxiety and worry that such an incident might
happen again at any time, coupled with a feeling that even their best efforts were
probably not enough to prevent all eventualities. One interviewee noted that these
feelings of anxiety were not confined to the ward staff themselves, but seized hold of
the entire management hierarchy.
I think there was, I think there was a lot of fear really, a lot of fear and I don't think
that was just fear on the ward, I think there was fear going up the management levels
as well so I don't think it just affected you know unqualified staff, D grades [and] E
grades [qualified nurses], myself.
I think it, it had an effect on the operational
manager, it had an effect on the matron, it had an effect on the lead nurse and so I
think it was felt all the way, all the way through really. (Occupational Therapist)
Managerial responses
Interviewees mentioned a variety of managerial responses, and these fell into three
groups: support, investigation and change.
(a) Support
Support was, of course, received very positively by staff, who were emotionally
traumatised by some SUIs. The presence of managers on the ward, visiting even if
only for short periods to ask how staff were was highly valued. However this seemed
more likely to be mentioned if the incident was of a lesser severity, or if it was
immediately apparent to everyone concerned that nothing could have been done to
136
prevent its occurrence. A couple of interviewees mentioned that professionals from
'outside' had been drafted in to facilitate discussions, or that counselling for staff had
been made available; both of these were experienced as supportive and helpful.
(b) Investigation
Investigation of the SUI was experienced in different ways. For very serious
incidents, managers came to the ward and took away all notes and records, and while
one interviewee saw this as normal procedure, another saw it as part of a process of
looking for someone to blame. Discussion and debriefing about the incident occurred
at different levels. The ward manager might bring the staff together to talk, or
managers might come to the ward to discuss the event with the staff. These meetings
could be helpful, as they got things into the open with the team, and enabled those
who were not on duty at the time of the incident to talk more easily with those who
were. However at these meetings difficult questions might be asked about why certain
actions were or were not carried out, hence they could be uncomfortable.
I highlighted to people that, you know, 10 p.m. why would you give somebody a razor
who is not going out to work in the morning, who is, who lives here, you know, 24
hours, why would you give him a razor? Oh I thought, you know, theory said, I said
forget about theory, forget about, use your head. (Ward Manager)
(c) Change
Changes introduced in the wake of an SUI could take place straight away, or be
introduced later as a response to issues thrown up by more thorough investigation
137
(e.g. the removal of potential ligature points). Senior managers sometimes had to take
more drastic action, such as suspending staff, occasionally ultimately terminating their
employment. In due course a number of other changes were introduced to prevent the
recurrence of the same incidents, these could include new policies, documentation, or
physical changes to the ward environment. Interviewees mentioned new policies for
special observation (with associated documentation), and changes to window and
fence design, and to door security practices. New policies were also variously
received by staff, with some seeing them as a device to further blame frontline staff
when things went wrong, whilst others saw them, if followed, as protective of staff
because they described best practice.
As these changes indicate, SUIs led to increases in the use of various means of
containing acutely mentally disturbed patients, and a general tightening of all
procedures in this area. This tended to happen quite separately from, and additionally
to, the managerial responses to the incident. Interviewees mentioned a greater
emphasis on risk assessment, a greater reluctance to give patients leave from the
ward, more rigorous documentation and form-filling, more regular checks on patients
throughout the day and night, and the nailing up of windows providing ventilation (as
well as egress). Doctors noticed that nurses required them to take more decisions,
with those decisions being recorded and signed for. Nurses noticed that doctors were
more prone to put patients on continuous special observation. All in all there was a
heightened sense of vigilance and alertness.
138
Patient responses
There were few comments about the reactions of other patients to these incidents.
Some interviewees spoke of breaking the news of a death to other patients, with an
Occupational Therapist reporting that there had been discussion about how to do so,
another mentioning that patients had received counselling, and a Consultant
Psychiatrist who was struck by the lack of reaction.
We had lots of different meetings over the course of the day, which was really quite
surreal, but one of them involved all the other patients because obviously we had to tell
them and I was struck by how disinterested they superficially appeared. Very few of
them seemed to take any of that information on board at all and I did talk about it with
a few people subsequently, but people seemed to move on very quickly. (Consultant
Psychiatrist)
Other comments about patient reactions were concern about copycat incidents, and an
acknowledgement that patients experienced heightened fear and anxiety following an
assault. Although the scope of the interview questions asked were broad, for example
"did that have an impact on the ward", this was largely interpreted by interviewees to
mean exclusively the staff.
139
SUMMARY
Based on our analysis, a clear statement of the nature and purpose of acute psychiatry
is as follows. Patients are admitted to acute psychiatric wards because they appear
likely to harm themselves or others, and because they are suffering from a severe
mental illness, and/or because they or their family/community require respite, and/or
because they have insufficient support and supervision available to them in the
community. The tasks of acute inpatient care are to keep patients safe, assess their
problems, treat their mental illness, meet their basic care needs and provide physical
healthcare. These tasks are completed via containment, 24-hour staff presence,
treatment provision, and complex organisation and management.
Multidisciplinary working on acute psychiatric wards consists largely of attempts to
ensure harmonious relations, good communications and mutual respect between
disciplines. There is little evidence of staff working alongside each other in a more
integrated, collaborative fashion.
Staff suffer considerable stress and trauma as a result of patient suicides and other
serious untoward incidents, that impact is not restricted to the ward where the patient
resided, and it can endure for many years. Staff reported feelings of shock,
depression, demoralisation, upset, loss, and grief, followed by ruminations, guilt and
anxiety. Levels of containment increased, as did the focus on risk assessment.
Processing of the emotional impact was hindered by the pace of ward life, a lack of
external support, and management investigations. Patient responses were largely
ignored. A few staff responded negatively, hindering service improvements.
140
5.
ADVERSE
WORKFORCE
INCIDENTS,
VARIABLES,
PATIENT
TRAINING
FLOW,
AND
TEMPORAL ECOLOGY
INTRODUCTION
Adverse incidents are a matter of no small concern to the providers of acute inpatient
psychiatric services. Patients pose the most risk, and are most vulnerable during the
acute phases of their illness. These risks can, in rare cases, be extremely serious and
include homicide or suicide. However, even the less severe incidents can result in
injuries to staff and patients, both physical (Hunter & Carmel, 1992) and
psychological (Needham, Abderbalden, Halfens, Fischer, & Dassen, 2005). There is a
great deal of public concern about these incidents, sometimes leading to public
inquiries (Sheppard, 1996), and always resulting in a careful investigation of potential
causal factors. However the prediction and prevention of these incidents is not easy,
and some argue that anxiety about patient safety is fomenting excessively defensive
practice by psychiatric professionals (Wells, 1995).
For some time there has been rising concern about patient violence on psychiatric
wards. It has been estimated that nursing staff have a 10% risk of being subject to a
physically violent attack during the course on one year (Healthcare Commission
2005). Although the majority of such attacks result in little or no physical injury,
psychological responses can be significant, with reports of consequent anger, anxiety,
141
post-traumatic stress disorder symptoms, guilt, self-blame and shame (Needham et al.
2005). There have been additional concerns about injuries to patients during the
management of violent incidents, particularly manual restraint related deaths (Blofeld
et al. 2003;Paterson et al. 2003).
These concerns have led to the development and implementation of courses for
nursing staff on the Prevention and Management of Violence and Aggression
(PMVA). In the UK, such courses originated within the prison system, and were then
imported into general psychiatry, with modifications, via forensic psychiatric
hospitals (Wright 1999). Such training is often referred to as ‘Control and Restraint’
and appears to be the dominant form of training in the UK, although many other types
and variations are also in use. More recently, such courses have become mandatory
for UK psychiatric service providers (National Institute for Mental Health in England
2004).
There is little published data on the frequency of use of manual restraint in the UK,
with one study (Duff, Gray, & Brostor 1996) suggesting eight times per year on an
average ward in order to manage aggressive behaviour. The hospitals in which this
study took place did not routinely collect information on manual restraint use, nor is it
easy to distinguish manual restraint from lower level coercion (Ryan & Bowers
2005). Manual restraint is used throughout psychiatric services in the UK, seclusion is
only used in 70% of acute wards nationally (Garcia et al. 2005), and mechanical
restraint is not used at all.
142
The evaluation of PMVA courses has not been rigorous. There are no randomised
controlled trials of manual restraint techniques (Sailas & Fenton 2005). A number of
studies have shown that staff feel safer and more confident in dealing with aggressive
situations following training (Beech & Leather 2004;Collins 1994;van Rixtel, Nijman,
& Jansen 1997) however this is not the same as demonstrating that violent incidents
are subsequently prevented or better managed. There is surprisingly little peer
reviewed outcome data on the effects of training. Reductions in incident rates and
injuries following the introduction of training courses have been reported by some
(Carmel & Hunter 1990;Gertz 1980;Mortimer 1995;St.Thomas Psychiatric Hospital
1976). Others have reported no change in incident rates and an increase in injuries
following the implementation of a course (Parkes 1996), or no reduction in incidents
for staff who were trained, as compared to an untrained control group (van Rixtel,
Nijman, & Jansen 1997). The most rigorous trial conducted so far found no
convincing impact of training on aggression frequency (Needham I. 2004;Needham et
al. 2004). No previous study has used a longitudinal design to evaluate the outcome of
PMVA training, although one provided graphs for one ward over a 31-month period,
showing decreases in aggression frequency once a threshold of 60% of staff trained
had been achieved (Mortimer 1995).
Previous studies of aggression in psychiatry have suggested that new staff members
may experience more anxiety in their first weeks and months working in psychiatry.
This is the case, for instance, with junior doctors who appear to prescribe higher
levels of sedating drugs to patients (Appleton 1965). Nursing students have also been
reported to be particularly vulnerable to being assaulted by patients (Hodgkinson et al
1984), and their presence has been associated with more frequent incidents of
143
aggression (Owen et al. 1998;Tam et al 1996), although this has not been uniformly
found, with one study even showing lower risks for students (Rix & Seymour 1988).
Findings on the weekly distribution of aggressive incidents are similarly varied, with
some studies reporting lower rates at weekends (Carmel & Hunter 1989; Cooper et al.
1983; Gudjonsson et al 1999; Larkin et al 1988; Noble & Rodger 1989; Rasmussen &
Levander 1996; Walker et al 1994), others reporting average rates at weekends
(Cooper & Medonca 1991; Depp 1983; Grassi et al. 2001; Ionno 1983; Nijman et al.
1997; Soliman & Reza 2001; Stockman & Heiber 1980), and two reporting the lowest
rates on Saturday and the highest on Sunday (Coldwell & Naismith 1989;Dooley
1986). In one of these studies an association was found between ward round days and
aggressive incidents (Cooper et al 1983).
There is little information on the weekly distribution of self-harm incidents, although
there is one report of no difference by day of the week (Nijman & a Campo 2002).
We have been unable to find any study relating self-harm or absconding to nursing
students or junior doctors. The weekly distribution of absconding has been the subject
of varying reports, with peak rates being reported during the week by some studies
(Farragher et al 1996; Kernodle 1966; Kleis & Stout 1991; Sommer 1974; Walsh et
al. 1998), some reporting peaks at weekends, especially forensic units (Cancro 1968;
Dolan & Snowdon 1994; Swindall & Molnar 1985), and another reporting no
difference by day of the week (Greenberg et al 1994). Ward rounds occur when the
consultant psychiatrist and the multidisciplinary team visit the ward to review patient
care. One study has reported no relationship between ward rounds and absconding
rates (Bowers et al. 2000).
144
DATA AND ANALYSIS
This chapter of the report draws upon officially collected data relating to the 14 acute
wards participating in the study. The period covered by this analysis was from 2002
(week 14) to 2004 (week 45), roughly two and a half years. As well as data on
admissions, discharges and patient characteristics; on workforce variables; and on
attendances of staff on PMVA courses; this included data on adverse incidents.
Adverse incidents
We were provided with the dates and wards of all incidents falling into the following
categories: verbal abuse, property damage, physical assault, self-harm, and
absconding. Some of these incidents were severe, requiring special investigation and
report, and these were referred to as ‘serious untoward incidents’ (SUIs). An SUI was
any incident where medical treatment was required or death occurred, or where
moderate to high financial loss, or loss of reputation might occur. Managers, using
guidelines from the National Patient Safety Agency, decided whether an incident was
counted as an SUI.
PMVA training
PMVA training has been given to all acute psychiatric ward staff in the study district
for many years. A team of two trainers provided the courses over the period of the
study. Courses consisted of either a five-day foundation course, or a one-day annual
update. The five-day course covered the prediction, anticipation and prevention of
145
violence; reporting requirements; the role of personal, environmental and
organisational factors in violence reduction; responses to aggression, involving deescalation, communication skills, problem solving and negotiation; and the principles
and practice of breakaway and manual restraint skills. Update courses covered manual
restraint skills only. The current PMVA trainers made full training records for all
wards, covering the full study period, available to us.
Staffing rotations
Nursing student allocations to the wards, with dates, during the study period were
collated from centrally-held records at the relevant school of nursing, and included
546 student allocations to wards. Ward round days on each ward were identified by
contacting each ward and requesting this information (during spring 2005). Junior
doctor rotation dates were obtained in a similar fashion, and included 134 fresh
allocations to wards.
Analysis
On receipt, data was screened for outliers and obvious errors, which were checked
against other sources of information and/or removed. All data was then imported into
a database program and collated using structured query language (SQL). The data was
then exported as text files and imported into STATA for statistical analysis. An ethnic
minority admission was counted as any admission not explicitly identified in our data
as "White British". A psychotic admission was counted as any with a primary
diagnosis of any organic or functional psychosis. A substance use admission was
146
counted as any with a primary, secondary or tertiary diagnosis of substance use,
inclusive of alcohol.
Poisson regression modelling was used to identify individual variables that might
have a significant effect on various incident types. The modelling used the occupied
bed days as the exposure variable in all analyses as this allowed for the differing ward
size. Lagged variables, of one and two weeks, were created for admission variables to
examine any time dependent effects of admissions on the wards. Any variables found
to be significant in univariate models were then entered into a multivariable Poisson
regression to examine the relative importance of the variables in the final model
selected for each incident type. Variables were eliminated in a backward selection
process deselecting the least significant at each stage. This analytic strategy was
applied to all incidents, and in a separate exercise to serious untoward incidents.
Incident rate ratios are reported for each model's significant independent variables.
These are a measure of relative incidence of the dependent variable due to an
independent variable. For example, if the dependent variable is incidents and the
independent variable is admissions and the IRR for the independent variable is 1.5.
Then for a one unit increase in admissions there is an increase of 1.5 in incidents.
In relation to PMVA training, the basic form of this data was incident and training
counts by week by ward, therefore Poisson regression was again used. Two different
time frames were applied: four-week periods, and weeks. Four-week periods smooth
out daily and weekly variation due to other factors, and were used to assess
relationships between variables over longer intervals of time. Weekly data were used
to conduct a finer grained analysis of short-term influences. The number of occupied
147
bed days was used as the exposure, thus controlling for fluctuations in the numbers of
patients present on the wards. The effect of incidents on training was assessed by
regressing lags of incident rates on counts of staff training attendances (e.g. the
numbers of physically aggressive incidents in one month was related to the following
month's number of staff on training courses, etc.). A similar method was used to
assess the effect of training on incidents (e.g. the number of course attendances in one
month was related to the following month's number of verbally aggressive incidents,
etc.). Following initial analysis, each least significant variable was then removed
sequentially, until only significant variables were in the model. Adjusted r-squared
values were calculated for each model, and incident rate ratios (IRR) provided as a
guide to effect sizes.
Tables and graphs of incidents by days of the week were prepared using SPSS v11.5.
Chi squared tests were used to identify statistically significant differences. In order to
test for the effect of ward round days, incident rates on ward-round days were
compared to incident rates on non-ward-round weekdays. For this analysis, data from
2004 only were used, as ward round days were subject to change over time. All these
tests on the weekly distribution of incidents used data from both acute wards and
PICUs. The occurrence of public holidays was ignored in these analyses, as there
were too few for meaningful statistical analysis. Poisson regression was used to
analyse the staffing rotation data, in a similar process to that applied to adverse
incidents and to PMVA training. The effect of new staff on incidents was assessed by
regressing lags of new staff on counts of incidents. Following initial analysis, each
least significant variable was then removed sequentially, until only statistically
148
significant variables (p < 0.05) were in the model. Adjusted r-squared values were
calculated for each model, and incident rate ratios provided as a guide to effect sizes.
ADVERSE INCIDENTS, PATIENT FLOW AND WORKFORCE
Table 1 gives frequency data for the variables reported in this study. These are
provided as raw frequencies per week, then as adjusted to either occupied bed days or
numbers of beds, to enable subsequent researchers to make accurate comparisons
(Bowers, 2000).
Table 1. Rates of incidents, admissions and nursing workforce variables
Serious untoward incidents
All
Absconds
Aggression
Self-harm
Other
All incidents
All
Physical aggression
Verbal aggression
Property damage
Self-harm
Absconds
n
Ward week
Mean
Std. Dev.
100 bed days
Mean
Std. Dev.
69
21
26
19
3
0.049
0.015
0.018
0.013
0.002
0.22
0.13
0.14
0.12
0.05
0.039
0.012
0.015
0.009
0.001
0.18
0.10
0.11
0.08
0.04
1174
370
226
88
147
238
0.836
0.263
0.161
0.063
0.105
0.169
1.37
0.65
0.51
0.28
0.38
0.50
0.688
0.216
0.135
0.084
0.053
0.142
1.15
0.56
0.41
0.31
0.23
0.42
275
45
358
98
86
102
224
37
298
91
72
119
Nursing workforce
Bank and agency hours
Special observation hours
Total staff absence
20 beds
Admissions & discharges
All admissions
Male admissions
Under 36 yrs of age admissions
Psychotic admissions
Ethnic minority admissions
Substance using admissions
All discharges
5384
2802
2550
2863
3307
848
5552
3.15
1.79
1.50
1.69
1.95
0.50
3.25
1.98
1.49
1.36
1.39
1.54
0.86
2.10
3.62
2.06
1.73
1.93
2.24
0.58
3.72
2.38
1.79
1.61
1.63
1.84
1.02
2.49
149
Serious untoward incidents
The incident rate ratios for each of the serious untoward incident models are presented
in Table 2.
Table 2. Incident rate ratios (IRR) for each serious untoward incident model
Dependent
variable
Lag 1 week male admissions
Admissions under 36 yrs of age
Independent Lag 2 week psychotic admissions
variables
All admissions
IRR (95%CI)
Verbal aggression
Property damage
All
Absconds
Aggression
1.17 (1.01,1.35)
1.17 (1.01,1.37)
0.78 (0.64,0.96)
Self-harm
1.37 (1.08,1.74)
1.28 (1.06,1.53)
1.67 (1.28,2.17)
2.46 (1.29,4.7)
There appears to be an association between total number of SUIs and increased under
36 years of age admissions, increased male admissions the previous week and reduced
psychotic admissions two weeks previously (adj r2=0.025, p=0.003). The variables
significantly associated with serious absconds were verbal aggression, and increases
in all admissions, no matter their specific diagnosis (adj r2=0.06, p=0.002). The only
variable significantly associated with serious aggression was an increase in property
damage (adj r2=0.02, p=0.029). The only significant variable associated with serious
self-harm was an increase in the one week lag in male admissions, that is male
admissions from the previous week (adj r2=0.03, p=0.018).
150
All incidents (SUIs and others)
The incident rate ratios for each of the other incident models are presented in Table 3.
Table 3. Incident rate ratios (IRR) for all incident models
Dependent
variable
Male admissions
Lag 1 week male admissions
Lag 2 weeks male admissions
Psychotic admissions
Lag 1 week psychotic admissions
Lag 1 week minority admissions
Lag 2 weeks subs. use admissions
Physical aggression
Independent
Verbal aggression
variables
Deliberate self harm
IRR (95% CI)
Property damage
Absconds
Observation hours
Total staff absence
All discharges
Season_2
Season_3
Season_4
All incidents
Physical
aggression
1.12 (1.05,1.21)
1.12 (1.04,1.21)
1.08 (1.01,1.16)
1.2 (1.08,1.34)
Verbal aggression
Deliberate self
harm
Property
damage
1.15 (1.01,1.31)
Absconds
1.1 (1.01,1.19)
1.46 (1.15,1.86)
0.73 (0.58,0.92)
1.45 (1.27,1.66)
1.60 (1.21,2.13)
0.65 (0.46,0.91)
1.37 (1.04,1.8) 1.39 (1.10,1.76) 1.64 (1.31, 2.06)
1.48 (1.26,1.75) 1.67 (1.30,2.16)
1.54 (1.13,2.1)
1.85 (1.43,2.4)
1.46 (1.01, 2.11)
1.11 (1.02,1.2)
1.11 (1.06,1.16)
1.05 (1.0,1.11)
0.84 (0.64,1.11)
0.80 (0.60,1.06)
1.39 (1.01,1.88)
1.10 (1.02,1.19)
1.22 (1.11,1.34)
1.14 (1.01,1.28)
The model showed that increases in total staff absence, overall discharges, male
admissions during the week as well as those from one and two weeks’ prior were
significant predictors of total incident numbers. The winter season had significantly
more incidents compared to the other seasons (adj r2=0.059, p<0.0005). The variables
significantly associated with physical aggression were increases in one week lag in
male admissions, verbal aggression, absconding and total staff absence and vacancy
(adj r2=0.04, p<0.0005). Verbal aggression was significantly associated with
increases in psychotic admissions, physical aggression and property damage (adj
r2=0.038, p<0.0005). Self-harm was significantly associated with increases in
physical aggression, total staff absence and all discharges (adj r2=0.065, p<0.0005).
Property damage was significantly associated with increases in male admissions,
physical aggression, verbal aggression, deliberate self-harm but also with a decrease
in substance abuse admissions from the two weeks prior to the damage (adj r2=0.06,
151
p<0.0005). Absconding was significantly associated with increases in psychotic
admissions from the previous week, physical aggression, verbal aggression and
observation hours but also with a decrease in minority ethnic admissions from the
previous week (adj r2=0.079, p<0.0005).
PREVENTION AND MANAGEMENT OF VIOLENCE AND AGGRESSION
TRAINING
Incident rates and fluctuations over time
During the analysis period 144 ward staff attended 5-day PMVA courses, and 168
attended updates. These figures equate to roughly one staff per ward attending a
PMVA course every five weeks. Figure 1 displays the frequency of all aggressive
incidents for the three hospital sites.
152
Chart 1: Aggressive incidents in the three hospitals over time (8 week moving
0
1
All aggression
2
3
4
5
average)
2002 (wk 26)
2003 (wk 1) 2003 (wk 26) 2004 (wk 1) 2004 (wk 26)
Time in weeks
Refuge Hospital
Shelter Hospital
Haven Hospital
Refuge Hospital joined the central incident recording system in 2003, and incidents
peaked in summer 2004 then declined. A similar peak occurred at Haven Hospital
during late 2002, thereafter evening out at a random walk around a mean of one
aggressive incident per week. Shelter Hospital seems to have a more fluctuating rate
around a higher mean of two incidents per week. Overall there is no trend towards an
increase or decrease in aggression over the study period.
Associations within four-week periods
The relationship between training and aggression was explored by examining the
association of aggression to training in the following months, and of training to
aggression in the following months. This analysis was conducted for each type of
violence and each type of course, using lags of one, two and three months.
153
With respect to aggression leading to course attendance, property damage in the
preceding month (p = 0.021, IRR = 1.38), and physical violence during the month of
the course (p = 0.03, IRR = 1.16) were associated with greater 5-day PMVA course
attendance; and physical violence three months before (p = 0.012, IRR = 0.78) was
associated with less course attendance (adj. r2 = 0.029). This means that for every one
incident of property damage in the preceding month, there was an increase of 38% in
course attendances, for every one incident of physical violence during the month of
the course there were 16% more course attendances, and for every incident of
physical violence three months before there were 22% fewer course attendances.
With respect to aggression leading to PMVA update course attendance, verbal
aggression at one (p = 0.049, IRR = 1.13) and two (p = 0.003, IRR = 1.20) months
before were associated with greater attendance; and property damage at one (p =
0.009, IRR = 0.58) and three (p = 0.015, IRR = 0.60) months before were associated
with less attendance (adj. r2 = 0.036). These findings provide some limited support
for the idea that aggression in the months prior to courses prompts greater attendance,
but the pattern of results is inconsistent and therefore unconvincing.
Course attendance also had discernible effects upon incident rates in the following
months. Greater physical aggression was associated with PMVA update course
attendance in the preceding month (p < 0.001, IRR = 1.17, adj. r2 = 0.016). Greater
verbal aggression was associated with update course attendance two months before (p
= 0.026, IRR = 1.13) and less verbal aggression with update course attendance the
month before (p = 0.019, IRR = 0.79, adj. r2 = 0.013). There was no relationship
between rates of property damage and previous course attendance. Again these results
154
are inconsistent, and provide little support for the idea that course attendance leads to
substantive decreases in aggression rates over several months.
