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Association Between Staff Factors and Levels of Conflict and Containment on Acute Psychiatric Wards in England

Dr. Bowers is affiliated with the Department of Mental Health and Learning Disability, City University, Philpot St., Whitechapel, London E1 2EA, United Kingdom (e-mail: l.bowers{at}city.ac.uk).

OBJECTIVE: Conflict (for example, aggression, substance use, and absconding) threatens the safety of patients and staff, and containment use (for example, coerced medication, special observation, and manual restraint) arouses strong feelings and is controversial. Previous work suggests that three staff factors have an impact on rates of these events: the positive appreciation of patients by staff, the staff's management of their own emotional reactions to patient behavior, and the provision of an effective structure. The aim of this study was to test this theory. METHODS: A multivariate cross-sectional design was utilized. Data were collected for a six-month period on 136 acute psychiatric wards in 26 National Health Service Trusts in England. Multiple regression was conducted to determine the factors most strongly associated with total conflict and containment rates. RESULTS: Provision of an effective structure of rules and routines for patients was the staff feature most strongly and consistently associated with lower conflict and containment rates, with other elements of the theory less well supported by the data. Other patient and ward factors were also significantly associated with differences in conflict and containment rates between wards, in particular the proportion of patients formally detained under mental health legislation, the quality of the physical environment, and staff and patient race-ethnicity. CONCLUSIONS: Conflict and containment are reliable and meaningful concepts. Staff factors are relevant in the determination of conflict and containment rates on wards, but the most important of these is the provision of an effective, well-organized structure of rules and daily routines. There are a number of ways in which conflict on wards might be reduced, including a greater emphasis on the production of effective structure and order on the ward and work in the community to reduce the numbers of compulsory admissions.

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