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Articles   |    
Correlation Between Levels of Conflict and Containment on Acute Psychiatric Wards: The City-128 Study
Len Bowers, R.M.N., Ph.D.; Duncan Stewart, B.A., Ph.D.; Chris Papadopoulos, B.Sc., Ph.D.; Joanne DeSanto Iennaco, Ph.D., A.P.R.N.
Psychiatric Services 2013; doi: 10.1176/appi.ps.201200328
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Dr. Bowers and Dr. Stewart are affiliated with the Department of Health Service and Population Research, Institute of Psychiatry, King’s College London, 16 De Crespigny Park, London SE5 8AF, United Kingdom (e-mail: len.bowers@kcl.ac.uk).
Dr. Papadopoulos is with the Institute for Health Research, University of Bedfordshire, Bedfordshire, United Kingdom.
Dr. Iennaco is with the Yale School of Nursing, New Haven, Connecticut.

Copyright © 2013 by the American Psychiatric Association

Abstract

Objective  Attainment of safe, calm inpatient psychiatric wards that are conducive to positive therapeutic care is crucial. On such wards, rates of coerced medication, seclusion, manual restraint and other types of containment are comparatively low, and, usually, rates of conflict—for example, aggression, substance use, and absconding—are also low. Sometimes, however, wards maintain low rates of containment even when conflict rates are high. This study investigated wards with the counterintuitive combination of low containment and high conflict or high containment and low conflict.

Methods  The authors conducted a secondary analysis of cross-sectional data collected from 136 acute psychiatric wards across England in 2004–2005. The wards were categorized into four groups on the basis of median splits of containment and conflict rates: high conflict and high containment, high conflict and low containment, low conflict and low containment, and low conflict and high containment. Features significantly associated with these ward types were identified.

Results  Among the variables significantly associated with the various typologies, some—for example, environmental quality—were changeable, and others—such as social deprivation of the area served—were fixed. High-conflict, low-containment wards had higher rates of male staff and lower-quality environments than other wards. Low-conflict, high-containment wards had higher numbers of beds. High-conflict, high-containment wards utilized more temporary staff as well as more unqualified staff. No overall differences were associated with low-conflict, low-containment wards.

Conclusions  Wards can make positive changes to achieve a low-containment, nonpunitive culture, even when rates of patient conflict are high.

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Figure 1 Scattergram of 136 acute psychiatric wards, by mean daily incidents of conflict and containmenta

a The rates of conflict and containment reflect standardization of ward size to 20 beds. Lines dividing the four quadrants represent median rates.

Figure 2 Results of multivariate analysis comparing acute psychiatric wards, by rates of conflict and containmenta

a Variables (in bold) in subquadrant 1.1 were significantly different in high-conflict, low-containment wards than in high-conflict, high-containment wards (subquadrant 1.2), low-conflict, low-containment wards (1.3), and low-conflict, high-containment wards (1.4). Variables that appear in more than one subquadrant are italicized.

b Compared with high-conflict, high-containment and low-conflict, low-containment wards (p<.001) wards and with low-conflict, high-containment wards (p<.05)

c Compared with high-conflict, high-containment wards (p<.01), low-conflict, low-containment wards (p<.001) wards, and low-conflict, high-containment wards (p<.05)

d Compared with low-conflict, low-containment wards (p<.01) and with low-conflict, high-containment and high-conflict, low-containment wards (p<.001)

e Compared with low-conflict, high-containment and low-conflict, low-containment wards (p<.001) and with high-conflict, low-containment wards (p<.01)

f Compared with high-conflict, low-containment and low-conflict, low-containment wards (p<.05) and with high-conflict, high-containment wards (p<.001)

*p<.05, **p<.01, ***p<.001

Figure 3 Mean daily rates of conflict on 136 acute psychiatric wards, by ward categorya

a Wards were categorized by rates of conflict and containment.

Figure 4 Mean daily rates of containment on 136 acute psychiatric wards, by ward categorya

a Wards were categorized by rates of conflict and containment.

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Table 1Characteristics of 136 acute psychiatric wards, by rates of conflict and containment, in percentagesa
Table Footer Note

a The rates of conflict and containment reflect standardization of ward size to 20 beds.

Table Footer Note

b df=3 and 132

Table Footer Note

c Possible scores range from 19 to 49, with higher scores indicating a better environment.

Table Footer Note

d Measures social deprivation of the area sharing a postal code with the ward; possible scores range from 0 to 100, with higher scores indicating greater deprivation.

Table Footer Note

e Measures social fragmentation and is expressed as a z score; 95% of scores are between ±1.96, with higher scores indicating greater fragmentation.

Table Footer Note

f Measured by the Ward Atmosphere Scale; possible scores range from 0 to 10, with higher scores indicating more order and organization or program clarity.

Table Footer Note

g Measured by the Multifactor Leadership Questionnaire; possible scores range from 0 to 16, with higher scores indicating more transactional leadership.

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