Associations within weeks
A similar analysis was therefore conducted at the level of ward weeks, exploring the
relationships between aggression and courses using lags of one, two, three and four
weeks. Greater PMVA 5-day course attendance was associated with physical violence
three weeks before (p = 0.019, IRR = 1.29) and the week of the course (p < 0.001,
IRR = 1.43, adj. r2 = 0.018).
With respect to aggression leading to PMVA update course attendance, verbal
aggression four weeks before (p = 0.031, IRR = 1.32) and the week of the course (p =
0.011, IRR = 1.33) were associated with higher course attendances, and physical
violence three weeks before (p = 0.023, IRR = 0.65) with lower attendance (adj. r2 =
0.014). Again, there were some indications of aggression prompting course
attendance, but no consistent picture emerges. However what does stand out clearly is
that 5-day course attendance has an opportunity cost, in that the withdrawal of regular
staff from the wards on study leave seems to lead to an increase in physical violence.
The impact of course attendance on aggression in the following weeks is clearer.
Greater physical aggression was associated with PMVA update course attendance
three weeks (p = 0.04, IRR = 1.17) and four weeks (p = 0.019, IRR = 1.20) before,
and with PMVA 5-day course attendance (p < 0.001, IRR = 1.50) in the same week
(adj. r2 = 0.012). There was also a trend towards an association with update course
155
attendance the week before. For verbal aggression, greater frequency was associated
with 5-day (p = 0.042, IRR = 1.34) and update courses (p = 0.038, IRR = 1.21) in the
same week (adj. r2 = 0.005). Rates of property damage had no relationship to
previous course attendances. These findings suggest that PMVA update courses might
precipitate a short-term increase in physical violence.
JUNIOR STAFFING CHANGES AND THE TEMPORAL ECOLOGY OF
ADVERSE INCIDENTS
Junior doctor rotations
Of the 134 fresh allocations of junior doctors to the wards, all were of two doctors and
followed a regular pattern of change (rotation) every six months. The six weeks
following the arrival of new junior doctors on the wards, plus the week when they
arrived, were tested for their impact on different types of adverse incidents. Following
the arrival of junior doctors, physical aggression decreased in week 3 (IRR = 0.65, r2
= 0.003, p = 0.036) and absconding decreased in week 3 (IRR = 0.56, r2 = 0.004, p =
0.048); there was no change in verbal aggression, property damage, or self-harm.
Nursing student allocations
Of the 546 fresh allocations of students to wards, 124 were of one student, 77 of two
students, 56 of three students, 21 of four students and four of five students. The six
weeks following the arrival of new nursing students on the wards, plus the week in
156
which they arrived, were tested for their impact on different types of adverse
incidents. Following the arrival of students, physical aggression decreased in the
following week (IRR = 0.82, r2 = 0.004, p = 0.014); there was no change in verbal
aggression, property damage, absconding or self-harm.
Days of the week
The distributions of incidents by days of the week are displayed in Table 4.
Table 4. Adverse incidents by days of the week
Day of the week
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Chi square (df = 6)
p
Abscond
Yes
No
36 1742
35 1743
44 1734
37 1741
51 1727
50 1728
28 1750
10.91
0.089
Physical
aggression
Yes
No
55 1723
81 1697
80 1698
72 1706
78 1700
80 1698
54 1724
12.48
0.052
Property
damage
Yes No
20 1758
22 1756
11 1767
8 1770
21 1757
10 1768
15 1763
13.16
0.041
Self-harm
Yes No
26 1752
21 1757
19 1759
24 1754
28 1750
19 1759
24 1754
3.17
0.787
Verbal
aggression
Yes
No
38 1740
43 1735
40 1738
45 1733
46 1732
38 1740
33 1745
3.17
0.787
All
incidents
Yes
No
175 1603
202 1576
194 1584
186 1592
224 1554
197 1581
154 1624
17.07
0.009
Self-harm did not vary by day of the week, nor did verbal aggression. However,
property damage was less frequent on Wednesdays and Fridays, and all incidents
counted together were less likely at weekends. Further testing showed that weekend
incident rates were significantly different from weekday rates ( 2 = 10.96, df = 1, p =
0.001), but not that Wednesdays were different from other weekdays ( 2 = 1.5, df = 1,
p = 0.221). There were also trends for physical aggression to be lower at the
weekends and midweek, and for absconding to peak on Thursdays and Fridays.
157
Ward-round days
At ward rounds decisions are made that are sometimes unpalatable to patients, e.g.
refusals to grant leave or discharge, or to increase doses of unwanted medication.
Absconding was no more or less likely to occur on ward round days ( 2 = 0.045, df =
1, p = 0.832). The same was the case for physical aggression ( 2 = 0.447, df = 1, p =
0.504), property damage ( 2 = 0.039, df = 1, p = 0.760), self-harm ( 2 = 1.445, df = 1,
p = 0.229), verbal aggression ( 2 = 0.422, df = 1, p = 0.516), and all incidents counted
together ( 2 = 0.352, df = 1, p = 0.553).
A total of 31 ward rounds per week occurred across the sample wards, with 2 on a
Monday, 11 on a Tuesday, 4 on a Wednesday, 9 on a Thursday and 5 on a Friday.
This uneven distribution makes it difficult to compare the distribution of adverse
events, as any pattern of association (on non-association) may be due to other facets
of the way the working week is organised. The results of the comparison are
presented in Table 5. Incidents were more likely on the days before and after ward
rounds. These effects were most pronounced for aggressive behaviours, and a nonstatistically significant trend was seen for absconding, self-harm and property
damage.
Table 5. Ward rounds and incidents: number of incident days by type of day
Type of day
no proximate ward round
day before
ward round
day after
day after and day before
Chi square (df = 4)
p
Absconds
Yes
No
3
447
16
839
21 1419
11
664
3
177
3.04
0.551
Physical
aggression
Yes
No
9
441
43
812
64 1376
38
637
6
174
9.78
0.044
Property
damage
Yes
No
2
448
8
847
9 1431
5
670
2
178
1.60
0.809
Self-harm
Yes
No
6
444
12
843
12 1428
8
667
4
176
3.65
0.455
Verbal
aggression
Yes
No
3
447
16
839
24 1416
19
656
9
171
15.72
0.003
All incidents
Yes
No
25
425
108
747
142
1298
91
584
27
153
25.19
<0.001
158
SUMMARY
Adverse incidents were more likely during and after weeks of high numbers of male
admissions, during weeks when other incidents also occurred, and during weeks of
high regular staff absence through leave and vacancy.
This longitudinal dataset of official reports showed a positive association between
PMVA training and violent incident rates. It provides weak evidence that aggressive
incident rates prompt course attendance, no evidence that course attendance (either 5day or updates) reduces violence in the short or long term, and some evidence that
update courses trigger short term (four week) rises in rates of physical aggression. In
addition, they show that course attendance leads to a significant rise in physical and
verbal aggression on the ward whilst staff are away.
No evidence was found that new junior staff elicit more aggressive or other adverse
incidents from patients. In contrast trends suggesting the opposite were found.
Tension and raised anxiety among patients appears to be linked to greater adverse
incident rates, particularly aggression. This is visible in pre- and post-week, and preand post-ward round raised incident rates. These tensions appear to have a larger
impact on incident rates than symptoms alone, as incidents rates were very low at
weekends. The link between stress on the ward community and adverse incidents is
also supported by our other findings on admission rates and staff availability
presented in this chapter.
159
6. THE THREE PSYCHIATRIC INTENSIVE CARE UNITS COMPARED
INTRODUCTION
Psychiatric Intensive Care Units have been in existence from at least the 1970s and
probably earlier (Crowhurst & Bowers 2002), and consist of small wards with higher
staffing levels and greater security, set up to cater for patients who are too disruptive
or dangerous to be managed on ordinary acute wards (Dix 1995). Such facilities have
been set up as pragmatic responses to difficulties in caring for difficult patients. To
date there is little evidence on whether they are effective in keeping staff and patients
safer, or in promoting recovery. Much of the previous research has described the
opening or operation of single units (Jones 1985;Saverimuttu 1996), and although
several large surveys have been carried out (Beer, Paton, & Pereira 1997;Ford &
Whiffin 1991;Mitchell 1992), there have been no detailed comparisons of different
units, save for one study of two PICUs in Slovenia, described only in brief
(Dernovsek et al. 2003), and another in Australia highlighting differences in seclusion
use (Hafner et al. 1989). Some previous UK research has raised concerns that ethnic
minority patients are over-represented in the PICU (Brown & Bass 2004;Feinstein &
Holloway 2002;Pereira et al. 2006), although in their analyses none of these studies
controlled for the potential confounding factors of age, gender and diagnosis.
The data we report here were collected as part of the Tompkins Acute Ward Study, a
multi-method longitudinal investigation of links between adverse incidents and staff
factors. Previous papers from this study have described the nature and purpose of
160
acute wards (Bowers et al. 2005), and the role of the Occupational Therapist
(Simpson et al. 2005).
DATA AND ANALYSIS
Three sources of data were drawn upon for the results presented in this chapter:
1. Official statistics: These included data on the date, age, gender, and diagnosis of all
admissions; details and dates of adverse incidents reported by nurses; and information
on workforce availability and deployment. The data were drawn from several
different departments of the NHS Trust concerned and collated by the research team.
The period covered by this data was from 2002 (week 14) to 2004 (week 45), roughly
two and a half years. Data on the local population were drawn from the 2001 census.
2. Clinical audit: The Trust Pharmacy Department conducted an audit of antipsychotic
prescribing on inpatient wards using random samples of patients within wards, during
2002 and 2003. This data was provided to the research team.
3. Interviews: A total of 9 staff across the three PICUs were interviewed using the
Operational Philosophy and Policy Interview, comprising 3 ward managers, 3 F grade
nurses, and 3 occupational therapists. All PICU consultant psychiatrists declined to be
interviewed at this stage of the study. All interviews were tape recorded and
transcribed.
Admissions, workforce and adverse incident data were summarised using simple
descriptive statistics for comparison between the three PICUs. Logistic regression was
used to compare patients having any stay on the PICU, with those who were only
161
admitted to an acute ward. Interview transcripts were imported into qualitative data
analysis software (QSR N6) All interviews were then read by three researchers, who
met to collate ideas on analytic categories and priorities. For this study, data was
extracted and collected from the interviews pertaining to ward management and
function, developments and staff changes over the past year, team functioning,
multidisciplinary relationships, and the management of difficult and challenging
patients.
RESULTS
Patients arrived on the PICUs from prison, the courts, brought in by the police under
mental health legislation, or transferred from acute admission psychiatric wards. The
latter constituted 46% of all admissions to the PICUs, and the criteria for such
transfers were that patients posed a risk of violence to self or others, or of absconding,
were acutely ill, and difficult to manage in an ordinary acute ward environment. All
three PICUs had similar admission criteria, as stated by those we interviewed.
Differences between patients who were admitted to acute psychiatric wards but did
not have a PICU stay, and those that did or who were directly admitted there were
explored using a table of unique patients (i.e. readmissions were ignored, but any stay
on a PICU during the period classified the patient as a PICU patient). Logistic
regression was used to contrast the two groups, and the results are presented in Table
1.
162
Table 1. Logistic regression of variables predicting PICU rather than acute ward only
admission
Black Caribbean
Asian
Bipolar affective disorder
Recurrent depressive disorder
Schizoaffective disorder
Schizophrenia
Unspecified nonorganic psychosis
Drug induced disorder
Male gender
Age
[95% Conf.
Odds
Ratio
Std. Err.
z
P>z
2.33
0.55
5.01
5.29
6.88
3.84
3.08
2.65
7.01
0.97
0.43
0.1
2.03
3.71
3
1.48
1.27
1.15
1.06
0.01
4.57
-3.21
3.97
2.38
4.42
3.49
2.73
2.25
12.9
-5.37
< 0.001
0.001
< 0.001
0.017
< 0.001
< 0.001
0.006
0.025
< 0.001
< 0.001
Interval]
1.62
0.38
2.26
1.34
2.92
1.8
1.37
1.13
5.22
0.96
3.34
0.79
11.11
20.91
16.17
8.17
6.89
6.22
9.43
0.98
No. of observations = 3849, Pseudo R squared = 0.1743
A PICU stay was positively associated with male gender, younger age, and a range of
mainly psychotic diagnoses including bipolar affective disorder, recurrent depression,
schizoaffective disorder, schizophrenia, unspecified non-organic psychosis and drug
induced psychosis. With respect to ethnicity, Caribbean patients were more than twice
as likely, whilst Asian patient were half as likely to have a PICU stay, with no
significant differences for Black African, Irish, White and 'other' ethnic groups.
Figure 1 compares the ethnic makeup of the local population with that of PICU and
acute ward patients, making these differences clearer.
163
Figure 1. Ethnic composition of acute ward and PICU patients compared to local
population (20-64 yrs)
Ethnicity of Acute and PICU patients as compared to local population (20-64 yrs)
0.45
0.40
0.35
0.30
0.25
Proportion within acute
Proportion within PICU
Proportion within population
0.20
0.15
0.10
0.05
0.00
Black African
Black Caribbean
Asian
Irish
White British
Other
In case these ethnic differences were due to differential routes of admission by
ethnicity (e.g. more Caribbean admissions via the criminal justice system), logistic
regression was used to contrast direct admissions with transfers from acute wards.
Other than the direct admissions being slightly older than the transfers, there were no
differences in gender, diagnosis or ethnicity.
Table 2 presents comparative data on the three PICUs and the acute ward (and
locality) populations they serve, together with staffing and patient throughput. This
table is drawn upon in the case analysis below, together with material from the
interviews.
164
Table 2. Beds, admissions, patients, populations, deprivation and staffing compared
across the three PICUs
Refuge
Haven
Shelter
All
No. beds
No. acute beds served
Population served (000s, 2001 census)
Admissions/week
Transfers in/week
Mean occupancy/week
New patients per bed per week
Acute beds per PICU bed
Population per PICU bed (000s)
Mini 2000
15
88
210
2.25
1.53
0.95
0.25
5.87
14.00
1.83
9
74
196
0.38
0.88
0.81
0.14
8.22
21.78
1.90
8
66
244
0.78
0.53
0.95
0.16
8.25
30.50
1.76
32
228
650
3.41
2.94
0.90
0.56
7.13
20.31
1.83
Mean age PICU
Proportion male PICU
Proportion African PICU
Proportion Caribbean PICU
Proportion Asian PICU
Proportion Irish PICU
Proportion White British PICU
Proportion other ethnicity PICU
32.73
0.96
0.17
0.22
0.04
0.03
0.24
0.29
31.92
0.69
0.09
0.10
0.24
0.02
0.33
0.22
34.11
0.91
0.19
0.13
0.23
0.00
0.23
0.23
32.92
0.85
0.16
0.18
0.12
0.02
0.26
0.26
Mean age Acute
Proportion male Acute
Proportion African Acute
Proportion Caribbean Acute
Proportion Asian Acute
Proportion Irish Acute
Proportion White British Acute
Proportion other ethnicity Acute
37.14
0.46
0.13
0.12
0.05
0.03
0.34
0.32
37.33
0.61
0.06
0.03
0.25
0.02
0.47
0.16
35.33
0.56
0.15
0.06
0.22
0.01
0.35
0.21
36.60
0.54
0.12
0.07
0.17
0.02
0.38
0.23
All incidents per bed per week
Absconds per bed per week
Physical aggression per bed per week
Verbal aggression per bed per week
Property damamge per bed per week
Self-harm per bed per week
0.033
0.006
0.011
0.006
0.004
0.002
0.138
0.022
0.068
0.027
0.008
0.006
0.036
0.004
0.014
0.009
0.003
0.001
0.069
0.011
0.031
0.014
0.005
0.003
Nursing establishment WTE per bed
Nursing WTE vacancy per bed
Nursing WTE sick leave per bed
Nursing WTE bank and agency use per bed
2.01
0.59
0.01
0.48
3.68
1.24
0.18
1.01
2.71
0.46
0.08
0.58
2.80
0.76
0.09
0.69
165
Refuge PICU
Population and patients: This was the largest of the three units, with the highest
throughput of patients. In terms of its locality, this unit provided a higher proportion
of PICU beds to acute beds, and higher proportion of PICU beds to the population
served. However it had a significantly lower nurse staffing level compared to the
other two units. Nevertheless it used few bank or agency staff and had the lowest
sickness rate. Over the study time period it accommodated almost entirely male
patients. The largest proportion of admissions were of ‘other’ ethnicity patients,
followed by white British and Caribbeans.
Developments: The ward team had been stable for the previous four years, with few
changes. Some improvements had been made to the physical environment, including
the addition of a pool table for patients. Prevention and Management of Violence and
Aggression training had changed techniques taught from holds using pain to obtain
compliance, to non-painful holds based on leverage.
Multidisciplinary relationships: There were solid, mutually trusting and respecting
relationships between all three professions (occupational therapy, nursing and
medical), which had existed for some years.
Containment: In both prescribing surveys Refuge PICU had the highest levels of
antipsychotic prescribing (2002 mean CPZ equivalent per patient per day 200mg,
2003 122mg). The nurses commented in the interviews that the Consultant prescribed
liberal dosages and that they sometimes thought less might be better. Refuge PICU
166
had a seclusion room that was used for patients from other wards in the rest of the
unit, as well as for PICU patients.
Conflict incidents: There was a low rate of all incidents by bed, with a similarly low
rate of each of the different subtypes, and a similar incident prevalence profile to
Shelter PICU. Interviewees reported one recent suicide of a patient who ran off whilst
on escorted leave, and two serious suicide attempts by patients on the ward.
Haven PICU
Population and patients: In terms of size and throughput, this unit was similar to
Shelter PICU: a smaller number of beds, a slower throughput of patients, and more
acute beds per PICU bed. Although all three units served deprived areas, this area was
the most deprived of the three, with the most psychiatric need and likely morbidity as
measured by the MINI 2000. Haven PICU had the highest nursing establishment
figures, however it also had the highest sickness rate and the highest vacancy rate, and
was the highest user of bank and agency staff. Just above 30% of admissions were
female – a far higher proportion than the other two units. The largest proportion of
admissions were white British, followed by Asian and ‘other’ ethnicity.
Developments: Two years prior to interviews the previous ward manager left, and was
succeeded by a series of short-term and temporary post holders. The current ward
manager was appointed 7 months prior to the interviews, and found the ward
medically dominated with high sickness rates among the nursing staff. Following a
series of absconds due to physical security deficits, changes were made to the
167
structure of the ward as pushed for by the ward manager. The ward closed for two
days for training, the team developed a new ward philosophy, and the implementation
of all safety and security related policies was tightened.
Multidisciplinary relationships: the relationship between the new ward manager and
the medical team was poor, with disputes over major items like medical control over
admissions and the appropriateness of leave for PICU patients, and more minor issues
like the location of ward rounds.
Containment: Haven PICU does not have a seclusion room. Staff had been using a
side room as an extra care area where disturbed patients were kept accompanied by
nurses, however this practice was discontinued some time before the interviews took
place.
Conflict incidents: The rate of adverse incidents was three to four times higher than
on the other two PICUs, and that differential existed for every type of incident, from
aggression through absconding to self-harm. Interviewees described a number of
absconds which could be ascribed to poor physical security issues (defective doors,
windows and fence) which were not quickly remedied. They also described two
patients in the recent past that had repeatedly assaulted staff. One of these two could
not be managed on the PICU, as he was assaulting staff several times a day, and was
eventually reluctantly transferred by the Consultant to a more specialist unit.
168
Shelter PICU
Population and patients: In terms of size and throughput, this unit was similar to
Haven PICU: a smaller number of beds, a slower throughput of patients, and more
acute beds per PICU bed. However this unit had a very much higher numbers of the
local population per bed, a third more than Haven PICU, and twice as many as Refuge
PICU. Nursing establishment figures were closer to the lower numbers on Refuge
PICU, although still not as low, while the vacancy rate and use of bank and agency
staff were similar. Again like Refuge PICU, this unit admitted mostly men. The
largest proportion of admissions were white British and ‘other’ ethnicity patients,
followed by Caribbeans.
Developments: Overall stability of philosophy and approach set by the ward manager
who opened the unit in a newly built hospital more than two years previously. Some
changes of staff (ward manager and consultant), but the 'acting up' of an existing
nursing team member is maintaining the culture.
Multidisciplinary relationships: Some relationship strain was described, with the
occupational therapist and some nurses feeling undervalued by the medical team, and
reports of arguments between the PICU consultant and other consultants about
admissions and discharges.
Containment: In both prescribing surveys, Shelter PICU had the lowest level of
antipsychotic prescribing (2002 CPZ equivalent per patient per day 73mg, 2003
35mg). A seclusion room was available, but this was hardly used.
169
Conflict incidents: There was a low rate of all incidents by bed, with a similarly low
rate of each of the different subtypes, and a similar incident prevalence profile to
Refuge PICU. Interviewees spoke about two absconds through a defective window
and over an inadequate fence, and also mentioned a serious, frightening inter-patient
fight.
SUMMARY
The provision of PICU care was hugely variable, even within the contiguous districts
served by a single NHS Trust. Size, staffing and incidents rates all varied enormously.
The latter may have varied due to patient factors, or to staff group factors such as
leadership and teamwork. There were also important variations in PICU usage by
ethnicity, particularly in relation to an apparent over representation of Caribbean
patients.
170
7. STAFF ATTITUDES, WARD STRUCTURE, AND
CONFLICT AND CONTAINMENT
BACKGROUND
During 1998 a large interview study and survey took place of staff working in the
three English High Security Psychiatric Hospitals, the findings of which were
subsequently published in a book and several papers (Bowers 2002, Bowers 2003a,
Bowers 2003b). The interviews of 121 nursing staff were on the topic of the care and
management of patients with personality disorder, generally considered to be the most
difficult and unpopular patients within the psychiatric system. Those interviews
showed that staff with more positive attitudes thought different, believed different
things and had different priorities from staff with more negative attitudes. They also
contained very suggestive evidence that staff with positive attitudes responded to
patients in ways that diminished the likelihood of aggression and other difficult
behaviours on the part of patients. These nursing responses to patients or social
processes were clearly generic, rather than specific to the care of people with
personality disorder, and were summarised as:
1. Positive Appreciation: liking and enjoying being with patients
2. Emotional Regulation: able to contain their own natural negative emotional
responses (anger and fear) to patients
171
3. Effective Structure: the provision of consistent rules and routines for patients,
underpinned by and ethical rather than a punitive stance
As part of the same study, and in advance of the interviews being conducted and
analysed, a new Attitude to Personality Disorder Questionnaire (APDQ) was
constructed. Factor analysis of that questionnaire led to the identification of five
dimensions of attitude: enjoyment, security, acceptance, purpose and enthusiasm.
A second study was conducted in a new Dangerous and Severe Personality Disorder
Unit in a High Security Prison during 2001-03. In this study, which aimed to confirm
and extend the previous one, Prison Officers were interviewed and completed
questionnaires in three waves. This study established that there was a statistically
significant association between Positive Appreciation, Emotional Regulation, and
Effective Structure as assessed by interview, and APDQ scores (r = 0.3 – 0.4). It also
demonstrated that APDQ scores were associated with lower burnout, reduced stress,
better work performance, and a more positive view of managers (Bowers, CarrWalker et al 2006). No relationship was found between APDQ and interaction rates
between Prison Officers and inmates, and numbers of adverse incidents were too low
for any test of association. Change events occurring in between waves of data
collection were shown to be related to changes in APDQ scores. The main influences
were education, patient behaviour, and the overall organisation of the unit,
specifically the achievement of a common philosophy or ideology (Bowers, CarrWalker et al 2005). This study and others also provided the opportunity for further
psychometric work on the APDQ, validating its structure and confirming its reliability
(Bowers and Allan 2006).
172
Subsequently an intervention study has been conducted, in which expert nurses have
been working with acute psychiatric wards to reduce rates of conflict and containment
by promoting Positive Appreciation, Emotional Regulation, and Effective Structure.
Early results from the first phase of this study have been promising (Bowers, Flood et
al 2006).
There is therefore support for the working model that has been generated from these
studies, in that staff cognition and behaviour are associated with reduced conflict.
APDQ scores appear to be associated with these staff behaviours, and the working
model may be applicable throughout psychiatry, not just to those patients with
personality disorder. However these connections still require further empirical
support.
AIM
To assess the evidence for the following three hypotheses:
•
More positive staff attitudes to patients lead to lower rates of conflict and
containment
•
Greater staff emotional regulation leads to lower rates of conflict and
containment
•
Greater ward structure leads to lower rates of conflict and containment
173
DATA ANALYSIS
Mean questionnaire scores (APDQ and WSQ) were calculated by ward and wave, and
matched with the following two months conflict and containment rates (PCC-SR). For
self-harm two different forms of scoring had been used at different stages, as
described above. In order to provide a uniformly measured rate over the whole study
period, self-frequencies were separately converted into z scores for each period,
before being combined. Regression of questionnaire scores on conflict and
containment rates was then conducted, with an adjustment for clustering by ward. The
same analytic strategy was used to assess the impact of conflict and containment on
questionnaire scores for the period following. These analyses are diagrammatically
represented in Figure 1.
Aug-06
Jun-06
Jul-06
May-06
Apr-06
Feb-06
Mar-06
Jan-06
Nov-05
Dec-05
Oct-05
Aug-05
Sep-05
Jun-05
Jul-05
May-05
Apr-05
Feb-05
Mar-05
Jan-05
Nov-04
Dec-04
Sep-04
Oct-04
Jul-04
Aug-04
Figure 1. Longitudinal analyses conducted
Analysis 1
Staff APDQ/WSQ
PCC-SR
Patient WSQ
PCC-SR
Analysis 2
Staff APDQ/WSQ
PCC-SR
Interviews (PPSI) were scored by a researcher (AS), with a second researcher
independently scoring a random sample of thirty to allow the calculation of inter rater
174
reliability. These scores were then treated in the same way as those derived from the
questionnaires. All data analysis was conducted in SPSS v12 and Stata v8.
FINDINGS
The data
Rates of different forms of conflict and containment over the study period are
presented in Table 1, based on 15,006 PCC-SRs collected. These rates are very close
to the national norms from the City-128 study of 136 acute psychiatric wards,
indicating that the study wards are representative in relation to their rates of conflict
and containment events.
175
Table 1. Mean rate of conflict and containment events per shift (excluding self-harm).
Mean
SD
Verbal aggression
Physical aggression against objects
Physical aggression against others
Total aggression
0.58
0.11
0.08
0.77
1.18
0.44
0.43
1.65
Smoking in a no smoking area
Refusing to eat
Refusing to drink
Refusing to attend to personal hygiene
Refusing to get up and out of bed
Refusing to go to bed
Refusing to see workers
Total rule breaking
0.63
0.19
0.08
0.39
0.16
0.16
0.03
1.64
1.16
0.48
0.32
0.88
0.51
0.57
0.21
2.46
Alcohol use (suspected or confirmed)
Other substance misuse (suspected or confirmed)
Total substance use
0.09
0.10
0.19
0.36
0.40
0.62
Attempting to abscond
Absconding (missing without permission)
Absconding (official report)
Total absconding
0.18
0.06
0.04
0.28
0.49
0.28
0.24
0.72
Refused regular medication
Refused PRN medication
Demanding PRN medication
Total medication related
0.20
0.10
0.35
0.66
0.47
0.38
0.75
1.14
Given PRN medication (psychotropic)
Given IM medication (enforced)
Sent to PICU or ICA
Seclusion
Special observation (intermittent)
Special observation (constant)
Show of force
Physically restrained
Time out
0.65
0.05
0.01
0.02
0.52
0.20
0.08
0.05
0.12
0.97
0.25
0.09
0.15
1.13
0.56
0.40
0.30
0.45
Total conflict
Total containment
3.61
1.71
4.40
2.13
176
Mean Attitude to Personality Disorder Questionnaire scores are presented in Table 2.
These do not differ from published norms for multidisciplinary acute psychiatric staff
(Bowers and Allan 2006).
Table 2. Mean Attitude to Personality Disorder Questionnaire scores (n = 320)
Mean
SD
3.17
4.54
4.78
4.34
3.69
0.96
0.86
0.88
1.08
1.19
Enjoyment
Security
Acceptance
Purpose
Enthusiasm
Patient and Staff Ward Structure Questionnaire mean scores are presented in Table 3.
It can be seen that staff generally provide higher scores, considering their wards to
have more rules and routine, which are better communicated and applied in a more
ethical spirit. Patients do not see the ward structure as quite so positive.
Table 3. Patient and Staff Ward Structure Questionnaire mean scores (patients n =
136, staff n = 399)
Mean
Rules
Communication
Routine
Value
3.99
4.66
4.30
4.47
Staff
SD
0.76
1.03
0.71
0.59
Patient
Mean
SD
3.62
3.99
3.99
3.78
0.94
1.45
1.12
0.91
Test of difference
t
df
4.61
5.87
3.76
9.93
529
524
512
509
p
<0.001
<0.001
<0.001
<0.001
Patient Perception of Staff Interview was conducted with 119 patients. Random
selection of inpatients followed discussions with ward staff on suitability and
177
availability of inpatients on each ward. On a minority of wards no such advice was
given and we were told to introduce ourselves to any patient on the ward. Some
patients were excluded for the following reasons; language barriers, those considered
too unwell to participate, considerations of well-being and safety issues such as
known histories of aggression. Other patients were on leave or otherwise engaged
with activities, visitors or sleeping. It was intended to collect two interviews on each
ward at 6 monthly intervals, at four different time points. Interviews were conducted
during the period Dec 2004-Feb 2005, May 2005-July 2005, Nov-Dec 2005 and MayJuly 2006. The majority of interviews (n= 100) were conducted by a service user
researcher (DH), an experienced, independent service user consultant and trainer who
received training in conducting research interviews. Due to some practical difficulties
a small number of the interviews were conducted by the research assistant (SE) (n =
17) or the research fellow (AS) (n = 2). Table 4 depicts further details of this sample.
Table 4. PPSI respondent characteristics
Wave 1
Wave 2
Wave3
Wave 4
Total
29
30
28
32
119
Female
7
15
8
9
39
Male
22
14
18
23
77
Unknown/missing
0
1
2
0
3
Under 20’s
0
0
1
2
3
20 -29
6
9
3
8
26
30 -39
10
11
12
9
42
40 -49
9
5
7
6
27
50- 59
2
3
4
2
11
60 plus
2
1
0
1
4
Unknown/missing
0
1
1
2
4
Number
Gender
Age
Admission details
178
1st admission
5
6
9
12
32
More than 1 admission
24
24
18
20
86
Unknown/missing
0
0
1
0
1
3
0
4
6
13
15
12
2
10
39
9
8
13
10
40
Mixed
0
2
2
1
5
Other
2
6
5
3
16
0
2
2
2
6
Ethnicity
Asian/Asian British
(Indian,
Bangladeshi,
other
Asian)
White/White British
(British, Irish, other white)
Black/Black British
(Caribbean,
African,
other
black, Somalian, West-Indian)
(European,
English/British
only, Arabian, Christian)
Unknown/missing
Scores derived from the PPSI are presented in Table 5. Ratings of positive
appreciation (PA) are probably reliable and meaningful, as most interviews contained
a lot of relevant responses. Ratings of emotional regulation (ER) were much more
difficult. There was little material that could be coded under ER, and even where
some text existed it was often too brief to make an overall judgement. The ratings
regarding effective structure (ES) seemed less reliable than those for PA. Perception
of activities and rules was affected considerably by whether the person was unwell,
under a section or other restrictions (e.g. if they could not leave the ward they were
more likely to feel things were unfair), or if the interviewee had a generalised sense of
injustice towards staff or the system. Often there were contradictory responses for the
category, e.g. the ward may have had regular well-regarded activities, but invisible or
inconsistent rules. All three scores were moderately correlated with each other (r =
0.41 – 0.54). Mean scores for PA and ER indicated an overall view that was slightly
179
more positive than negative, for ES the reverse was the case. An inter rater reliability
exercise was conducted with these interview scores. The first 35 interviews were
scored by an independent rater who was blind to outcomes and to other ratings.
Results were strongest for PA (Intraclass Correlation Coefficient, ICC = 0.41), weak
for ER (ICC = 0.22) and very weak for ES (ICC = 0.05).
Table 5. Patient Perception of Staff Interview scores (n = 119, but not all interviews
could be rated for all three scores)
Positive appreciation (PA)
Emotional regulation (ER)
Effective structure (ES)
N
Min
Max
Mean
SD
115
28
110
1
1
1
3
3
2
2.40
2.14
1.41
0.66
0.71
0.49
Relationships between questionnaires
Staff APDQs and WSQs were collected at the same time from the same staff,
allowing a comparison between the two sets of scores. Table 6 shows the resulting
correlation matrix. There are multiple significant correlations. APDQ enjoyment was
significantly associated with all scores on the WSQ. APDQ Security, Purpose and
Enthusiasm showed a pattern of association with all WSQ scores except Rules. APDQ
Acceptance was only associated with WSQ Value.
180
Table 6. Correlations of staff APDQ and WSQ scores
Rules
Communication
Routine
Value
Pearson Correlation
Sig. (2-tailed)
N
Pearson Correlation
Sig. (2-tailed)
N
Pearson Correlation
Sig. (2-tailed)
N
Pearson Correlation
Sig. (2-tailed)
N
Enjoyment Security Acceptance Purpose Enthusiasm
0.180
0.040
-0.045
0.076
0.010
0.003
0.519
0.465
0.224
0.867
262
260
260
259
260
0.257
0.153
0.078
0.189
0.237
<0.001
0.014
0.211
0.002
<0.001
261
259
259
259
260
0.126
0.123
0.037
0.113
0.213
0.045
0.050
0.557
0.071
0.001
255
254
253
254
254
0.125
0.157
0.162
0.138
0.207
0.045
0.012
0.010
0.028
0.001
255
254
253
254
254
Questionnaires were aggregated by calculating mean values by ward, thus providing
scores for each of the 16 wards covering the whole two-year data collection period.
This analysis was conducted at the top level of Total Conflict and Containment, and at
the mid level of different conflict domains (i.e. Total Aggression, Total Rule
Breaking, etc.), with conflict and containment variables standardised to bed numbers.
No APDQ score was consistently associated with any conflict of containment (there
was one significant positive correlation between Total Absconding and APDQ
Enthusiasm, but this may have been due to chance within the context of so many
statistical tests being applied). Patient WSQ Rules was strongly inversely related to
Total Absconding (r = - 0.60, n = 16, p = 0.014) and positively related to total
aggression (r = 0.53, n = 16, p = 0.033), but no other relationships were found
between patient WSQ scores and conflict and containment. Staff WSQ scores showed
a stronger pattern of relationships to conflict and containment. WSQ Rules was
inversely associated with Total Absconding (r = -0.52, n = 16, p = 0.039) and
positively associated with Total Aggression (r = 0.64, n = 16, p = 0.008), just as the
patient WSQ Rules score was. WSQ rules was also associated with Total
181
Containment (r = 0.57, n = 16, p = 0.021). However WSQ Communication was
inversely associated with Total Self-harm (r = -0.51, n = 16, p = 0.045); WSQ Routine
was inversely associated with Total Rule Breaking (r = -0.60, n = 16, p = 0.014) and
Total Conflict (r = -0.56, n = 16, p = 0.025); and WSQ Value was inversely associated
with Total Medication-related conflict (r = -0.56, n = 16, p = 0.023). PPSI(ES) was
inversely associated with Total Self-harm (r = -0.86, n = 16, p < 0.001) as was
PPSI(PA) (r = -0.63, n = 16, p = 0.009). PPSI(ER) was inversely associated with
Total Medication related conflict (r = -0.57, n = 16, p = 0.042).
When compared at the ward level, patient and staff WSQ scores showed only one
significant correlation, between the two WSQ Rules scores (r = 0.78, n = 16, p <
0.001). There were two waves where patient and staff WSQs were collected in the
same time frame, enabling an analysis of correlations by ward and wave, and again
the only correlation was between the WSQ Rules scores (r = 0.49, n = 24, p = 0.015).
Staff WSQ scores were strongly related to WAS scores relating to structure (both at
the ward level), but patient WSQ scores were unrelated to WAS scores. WSQ
Communication was positively correlated with WAS Order and Organisation (r =
0.76, n = 16, p = 0.001) and WAS Program Clarity (r = 0.58, n = 16, p = 0.018), and
negatively correlated with WAS Staff Control (r = - 0.67, n = 16, p = 0.004). WSQ
routine was positively correlated with WAS Order and Organisation (r = 0.75, n = 16,
p = 0.001) and WAS Program Clarity (r = 0.51, n = 16, p = 0.046). WSQ Value was
positively correlated with WAS Order and Organisation (r = 0.67, n = 16, p = 0.004),
and negatively correlated with WAS Staff Control (r = - 0.65, n = 16, p = 0.007).
182
WSQ Rules was not associated with any WAS structure score. These results provide
evidence for the convergent validity of the WSQ.
Relationships between the PPSI scores and other scales were sparse and inconsistent.
There was no relationship with any WAS score; one inverse relationship between
PPSI(ES) and APDQ Enthusiasm (r = -0.52, n = 16, p = 0.037); one positive
relationship between PPSI(ER) and staff WSQ Value (r = 0.58, n = 13, p = 0.38); and
one positive relationship between PPSI(PA) and patient WSQ Routine (r = 0.67, n =
16, p = 0.004).
Staff WSQ and APDQ as precursors and/or consequences of conflict and
containment
Six waves of questionnaires were collected from staff at roughly four-month intervals.
The mean number of WSQs per ward per wave was 4.79 (sd = 2.71), with 12 of the
96 possible ward waves having no returns. The mean number of APDQs per ward per
wave was 4.61 (sd = 2.62), with 11 of the 96 possible ward waves having no returns.
There was a mean of 85 (sd = 47) PCC-SRs per ward per wave. As described under
'data analysis', scores from the WSQ and APDQ were regressed on the following two
months conflict and containment rates. Analyses were conducted at all three levels of
PCC scores.
Figure 2 displays the relationships between the staff questionnaire scores and Total
conflict and containment. High routine precedes lower conflict, but with higher
183
conflict preceding lower routine. Higher conflict also precedes lower APDQ
Enjoyment, while higher Total Containment precedes higher APDQ Enjoyment.
Figure 2. Staff WSQ/APDQ and Total Conflict and Containment, with standardised
beta weights
Routine
-0.29
-0.27
Total
Conflict
Routine
-0.24
+0.29
Enjoyment
Total
Containment
A similar pattern is visible in the mid level analysis displayed in Figure 3. Routine
serves to decrease Total Rule breaking, and rules serve to decrease Total Absconding;
while Total Rule Breaking erodes WSQ Routine and Communication, and Total
Absconding reduces APDQ Purpose. Total Aggression and Total Medication-related
conflict were not associated with questionnaire scores in either direction.
184
Figure 3. Staff WSQ/APDQ and mid level Conflict and Containment frequencies,
with standardised beta weights
Total
Aggression
Routine
-0.26
-0.28
Total
Rule breaking
-0.18
Routine
Communication
+0.18
Total
Substance use
Rule
-0.23
Total
Absconding
-0.23
Purpose
Total
Meds related
Table 7 depicts the relationships that existed at the level of individual conflict and
containment event frequencies. As might be expected, this is more complex, but
supports the overall picture of greater ward structure leading to reduced conflict but
not containment; greater conflict leading to decay of the ward structure; and greater
containment leading better staff attitudes while greater conflict leads to worse.
Routine appeared to have a beneficial impact on lowering conflict, particularly rule
breaking as known from the mid level analysis, but also absconding missing and
official, a fact hidden by the inclusion of attempted absconding in Total Absconding
in the mid level analysis. Other notable findings are that verbal abuse led to decreased
routine and security; officially reported absconding seems to have a positive effect on
staff attitudes, whereas missing without permission has the reverse effect; use of the
185
milder containment methods seems to enhance routine; and use of intermittent
observation seems to have a broad positive impact on staff attitudes to patients.
Table 7. Staff WSQ/APDQ and mid level Conflict and Containment frequencies (+ =
positive and - e= negative correlations)
Enthusiasm
Purpose
Acceptance
Security
Enjoyment
Communication
Value
Rules
Following
Ward Structure
Staff attitudes
Routine
Conflict and Containment
Enthusiasm
Acceptance
Purpose
Security
Enjoyment
Communication
Value
Rules
Routine
Preceding
Ward Structure
Staff attitudes
Verbal aggression
Physical aggression against objects
Physical aggression against others
Smoking in a no smoking area
Refusing to eat
Refusing to drink
Refusing to attend to personal hygiene
Refusing to get up and out of bed
Refusing to go to bed
Refusing to see workers
Alcohol use (suspected or confirmed)
Other substance misuse (suspected or confirmed)
Attempting to abscond
Absconding (missing without permission)
Absconding (official report)
Refused regular medication
Refused PRN medication
Demanding PRN medication
Self-harm
Given PRN medication (psychotropic)
Given IM medication (enforced)
Sent to PICU or ICA
Seclusion
Special observation (intermittent)
Special observation (constant)
Show of force
Manually restrained
Time out
Overall these results evidence a bi-directional or cyclical set of effects between ward
structure and conflict, with greater structure serving to reduce conflict, but greater
conflict eroding structure. The results do not support the idea that staff attitudes to
186
patients influence conflict and containment rates, but suggest that the reverse is the
case: conflict and containment rates influence staff attitudes.
Patient WSQ as a precursor of conflict and containment
Four waves of questionnaires were collected from patients, although most of the final
wave could not be used in this analysis as they came at the end of the study, with no
following PCCs. The mean number of WSQs per ward per wave was 2.16 (sd = 0.7),
with one of the 64 possible ward waves having no returns. There was a mean of 74 (sd
= 50) PCC-SRs per ward per wave. Four ward waves were deleted from the analysis
due to low numbers of PCC-SRs in the outcome period. The number of ward waves
for analysis is therefore lower than in the staff data, and the analysis has less power to
identify associations that might exist.
No relationship was found between patient WSQ scores and Total Conflict or Total
Containment. In the mid level analysis, WSQ Communication was positively
associated with Total Medication-related conflict (Unstandardised Coefficient =
0.094, p = 0.032). In the individual item level analysis, WSQ Communication was
positively related with Refusing to Drink (Coef = 0.038, p = 0.049), Absconding
(missing) (Coef = 0.19, p = 0.024), and PRN medication refusal (Coef = 0.19, p =
0.029). WSQ Value was positively associated with Refusing to see workers (Coef =
0.16, p = 0.008). WSQ Rules was associated inversely with Absconding (missing)
(Coef = -0.27, p = 0.016).
187
It was not reasonable to look at the effect of conflict and containment in the preceding
two months on patient WSQ scores, as most patients are not on the ward for more
than two-three weeks.
Patient interview (PPSI) scores as a precursors of conflict and
containment
Four waves of interviews were completed with an attempt to get two patients
interviewed per ward per wave, resulting in 119 interviews which were rated,
providing three scores (positive appreciation [PA], emotional regulation [ER] and
effective structure [ES]). This represents 93% of the possible total of 128 interviews.
The interview scores were matched with the PCC-SR data from the same wards for
the following two months. There was a mean of 71 PCC-SRs returned per ward wave,
Seven ward waves had no following PCC-SR returns and six waves were deleted
from the analysis due to too few PCC-SRs, most from the end of the study when data
collection was either ceasing or tailing off.
No relationship was found between PPSI scores and Total Conflict or Total
Containment. In the mid level analysis, PPSI(PA) was positively associated with
Total Absconding (Coef = 0.15, p = 0.027), and PPSI(ES) was negatively associated
with Total Absconding (Coef = -0.29, p = 0.025). In the individual item level analysis,
PPSI(PA) was positively associated with Special Observation (Constant) (Coef =
0.15, p = 0.028).
188
SUMMARY
The data support the interpretation that ward structure leads to reductions in conflict.
The evidence is most strong for the presence of a routine for patients on the wards,
and to this extent, the working model is confirmed. However there is also evidence
that conflict behaviours on the part of patients erode routine and elicit negative
attitudes from staff.
189
8. DISCUSSION
THE NATURE AND PURPOSE OF ACUTE INPATIENT PSYCHIATRY
Summarising the purpose of acute inpatient wards enables the definition of what
constitutes effective and efficient acute care. An effective acute ward is one where
patients are kept safe, accurately assessed, given treatment that works, given basic
care that meets their needs, and provides any necessary physical healthcare. An
efficient ward is one that accomplishes those targets speedily and at minimal cost.
These definitions provide a focus for the management and clinical audit of acute
psychiatric wards. They also define the essential outcome indicators for any research
that seeks to assess different forms of ward regime or management, or that seeks to
assess replacement acute inpatient care with other forms of treatment provision such
as home care or day care. By implication, they also specify the training needs of the
staff that are employed to provide those services, and could give shape to basic and
post-basic education of professional staff.
Bureaucracy
Acute ward nurses are, at times, criticised for spending time in the ward office (Ford
et al 1998). And yet the many demands of patient managements and the wider
administration of care translate into a lot of work on the telephone and a significant
amount of writing reports, applications, etc., that nurses increasingly complain about
190
(Deacon 2003). Bureaucracy associated with the Care Programme Approach
(Simpson et al 2003), Care Management (Parry-Jones et al 1998), and management
information systems (Department of Health 1999) add to this burden. Within the
scope of existing resources there may be ways of reducing the administrative burden
through the streamlining of systems, computerisation, rationalisation, and through
training staff in effective and efficient written communication. Further work needs to
be undertaken in order to analyse administrative time with a view to its reduction or
delegation, and the consequent release of nursing time for presence+, assessment and
treatment. Without such a step, expert qualified nursing staff may remain stuck in the
frustrating position of being predominantly case managers rather than direct care
providers, a situation that promotes low morale. More than anything else, it is the lack
of presence+ that service users complain about, or value when they receive it
(Goodwin et al 1999, Rogers et al 1993). However, it should be noted that, as far as
we know, little empirical study has been conducted on the association between time
spent in direct contact with patients on the one hand, and psychiatric health benefits
and required admission time on the other.
This study has demonstrated that there is a huge engine of managerial and
administrative activities that supports the main functions of the acute ward, and
enables high quality care and treatment. Notwithstanding the comments above about
prioritising presence+ for patients, this administration is a valuable component of the
provision of acute care, and its place needs to be honoured rather than denigrated as
irrelevant paperwork, over-bureaucratisation, or ‘red tape’. This is not the first study
in recent years to highlight the critical importance to patients of the effective
administration of care (Cleary 2004, Deacon 2003).
191
Service provision levels: beds and staff
A fresh starting point is provided for such questions as how many staff are required to
run an acute ward. It may be possible to work backwards from the aims of acute care
and assess how many staff from what disciplines are required to provide an effective
and efficient service. Such an analysis has the potential to highlight significant
shortfalls in current service provision. New and more appropriate acuity based
workload management systems could also be produced, relevant to this sector of
psychiatric care, replacing those which have been found inadequate (O’Brien et al
2002). Alternatively, it may be possible to consider a complete restructuring of the
disciplinary mix providing acute care. An investment in high-level administrative
staff might make more professional time available. Traditional boundaries between
different professions could be broken down and reconfigured, for example that
between occupational therapists and nurses, or between psychologists and
psychiatrists. Debate about the future role of psychiatrists is under way in the UK
(National Working Group on New Roles for Psychiatrists 2004), and there may also
be scope for the involvement of non-professionals and service users and carers
(Department of Health 2002). Such reconfigurations and restructurings should be
acceptable, so long as the purposes of acute care are effectively met.
These findings may also have implications for policy in the provision of acute care.
The controversial issue of how many beds are necessary may be viewed differently by
asking more specific questions about how many beds are required in order to provide
a population with a given level of safety, or how many patients per year require
192
inpatient assessment, etc. Of course such questions can only be answered with both
greater knowledge of outcomes, other services provided locally, and the local
demography. Nevertheless such questions are much more specific than calculations
based on norms and deprivation levels (Glover 1997), or arguments based on over
occupancy statistics (Johnson and Thornicroft 1997).
Other issues
Whilst medication is central to treatment on acute wards, and is well evidenced, the
diverse and rather idiosyncratic range of psychosocial treatments on offer raises
questions about their efficacy, who is responsibility for carrying them out, and the
training of those who conduct them. The evidence base for such interventions is
generally poor. There is evidence for cognitive-behavioural interventions in this
setting (Drury et al 1996a, 1996b), and for group interventions to enhance compliance
with medication (Kemp et al 1996), but very little else that has been rigorously
evaluated. There is much scope for the development and testing of new interventions
in this area.
Physical health problems can be a consequence of mental disorder (mentality 2003), a
cause, or a complication (e.g. of a chronic condition like diabetes). The inclusion of
the provision of physical healthcare as part of the role of acute psychiatry supports the
medical training of psychiatrists, the common core education of psychiatric nurses
with other branches of the nursing profession, and the generic education of
occupational therapists. However it may also be possible for nominated staff to
193
develop a specialist role in this regard, allowing others to focus their expertise on
other issues.
The different points of view on appropriate admissions, coupled with variability in
risk thresholds between staff, means different wards have differing patient
populations (Flannigan et al 1994). Those differences may be accentuated by locality
epidemiological and demographic differences. At one level this means that different
wards may have little in common, and variation in wards incident rates (Bowers et al
in press), or treatment approaches, for example, may have as much to do with the
differing patient populations they serve as it does the strength and quality of their
professional staff. At a deeper level these variables introduce a random factor into
who gets admitted to a particular ward, with the result that there is considerable
unevenness in the patient population, and the development of a uniform management
and treatment response from the multidisciplinary team is made more difficult. Such
variability in admissions may also engender conflict within the team. Ways to remedy
this situation include a provision of a single route of access to admission (via an
admission ward, or through the use of a crisis team), restricting admission decisions to
more senior staff, or subjecting those decisions to open review after they have been
made.
Statement of purpose
Based on our analysis, a clear statement of the nature and purpose of acute psychiatry
is as follows. Patients are admitted to acute psychiatric wards because they appear
likely to harm themselves or others, and because they are suffering from a severe
194
mental illness, and/or because they or their family/community require respite, and/or
because they have insufficient support and supervision available to them in the
community. The tasks of acute inpatient care are to keep patients safe, assess their
problems, treat their mental illness, meet their basic care needs and provide physical
healthcare. These tasks are completed via containment, 24-hour staff presence,
treatment provision, and complex organisation and management.
This definition of purpose can assist in the shaping of training, education, clinical
audit, outcome research, skills development, and a potential restructuring of the way
in which acute care is delivered. Whilst we recommend that education, audit and
research align themselves with what acute inpatient care currently does, we also
consider it timely to begin an informed discussion about what inpatient care could be
in future, and how services and professions could be organised to deliver that vision,
whatever it may be. However we caution that any vision for the future must describe
how the current functions of acute inpatient care should be provided in an alternate
fashion, or to say which is to be abandoned, and why. For far too long acute inpatient
care has been both neglected and, by implication, devalued. To move forward, a
concentration on essentials is required by all professions and at all levels of
management.
INTERPROFESSIONAL WORKING IN ACUTE PSYCHIATRY
The literature on team working in healthcare suggests that integrated, collaborative
teams are more effective with benefits for patients and staff alike (Borrill, et al. 2000;
Miller, et al. 2001; Onyett, 2002). However, for a variety of reasons, fragmented
195
teams are more commonplace, although some teams have a ‘core’ of collaborative,
harmonious working between some professions with other staff on the ‘periphery’
(Miller, et al. 2001). On many wards in this study, positive relations between nurses
and OTs or nurses and doctors existed, with other staff excluded from ward
communication and decision processes. Staff most often spoke of attempts to ensure
harmonious relations, good communications and mutual respect, but aside from a few
examples of nurses working alongside OTs in the provision of group activities, there
was little evidence of collaborative working. On a minority of wards, even
establishing respectful communications and discussion between different professions
remained a distant aim. However, small measures were being introduced to encourage
and nurture collaboration and integration.
Model of interprofessional working
Figure 1 illustrates a model of multidisciplinary working based on the findings from
this study and related literature, particularly Miller et al. (2001). The model suggests
‘cooperative’ teams exist where contributions are encouraged from all professions and
collaboration is actively promoted. In contrast, ‘fragmented’ ward teams are those
where staff are frequently in conflict and excluded from discussions and decisionmaking. Other ward teams have a ‘core’ of members working harmoniously, but
others are excluded by being on the ‘periphery’ of team structures and processes. The
final, ‘contradictory’ type of ward team sees different staff adopting contrary
approaches towards multidisciplinary working or expressing conflicting views about
teamwork. The key features of the four patterns of teamwork and predicted ward
196
cultures and outcomes in terms of patient care planning and staff-patient conflict are
described in Table 1.
Figure 1: Working model of teamwork on acute psychiatric wards
CONTRADICTORY
TEAMS
Contributing
Collaboration
Conflict
FRAGMENTED
TEAMS
COOPERATIVE
TEAMS
Excluding
CORE &
PERIPHERY
TEAMS
197
Table 1: Features of different patterns of teamwork with predicted ward culture and
outcomes
Type
of
teamwork
Cooperative
Core
periphery
and
Fragmented
Contradictory
Features
Predicted ward culture
Predicted outcomes
Good MDT relations
Joint working common (e.g.
assessments/discharge planning)
Inclusive culture
Respect for views/expertise
Regular MDT meetings
Good
and
varied
MDT
communication
Joint, agreed decision-making
MDT learning/training/days
Good relations between some
disciplines
but
others
excluded/side-lined
Some good communications but
others not informed or involved
in meetings
Decision-making involves some
but not others
Uni-professional
learning/
training
Poor or hostile relations
between disciplines
Lack of respect for others’
expertise
Use of ‘illegitimate power’
Generally poor communications
Decision-making arbitrary and
dominated by one discipline or
person
Uni-professional
learning/
training
Differing views as to quality of
relations
Different consultants or others
with conflicting approaches to
teamwork
Inconsistent
approaches
to
communication and learning/
training
Shared aims/ideology
Clear, agreed rules and
structures
Clear communication
Mutual staff support
High agreement on
care
planning
between disciplines
Low
staff-patient
conflict
Some inconsistency over
aims/ideology
Some inconsistency in
application of rules
Inconsistent or confused
communication
Support
may
be
conditional
Some agreement on
care planning but
tendency
for
disputes
or
confusion
Low-moderate staffpatient conflict
Inconsistent aims and
ideology
Lack of clear rules and
little or no structure
Poor and inconsistent
communication
Little or no mutual
support
Interprofessional
and
interpersonal tensions
Frequent
disagreement over
care planning
High
staff-patient
conflict
Inconsistent aims and
ideology
Some inconsistency in
application of rules
Inconsistent or confused
communication
Support inconsistent and
conditional
Interprofessional tensions
likely
Some agreement on
care planning but
risk of disputes and
confusion
Moderate-high staffpatient conflict
198
The 14 psychiatric wards in this study were mapped against this model. Six appeared
to have contradictory team relationships. Most often this was because working
relationships with one consultant psychiatrist were constructive and collaborative but
relations with a second consultant serving the same ward were problematic.
Conflicting views about interprofessional relationships were expressed by members of
the team on two of these six wards. Highly cooperative working relationships were
reported on two wards and two others appeared to have good core relations between
the medical and nursing teams, although the occupational therapists were on the
periphery. This may have been partly because the occupational therapists held junior
positions in terms of their age, length of time since qualifying, in their current role
and working on the ward. For the majority, this was their first post following
qualification. Four ward teams were identified as fragmented with high levels of
interprofessional antagonism and hostility reported.
Gomez et al. (1980) have
described how malfunctioning inpatient teams can become counter-therapeutic if
conflicts are not addressed. Our future research will determine whether these patterns
of teamwork remain constant over time and what influence the style of teamwork has
on levels of conflict and containment on each ward.
The key role of the ward manager was apparent and widely acknowledged by
participants in this study. However, the tendency of ward managers to ensure their
staff teams accommodated the different approaches of individual consultants and to
take singular responsibility for the management of beds and the psychiatrists’ wardrelated workload, has echoes of the strategies employed by nurses in other settings to
‘manage’ or ‘manipulate’ doctors to meet patients’ needs (Stein, 1968), as it is ‘less
199
hassle’ than challenging the doctors directly (Lutzen & Schreiber, 1998). In so doing,
ward managers are in danger of placing themselves at odds with their recognised
skills and expertise. By establishing a more assertive approach and a more
collaborative and equitable arrangement, ward managers could provide a positive
leadership role model for more junior nurses, as desired by some doctors (Wicks,
1998).
The uni-professional focus on professional development and training offers the
suggestion of one way in which multidisciplinary teamwork could be better
considered and addressed. The tendency to emphasise uni-professional problem
solving in acute psychiatry negates the possibility of more collaborative approaches
with service users, family carers and other professionals (Meades, 1989). An
interprofessional focus on training in core skills such as risk management, care and
discharge planning, control and restraint, could encourage the development of
interprofessional solutions to many issues facing staff. Interprofessional education, in
which two or more professions take part in interactive learning, can improve
interprofessional collaboration and enhance the delivery of patient care (Reeves
2001). However, challenges to interprofessional learning include availability and
replacement of staff, diversity of learning needs and financial costs (Clarke, 2004).
These and other difficulties in establishing and maintaining an interprofessional focus
on patient care in psychiatric inpatient settings (Zeiss, 1997) must not be overlooked
and further research into the opportunities for and barriers to interprofessional
working and learning are required.
200
Multidisciplinary working on acute psychiatric wards consists largely of attempts to
ensure harmonious relations, good communications and mutual respect between
disciplines. There is little evidence of staff working alongside each other in a more
integrated, collaborative fashion. Opportunities for interprofessional working and
learning need to be explored.
SERIOUS UNTOWARD INCIDENTS AND THEIR AFTERMATH
Acute feelings were aroused in staff as a consequence of SUIs. Factors involved in
the impact of SUIs appeared to be the severity and outcome of the incident, the
strength of the relationship with the patient involved, the availability (or lack of)
support and aftercare directly after the incident, the perception of whether the SUI
could have been prevented in some way, and managerial responses.
Although some of the resulting feelings were akin to those following loss and
bereavement, there was no obvious sequence or process to those feelings. However
the nature of the feelings reported is similar to previous studies (Cotton 1983; Bartels
1987; Little 1992). Staff struggled to keep things in proportion regarding
investigations when they were in a state of emotional shock and turmoil. Managers
conducting the investigation were also not immune to anxiety and dysphoria, perhaps
in part arising out of their complicity in organisational policy and practice, and in part
out of the fact that they themselves will be judged by those above them, and
increasingly by the media (Paterson and Stark 2001). Clearly managers, who are
responsible for investigating the incident, and who may need support themselves,
201
cannot at the same time give those staff support in a genuine or meaningful way. The
inexorable pace of ward life compelled staff to put their feelings to one side and get
on with caring for others. In combination with a lack of external support in many
cases, this hindered staff in talking with each other about the event and its
consequences.
Need for support systems and 'blame'
Frontline staff in these interviews spoke of the value of outside support where it was
made available. This could be commissioned by employers, but not provided by them,
or provided by different managers or specialist personnel within the organisation
(separate from those responsible for post-incident investigation). This would not then
prejudice the outcome of any investigation. It could be that such help aids staff in
recovering, but it could also be that it makes post-incident adjustment more difficult
or worse. In the latter case, the pace of ward life and the lack of external support may
actually be protective, and oblige staff to make a quick recovery. However, virtually
no research has been done on the impact of SUIs on staff over the longer term. The
staff in this study clearly expressed their need for (and valuing of) external support,
and these evaluations should be taken seriously and support provided.
By adopting Root Cause Analysis, both JCAHO in the US and the NPSA in the UK
are making a determined effort to shift the focus of post-incident investigation away
from blaming individuals and towards the ways systems of work facilitate or hinder
errors. As this study collected data on events prior to the diffusion of this new method
in the UK, it cannot provide direct evidence on whether this will be successful.
202
However it does indicate that the primary sources of blame are from the staff who
were involved: they blame themselves and each other. Secondly, the sheer fact of the
post-incident investigation, the necessity to write reports, be interviewed, submit
documentary evidence, all intensify the self-scrutiny that is already underway. It may
take some time for Root Cause Analysis to impact upon these processes, if it can do
so at all.
Critical incident analysis is used in intensive care and anaesthesia as a means of
structuring, collating and analysing information on critical incidents. This information
is used in quality assurance programmes to improve patient care and is embedded
within the workplace culture. The technique of voluntary, anonymous, non-punitive
critical incident reporting has the potential to identify incidents and latent errors
before they become self-evident through a major incident. This systems approach
focuses on organisational and communication problems. Standards and guidelines
may help in weighing up the benefits and risks of invasive procedures, and
interventional studies have shown that implementation of standards and guidelines
can improve outcome (Frey & Argent, 2004). There are also many other forms of
post-incident analysis, derived from both industrial and healthcare settings, which
may be usefully applied in psychiatry (Woloshynowych et al 2005).
Defensive psychiatry and other outcomes
This study shows that SUIs had a continuing emotional and practice influence up to
10 years after they had occurred. Heightened alertness, attentiveness to risk
assessment, more rigorously pursued policies, greater use of containment methods
203
like special observation and higher environmental security may or may not be good.
They are certainly better than a laissez-faire, lax, overconfident, complacent staff
culture which is imbued with the idea that incidents cannot really be prevented.
However the use of containment methods (special observation, security measures,
sedating medication, seclusion etc.) can become excessive to the degree that they have
a negative and harmful impact on patients (Dodds and Bowles 2001), or risk
assessment can be emphasised to the point that it dominates practice and draws
attention away from treatment (Hardwick 2003). Only when the SUI is as a result of
containment itself does this work the other way (e.g. Goldney et al 1986; Blofeld et al
2003). Finding the right balance between risk and containment is complicated by the
emotions left over from professionals' previous experiences of SUIs, and a lack of
evidence on what constitutes good risk assessment or an effective level of
containment. Thus judgments both vary widely and tend to be emotionally charged,
perhaps the least helpful of all possible resulting scenarios.
It may help staff cope with the emotional repercussions if they prepare themselves for
this reality, and consider in advance the possibility that SUIs may occur (Bartels
1987). The benefits of this would be more than a mindset that is more prepared to
cope with the aftermath of an incident. There is a temptation to ignore the chance of
such things happening (coupled with a hope that they will happen on someone else's
shift or ward), which engenders a sense of powerlessness and passivity (Brennan et al
2006). By avoiding this, a sense of openness and alertness can be maintained. In turn
that means that the possibility of SUIs will be discussed, risks will be borne in mind,
procedures will be followed correctly, reviewed frequently, and improvements to
practice implemented swiftly and thoroughly. Further sound foundations for good
204
practice related to SUIs are appropriate training and regular clinical supervision.
Advance preparation means that when, as inevitably happens sometimes, an SUI does
occur, staff will be to a lesser degree shocked, doubtful, guilty, or anxious about the
investigation that follows, and more confident about their practice.
Our interviews showed that many staff responded positively to the outcome of
investigations, and implemented improvements to practice that increased their
confidence. However there were indications that for a few, the feeling that they were
being blamed led them to reject improved policy and documentation as instruments of
further blame in the future, or as devices to protect the organisation from future
blame. Such feelings of passivity, vulnerability, victimisation and hostility clearly
have the capacity to undermine good practice, and may make future SUIs more likely.
The relative lack of reference to the reactions of patients contrasted with the emphasis
on staff concerns. Staff's preoccupation with their own reactions is perhaps
understandable when they are so strong, and when so much has to be coped with
suddenly, all at once. The care of other patients could perhaps be better organised by
careful planning in advance how these things should be done, and how they should be
followed up. Staff would then have guidelines and a format to follow at a time when
their cognitive abilities are likely to be somewhat curtailed. Bringing in outside
support for staff might also give space for staff to deal with their emotions, so that
they can more properly care for other patients. This issue is important, because it is
clear that adverse incidents can trigger similar actions in other patients (Chapter 5).
205
The context of acute psychiatry in the UK makes the post-incident actions
recommended in the literature difficult to follow. Occupancy and throughput of
patients are both at extremely high levels, and nursing and psychiatrist vacancy rates
are high (Garcia et al 2005, Royal College of Psychiatrists 2001). Closing the ward to
allow reflection, cancelling patient leave, and holding staff meetings are nearly
impossible to do in these circumstances. The most serious SUIs can also get adverse
and hostile national media coverage. In such a system under pressure, only significant
planning and extra investment is likely to provide the context within which staff and
patients can receive the proper post-incident support and care.
The findings confirm previous studies that staff suffer considerable stress and trauma
as a result of patient suicides and other serious untoward incidents, show that impact
is not restricted to the ward where the patient resided, and that it can endure for many
years. There is a need for staff to prepare themselves for these events in advance, and
for them to receive external support once they have occurred. Both may assist staff to
respond in ways that positively improve their practice, rather than adopt a position in
which they see themselves as victims of punitive system that blames them for events
outside of their control. It is as yet unclear whether Root Cause Analysis will bring
improvements to staff's capacity to respond positively. Resource constraints and an
over pressured work environment handicap proper post-incident support and
management. There is an urgent need for a deeper consideration of the responses of
other patients to these incidents, and to plan in advance how to help them respond
positively. Finally, it would appear that these incidents drive an ever-increasing
ratchet of greater security and more intensive containment, with ultimately unknown
effects.
206
ADVERSE INCIDENTS, PATIENT FLOW AND WORKFORCE
There is currently no national data on the nursing workforce variables we report,
although several papers suggest that, per week per ward, between 44 and 455 hrs of
nursing time is spent on special observation (Childs, Thomas, & Tibbles, 1994;
Porter, McCann, & McGregor, 1998). Our results (45 hrs) are at the lower end of this
continuum. The available national data on admissions does not separate out acute
admissions, and does not give admission rates to bed number ratios, making
comparisons difficult. Smith et al (1996) use 1991/2 data from England to give an
admission rate (including children) of 4.2 per 1,000 population, whereas Thompson et
al (2004) give a lower figure (excluding children) of 3.2 per thousand for the year
1999/2000. Our figure, calculated from Table 1 (chapter 5), for adult acute admissions
only, is 4.3 per 1000 population. The varying ways in which violent incident rates
have been reported, coupled with the differing criteria used, make comparisons
exceedingly difficult. Fottrell et al (1978) surveyed violence in a UK hospital, and it is
possible to estimate a figure of 0.68 incidents per 100 bed days from their data, with a
similar study providing an estimate of 0.63 per 100 bed days for 1987 (Noble &
Rodger, 1989). Both these figures are based on all types of wards, and are higher than
the figure of 0.43 per 100 bed days for all aggression found during this study of acute
wards only. A recent study of absconding cites mean rates of 0.57 per 100 bed days
on 15 acute admission wards prior to the use of an anti-absconding intervention
(Bowers, Simpson, & Alexander, 2005), this being at least four times higher than the
rate during this study. The study district, although being an inner city service, appears
207
to have lower rates of aggression and absconding, lower rates of the use of special
observation by nurses, and slightly higher than average rates of admission.
The effect of admissions
The findings display a clear link between admissions and adverse incidents,
particularly male admissions, but perhaps also younger admissions and admissions of
those with a psychotic disorder. There has been some controversy about the issue of
gender and the disruptive behaviour of inpatients, with some studies finding no
difference (Bowers, Simpson, & Alexander, 2003) and others finding that male
patients are involved in more violent incidents (Pearson M, Wilmot E, & Padi M,
1986) and absconding (Bowers, Jarrett, Clark, Kiyimba, & McFarlane, 2000). More
recently, findings have been published showing that although the number of violent
incidents by inpatients is similar, male community patients tend to be more violent
than females (Krakowski & Czobor, 2004). Due to the nature of our data, we are
unable to say that it is the recently admitted men who are the perpetrators of the
incidents that have been recorded. This is likely, because most adverse incidents occur
during the early stages of an admission (Nijman, Merckelbach, Evers, Palmstierna, &
Campo, 2002). However it is also possible that increased male admission rates have a
disturbing influence on those patients already on the ward, raising anxiety through a
heightening of unpredictability; or that they stretch the ability of the staff to provide
care and support to all patients, thus precipitating adverse incidents.
208
A feedback cycle of incidents
These same two mechanisms may in part explain the link between adverse incidents
of different types. Although some of this association is possibly due to the same
patient being involved in more than one incident type in the course of a week (Bowers
et al., 2003), this may not be the whole story. Again it seems likely that adverse
incidents have an impact on the ward as a community. Perhaps they prompt further
incidents from others by introducing an element of stress and uncertainty into the
social environment of the ward, or by occupying staff time, or by provoking 'copycat'
events in some form of chain reaction. Certainly, patients report absconding from
psychiatric wards in response to disruptive or disturbing events (Bowers, Jarrett,
Clark, Kiyimba, & McFarlane, 1999).
Regular, consistent, available staff
The importance of nursing staff availability is the third consistent finding that
emerges from the modelling exercise. The use of temporary bank and agency staff has
previously been blamed for increases in incident rates on a psychiatric intensive care
unit (James, Fineberg, Shah, & Priest, 1990). Our data suggest that it is not the use of
temporary staff per se, but the total absence of regular staff through a diverse range of
factors: vacancies, sick, study, annual and maternity leave. There has always been
much discussion about appropriate nurse staffing levels in acute psychiatry, and
although there have been findings linking adequate nurse staffing to positive care
outcomes in general hospitals (Needleman, Buerhaus, Mattke, Stewart, & Zelevinsky,
2002), we do not know of any previous evidence demonstrating the importance of
209
regular staff presence for the safety of patients and other staff. The 24 hour presence
of nursing staff is one of the mechanisms through which acute care functions,
providing scope for continuous assessment, monitoring and supportive relationships
(Bowers, 2005).
In most respects, serious untoward incidents follow a similar pattern to other adverse
incidents: high levels of admissions (in the week before and the week of the SUI) and
other incidents (non SUIs) prompt their occurrence. Perhaps of particular note is the
large significant relationship between a physically aggressive SUI and property
damage, suggesting that events where patients break the furniture or fittings of a ward
need to be managed swiftly and competently to minimise any escalation of
disturbance.
Implications
Our findings suggest new ways to predict and prevent adverse incidents, including
SUIs. Firstly wards need to be fully staffed with a zero vacancy factor, and staff need
to be managed so that the demands of annual and study leave are spread evenly across
the year. Both strategies would reduce the occurrence of periods of staffing crisis
where few regular staff are available. However, it has to be acknowledged that
exercising such control over staff holidays and other commitments does run counter to
requirements to permit flexible working and hence the retention of staff (Sainsbury
Centre for Mental Health, 2000). Secondly, the link between admissions/incidents and
further incidents suggests that when there is a period of unusual patient turnover on a
ward, or when there is an officially reported incident, wards should be provided with
210
extra numbers of experienced qualified nursing staff for a period, over and above their
establishment figures, with a view to suppressing the opportunity for further adverse
incidents or SUIs to occur. Other potential solutions involve the deployment of
additional 'visiting' staff from other professions or teams, or other creative ways of
increasing the staffing resources (and expertise) available to the ward at such times.
Alternatively, the current pressure for acute admission beds (Ford, Durcan, & Warner,
2005) could be relieved by the provision of alternative services or additional capacity,
thus reducing the risk of periods of rapid and intense patient turnover that appear to
contribute to incidents.
It is worthy of note that recent changes to pay and conditions for nurses (Agenda for
Change Project Team, 2004) have resulted in more annual leave for ward staff,
without any provision being made for funding increased staffing numbers to fill the
gap that has been created. Acute psychiatric inpatient services are also currently faced
with demanding requirements to train all staff in race equality (Department of Health,
2005), resuscitation (National Institute for Clinical Execellence, 2005), dual diagnosis
(Department of Health, 2003), acute inpatient psychiatry as a speciality (Clarke,
2004), and manual restraint (National Institute for Mental Health in England, 2004).
In addition, investment in acute inpatient services has significantly decreased over the
past five years, with reductions of 4.7% in acute bed numbers, and further reductions
in investment projected (Appleby, 2004). Our findings suggest that these initiatives
may have a cost in terms of adverse incidents and injuries, sometimes serious, to
patients and staff.
211
PREVENTION AND MANAGEMENT OF VIOLENCE AND AGGRESSION
TRAINING
Our data covering a period of nearly three years provide no indication that violent
incident rates are rising. Steeply rising trends were reported in a comparable London
hospital during the 1980s (Noble & Rodger 1989). Comparisons are not easy to make
because of differences in ward types, but it would appear that had those trends
continued, our data should have shown rates of two violent incidents per ward per
week. Instead, the rate of incidents in our study was 0.26 per ward per week. There is
little hard evidence that violent incidents in psychiatry are increasing in the UK.
Impact of courses
The findings on the impact of training are an uncomfortable set of results. The authors
had hoped to identify reductions in aggression following course attendance.
Theoretical thinking and previous work had suggested that greater technical mastery
in the interpersonal management of aroused patients, coupled with a calm and
confident demeanour on the part of staff, would together lead to more frequent
resolution of tense situations without violence (Bowers 2002). Such training should
have its greatest impact just after it has been completed, with its effect gradually
attenuating thereafter. Instead the results point in the other direction, with update
courses apparently triggering small rises in physical violence. In addition, course
attendance takes staff away from the ward, stimulating more violence while they are
away.
212
These results are based on officially reported data, indicating that they should be
accepted with caution. Official data is subject to a number of different influences (for
example the concerns of managers and the constant changes in policy in the UK
health service). Official statistics on violence are also rather notorious for being a
product of under-reporting (Lion, Snyder, & Merrill 1981). It is therefore possible that
the relationships we have found are a product of chance, or of course attendance
stimulating an increase in reporting. However, if this was the case, verbal abuse and
property damage should also show more rises after the course, and similar rises
(possibly even larger) should occur after the 5-day course. Neither of these
relationships was evident in our data.
Alternative explanations
Another potential explanation might be that these findings are a local product, and the
local circumstances have produced anomalous results. Whilst PMVA courses in
general elsewhere may produce the drop in incident rates we had anticipated, either
the local content or teaching delivery may have led to the opposite effect. However
we have no evidence or reason to believe this. The course content is fairly standard
and the local trainers who deliver it are qualified, experienced and competent.
Alternatively, the effect may have been produced by the combination of the course
with local service characteristics. The acute wards in this study suffer from staff
shortages. Although data is not available for the whole period of the study, for most of
2004 the mean vacancy rate was 24%. This may explain the increase in incidents
when staff were away on the PMVA training courses, on the grounds that any strain
on this fragile staffing situation had negative consequences. Approximately 10% of all
213
ward nursing staff study leave in the locality is for attendance on PMVA courses.
Vacancy rates may also have contributed in some way to the rise in incidents
following updates courses. However we are unable to explain why this might happen,
and why the effect is specific to update courses and not the 5-day courses as well.
The most positive gloss that can be placed on the failure to discover a drop in incident
rates following training is that the culture of violence prevention in the locality is in a
steady state. Further training maintains a low level of violence, rather than lowering it
from a high level. The discrepancy between our findings and those of some previous
studies could thus be due to maximal impact on violent incident rates only occurring
when training is first introduced. Violent incidents in the study district may have
reduced some years before when PMVA training was first introduced, and stayed low
as the training scheme continued. This interpretation would be supported by data
showing sustained decreases in incident rates once a 60% threshold in PMVA trained
staff had been achieved (Mortimer 1995). Alternatively, the early impact of training
on aggression rates may be a ‘Hawthorne Effect’, due to novelty, and wear off in the
longer term. The most negative interpretation is that training in the management of
aggression makes staff more confident and more likely to confront patients, elicit a
violent response and use the manual restraint techniques they have been taught
(Morrison 1990). It may be that such a response only occurs with more superficial
training, thus the rise in violence following update rather than 5-day courses. It is
perhaps noteworthy that in the study district, update courses concentrate solely on
violence management skills, and do not refresh participants' knowledge of violence
prevention and de-escalation.
214
The evidence regarding the efficacy of PMVA training in reducing aggression rates is
finely balanced. Although some reported studies are positive, in most cases the
methodologies used have not been highly rigorous, with nearly all being uncontrolled
natural experiments. Assessing this evidence is complicated by variation in course
content, delivery and duration. Our results do raise questions about the necessity for
annual updates, but further research is clearly required before any changes in policy
are considered.
Even if such courses do not prevent aggression, they may still have value for the skills
they teach in safe manual restraint techniques. However, there remains a paucity of
evidence on outcome in terms of staff and patient injuries, as well as prevention. We
clearly need to know more about the effect of differing course content, and identify
what teaching does and does not lead to successful prevention, as well as
management.
JUNIOR STAFFING CHANGES AND THE TEMPORAL ECOLOGY OF
ADVERSE INCIDENTS
The general decrease of incidents at the weekend on acute wards confirms some
previous work (Carmel & Hunter 1989;Cooper et al. 1983;Gudjonsson et al
1999;Larkin et al 1988;Noble & Rodger 1989;Rasmussen & Levander 1996;Walker et
al 1994), and requires some explanation. At the weekends there is less pressure on
patients to get out of bed at an early hour. There may be fewer group and individual
activities that patients are pressured to join at weekends. It might be argued that
215
expectations are lower for patients at the weekend, and that there is less pressure on
them to do anything that they might find unpalatable, thus reducing conflict with staff.
Alternatively, it might be argued that there are fewer patients on the wards at
weekends because many are on leave. However, it is the more able and less
symptomatic patients who are given leave, rather than those who are judged to be at
high risk of harming themselves or others.
Psychiatric symptoms are a commonly-invoked explanation for aggressive behaviour
by patients, for example command hallucinations. Yet the decline in aggression at
weekends suggests that symptoms alone are not a sufficient explanation. We are not
aware of any evidence, for example, that psychotic symptoms subside at weekends,
but physical assaults on wards are fewer in number. It would seem that, just as for
absconding (Bowers et al. 1999), although symptoms may be involved, they do not
fully explain the decline in aggression at weekends.
Decreased stress among patients at weekends
It may be that weekends provide a less stimulating and anxiety-provoking social
environment for disturbed patients. There are fewer new admissions, fewer official
visitors (manager and clinicians of various disciplines), fewer telephone calls to the
staff, and no formal meetings. As a result, wards are literally quieter and nursing staff
are more available to interact with patients. There may be a substantial amount of
activity, for example weekend cleaning, baths, recreational endeavours, but this will
involve only nurses and patients, and there will be fewer patients (due to leave). This
generally relaxed atmosphere may be enhanced by expectations about the weekly
216
rhythms of life and the use of weekends for pleasurable, self-indulgent activities. A
similar theory has been advanced by Vittengl (2002) to explain the lower use of
seclusion and mechanical restraint at weekends. He argued that greater demands on
patients during weekdays increased stress and therefore negative behaviour.
Alternatively, it may be that lower stimulation and stress levels at weekends directly
reduce the acuity of psychotic symptoms, thus reducing adverse incidents
(Nuechterlein & Dawon 1984).
Either way, these findings suggest that we should seek ways to import these attributes
of weekends into weekdays to reduce adverse incidents. It may be possible to reduce
noise on the ward, limit visits by clinicians and managers, and hold meetings in an
area separated from the ward, for example. Alternatively, the ward might be declared
closed for periods of time during the week, as is already being tried in some places
(Kent 2005).
By themselves, such explanations might be considered speculative, but they are
supported by the relationship of incidents to ward rounds. While the initial analysis of
ward round days showed no effect on incident rates, the more detailed analysis of
days prior to and after ward rounds did demonstrate raised rates of absconding and
aggressive behaviours. This suggests that anticipatory and post-event tensions may
contribute to raised incident rates, a theory that has been previously advanced by
others (Cooper, Brown, McLean, & King 1983). Alternatively, it may be that
incidents the day before are indirect patient attempts to influence decisions made on
the day itself, and that incidents the day after are reactions to decisions which have
been made.
217
Staff stress
Staff stress and tension, however, do not appear to be so closely linked to increased
incidents. We might expect that the arrival of new members of the ward team would
cause heightened anxiety. The new staff would themselves be nervous about their
roles and new environment, and existing staff might be concerned to provide closer
supervision, assess the new team members and develop relationships with them. It
may also be expected that newer staff would be less skilled in their interactions with
patients and therefore evoke greater numbers of incidents, or that patients might
experience greater anxiety when exposed to newer and incompletely trained staff. Yet
none of these factors seemed to have an impact on incident rates. The statistically
significant findings found pointed in the direction of lowered incident rates, and might
in any case have been the spurious false positive findings that occur when multiple
statistical tests are conducted. However, if these findings are indications of a
substantive effect, then they may indicate that new staff are more caring, sensitive,
and keen to respond to patients' needs, thus reducing the number of adverse incidents.
The variability of previously reported findings on the weekly variation of adverse
incidents suggests that our findings may only be locally valid. However, the cause of
that variability may be setting and service differences, as much of the previous work
took place in the USA and/or in secure forensic psychiatric hospitals. There is only
one previously published study on the weekly variation in absconding rates from UK
general acute psychiatric units, and this showed no variation by day (Bowers et al
2000). In the field of aggressive behaviour, limiting the literature to studies of UK
218
acute psychiatric wards means that there are only four previous studies, one of which
reports no difference across the week (Soliman & Reza 2001), with the remainder
reporting lower rates at weekends (Cooper et al 1983; Noble & Rodger 1989; Walker
et al 1994). Previous results from analogous UK services are therefore largely
consistent with our findings.
This study found no evidence that new junior staff elicit more aggressive or other
adverse incidents from patients. In contrast trends suggesting the opposite were found.
Tension and raised anxiety among patients appears to be linked to greater adverse
incident rates, particularly aggression. This is visible in pre- and post-week, and preand post-ward round raised incident rates. These tensions appear to have a larger
impact on incident rates than symptoms alone, as incidents rates were very low at
weekends. The link between stress on the ward community and adverse incidents is
also supported by our other findings on admission rates and staff availability (Chapter
5).
Concern about heightened risk at times of new staff influxes to acute psychiatric
wards are misplaced. It may be possible to reduce incident rates by moderating
stimulation, change and uncertainty in the patient environment, and by mobilising
nursing support for patients at times of higher stress. Further research is required on
the social and contextual causes of adverse incidents on acute psychiatric wards.
219
COMPARISON OF THREE PICUs
Ethnicity
The gender age and diagnostic profile of PICU patients confirms that of previous
studies: PICU patients are younger than acute populations, more likely to suffer from
psychotic disorders, and more likely to be male (Brown & Bass 2004). It is known
that Caribbeans in the UK and The Netherlands are at higher risk of schizophrenia and
are more likely to be perceived as violent (Mulder, Koopmans, & Selten 2006;Singh
et al. 1998). Some previous studies have also drawn attention to the high numbers of
ethnic minority patients within PICUs (Feinstein & Holloway 2002;Pereira, Sarsam,
Bhui K., & Paton 2006), and expressed concern that this might be due to racially
biased, exaggerated assessments of risk, e.g. ‘big black and dangerous’ (Prins 1993).
Our findings suggest that the question is far more complex, in that although Caribbean
patients were more prevalent in the PICUs, African patients were not, and Asian
patients were significantly less likely to get admitted there. This suggests that there is
a particular aspect of the Caribbean mentally ill population (rather than racist
perceptions of dangerousness) that leads to their excessive numbers in the PICUs.
Explanations for the twofold over-representation of Caribbean patients on the PICUs
are not easy to find. Caribbeans are in reality no larger in body size than the white
majority population (Erens, Primatesta, & Prior 1999) therefore appear no more
threatening. Evidence on the abuse of drugs by Caribbeans is divided, with a large
survey showing no difference (Home Office 2006), but two PICU based studies
showing a link between cannabis use, delayed recovery and Caribbean ethnicity
(Feinstein & Holloway 2002;Isaac, Isaac, & Holloway 2005). Unfortunately the
220
ethnic breakdown of crime figures by the Home Office does not separate Africans
from Caribbeans, but there is evidence for higher rates of crime in both these groups
(Home Office 2004). However crime statistics are themselves socially produced by a
criminal justice system that may excessively scrutinise some minority populations,
thus producing spurious differences in the figures. Some recent research suggests that
higher rates of schizophrenia amongst UK Caribbeans may be due to more unstable
family backgrounds (Murray, 2006), so it is possible this same factor may account for
more challenging behaviour (through the association of deprivation and abuse with
anti-social personality disorder, Robins 1966, West 1982) in this ethnic group. Much
less previous research has focussed upon the Asian group of patients, and it is difficult
to know why they were less likely to need PICU care.
Differences between the PICUs
Although the PICU patient sample clearly was different from the more general acute
psychiatric population, large differences between the three PICUs as far as ward
organisation and patient composition were found. In other words, the three PICUs
described have been shown to have very different styles and characters, even though
they co-exist within the same NHS Trust within the same policy framework, both
locally and nationally.
The situation on Haven PICU described in this study raises the most interesting
questions around the causes of the high rates of adverse incidents. A number of
possible explanations exist for this:
221
1. Conflict behaviours from the patients may have reflected and been produced by the
discord within the multidisciplinary team. One way this might have been produced
would be via inconsistency between different members of the team. However there
was also evidence for some discord among the team on Shelter PICU, and yet this did
not seem to lead to more adverse incidents.
2. The period of poor ward leadership prior to the appointment of a permanent new
ward manager may have weakened by skills and clinical nursing care over a sustained
period, leading to a poor and ineffective ward culture, high sickness and vacancy rates
and therefore a high rate of incidents. The interviews gave some evidence for this in
that the new ward manager stressed the need for better leadership and more training in
clinical nursing skills.
The low adverse incident rate in Refuge PICU does not appear to be explained by the
high levels of antipsychotic prescribing there. Shelter PICU, with the lowest dosages
per patient out of the three units, has a similar frequency of incidents. The low
frequency of incidents on Shelter does not seem to be explained by this ward having
less admission pressure and more easily manageable patients as a result of this. That
is to say, Shelter PICU should be the most high pressured and acute of the three units.
It has the fewest number of beds to the population served, suggesting that only the
most acutely of acutely ill patients in the district gain access. Yet this unit has one of
the slowest patient turnover rates and a low rate of incidents.
The similar accounts of absconds through windows and over fences, from both Haven
and Shelter PICUs, indicate that physical security is an important component of PICU
provision and an effective way to prevent absconds. Previous research in acute
222
psychiatric wards has found peak absconding times during nursing shift handovers
(Bowers et al. 1999), also indicating the importance of supervision and security.
However the efficacy of locked doors in preventing absconding in acute psychiatry is
in dispute, with door locking increasing (Bowers et al. 2002) but research showing
that absconding can be decreased whilst keeping the door unlocked (Bowers,
Alexander, & Gaskell 2003). The lesson from these three PICUs is that physical
security to prevent absconds needs to encompass more than just the front door to the
ward, and include windows and fences.
The provision of PICU care is hugely variable, even within the contiguous districts
served by a single NHS Trust. Guidance on levels of PICU provision is totally absent
from UK government recommendations (Department of Health 2002). Given the
variability that has been uncovered, more research needs to be undertaken to
determine what are the most effective care configurations for patient safety and
therapeutic efficacy. That research will also need to further investigate the interface
between the psychiatric and criminal justice system, as they impact on PICU bed use,
with a view to defining appropriate and effective usage. The impact of
multidisciplinary relationships and staffing changes on patients are also important
topics for further research.
The accounts of staff about the relationship between physical security and absconds
provides prima facie evidence that windows and fences of sufficient strength can be
effective. Any strategy to prevent or minimise absconding with thus need to set
appropriate levels of physical as well as relational security.
223
There are important variations in PICU usage by ethnicity that do not appear to be
explicable in terms of racism. Instead such differences might arise out of culturally
different patterns resilience or vulnerability to mental disorder, or ways of interacting
with the psychiatric service, or means of expressing distress. Further research into the
nature of these interactions may deliver findings of benefit to people of all ethnicities.
STAFF
ATTITUDES,
WARD
STRUCTURE,
AND
CONFLICT
AND
CONTAINMENT
The study wards appear to be well representative of acute psychiatric wards
nationally, with levels of conflict, containment and attitudes to difficult patients all
consistent with previously published norms.
Model confirmation
The finding of a positive association between ward structure and positive attitudes to
patients supports the working model, and is in line with its predictions. The pattern of
relationships between the APDQ and WSQ is intriguing. It would appear that a
greater number and level of certainty about the ward rules enables nurses to have
more positive feelings for difficult patients. It might have been predicted that more
rules would be associated with more APDQ Security, but this was not evident, in fact
rules were not associated with any other dimension of attitude. It is not clear why this
is the case. APDQ Acceptance was only associated with WSQ Value. Acceptance is
made up of questionnaire items indicating equanimity, calm, and not becoming
224
irritated, annoyed or angry. The two scores may be associated because it is possible to
assert rules, communicate them and implement a routine imbued with angry feelings,
however valuing patients and treating them as equals is not compatible with anger.
The working model is also supported by the finding that increases in ward structure,
more specifically routine, leads to decreases in conflict rates. A review of the extant
literature and research on ward rules for inpatients has not resolved whether a high
level of structure is beneficial to patients or detrimental, whether it engenders more
conflict and aggression, or reduces it (Alexander and Bowers 2004). Most previous
studies have been based on single case (ward) studies, single ward samples, and
descriptively evaluated natural experiments. These methodological weaknesses may
have led to the widely varying results reported. In this larger longitudinal study, more
structure was significantly associated with lower conflict levels, confirming
deductions initially made in a large, cross sectional interview study (Bowers 2002).
This study hypothesis is therefore confirmed.
However, the relationship between structure and conflict has also been found to
operate in both directions (Figure 5). There is therefore a dynamic relationship
between the two, which seems likely to act as an amplification mechanism over time,
resulting in wide swings in conflict rates. For example, the initiation of a strong ward
structure will lead to low conflict, which in turn will strengthen structure, until the
system is challenged, perhaps by the admission of some particularly difficult patients
whose behaviour leads to decay of the structure, leading to more conflict, etc. This
implies that ward structure will need to be repeatedly rebuilt and re-accomplished,
even in a system that is perhaps otherwise static (for example run by the same staff).
225
Even with the best of staff, any acute psychiatric ward is going to have periods that
are more chaotic than others, and that will have to be worked through in order to
recreate the structure and restart the beneficial rather than detrimental cycle.
Figure 5. Relationship between Ward Structure and Conflict
Ward
Structure
Conflict
Greater ward structure has not been shown to be related to reduced containment
method use in the predicted way. It would appear instead that there are indications
that greater use of containment leads to high levels of structure, and that perhaps
greater use of containment is the way in which staff regain a sense of control and
mastery, and are able to rebuild or enhance the structure in the face of challenging
behaviour by patients. In the individual event analysis, it appears that it is the milder
forms of containment that lead to greater structure (PRN medication use, special
observation, time out), however it cannot be excluded that more severe containment
such as seclusion, manual restraint, coerced IM medication also have this effect.
These latter, more severe forms of containment, are used less frequently, thus
relationships are more difficult to detect statistically.
226
The hypothesis that positive attitudes lead to reduced conflict and containment is not
supported by these findings. Instead they support the interpretation that staff attitudes
to patients are a consequence, or follow from conflict and containment. Moreover,
they suggest that while more conflict behaviours on the part of patients lead to worse
staff attitudes, they also suggest that more use of containment leads to improved staff
attitudes. As we already have evidence that attitude is linked to stress, burnout, work
performance and perception of managers (Bowers Carr-Walker et al 2006), it is
therefore a possibility that all these are driven by patient behaviour, rather than
productive of it. This is somewhat similar to earlier work by Kellam et al (1966),
which demonstrated that staff liking for patients increased as they got better.
The significance of this is that attitudes to difficult patients, defined as enjoying being
with them, feeling secure in their presence, being accepting of them, having a sense of
purpose in working with them and being enthusiastic, might be considered an
epiphenomenon. Attempts to change staff attitudes, or it might be said, feelings
towards or about patients, are not therefore the correct or most efficacious route to
reducing levels of conflict on wards. This research indicates that a better method
might be to assist and support ward staff in the establishment of a high degree of ward
structure.
Individual conflict and containment events
It is difficult to know how far to press the interpretation of associations that were
found at the level of individual conflict and containment events. When so many
statistical tests are applied, it is likely that some proportion of the significant
227
associations are due to chance. With that caution, it is still of interest to examine some
of the patterns that have emerged.
The use of intermittent observation had a broad positive impact on staff attitudes to
patients. This may tie in with other findings, for example in the City 128 Study of 136
wards, intermittent observation has been reported to be associated with lower rates of
self-harm by patients (Bowers Whittington et al 2006). Also, in a study of student
nurses attitudes towards different containment measures (Bowers Simpson &
Alexander et al 2006), positive evaluations of intermittent observation were found to
be associated with positive attitudes to patients. Use of intermittent observation has
also been shown to reduce absconding (Richmond et al 1991). Clearly something
important is happening in relation to nurses' stance towards, and use of, intermittent
observation. The difficulty is in understanding and explicating exactly what is going
on in a way that enables us to improve acute care and keep patients safe. It may be
that intermittent observation makes staff available to patients, and facilitating
interaction from which both parties derive benefit. There are no ethnographic,
observational, descriptive or interview studies about intermittent observation. More
research on this topic is therefore required.
Officially reported absconding appeared to have a positive impact on attitudes to
patients, where absconding (missing without permission) had the opposite effect. This
could be a spurious chance effect, or it could be that officially reported absconding
takes away the threatening patient from the ward, whereas the patients who go
missing without permission may be those who are more rewarding to staff. Routine
has a beneficial impact on lowering conflict, particularly rule breaking as known from
228
the mid level analysis, but also absconding missing and official, a fact hidden by the
inclusion of attempted absconding at the mid level. This confirms findings from a
study on reasons why patients abscond, which found that boredom and lack of
occupation were important factors (Bowers et al 1999).
Verbal abuse was found to have negative impact on feelings of security and on
routine. Getting a handle on this and refusing to tolerate it might therefore have
considerable gains, and this could be part of an intervention to reduce conflict on
wards. This would also fit with a 'zero tolerance' philosophy (NHS Executive 1999),
which suggests that confronting and dealing with minor antisocial behaviour acts to
reduce the incidence of more severe events. The split finding over ward structure and
physical assault is intriguing, with WSQ Value being associated with reduced
physical assault frequency and WSQ Communication with increased assaults. It
suggests that communicating the rules too much may trigger assaults, whereas valuing
patients decreases them. Previous studies have made a connection between the
imposition of ward rules and violent incidents (Morrison 1992, Lanza 1988).
Patient evaluations of ward structure
The staff WSQ scores were significantly related to WAS, when the patient WSQ
scores were not. Staff and patient WSQs only agreed on Rules, not on any other score,
and whereas staff WSQ scores predicted conflict and containment items, patient WSQ
scores did not. The PPSI scores were not well related to WAS or to patient or staff
WSQ scores, had poor inter rater reliability, and did not predict conflict or
229
containment items. Together these results are disappointing, and suggest that there are
limitations to the collection of data from acutely ill patients. Those limitations
probably arise from the cognitive effects and distortions of being mentally ill, and
from the angry feelings aroused in patients through their formal detention in hospital
against their will.
We have previously used interviews of inpatients in ways that have been both
illuminating and helpful (Bowers et al 1999), enabling beneficial nursing
interventions to be devised and tested. The PPSI interviews were also a rich source of
data on how patients perceive staff, and are likely to prove valuable in a qualitative
analysis. However the failure of the quantitative measures demonstrates that
extrapolating quantitatively from inpatient interviews (e.g. most patients say X,
therefore X is a prevalent event on inpatient wards) may prove unreliable, that treating
patient statements collectively as objective reports may be mistaken, and that any
qualitative analysis needs to take into account the biases and distortions that may be
present. These results also call into question the validity (and therefore utility) of
patient versions of the WAS, the use of which is reported in a number of published
papers (e.g. Caplan 1993).
The data support the interpretation that ward structure leads to reductions in conflict.
The evidence is most strong for the presence of a routine for patients on the wards,
and to this extent, the working model is confirmed. However there is also evidence
that conflict behaviours on the part of patients erode routine and elicit negative
attitudes from staff. The findings suggest that staff should invest time and effort in the
production of a daily routine of activities for patients, and that they should expect to
230
have to regularly recreate that routine as it decays due to the demands of managing
difficult patient behaviours.
LIMITATIONS
The study took place in one NHS Trust in a metropolitan inner city area, and this may
have led to some bias in the results. For example, the functions of acute psychiatry,
the involvement of other disciplines in acute care, the types of patients admitted, and
the training and support structures for staff, may be somewhat different in other areas.
It might be argued that the findings from this study may not apply to other parts of the
UK. In certain respects this may be correct. Findings in relation to patient ethnicity
will only be applicable to those parts of the UK that have a high minority population,
in particular large cities. However concerns about the treatment of ethnic minority
patients within the psychiatric services are widespread, and have led to a large scale,
national key policy initiative (Department of Health 2005). Other aspects of the study
relate to the problem of violence and its prevention, as well as other adverse incidents.
These are common problems nationally for psychiatry, and there is no real reason why
the study district should be considered a special or unusual case in this respect. The
findings are therefore likely to have wide applicability. Indeed the principles behind
those findings and the theories they give rise to have international relevancy to all
areas where care is given to acutely mentally ill people who pose a danger to
themselves or others.
231
As is always the case, a larger scale study with a much wider sample would have been
preferable. However it is worth noting that such a study would run into other
problems, such as differences in the nature and content of violence management
courses, and in criteria and definitions for adverse incidents and their official
reporting. The intention with this study was to sample in depth and longitudinally in
one Trust in order to elucidate relationships between variables over time, providing
one way to accumulate evidence on causal relationships. This study was a partner
project to the 'City-128 Study of Observation and Outcomes' (Bowers et al 2006)
which collected data prospectively from 136 acute admission wards, using similar
research instruments. The basic design of that study was multivariate and cross
sectional, and it provides evidence on the generalisability of common findings. Taken
together, these studies provide a strong foundation of findings on which to base
conclusions.
A limited number of psychiatrists agreed to be interviewed, and there may be
response bias in the findings from that source. In addition, this one organisation might
have had specific characteristics (for example a management style, organisational
culture, philosophy, level of investment, etc.) that led to these particular findings. The
connections over time may therefore have been a product of these characteristics, and
may not be generalisable to other wards and organisations.
The strengths of the PICU analysis are that more than one unit is described, and
qualitative and quantitative data are brought together in a triangulation design. This is
an advance on much previously published research in this area. However this design
was still too small scale to provide answers to some of the questions that are raised by
232
differences between the units studied. Further research into PICUs on a larger scale is
required to answer these and other questions.
Some of the presented analyses are based on officially reported data, indicating that
they should be accepted with some caution. Official data is subject to a number of
different influences (for example the concerns of managers and the constant changes
in policy in the UK health service). Official statistics on violence are also said to be a
product of under-reporting (Lion, Snyder, & Merrill, 1981). However, the fact that all
incidents included were recorded by uniform reporting systems enhances the
comparability of the data.
In order to interpret the findings, the limitations of our longitudinal analysis of
adverse incidents need to be understood. The selection of significantly associated
variables and their building into explanatory models is a process likely to overidentify or exaggerate the power of the variables included. Such models are therefore
primarily offered as a basis for further research and subsequent confirmation, rather
than as firm findings in their own right. Nevertheless, some gross and substantive
patterns are visible in the data, and these are more likely to be generalisable than the
finer grained specific associations reported. The second utility of such modelling
exercises is that they suggest new theoretical insights. In both these senses our
findings have some clear lessons for the practice of acute psychiatry.
In the phase two prospective stage of the study, on average, there were small numbers
of questionnaires per ward per wave (excluding the PCC-SR). Staff found it irritating,
and difficult to understand the need to complete the same questionnaire over and over
233
again. Thus these small numbers were less representative of the total staff group on
the ward at the time then they could have been, detracting from the power of the
analysis. Some of the associations found could be produced through the drift of more
positive staff to low conflict and high structure wards. However this study covered a
two-year period, and if this process was occurring there would be a picture of growing
divergence between wards. This did not appear to be the case, and wards varied a
great deal over the course of the study.
234
9. CONCLUSIONS AND RECOMMENDATIONS
The working model of conflict and containment
This model was described in full in Chapter 2, and suggests that differences between
wards (and on the same ward from time to time) in conflict and containment rates are
determined by staff attitudes and behaviour, specifically positive appreciation of
patients, emotional self- regulation, and the provision of an effective structure of rules
and routines for patients.
Certain elements of this model were supported. The extent of a daily routine for
patients on the ward was found to be predictive of conflict rates, providing a strong
indication that structure is causal. Links were also found between positive attitudes to
patients and ward structure as measured by different scales, and the presence of
regular staff on the ward was found to be associated with lower incident rates.
However evidence was found for several factors influencing conflict rates which were
not in the working model. Stress in the ward community as a whole (admissions, ward
rounds, weekdays, other incidents) seemed to be linked to incidents. The physical
security of Psychiatric Intensive Care Units was found to be important in reducing
absconding. And some aspects of training courses may actually exacerbate rather than
reduce conflict rates. Unpredicted by the working model, adverse incidents and
235
conflict levels led to an erosion of ward structure over time, demonstrating that
structure and conflict were in a reciprocal relationship.
Several predictions made by the working model were not substantiated by the findings
of this study. Instead of determining conflict and containment rates, staff attitudes to
patients were found to be products of those rates. More conflict led to more negative
attitudes. More containment led to better attitudes. In addition, the working model
predicted that better technical mastery in interpersonal skills would lead to better staff
attitudes and thereby to lower conflict, whereas in fact training courses incorporating
de-escalation skills did not have any impact.
Methodological conclusions
Data collected from patients was disappointing when analysed quantitatively.
Evidence for its validity and reliability was very poor. We conclude that there may be
serious limitations to the use to data generated in this way from acutely ill patients.
Such data may be too biased by the context within which it was collected, and/or the
topic of ward structure and rules one that elicited emotional reactions that obstructed
objective reporting by patients. The experience of being compulsorily detained under
mental health legislation may particularly have influenced patient responses, leading
to idiosyncratic variability in scale completion or responses during interviews. Such
data may be more productively regarded as representing patient perceptions, and
remain important because the way in which patients regard their care will in part
determine how they respond to it.
236
General conclusions and recommendations
Although the management of inpatient care, and the administration of the patient's
care pathway, are both critical and important tasks, they do remove nursing and other
staff from direct patient contact and hinder the development of supportive
relationships with people in crisis.
•
A work analysis study should be conducted with a view to defining the right
staffing and modern technological resources to enable this work to be done at
maximum efficiency, and to identify unnecessary bureaucratic tasks for
elimination.
•
Psychiatric nursing professional bodies and organisations should be requested
to define core assessment and care documentation for acute inpatient
psychiatry with a view to eliminating redundant paperwork.
Nurse staffing levels and acute inpatient bed numbers are currently based on historical
factors and local traditions. The primary tasks of acute inpatient psychiatry are to keep
people safe, assess their mental state, treat their condition, meet their basic care needs
and provide physical healthcare. In order to provide an evidence base for staff and bed
resource investment:
•
The National Confidential Inquiry into Homicides and Suicides should be
requested to investigate the relationship between staffing levels, bed provision
and outcomes, controlling for levels of psychiatric need and morbidity.
•
Utilising a descriptive study of patient needs for safety, assessment, etc. the
ideal staffing mix of a ward should be defined by bringing together the
237
empirical data and professional judgment. Such an analysis should be
undertaken without bias due to professional 'turf' defence or potential cost
implications. It should then be trialled to assess its outcome.
•
In conjunction with this exercise, efficient working methods to provide safety,
assessment etc., should be devised, perhaps by the NHS Institute for
Innovation and Improvement, using methodologies similar to those used in the
'productive ward' and 'No delays (18 week wait)' exercises.
The absence of regular nursing staff, for whatever purpose, has been found to be
associated with raised adverse incident rates.
•
Wards should be fully staffed with a zero vacancy factor. For this to occur
adequate numbers of staff need to be trained, in the right localities (a
responsibility of the training commissioners, Strategic Health Authorities), and
Human Resource Departments need to promptly respond to resignations.
•
Wards should be managed to spread the demands of study and annual leave
evenly across the year.
•
Wards should have adequate regular staff numbers to enable the large number
of training courses required by government policy to take place without an
excessive cost in adverse incidents
Acute inpatient treatment may be considered to be overly dependent on medication
alone, with little evidence for the efficacy of anything else.
•
Research should be commissioned that investigates new psychosocial
treatments for the acutely mentally ill.
238
The tasks of acute inpatient care are to keep patients safe, assess their problems, treat
their mental illness, meet their basic care needs and provide physical healthcare.
•
Relevant University Departments (Psychiatry, Mental Health Nursing,
Occupational Therapy, Clinical Psychology) should review their curricula to
ensure that qualified professionals are equipped to contribute to these tasks.
•
NHS Trust training committees or responsible officers should review their
training to those staff involved in inpatient care to see that it supports staff in
these activities
•
Clinical Audit within NHS Trusts should address the implementation of best
professional practice in acute inpatient wards in relation to these activities.
Respectful communication between the different disciplines is a foundation and
primary requirement for collaborative interdisciplinary care for patients.
•
Trust management teams should identify any wards where this is not
occurring, and take effective action to resolve problems and require good
professional standards of working from all staff.
•
Engagement in relevant multidisciplinary training, with clear and appropriate
learning outcomes for all disciplines, should be required from all acute
inpatient staff.
Serious untoward incidents cause considerable distress for staff, and have the
potential to affect their practice and psychological equilibrium, sometimes for many
years. In order to reduce the risks for future incidents, and in order to fulfil their
responsibilities toward the health and safety of their staff, NHS Trusts should:
239
•
Psychologically prepare staff through a relevant training programme (this
could also usefully be incorporated in basic professional training).
•
After any SUI, provide psychological support to staff and teams via a suitably
qualified third party, at arms length from any necessary post incident
investigation.
Evidence was found for poor support of patients and few attempts to address their
needs in the immediate or longer term aftermath of an SUI:
•
NHS Trusts should ensure their SUI policy requires a debriefing of the patient
group, and that this is actually carried out. Extra staffing support to the ward
may be required to enable this to occur. Given other study findings this is
likely to reduce adverse incidents by other patients in the wake of an SUI.
•
Community practitioners should work with patients after discharge to resolve
any outstanding emotional issues relating to any SUI which may have been
witnessed. In order to do this they will need to engage with their patients
during admission and ask them about their experiences after discharge.
Stress in the patient community seems to be linked to higher conflict rates. High
numbers of admissions are associated with more incidents, as are incidents
themselves. Conflict erodes ward structure thus leading to more conflict. Weekdays
and the days before and after ward rounds have raised incident rates.
•
Ward staff should seek to promote a calm, quiet, relaxed, low stress ward
environment. This could be accomplished through noise reduction, decreased
hurry, a calm and confident demeanour, restrictions of visitors to the ward
240
(both other staff and patient visitors), prompt and caring control of disturbed
patients, and reassurance to other patients following incidents.
•
A trial should be conducted of the provision of extra staff to wards at times of
high stress (e.g. a surge in admissions or the occurrence of an officially
reported incident) to see if incident rates can be reduced.
Staff attendance on courses on the prevention and management of violent incidents
were not found to be associated in falls in adverse incident rates. The removal of
regular staff from the ward in order to attend lengthy courses was associated with
rises in incident rates. In addition, rises in violent incident rates were found following
attendance on follow-up update courses, apparently linked to such courses covering
solely manual restraint skills and ignoring the need to also update de-escalation skills.
•
Trust managers should confirm that the courses they run or purchase cover
both de-esclalation and manual restraint skills, especially the shorter refresher
courses.
•
Further research into the efficacy of such courses in reducing violent incident
rates is required.
Of all ethnic minorities, Caribbeans were the most over represented in the Psychiatric
Intensive Care Units, whereas Asian patients were least likely to be cared for in this
secure environment. These figures have no clear or certain explanation. In addition
the provision of PICU care was hugely variable, even within the adjoining districts
served by a single NHS Trust. This was coupled with massive variations in adverse
incident rates.
241
•
Further research should be commissioned to specifically examine the
relationship between ethnicity and PICU care.
•
More research should be commissioned to determine what are the most
effective care configurations for patient safety and therapeutic efficacy. That
research will also need to further investigate the interface between the
psychiatric and criminal justice system, as they impact on PICU bed use, with
a view to defining appropriate and effective usage.
There is considerable scope for the further analysis of the dataset collected using
additional statistical techniques to explore relationships between variables.
•
In order to maximise the return on the NHS investment in this study, further
analysis should be commissioned.
242
10. REFERENCES
Agenda for Change Project Team (2004). Agenda for change: what will it mean for
you? London: Department of Health.
Alexander, J. and Bowers, L. (2004) Acute Psychiatric ward rules: a review of the
literature. Journal of Psychiatric and Mental Health Nursing 11(5)623-631
Anderson & West (1999). Team Climate Inventory (TCI): User's Guide. Windsor:
NFER-NELSON Publishing
Appleby, L. (2004). The National Service Framework for Mental Health - Five Years
On London: Department of Health.
Appleby, L., Shaw, J., Amos, T., McDonnell, R., Harris, C., McCann, K., Kiernan,
K., Davies, S., Bickley, H. & Parsons, R. (1999) Suicide within 12 months of contact
with mental health services: national clinical survey. British Medical Journal, 318;
1235-1239.
Appleton, W. 1965, "The snow phenomenon: tranquilizing the assaultive patient",
Psychiatry, vol. 28, pp. 88-93.
Baker, S. (2000) Environmentally Friendly? Patients’ views of conditions on
psychiatric wards. London, Mind.
Bartels, S (1987) The aftermath of suicide on the psychiatric inpatient unit. General
Hospital Psychiatry 9 (3):189-197.
Bass & Avolio (1995) Multifactor Leadership Questionnaire. Redwood City, CA.:
Mind Garden
Baxter, E. Hafner, R. J. and Holme, G. (1992) Assaults by patients: the experience
and attitudes of psychiatric hospital nurses. Australian & New Zealand Journal of
Psychiatry. 26 (4):567-573.
Beech, B. & Leather, P. 2004, "Evaluating a Management of Aggression Unit for
Student Nurses", Journal of Advanced Nursing, vol. 44, no. 6, pp. 603-612.
Beer, M. D., Paton, C., & Pereira, S. 1997, "Hote beds of general psychiatry;
anational survey of psychiatric intensive care units", Psychiatric Bulletin, vol. 21 142144.
Blofeld, J Sallah, D. Sashidharan, S. P Stone, R and Struthers, J. (2003) Independent
inquiry into the death of David Bennett. Cambridge: Norfolk, Suffolk and
Cambridgeshire Strategic Health Authority.
Borrill, C., West, M., Shapiro, D., & Rees, A. (2000). Team working and
effectiveness in health care. British Journal of Health Care Management, 6(8), 354371.
Bowers, L. (1998) The Social Nature of Mental Illness. London: Routledge.
Bowers, L. (2000). The expression and comparison of ward incident rates. Issues in
Mental Health Nursing, 21, 365-374.
Bowers, L. (2002) Dangerous and Severe Personality Disorder: Response and Role of
the Psychiatric Team. London: Routledge.
243
Bowers, L. (2003a) Manipulation: searching for an understanding. Journal of
Psychiatric and Mental Health Nursing 10:329-334
Bowers, L. (2003b) Manipulation: description, identification and social ambiguity.
Journal of Psychiatric and Mental Health Nursing 10:323-328
Bowers, L. (2005). Reasons for admission and their implications for the nature of
acute inpatient psychiatric nursing. Journal of Psychiatric & Mental Health Nursing,
12, 231-236.
Bowers, L. (2006) Patient homicide causes nursing staff to leave. Journal of
Psychiatric and Mental Health Nursing 13:778-779
Bowers, L. and Allan, T. (2006) The Attitude to Personality Disorder Questionnaire:
psychometric properties and results. Journal of Personality Disorders 20(3)281-293
Bowers, L., Alexander, J. and Gaskell, C. (2003) A Controlled Trial Of An
Intervention To Reduce Absconding From Acute Psychiatric Wards. Journal of
Psychiatric and Mental Health Nursing 10:410–416
Bowers, L., Alexander, J., & Gaskell, C. 2003, "A trial of an anti-absconding
intervention in acute psychiatric wards", Journal of Psychiatric & Mental Health
Nursing, vol. 10, no. 4, pp. 410-416.
Bowers, L., Alexander, J., Callaghan, P., Eales, S., Guy, S., McCann, E., & Ryan, C.
(2002), Safety and security policies on psychiatric acute admission wards: results
from a London-wide survey, Journal of Psychiatric and Mental Health Nursing, vol. 9,
pp. 427-433.
Bowers, L., Carr-Walker, P., Allan, T., Callaghan, P., Nijman, H., Paton, J. (2006)
Attitude to personality disorder among prison officers working in a dangerous and
severe personality disorder unit. International Journal of the Law and Psychiatry
29:333-342
Bowers, L., Douzenis, A., Galeazzi, G., Forghieri, M., Tsopelas, C., Simpson, A., and
Allan, T. (2005) Disruptive and dangerous behaviour by patients on acute psychiatric
wards in three European centres. Social Psychiatry and Psychiatric Epidemiology
40:822-828
Bowers, L., Flood, C. Brennan, G. LiPang, M. and Oladapo, P. (2006) A trial to
reduce conflict and containment on acute psychiatric wards: City Nurses. Journal of
Psychiatric and Mental Health Nursing 13:165-172
Bowers, L., Jarrett, M. & Clark, N. (1998) Absconding: A Literature Review. Journal
of Psychiatric and Mental Health Nursing 5:343-353
Bowers, L., Jarrett, M. Clark, N., Kiyimba, F. & McFarlane, L. (1999) Absconding:
outcome and risk. Journal of Psychiatric and Mental Health Nursing 6(3)213-218
Bowers, L., Jarrett, M., Clark, N., Kiyimba, F., & McFarlane, L. (1999). Absconding:
why patients leave. Journal of Psychiatric & Mental Health Nursing, 6, 199-205.
Bowers, L., Jarrett, M., Clark, N., Kiyimba, F., & McFarlane, L. (2000). Determinants
of absconding by patients on acute psychiatric wards. Journal of Advanced Nursing,
32, 644-649.
Bowers, L., Jarrett, M., Clark, N., Kiyimba, F., & McFarlane, L. 1999, "Absconding:
how and when patients leave the ward... part 2", Journal of Psychiatric & Mental
Health Nursing, vol. 6, no. 3, pp. 207-211.
244
Bowers, L., Simpson, A., & Alexander, J. (2003). Patient-staff conflict: Results of a
survey on acute psychiatric wards. Social Psychiatry & Psychiatric Epidemiology.,
38, 402-408.
Bowers, L., Simpson, A., & Alexander, J. (2005). Real world application of an
intervention to reduce absconding. Journal of Psychiatric and Mental Health Nursing
12:598-602.
Bowers, L., Simpson, A., Alexander, J., Hackney, D., Nijman, H., Grange, A., &
Warren, J. (2005) The Nature and Purpose of Acute Psychiatric Wards: The
Tompkins Acute Ward Study. Journal of Mental Health 14[6], 625-635. 2005.
Bowers, L., Simpson, A., Alexander, J., Ryan, C. and Carr-Walker, P. (2005) Student
psychiatric nurses' approval of containment measures: relationship to perception of
aggression and attitudes to personality disorder. International Journal of Nursing
Studies doi:10.1016/j.ijnurstu.2005.03.002
Bowers L, Whittington R, Nolan P, Parkin D, Curtis S, Bhui K, Hackney D, Allan T,
Simpson A, & Flood C (2006) The City-128 Study of Observation and Outcomes on
Acute Psychiatric Wards.Report to the NHS SDO Programme. .
Brennan, G., Flood, C. and Bowers, L. (2006) Constraints and blocks to change and
improvement on acute psychiatric wards – lessons from the City Nurses project.
Journal of Psychiatric and Mental Health Nursing 13:475-482
Brown, B., Crawford, P., & Darongkamas, J. (2000). Blurred roles and permeable
boundaries: the experience of multidisciplinary working in community mental health.
Health and Social Care in the Community, 8(6), 425-435.
Brown, S. & Bass, N. (2004) The psychiatric intensive care unit: patient
characteristics, treatment and outcome, Journal of Mental Health, vol. 13, no. 6, pp.
601-609.
Brunnenberg, W. & Bijl, R. (1998) Suicide en suicidepreventie: in het psychiatrisch
ziekenhuis [Suicide and suicide prevention in the psychiatric hospital]. Maandblad
Geestelijke Volksgezondheid [Monthly Journal of Mental Health] 53, 13–26
Burns, T. & Lloyd, H. (2004) Is a team approach based on staff meetings costeffective in the delivery of mental health care. Current Opinion in Psychiatry, 17, 311314.
Burns, T., Knapp, M., Catty, J., Healey, A., Henderson, J., Watt, H., & Wright, C.
(2001) Home treatment for mental health problems: a systematic review. Health
Technology Assessment, Vol. 5, No. 15.
Cancro, R. 1968, "Elopements from the C. F. Meninger Memorial Hospital", Bulletin
of Meninger Clinic, vol. . 32: 228-238.
Caplan, C. (1993) Nursing staff and patient perceptions of the ward atmosphere in a
maximum security forensic hospital. Archives of Psychiatric Nursing 7 (1):23-29.
Carmel, H. & Hunter, M. (1989) Staff injuries from inpatient violence. Hospital and
Community Psychiatry, vol. 40(1): 41-46.
Carmel, M. D. & Hunter, M. (1990) Compliance with training in managing assaultive
behaviour and injuries from inpatient violence, Hospital and Community Psychiatry,
vol. 41(5): 558-560.
245
CHAI (2005) Count Me In: Results of a national census of inpatients in mental
hospitals and facilities in England and Wales. London, Commission for Healthcare
Audit and Inspection.
CHI (2004) What CHI has found in mental health trusts: sector report. London,
Commission for Health Improvement.
Childs, A., Thomas, B., & Tibbles, P. (1994). Specialist Needs. Nursing Times, Jan
19; 90(3) pp32-3.
Clark, N., Kiyimba, F. Bowers, L., Jarrett, M. & McFarlane, L. (1999) Absconding:
nurses views and reactions. Journal of Psychiatric and Mental Health Nursing
6(3)219-224
Clarke, S. (2004). Acute Inpatient Mental Health Care: Education, Training &
Continuing Professional Development for All. London: National Institute for Mental
Health and Sainsbury Centre for Mental Health.
Cleary M. (2004) The Realities of Mental Health Nursing in Acute Inpatient
Environments. International Journal of Mental Health Nursing 13:53-60
Coldwell, J. & Naismith, L. (1989) Violent incidents on special care wards in a
special hospital, Medicine, Science and the Law, vol. 29, pp. 116-123.
Collins, J. (1994) Nurses' attitudes towards aggressive behaviour, following
attendance at 'The Prevention and Management of Aggressive Behaviour
Programme", Journal of Advanced Nursing, vol. 20, pp. 117-131.
Cooper, A. & Medonca, J. (1991) A prospective study of patient assaults on nurses in
a provincial psychiatric hospital in Canada, Acta Psychiatrica Scandinavica, vol. 84,
pp. 163-166.
Cooper, S. J., Brown, F. W. A., McLean, K. J., & King, D. J. (1983) Aggressive
behaviour in a psychiatric observation ward, Acta Psychiatrica Scandinavica, 68(386393).
Corrigan, P.W., Yudofsky, S.C. & Silver, J.M. (1993) Pharmacological and
behavioral treatments for aggressive psychiatric inpatients. Hospital and Community
Psychiatry, 44, 125-133.
Cotton, P Drake, R Whitaker, A and Potter, J (1983) Dealing with suicide on a
psychiatric inpatient unit. Hospital and Community Psychiatry 34 (1):55-58.
Crammer, J. L. (1984) The special characteristics of suicide in hospital in-patients,
British Journal of Psychiatry, 145, pp. 460-463.
Crowhurst, N. & Bowers, L. (2006) Philosophy, care and treatment on the psychiatric
intensive care unit: themes, trends and future practice, Journal of Psychiatric and
Mental Health Nursing, 9:689-695.
Deacon, M. (2003) Caring for People in the 'virtual ward': The Practical
Ramifications for Acute Nursing Work. Journal of Psychiatric and Mental Health
Nursing 10:465-471.
Department of Health (1999) National service framework for mental health: modern
standards and service models. London: HMSO
246
Department of Health (2001) Five-year report of the National Confidential Inquiry
into Suicide and Homicide by people with mental illness. London: Department of
Health.
Department of Health (2002) Mental Health Policy Implementation Guide. Adult
Acute Inpatient Care Provision. London: Department of Health Publications.
Department of Health (2002). National Suicide Prevention Strategy for England.
London, Department of Health.
Department of Health (2003). Mental Health Policy Implementation Guide. Dual
Diagnosis Good Practice Guide. London: Department of Health.
Department of Health (2005). Delivering race equality in mental health care. An
action plan for reform inside and outside services. and The Government's response to
the independent inquiry into the death of David Bennett London: Department of
Health.
Department of Health (2002) National Minimum Standards for General Adult
Services in Psychiatric Intensive Care Units (PICU) and Low Secure Environments,
Department of Health, London,.
Department of Health. (2002). Mental Health Policy Implementation Guide:
Community Mental Health Teams. London: Department of Health Publications.
Depp, F. (1983) Assaults in a Public Mental Hospital, in Lion, J.and Reid, W.(Eds)
Assaults Within psychiatric Facilities.Orlando: Grune and Stratton.
Dernovsek, M., Novak-Grubic, V., Tavcar, R., & Zmitek, A. (2003) Psychiatric
intensive care units: Comment, Australian and New Zealand Journal of Psychiatry,
37(1)110.
Dix, R. (1995) A nurse led psychiatric intensive care unit, Psychiatric Bulletin, 19(5)
258-287.
Dodds P. and Bowles N. (2001) Dismantling formal observation and refocusing
nursing activity in acute inpatient psychiatry: a case study. Journal of Psychiatric and
Mental Health Nursing 8:183-188.
Dogget, A. M. (2004) A Statistical Comparison of Three Root Cause Analysis Tools.
Journal of Industrial Technology 20(2)2-9
Dolan, M. & Snowdon, P. (1994) Escapes from a medium secure unit, Journal of
Forensic Psychiatry, vol. 5(2).
Dooley, E. (1986) Aggressive incidents in a secure hospital, Medicine, Science and
the Law, 26:125-130.
Drury, V. Birchwood, M. Cochrane R., and Macmillan F. (1996a) Cognitive therapy
and recovery from acute psychosis: a controlled trial. I Impact on psychotic
symptoms. British Journal of Psychiatry 169, 593-601
Drury, V. Birchwood, M. Cochrane R., and Macmillan F. (1996b) Cognitive therapy
and recovery from acute psychosis: a controlled trial. II Impact on recovery time.
British Journal of Psychiatry 169, 602-607
Duff, L., Gray, R., & Brostor, F. (1996) The use of control and restraint techniques in
acute psychiatric units, Psychiatric Care, 3(6)230-234.
247
Erens, B., Primatesta, P., & Prior, G. (1999) Health Survey for England - The Health
of Minority Ethnic Groups '99, The Stationary Office, London.
Farragher, B., Gannon, M., & Ahmad, I. (1996) Absent without leave - can we predict
those who go AWOL?, Irish Journal of Psychological Medicine, 13(1)28-30.
Feinstein, A. & Holloway, F. (2002) Evaluating the use of a psychiatric intensive care
unit: Is ethnicity a risk factor for admission?, International Journal of Social
Psychiatry, 48(1)38-46.
Firth-Cozens, J. (1998). Celebrating teamwork. Quality in Health Care, 7(Suppl), S3S7.
Flannigan, C.B., Glover G.R., Wing, J.K., Lewis, S.W., Bebbington, P.E. and Feeney,
S.T. (1994) Inner London Collaborative Audit of Admission in Two Health Districts
III: Reasons for Acute Admission to Psychiatric Wards. British Journal of Psychiatry
165:750-759
Ford, I. & Whiffin, M. (1991) "The role of the psychiatric ICU", Nursing Times,
87(51) 47-49.
Ford, R., Durcan, G. & Warner, L. (1998) One day survey by the Mental Health Act
Commission of acute adult psychiatric inpatient wards in England and Wales. British
Medical Journal 317:1279-1283.
Fottrell, E., Bewley, T., & Sqizzoni, M. (1978). A Study of Aggressive and Violent
Behaviour Among a Group of psychiatric In Patients. Medicine, Science and the Law,
18(1)66-69.
Frey, B. & Argent, A. (2004) Safe paediatric intensive care. Part 2: workplace
organisation, critical incident monitoring and guidelines. Intensive Care Medicine
30(7)1292-7.
Garcia, I Kennett, C Quraishi, M and Durcan G. (2005) Acute Care 2004. A national
survey of adult psychiatric wards in England, London: Sainsbury Centre for Mental
Health.
Gertz, B. (1980) Training for Prevention of Assualtive Behaviour in a Psychiatric
Setting, Hospital and Commnity Psychiatry, 31(9)628-630.
Glover, G. (1997) The Mental Illness Needs Index. Epidemiologia Psichiatria Sociale
6(1 Suppl):13-20
Goldney, R. D. Spence, N. D. and Bowes, J. A. (1986) The safe use of high dose
neuroleptics in a psychiatric intensive care unit. Australian and New Zealand Journal
of Psychiatry 20 (3):370-375.
Gomez, E.A., Ruiz, P. & Langrod, J. (1980) Multidisciplinary team malfunctioning
on a state hospital unit: A case study. Hospital and Community Psychiatry, 31(1)3840
Goodwin, I. Holmes, G. Newnes, C. and Waltho, D. (1999) A qualitative analysis of
the view of in-patient mental health service users. Journal of Mental Health 8 (1):4354.
Gorman, P. (1998). Managing multi-disciplinary teams in the NHS. London: Kogan
Page.
248
Grassi, L., Peron, L., Marangoni, C., Zanchi, P., & Vanni, A. (2001) Characteristics
of violent behaviour in acute psychiatric inpatients: a 5 year Italian study, Acta
Psychiatrica Scandinavica, 104:273-279.
Greenberg, W. M., Otero, J., & Villanueva, L. (1994) Irregular discharges from a dual
diagnosis unit, American Journal of Drug and Alcohol abuse, 20(3)355-371.
Greengross, P., Hollander D. & Stanton, R. (1996) Pressure on adult acute psychiatric
beds. Results of a national questionnaire survey. Psychiatric Bulletin, 24: 54-56.
Gudjonsson, G. H., Rabe-Hesketh, S., & Wilson, C. (1999) Violent incidents on a
medium secure unit over a 17-year period, Journal of Forensic Psychiatry 10:249-263.
Hafner, R. J., Lammersma, R., Ferris, R., & Cameron, M. (1989) The use of
seclusion; a comparison of two psychiatric care units, Australian and New Zealand
Journal of Psychiatry, 23:235-239.
Hardwick, P. (2003) Formarrhoea. Psychiatric Bulletin 27: 388-389
Healthcare Commission (2005a) 2005 performance ratings for mental health trusts:
suicide rate. http://ratings2005.healthcarecommission.org.uk/home.asp
Healthcare Commission (2005b). National Audit of Violence (2003-2005). London,
Healthcare
Commission.
http://www.healthcarecommission.org.uk/assetRoot/04/01/74/51/04017451.pdf
Healthcare Commission 2005, Healthcare Commission NHS national staff survey
2004, summary of key findings, Commission for Healthcare Audit and Inspection,
London.
Herrman, H., Trauer, T., Warnock, J. & Professional Liaison Committee (Australia)
Project Team. (2003) The roles and relationships of psychiatrists and other service
providers in mental health services. Australian & New Zealand Journal of Psychiatry,
36(1), 75-80.
Hodgkinson, P., Hillis, T., & Russel, D. (1984) Assaults on Staff in psychiatric
Hospitals, Nursing Times, 80(18)44-46.
Home Office (2004) Statistics on Race and the Criminal Justice System 2004. A
Home Office publication under section 95 of the Criminal Justice Act 1991, Home
Office Research, Development and Statistics Directorate, London.
Home Office (2006) Ethnicity and drug use: key findings from the 2001/2002 British
Crime Survey. Findings 209, Home Office Research, Development and Statistics
Directorate, London.
Hunter, M. & Carmel, H. (1992). The cost of staff injuries from inpatient violence.
Hospital and Community Psychiatry, 43, 586-588.
Huxley, P., Reilly, S., Robinshaw, E., et al., (2003) Interventions and outcomes of
health and social care service provision for people with severe mental illness in
England. Social Psychiatry and Psychiatric Epidemiology, 38, 44-48.
Ionno, J. (1983) A Prospective Study of Assaultive Behaviour in Female Psychiatric
Inpatients, in Lion, J.and Reid, W.(Eds) Assaults Within psychiatric
Facilities.Orlando: Grune and Stratton., vol. 71-80.
249
Isaac, M., Isaac, M., & Holloway, F. (2005) Is cannabis an anti-psychotic? The
experience in psychiatric intensive care, Human Psychopharmacology: Clinical and
Experimental, vol. 20, no. 3, pp. 207-210.
James, D., Fineberg, N., Shah, A., & Priest, R. (1990). An Increase in Violence on an
Acute Psychiatric Ward: A Study of Associated Factors. British Journal of Psychiatry,
156: 846-852.
Johnson, S. and Thornicroft, G. (1997) Interpreting the evidence: conclusions and
possible solutions. In Johnson, S., Ramsay, R., Thornicroft, G. et al London’s Mental
Health. London: Kings Fund Publishing.
Joint Commission on the Accreditation of Healthcare Organizations (2005) Sentinel
Event Policy and Procedures. http://www.jcaho.org
Jones, J. R. (1985) The psychiatric intensive care unit, British Journal of Psychiatry,
146:561-562.
Kellam, S. G. Durell, J. and Shader, R. I. (1966) Nursing Staff Attitudes and the
Clinical Course of Psychotic Patients. Archives of General Psychiatry 14 (2):190-202.
Kemp, R. Hayward, P. Applewhaite, G. Everitt B., and David A. (1996) Compliance
therapy in psychotic patients: randomised controlled trial. British Medical Journal 312
(345)349
Kent, M. (2005) My Mental Health: Protected Therapeutic Time, Mental Health
Practice, 8(8)22.
Kernodle, R. W. (1966) Non medical leaves from a mental hospital, Psychiatry, 29:
25-41.
Kleis, L. S. & Stout, C. E. (1991) The high risk patient: A profile of acute care
psychiatric patients who leave without discharge, Psychiatric Hospital, 22(4)153-156.
Krakowski, M. & Czobor, P. (2004). Gender differences in violent behaviours:
relationship to clinical symptoms and Psychosocial factors. American Journal of
Psychiatry, 161, 459-465.
Lanza, M. L. (1988) Factors Relevant to Patient Assault. Issues in Mental Health
Nursing 9 (239):257.
Larkin, E., Silvester, M., & Jones, S. (1988) A Preliminary Study of Violent Incidents
in a Speical Hospital (Rampton), British Journal of Psychiatry, 153:226-231.
Leathard, A. (1994). Inter-professional developments in Britain: An overview. In A.
Leathard (Editor), Going Inter-Professional: Working together for health and welfare
(pp. 3-23). London: Routledge.
Liberman, R.P., Hilty, D.M., Drake, R.E, & Tsang, H.W. (2001) Requirements for
multi-disciplinary teamwork in psychiatric rehabilitation. Psychiatric Services, 52,
1331-1342.
Lion, J. R., Snyder, W., & Merrill, G. L. (1981). Under-reporting of assaults on staff
in a state hospital. Hospital and Community Psychiatry, 32, 497-498.
Little, J. (1992) Staff response to inpatient and outpatient suicide: What happened and
what do we do? Australian and New Zealand Journal of Psychiatry 26 (2):162-167.
Lutzen, K. & Schreiber, R. (1998) Moral survival in a nontherapeutic environment.
Issues in Mental Health Nursing, 19, 303-315.
250
Main. T. F. (1957) The Ailment. British Journal of Medical Psychiatry 30: 129-145.
Maltsberger J and Buie, D (1974) Countertransference hate in the treatment of
suicidal patients. Archives of General Psychiatry 30:625-633.
Marks, I M; Connolly, J; Muijen, M; Audini, B; et al. (1994) Home-based versus
hospital-based care for people with serious mental illness. British Journal of
Psychiatry. 165(2)179-194
Maslach & Jackson (1981). The Maslach Burnout Inventory. Palo Alto, CA:
Consulting Psychologists Press.
Meades, S. (1989) Integrative care planning in acute psychiatry. Journal of Advanced
Nursing, 14, 630-639.
Meehan J et al. (2006) Suicide in mental health in-patients and within 3 months of
discharge. British Journal of Psychiatry, 188: 129-134.
Mental Health Act Commission (2005) In Place of Fear? The eleventh biennial report
of the Mental Health Act Commission. London, The Stationery Office.
Mentality (2003) Not All in the Mind: The physical health of mental health service
users. Radical mentalities briefing paper 2. London: mentality
Miller, C., & Freeman, M. (2003). Clinical Teamwork: the impact of policy on
collaborative practice. In A. Leathard (Editor), Interprofessional Collaboration: From
Policy to Practice in Health and Social Care (pp. 121-132). London: Routledge.
Miller, C., Freeman, M., & Ross, N. (2001). Interprofessional Practice in Health and
Social Care: Challenging the shared learning agenda. London: Arnold.
MIND (2004) Ward watch: Mind’s campaign to improve hospital conditions for
mental health patients: report summary. London: MIND.
Mitchell, G. D. (1992) A survey of psychiatric intensive care units in Scotland, Health
Bulletin, 50:228-232.
Moos, R. H. (1974) Ward Atmosphere Scale Manual. Palo Alto, CA: Consulting
Psychologists Press
Morgan H. G. and Priest, P. (1991) Suicide and Other Unexpected Deaths among
Psychiatric In-patients: The Bristol Confidential Inquiry. British Journal of Psychiatry
158:368-374.
Morrison, E. F. (1992) A Coercive interactional style as an antecedent to aggression
in psychiatric patients. Research in Nursing and Health 15:421-431.
Morrison, E. F. (1990) The Tradition of Toughness: A Study of Nonprofessional
Nursing Care in Psychiatric Settings, Journal of Nursing Scholarship, 22(1)32-38.
Mortimer, A. (1995) Reducing Violence on a Secure Ward, Psychiatric Bulletin,
19:605-608.
Mulder, C., Koopmans, G., & Selten, J. (2006) Emergency psychiatry, compuslory
admissions and clinical presentation among immigrants to The Netherlands, British
Journal of Psychiatry, 188:386-391.
Murray, R. (2006) First onset of schizophrenia in 3 English cities. Paper presented at
the NIMHE Delivering Race Equality conference, Birmingham, 22nd February 2006.
251
National Institute for Clinical Execellence (2005). Clinical Guideline 25 Violence: the
short-term management of disturbed/violent behaviour in psychiatric inpatient settings
and emergency departments London: National Institute for Clinical Excellence.
National Institute for Mental Health in England (2004). Mental Health Policy
Implementation Guide. Developing Positive Practice to Support the Safe and
Therapeutic Management of Aggression and Violence in Mental Health In-patient
Settings Leeds: NIMHE, Department of Health.
National Patient Safety Agency (2006) National Reporting and Learning System.
http://www.npsa.nhs.uk
National Steering Group (2004). Guidance on New Ways of Working for Psychiatrists
in a Multi-disciplinary and Multi-agency Context: Interim Report. London:
Department of Health.
National Working Group on New Roles for Psychiatrists (2004) New Roles for
Psychiatrists. London: British Medical Association and the Department of Health
NCISH (2005) National Confidential Inquiry into Suicide and Homicide by people
with
mental
illness.
Annual
figures.
http://www.national-confidentialinquiry.ac.uk/_media/documents/word/SuicidefiguresRevNov05.doc
Needham I. (2004) A nursing intervention to handle patient aggression: the
effectiveness of a training course in the management of aggression, PhD, Maastricht
University.
Needham, I., Abderbalden, C., Halfens, R., Fischer, J., & Dassen, T. (2005). Nonsomatic effects of patient aggression on nurses: a systematic review. Journal of
Advanced Nursing 49(3)283-296
Needham, I., Abderhalden, C., Meer, R., Dassen, T., Haug, H., Halfens, R., &
Fischer, J. (2004) The effectiveness of two interventions in the management of patient
violence in acute mental inpatient settings: report on a pilot study, Journal of
Psychiatric and Mental Health Nursing, 11:595-601.
Needleman, J., Buerhaus, P., Mattke, S., Stewart, M., & Zelevinsky, K. (2002). Nurse
staffing levels and the quality of care in hospitals. New England Journal of Medicine,
346, 1715-1722.
Neilson T., Peet M., Ledsham R., & Poole J. (1996). Does the nursing care plan help
in the management of psychiatric risk? Journal of Advanced Nursing 24: 1201-1206.
NHS Executive (1999) Campaign to stop violence against staff working in the NHS:
NHS zero tolerance zone. HSC 1999/226
Nijman HLI, Palmstierna T, Almvik R, Stolker JJ. (2004) Fifteen years of research
with the Staff Observation Aggression Scale: a review. Acta Psychiatrica
Scandinavica 4:1–10.
Nijman, H. L. I. & a Campo, J. M. L. G. (2002) Situational Determinants of Inpatient
Self-Harm, Suicide and Life Threatening Behavior 32(2) Summer 2002: The
American Association of Suicidology, vol. 167-175.
Nijman, H., Allertz, W., Merckelbach, H., & Ravelli, D. (1997) Aggressive Behaviour
on an Acute Psychiatric Admissions Ward, European Journal of Psychiatry, 11(2)106114.
252
Nijman, H., Merckelbach, H., Evers, C., Palmstierna, T., & Campo, J. (2002).
Prediction of Aggression on a Locked Psychiatric Amission Ward. Acta
psychiatr.scand., 105:1-6.
Nijman, H.L.I., à Campo, J.M.L.G., Ravelli, D.P. & Merckelbach H.L.G.J. (1999) A
tentative model of aggression on inpatient psychiatric wards. Psychiatric Services, 50,
832-834.
Niskanen, P. (1974) Suicide in Helsinki psychiatric hospitals 1964-1972, Pschiatria
Fennica, vol. 1974; 275-280.
Noble, P. & Rodger, S. (1989) Violence by Psychiatric In-patients. British Journal of
Psychiatry, 155, 384-390.
Norman, I. J., & Peck, E. (1999). Working together in adult community mental health
services: An inter-professional dialogue . Journal of Mental Health, 8(3), 217-230.
Nuechterlein, K. H. & Dawon, M. E. (1984) A heuristic vulnerability/stress model of
schizophrenic episodes. Schizophrenia Bulletin 10:300-312.
Nyberg-Coles, M. (2005) Promoting safer and therapeutic services. Mental Health
Practice, 8(7)16-17.
O’Brien, A., Abas, M., Christensen, J., Nicholls, T., Le Proux, T. and Vanderpyl, J.
(2002) Nursing Workload Measurement in Acute Mental Health Inpatient Units.
Aukland, NZ: Health Research Council of New Zealand.
Onyett, S. (2002). Teamworking in mental health. London: Palgrave.
Owen, C., Tarantello, C., Jones, M., & Tennant, C. (1998) Violence and Aggression
in Psychiatric Units, Psychiatric Services, 49(11)1452-1456.
Parkes, J. (1996) Control and Restraint training: A Study of its Effectiveness in a
Medium Secure Psychiatric Unit", The Journal of Forensic Psychiatry, 7(3)525-534.
Parry-Jones, B., Grant, G., McGrath, M., Caldock, K., Ramcharan, & Robinson, C. A.
(1998). Stress and job satisfaction among social workers, community nurses and
community psychiatric nurses: implications for the care management model. Health
and Social Care in the Community, 6(4)271-285.
Paterson, B. Stark C. (2001) Social policy and mental illness in England in the 1990s:
violence, moral panic and critical discourse. Journal of Psychiatric and Mental Health
Nursing 8(3) 257-267
Paterson, B., Bradley, P., Stark, C., Saddler, D., Leadbetter, D., & Allen, D. (2003)
Deaths associated with restraint use in health and social care in the UK. The results of
a preliminary survey, Journal of Psychiatric and Mental Health Nursing, 10(1)3-15.
Pearson M, Wilmot E, & Padi M (1986). A study of violent behaviour among inpatients in a psychiatric hospital. British Journal of Psychiatry, 149: 232-235.
Pereira, S., Sarsam, S., Bhui K., & Paton, C. (2006) The London Survey of
Psychiatric Intensive Care Units: psychiatric intensive care; patient characteristics and
pathways for admission and discharge, Journal of Psychiatric Intensive Care, 1(1)1724.
Porter, S., McCann, I., & McGregor, A. (1998). Auditing Suicide Observation
Procedures. Psychiatric Care, 5(1)17-21.
253
Powell, J. Geddes, J. Deeks, J. and Goldacre, H. K. (2000) Suicide in Psychiatric
Hospital In-patients: Risk factors and their predictive power. British Journal of
Psychiatry 176:266-272.
Priebe, S; Fakhoury, W; Watts, J; Bebbington, P; Burns, T; Johnson, S; Muijen, M;
Ryrie, I; White, I; Wright, C. (2003). Assertive outreach teams in London: Patient
characteristics and outcomes: Pan-London Assertive Outreach Study, Part 3. British
Journal of Psychiatry. 183(2)148-154
Prins, H. C. (1993) Report of the Committee of Inquiry into the Death in Broadmoor
hospital of Orville Blackwood and a Review of the Deaths of Two Other Afro
Caribbean Patients, "Big, Black and Dangerous".
Proulx, F., Lesage, A. D., & Grunberg, F. (1997) One hundred in-patient suicides,
British Journal of Psychiatry, 171:247-250.
Quirk, A. & Lelliott, P. (2001) What do we know about life on acute psychiatric
wards in the UK? A review of the research evidence. Social Science and Medicine,
53:1565-1574.
Quirk, A., Lelliott, P. & Seale, C. (2004) Service users’ strategies for managing risk
in the volatile environment of an acute psychiatric ward. Social Science & Medicine,
59, 3573-2583.
Rasmussen, K. & Levander, S. (1996) Individual rather than situational characteristics
predict violence in a maximum security hospital, Journal of Interpersonal Violence,
11(3)376-390.
Richmond, I. Dandridge, L. and Jones, K. (1991) Changing nursing practice to
prevent elopement. Journal of Nursing Care Quality 6 (1):73-81.
Rix, G. & Seymour, D. (1988) Violent incidents on a regional secure unit, Journal of
Advanced Nursing, 13:746-751.
Robins, L. N. (1966) Deviant children grown up: a sociological and psychiatric study
of sociopathic personality Williams and Wilkins, Baltimore.
Rogers, A. Pilgrim, D. and Lacey. R. (1993) Experiencing Psychiatry: Users' Views
of Services. London: Macmillan.
Rooney, J. L. and Vanden Heuvel, L. N. (2004) Root Cause Analysis For Beginners.
Quality Progress, July, pp45-53
Royal College of Psychiatrists (2001). Roles and Responsibilities of a Consultant in
General Psychiatry: Council report. London: Royal College of Psychiatrists.
Ryan J and Poster E (1989) The assaulted nurse: Short-term and long-term responses.
Archives of Psychiatric Nursing 3 (6):323-331.
Ryan, C. J. & Bowers, L. (2005) Coercive manoeuvres in a psychiatric intensive care
unit, Journal of Psychiatric & Mental Health Nursing, 12(6)695-702.
Ryan, T. Hills, B. (2002). Nurse staffing levels in acute mental health wards.
Manchester, North West Mental Health Development Centre
Sailas, E. & Fenton, M. (2005) Seclusion and restraint for people with serious mental
illnesses Cochrane Review 1.
Sainsbury Centre for Mental Health (1998) Acute Problems: a survey of the quality of
care in acute psychiatric wards. London: Sainsbury Centre for Mental Health.
254
Sainsbury Centre for Mental Health (2000). Finding and Keeping. Review of
Recruitment and Retention in the Mental Health Workforce. London: Sainsbury
Centre for Mental Health.
Saverimuttu, A. (1996) Starting from Scratch, Nursing Standard, 10(34)26-27.
Shah, A. (1997) Inpatient suicides in an Australian mental hospital", Australian and
New Zealand Journal of Psychiatry, 31:291-298.
Sheppard, D. (1996). Learning the Lessons London: The Zito Trust.
Simmons, S., Coid, J., Joseph, P., Marriott, S. & Tyrer, P. (2001) Community mental
health team management in severe mental illness: a systematic review. British Journal
of Psychiatry, 178, 497-502.
Simpson, A. (2004) Care co-ordination for people with severe mental illness.
Unpublished PhD. University of Brighton, Brighton.
Simpson, A., Bowers, L., Alexander, J., Ridley, C., & Warren, J. Occupational
Therapy and Multidisciplinary Working on Acute Psychiatric Wards: The Tompkins
Acute Ward Study. British Journal of Occupational Therapy 68[12], 545-552. 2005.
Simpson, A., Miller, C. and Bowers, L. (2003) The History of the Care Programme
Approach in England: Where did it go wrong? Journal of Mental Health 12(5)489-504
Singh, S., Croudace, T., Beck, A., & Harrison, G. (1998) Perceived ethnicity and the
risk of compulsory admission, Social Psychiatry & Psychiatric Epidemiology, 33:3944.
Smith, P., Sheldon, T., & Martin, S. (1996). An index of need for psychiatric services
based on in-patient utilisation. British Journal of Psychiatry, 169:308-316.
Soliman, A. & Reza, H. (2001) Risk factors and correlates of violence among acutely
ill adult psychiatric inpatients, Psychiatric Services, 52(1)75-80.
Sommer, G. (1974) A short term study of elopement from a state mental hospital,
Journal of Community Psychology, 2:60-62.
St.Thomas Psychiatric Hospital (1976) A program for the prevention and
management of disturbed behaviour, Hospital and Community Psychiatry, 27:724727.
Standing Nursing and Midwifery Advisory Committee (1999) Mental Health Nursing:
Addressing Acute Concerns. London: SNMAC, Department of Health.
Stein, L. (1978). The doctor-nurse game. In R. Dingwall, & J. McIntosh (editors),
Readings in the sociology of nursing (pp. 107-117). London: Churchill Livingstone.
Stockman, C. L. J. & Heiber, P. (1980) Incidents in hospitalised forensic patients,
Victimology 5:175-192.
Sundqvist-Stensman, U. B. (1987) Suicides in close connnection with psychiatric
care: An analysis of 57 cases in a Swedish county, Acta Psychiatrica Scandinavica,
76:15-20.
Swindall, L. E. & Molnar, G. (1985) Open doors and runaway patients: A
management dilema, Perspectives in psychiatric nursing, vol. 23(4)146-149.
Tam, E., Engelsmann, F., & Fugere, R. (1996) Patterns of violent incidents by
patients in a general hospital psychiatric facility", Psychiatric Services, 47(1) 86-88.
255
Thompson, A., Shaw, M., Harrison, G., Verne, J., Ho, D., & Gunnell, D. (2004).
Patterns of hospital admission for adult psychiatric illness in England: analysis of
Hospital Episode Statistics data. British Journal of Psychiatry, 185, 334-341.
Turns D and Gruenberg, E (1973) An attendant is murdered: The state hospital
responds. Psychiatric Quarterly 47 (4):487-494.
van Rixtel, A., Nijman, H., & Jansen, G. (1997) Agressie en Psychiatrie. Heeft
training effect? [Aggression and psychiatry. Does training have any effect].,
Verpleegkunde, 12:111-119.
Vittengl, J. R. (2002) Temporal regularities in physical control at a state psychiatric
hospital. Archives of Psychiatric Nursing 16(2)80-85
Vogel R and Wolfersdorf, M (1987) Staff response to the suicide of psychiatric
inpatients. The Journal of Crisis Intervention and Suicide Prevention 8 (2):178-184.
Walker, Z., Seifert, R., & Walker, Z. (1994) Violent Incidents in a Psychiatric
Intensive Care Unit, British Journal of Psychiatry, 164: 826-828.
Walsh, E., Rooney, S., Sloan, D., McCauley, P., Mulvaney, F., O'Callaghan, E., &
Larkin, C. (1998) Irish Psychiatric Absconders: characteristics and outcome,
Psychiatric Bulletin, 22:351-353.
Walton. P. (2000) Psychiatric hospital care-a case of the more things change, the more
they stay the same. Journal of Mental Health 9 (1):77-88.
Warner, L. (2005) Acute Care in Crisis. Chapter in Bell, A. & Lindley, P. (Eds)
Beyond the Water Towers: The unfinished revolution in mental health services, 19852005. London, Sainsbury Centre for Mental Health. p37-48.
Wells, J. S. G. (1995). Discontent without focus? An analysis of nurse management
and activity on a psychiatric in-patient facility using a 'soft systems' approach. Journal
of Advanced Nursing, 21: 214-221.
Wesson, M L; Walmsley, P. (2001) Service innovations: Sherbrook partial
hospitalisation unit. Psychiatric Bulletin. 25(2)56-58
West, D. J. (1982) Delinquency. its roots, careers and prospects Heinemann
Educational Books, London.
West, M. (1999). Communication and teamworking in healthcare. NTresearch, 4(1),
8-17.
West, M. A., & Poulton, B. C. (1997). A failure of function: teamwork in primary
health care. Journal of Interprofessional Care, 11(2), 205-216.
Wicks, D. (1998) Nurses and Doctors at Work: Rethinking professional boundaries.
Buckingham, Open University Press.
Woloshynowych M, Rogers S, Taylor-Adams S, Vincent C. (2005) The investigation
and analysis of critical incidents and adverse events in healthcare. Health Technology
Assessment 9(19).
Wright, S. (1999) Physical restraint in the management of violence and aggression in
in-patient settings: A review of issues, Journal of Mental Health, 8(5)459-472.
Zeiss, R.A. (1997) Interdisciplinary treatment and training issues in the acute inpatient
psychiatry unit. Journal of Interprofessional Care, 11(3)279-286.
256
APPENDICES
APPENDIX 1: Operational Philosophy and Policy Interview (OPPI)
Baseline version
Explain nature of the study. Give information sheet and get consent. Check tape
recorder working and sound levels adequate. Complete staff profile form.
1. Could you please describe the nature of the sector you work in?
Prompts:
What kind of place generally?
Particular social features impacting on psychiatry, e.g. Hostels, particular populations,
refugees, particular estates?
I'd now like to ask for your thoughts on the role of inpatient care in psychiatry and the
way you practice
2. What do you consider to be the type of cases that are a priority for admission?
Prompts:
What are the usual reasons you admit someone to your ward?
What are the main psychiatric conditions you treat there?
What are the main treatments offered on your ward?
Do you treat drug or alcohol problems with inpatient care?
How much is dual diagnosis (substance use and psychosis) an issue on your ward?
Do you admit people with a personality disorder? What are your thoughts and
preferences about that?
How do you deal with extremely demanding or violent individuals on the ward?
How do you deal with people who self-harm?
How do you manage absconding?
257
What do you consider to be the key indicators that a patient is ready for discharge?
Any other thoughts or comments on the role of acute admission psychiatry?
3. What do you see as the role of the nursing team in inpatient treatment?
Prompts:
Daily living care?
Carrying out treatment orders?
Observing and reporting?
Keeping patients safe?
Rehabilitation?
Other?
(Do not accept simple yes or no answers. Ask for more details.)
4. What do you see as the team’s strengths and weaknesses?
Prompts:
Are there things that work particularly well?
What would you like to see improve?
5. What do you see as the role of the medical team in inpatient treatment?
Prompts:
Admission and discharge decisions?
Treatment orders?
Monitoring progress?
Other?
(Do not accept simple yes or no answers. Ask for more details.)
6. Are there any other professions involved in the treatment of patients on your ward?
If so, what is their contribution?
Prompts:
Are there any professions/workers you would like to see working on
the ward?
7. What is your assessment of your ward's strengths and weaknesses?
Prompts:
Mmm. Yes. Can you tell me a bit more?
258
What would you like to see improve?
What aspects would you like to see done away with?
8. How would you describe the relationship between the nursing team and the other
staff on this ward?
Prompts:
Any particular difficulties?
What aspects of multi-disciplinary collaboration work well?
Can you say more about that?
9. What is your assessment of your consultant's strengths and weaknesses? (If more
than one, ask for an assessment of each separately)
Prompts:
Mmm. Yes. Can you tell me a bit more?
10. Do you work with more than one consultant on your ward? If so, how do you
make that work?
Prompts:
Pressures for beds for admission?
Differences over philosophy of inpatient care?
Different expectations on the nurses?
Different treatment practices?
9. Do you have any plans to change any aspect of the way you and your ward operate
with respect to inpatient care, over the coming year? If so, what are those aspirations
or plans?
Prompts:
Mmm. Yes. Can you tell me a bit more?
Many thanks for your time in participating in this interview. We will be coming back
to you periodically in the future to ask you how things are progressing and what
changes have occurred, and we hope you will agree to speak to us again.
259
Follow up version
Describe study, give information sheet and secure consent. Remind them that the
interview will remain anonymous and confidential. No names of wards or people will
be used. Check tape recorder working and sound levels adequate.
We would just like to catch up on any changes that have been happening on the ward
since we last interviewed you/the last ward manager in [INSERT DATE].
A1. Have there been any changes in personnel?
Please ask each of the following:
Nursing staff?
Consultants? Junior doctors?
Occupational therapists
Any other key personnel?
Any periods of 'acting up' or locums - for who?
Any changes in senior line management?
Any lengthy sickness – who?
Important: Obtain dates of all changes - accurate to calendar month.
A2. Have there been any changes in the community services?
Please ask each of the following:
Any new services like assertive outreach or home treatment teams?
Any changes in the CMHTs or how they relate to the ward?
Any staff changes in those teams?
Important: Obtain dates of changes - accurate to calendar month.
A3. Have there been any changes in the catchment area or locality that you serve?
Please ask each of the following:
260
Any boundary changes?
Any changes in the population?
Any changes in the ethnic mix?
A4. Have there been any changes to the ward profile?
Please ask each of the following:
New location?
Bed numbers?
Staffing establishment?
Structure of the ward team? [Changes in pay/grade?]
Redecoration? Refurbishment? New furniture?
Important: Obtain dates of all changes - accurate to calendar month.
A5. Has any member of the team attended any training (courses or conferences)?
Remind interviewee of the time frame we are talking about.
Prompt:
Ward manager, Nursing team, OT, Consultant?
Important: Obtain dates of any training - accurate to calendar month.
A6. Have there been any changes in ward policy?
Please ask each of the following. If any positive responses, please follow-up with
‘When was that and what impact has that had?’
Any changes in ward rules?
Any changes in ward policies on admission, treatment, patient management, or
discharge?
Changes in the methods of working in the team?
Any changes in Trust policy or any new initiatives?
Any changes or new national/Government policies?
261
Important: Obtain dates of changes - accurate to calendar month.
A7. What has been happening to the social dynamics of the ward team?
Please ask each of the following. If any positive responses, please follow-up with
‘When was that and what impact did that have?’
Any social events?
Any staff or team tensions or difficulties?
Any suspensions, disciplinaries, formal complaints?
Team relationships?
Team member events (e.g serious sickness, major life events, weddings)?
Important: Obtain dates of changes - accurate to calendar month.
A8. Have there been any major incidents in that have had an impact?
Please ask each of the following:
Any self-harm or suicide attempts?
Any major violence against staff or other patients?
Drug problems?
Any police involvement?
Any crises of any sort?
Important: Obtain dates of changes - accurate to calendar month.
We have almost finished now.
A9. Have there been any specifically influential people on the ward in that time?
Prompts:
Any particular patients (e.g. very difficult patient in some way)
Staff?
If any positive responses, please follow-up with ‘When was that and what impact did
they have?’ Important: Obtain dates of episodes - accurate to calendar month.
262
A10. Is there anything else I haven’t mentioned that you may have expected me to ask
or you would like to mention?
Prompts:
Nothing else important that has happened that has had a big impact?
Thank you for very much. That was really helpful.
263
APPENDIX 2: Patient-staff Conflict Checklist – Shift Report (PCC-SR)
TAWS
Patient-staff Conflict Checklist- shift report
Please complete in blue or black biro. Keep text in the boxes. Tick the boxes that apply. If you make a mistake, cross
it out and tick the correct box. Please complete both sides of this questionnaire carefully and accurately at the end of
each shift. THANK YOU from the Tompkins Acute Ward Study research team.
Q1
Date (dd/mm/yy, e.g. 25/12/04)
Q3
Shift
AM ...........
Q2
PM ...........
Night ........
Number of staff at start of shift
0
1
2
3
4
5
Qualified
Unqualified
Q4
Main ward door locked to patients leaving?
Bank/agency qual
More than
3 hours.....
Student nurses
Q5
Less than
1 hour ......
Whole
shift ..........
Not at all...
Bank/agency unqual
1-3
hours........
How many incidents of aggression to self or others have there been during the shift?
0
1
2
3
4
5
6
7
8
9
10
>
7
8
9
10
>
7
8
9
10
>
7
8
9
10
>
9
10
>
Verbal aggression.........................................................
Physical aggression against objects .............................
Physical aggression against others...............................
Physical aggression towards self ..................................
Suicide attempt ............................................................
Q6
How many incidents of general rule breaking have there been during the shift?
0
1
2
3
4
5
6
Smoking in a no smoking area .....................................
Refusing to eat .............................................................
Refusing to drink ..........................................................
Refusing to attend to personal hygiene .........................
Refusing to get up and out of bed .................................
Refusing to go to bed ...................................................
Refusing to see workers ...............................................
Q7
How many incidents of drug or alcohol use have there been during the shift?
0
1
2
3
4
5
6
Alcohol use (suspected or confirmed)
Other substance misuse (suspected or confirmed)........
Q8
How many incidents of absconding behaviour have there been during the shift?
0
1
2
3
4
5
6
Attempting to abscond..................................................
Absconding (missing without permission) .....................
Absconding (official report) ...........................................
Q9
How many incidents of medication related behaviours have there been during the shift?
0
1
2
3
4
5
6
7
8
Refused regular medication ..........................................
Refused PRN medication..............................................
Demanding PRN medication.........................................
264
PLEASE TURN OVER AND COMPLETE THE OTHER SIDE! THANK YOU.
Q10 How many uses of these containment measures have there been during the shift?
0
1
2
3
4
5
6
7
8
9
10
>
Given PRN medication (psychotropic) ..........................
Given IM medication (enforced) ....................................
Sent to PICU or ICA .....................................................
Seclusion .....................................................................
Special observation (intermittent)..................................
Special observation (continuous) ..................................
Show of force ...............................................................
Physically restrained.....................................................
Time out.......................................................................
Q11 [Office use only] Research number
0
1
2
3
4
5
6
7
8
9
First digit
Second digit
265
APPENDIX 3: Attitude to Personality Disorder Questionnaire (APDQ)
Attitude to Personality Disorder Questionnaire
Please do not write your name on this form. Your responses will be kept anonymous. First, please tell us a few basic
things about yourself
Q1
Your age in years?
Under 20
Q2
20 - 29 ...
30 - 39 ...
50 - 59 ...
60 or
over .......
Your gender
Male...................................................................
Q3
40 - 49 ...
Female...............................................................
Your discipline/occupation
Nurse....................
Social Worker .......
Psychologiist.........
Psychiatrist ...........
Occ. Therapist ......
Prison Officer........
Health Care Asst...
Now please take a moment to reflect upon your experience of working with people with personality disorder (PD).By
PD we mean personality disorder by any commonly used diagnostic system, including PD combined with other
conditions, e.g. Learning Disability, Schizophrenia, etc. We recognise that PD patients vary a lot, but these difficult
people do exist and we do have to manage and treat them. The behaviours typical of PD people are impulsive,
histrionic, antisocial, immature and paranoid. For the purposes of this questionnaire we would like you to think about
your feelings towards PD patients overall. We realise that you may have different mixtures of feelings about different
PD patients you have come across in the past. For this questionnaire we would like to you try and average those out
and tell us what your responses are in general towards PD people as a whole.
For each response listed below please indicate the frequency of your feelings towards people with a personality
disorder. Please circle your choice quickly, rather than spending a long time considering it. We want to know your
honest, gut feelings
Never
Seldom
Occasio
nally
Often
Very
often
Always
I like PD people ..............................................................................
I feel frustrated with PD people ......................................................
I feel drained by PD people ............................................................
I feel fondness and affection for PD people ....................................
I feel vulnerable in PD people's company .......................................
I have a feeling of closeness with PD people..................................
I feel manipularted or used by PD people .......................................
I feel uncomfortable of uneasy with PD people ...............................
I feel I am wasting my time with PD people ....................................
I am excited to work with PD people...............................................
I feel pessimistic about PD people..................................................
I feel resigned about PD people .....................................................
I admire PD people ........................................................................
I feel helpless in relation to PD people............................................
Please turn over aqnd complete the other side.
266
Never
Seldom
Occasio
nally
Very
often
Often
Always
I feel frightened of PD people .........................................................
I feel angry towards PD people.......................................................
Interacting with PD people makes me shudder ...............................
PD people make me feel irritated ...................................................
I feel warm and caring towards PD people .....................................
I feel protective towards PD people ................................................
I feel oppressed or doiminated by PD people..................................
I feel that PD people are alien, other, strange.................................
I feel understanding towards PD people .........................................
I feel powerless in the presence of PD people ................................
I feel outmanoeuvered by PD people..............................................
Caring for PD people makes me feel satisfied and fulfilled..............
I feel exploited by PD people ..........................................................
I feel patient when caring for PD people .........................................
I feel able to help PD people ..........................................................
I feel interested in PD people .........................................................
I feel unable to gain control of the situation with PD people ............
I feel intolerant. I have difficulty tolerating PD people's behaviour ...
Q6
[Office use only] Research centre
Q7
[Office use only] Research number
0
North ................................................................
Central .............................................................
First digit...........
South ...............................................................
Second digit......
1
2
3
4
5
6
7
8
9
267
APPENDIX 4: Ward Structure Questionnaire (WSQ)
Ward Structure Questionnaire (City Nurses project)
We’d like to know what the structure on your ward is like. Please read each statement carefully, and decide
to what extent or with what frequency it occurs on your ward, then tick the box that applies. Please rate
what actually happens on your ward. It is important that you complete this questionnaire by yourself,
without conferring with others or trying to find out what their answers are. When the questionnaire is
complete you may discuss it with others. Please be accurate and honest in your answers. Please try to
answer all the questions. Thank you for your co-operation.
Q1
Q2
Ward ID
Q3
Your age in years?
Ward 1 .....
Ward 3 .....
Ward 5 .....
Under 20 ..
30 - 39......
50 - 59......
Ward 2 .....
Ward 4 .....
Ward 6 .....
20 - 29......
40 - 49......
60 or over.
+Date (dd/mm/yy, e.g. 25/12/04)
Q4
Your gender
Male .........
Q5
Female .....
GENERAL RULES. On my ward .....
Never
Seldom
Occasio
nally
Often
Very
often
Always
Seldom
Occasio
nally
Often
Very
often
Always
The ward exit is locked during the day..................................
Swearing is not allowed. ......................................................
Patients are allowed to have lighters/matches......................
On admission, patients' bags are opened and checked ..... ..
On admission, patients' pockets are emptied and
searched .............................................................................
Patients must bath/shower at least weekly ...........................
Patients can take a bath without supervision ........................
Patients must wear clean clothes .........................................
Patients are expected to change into night attire on going
to bed ..................................................................................
Q6
COMMUNICATION AND TEAMWORK. On my ward .....
Never
Patients are given written material specifying the rules.........
Newly admitted patients are told about the rules ..................
All patients on this ward know what the rules are .................
All staff on this ward know what the rules are.......................
Patients who break the rules know what will happen to
them ....................................................................................
Rules are formulated by the multidisciplinary team ...............
There are guidelines and boundaries that everybody sticks
to .........................................................................................
The ward nursing team decides on new rules after
discussion............................................................................
268
Q7
ROUTINE AND ACTIVITIES. On my ward .....
Never
Seldom
Occasio
nally
Often
Very
often
Always
Seldom
Occasio
nally
Often
Very
often
Always
Seldom
Occasio
nally
Often
Very
often
Always
Patients have to be up at a set time during the week............
The ward lights are turned off at a set time at night ..............
The majority of patients follow a regular schedule each
day.......................................................................................
There are organised activities for patients on the ward.........
Staff work hard to persuade patients to engage in
activities...............................................................................
Patients attend a programme of activities off the ward .........
There are no organised activities for patients .......................
Nursing staff organise activities for patients .........................
Activities on the ward are well attended ...............................
Things are very disorganised ...............................................
Patients have to be in bed by a set time during the week .....
Q8
RELATIONSHIPS AROUND RULES. On my ward ......
Never
Patients get full explanations of why rules exist ...... .............
Patients opinions and feedback about the rules are heard
by staff .................................................................................
Nurses openly admit when they make mistakes about the
rules.....................................................................................
Patients are informed how to complain about the rules.........
Staff believe patients should just obey the rules ...................
Staff cosider patients too ill to understand the reasons for
rules.....................................................................................
Staff listen to patients concerns about the rules ...................
Q9
RULE BREAKING. On my ward ......
Never
Confrontations about rules with aggressive patients are
avoided ...... .........................................................................
Staff give patients honest feedback about their own
reactions to the patient's behaviour. .....................................
Staff don't hide behind technical psychiatric jargon...............
Staff stand their ground with patients ...................................
Nurses are willing to confront patients about their
behaviour and its effects ......................................................
Staff give way to prevent complications................................
Explain the reason for the rule..............................................
Ignore the patient until the rule is complied with ...................
Reprimand the patient for breaking the rules ........................
Issue commands like policemen...........................................
Quietly but assertively confront the patient ...........................
THANK YOU FOR COMPLETING THIS QUESTIONNAIRE
269
APPENDIX 5: Patients' Perception of Staff Interview (PPSI)
Explain nature of the study. Give information sheet and get consent. Check tape
recorder working and sound levels adequate.
The purpose of this project is to discover how psychiatric wards change over time.
We are particularly interested in variation in conflict rates - things like absconding,
violence, verbal abuse etc. - and would like to find out more about the factors that
influence them.
So, I will ask you about some of your experiences on the ward. But first, could I ask a
few questions about you?
P1. Male/Female?
P2. How old are you?
P3. How would you describe your ethnicity?
P4. How long have you been on this ward?
P5. Is this your first admission to a psychiatric hospital?
Thank you. Now I will ask you about your experiences on the ward.
About the ward (effective structure)
Q1 How would you describe your typical day on this ward/in this unit?
Prompts: What sort of time do you get up? What happens next?
Q2. What kind of things are you not allowed to do or have on this ward/in this unit?
Prompts: Can you leave when you want?
Can you bring anything you want on to the ward?
Q3. Who told you about these rules?
270
Prompts: Were you told when you were admitted or later? Who by?
Q4. Have you been given any written information about the ward?
Prompts: Have you received ‘welcome pack’ or leaflet about the ward?
Q5. What happens to a patient if they break the rules?
Prompts: What are the consequences of rule breaking?
Q6. Is this the same for all patients?
Prompts: Do some patients get treated differently?
Q7. How do members of staff make sure the rules are kept to?
Prompts: How do they make sure that patients follow the rules?
Q8. Is that all staff or just some?
Prompts: Do they all treat the rules in the same way?
Q9. Is it affected by who is in charge of the shift?
Prompts: Do different charge nurses do things differently?
Q10. Do all members of staff behave fairly in implementing these rules?
Prompts: Do they treat all patients the same?
Q11. What sort of reasons do staff give for the rules on the ward?
Prompts: Do they explain why the rules are necessary?
Q12. If a patient breaks any of the rules who tells them that they have done so?
Prompts: Is it more likely to be staff or other patients?
Q13. Are the rules different at night and/or at weekends?
Prompts: Are rules treated differently at nights or weekends?
Do you know why there are changes in the rules at night?
Q14. Finally, on this part, do you think rules are necessary?
Prompt: What do you like/not like about particular rules?
What would it be like if there were no rules?
271
Thank you. We are about half way. Would you like a short break or are you Ok to
continue?
I will now ask you about how members of staff work with patients on the ward.
How members of staff work with patients on the ward (emotional self-regulation
Q15. How do members of staff spend their time on the ward?
Prompts: What do you see them doing?
Q16. Do you think staff enjoy their work?
Prompts: How do you think the staff feel about their work?
Q17. Do all members of staff spend some time with patients?
Prompts: Do some staff spend more time with patients than others?
Q18. What do the members of staff do when they are in the areas on the ward with
patients?
Prompts: Do they interact with patients or do other things?
Q19. What kind of meetings are there where staff and patients talk together?
Prompts: Are there any weekly ward or community meetings
Q20. How do the ideas/issues raised by patients at these meetings get followed up?
Prompts: Are things acted on? How do you know if things are
addressed?
Q21. Do you feel that the staff listen to patients?
Prompts: Can you give me an example of where staff did or did not
listen to patients?
Q22. What frustrates patients the most?
Prompts: Are there any particular things that the patients feel really
annoyed about?
Q23. When a member of staff is trying to attract your attention how do they do so?
272
Prompts: Would they approach you directly or call out? Would they use
your name?
Q24. What do you think staff members generally think or feel about the patients?
Prompts: What sort of attitudes do they display towards patients?
Q25. Do you think the staff are interested in patients as people?
Prompts: What do they do to make people think this?
Q26. Do you feel that staff respect the multi-cultural nature of the patients on this
ward?
Prompts: How are people with different cultural needs treated?
Can you give me some examples?
Q27. Finally, if you could change one thing about the staff on this ward, what would
it be?
Q28. Is there anything you would like to add that you think we should have asked you
about?
Thank you very much for your time. That was very helpful.
273
APPENDIX 6: Confidentiality guidelines, 2/1/04
This research project poses particular challenges for us to keep faith with the promises
of confidentiality we have given to interviewees, because all of the research team
have relationships with the operational arms of XXXMHT. As a team we have
discussed this several times, and the outcomes of those discussions are summarised in
this document.
The maintenance of confidentiality in relation to this project can be thought about in
terms of knowledge and practice at four levels: the operational research lead, the core
research team, the wider research team and all collaborators, and public material.
The operational research lead
This is the person actively managerially in charge of the day to day running of the
project (currently Alan Simpson). They alone will have access to a record of which
ward is which, and to the true identities of interviewees. All the rest of us will talk
about the wards using pseudonyms at all times, to help us separate the research data
from our regular dealings with the wards on other projects and issues.
The core research team
Consisting of the operational research lead, the principal investigator, and the project
research assistant. Will have access to full interview transcripts which have had
names replaced with pseudonyms, and whose files are named in accordance with the
274
agreed pseudonyms. Any printed transcripts must be treated as confidential, and
shredded after use.
The wider research team and all collaborators
Only digested issues will be discussed, no names and no specific events will be
mentioned in an identifiable format. Original interview transcripts will not be shared.
Coded extracts only, with names removed, may be discussed. SUIs will only be
identified as three types, suicide, homicide or abscond. No identifying features will be
shared. Only pseudonyms will be used in team discussions about wards and
personnel. Quantitative material to be freely shared and discussed in the team, but not
to be discussed outside the team until formally released to Trust staff. And any graphs
etc., must go to the wards at the same time as they go to managers. Even in this case,
it would be better for the team to identify wards using the pseudonyms, and the only
accurately named materials to go to the Trust.
Publications and reports
Great care to be taken in publication and at conferences to disguise true identities, and
the true detailed nature of events. Late publication, so things become history before
they appear in print, and are thus neutralised.
Other issues
275
Other contacts with the Trust (e.g. formal committee meetings) are not data collection
for the project, and must not be used as such, as informed consent has not been given.
276