As such they have six aspects or collections of features that can influence the frequency of conflict and/or containment. Psychiatric wards are social and physical locations, separate from patients normal residences, and provide 24/7 mental health care on a basis of mixed voluntary and legal coercion. The Safewards Model represents our attempt to fill this gap. Where they have been offered, they are restricted to specific types of conflict, most often aggression ( Nijman et al. Explanations for these differences have not often been sought or described in a systematic way. 2005), and containment methods used in some countries are not used in others ( Bowers et al. Rates also vary internationally ( Bowers et al. Wards vary significantly in their rates of conflict and containment, sometimes by a tenfold margin ( Bowers 1998, 2009, Bowers et al. The implication of these commonalities is that the different events and actions have common causes, and that making an attempt to delineate these in a single model is a sensible thing to do. Studies of community samples of young people have also found evidence for a common factor between different problem behaviours ( Cooper et al. wards that have high rates of aggression also have high rates of absconding, or wards that have high rates of coerced intramuscular medication of patients also have high rates of special observation use ( Bowers 2009). Second, different conflict and containment rates cluster within wards, i.e. these behaviours cluster within patients ( Bowers et al. First, patients who exhibit one sort of conflict behaviour are likely to exhibit others, i.e. The idea that different events (aggression, self-harm, absconding, etc.) can be grouped together as conflict, and different management methods (as required medication, seclusion, manual restraint, etc.) grouped together as containment, is supported by two main arguments. Reducing the frequency and severity of these events is clearly very important for wards, the patient who reside there and the staff who work there. The use of force and coercion that can be involved in containment arouses staff ambivalence and can result in unintended injury to patients, or spoil cooperative staff–patient relationships. Self-harm is also injurious, and its management and prevention tax nursing skills, as well as self-harm being an indicator of increased suicide risk ( James et al. Suicides, by definition, involve the death of a patient, and absconding is associated with suicide risk ( Appleby et al. Violent incidents can lead to injuries, sometimes serious, to staff or patients ( Langsrud et al. We describe this model systematically and in detail, and show how this can be used to devise strategies for promoting the safety of patients and staff.Ĭonflict (aggression, self-harm, suicide, absconding, substance/alcohol use and medication refusal) and containment (as required medication, coerced intramuscular medication, seclusion, manual restraint, special observation, etc.) are important matters for hospital management and nursing practice. Staff interventions can modify these processes by reducing the conflict-originating factors, preventing flashpoints from arising, cutting the link between flashpoint and conflict, choosing not to use containment, and ensuring that containment use does not lead to further conflict. These domains give risk to flashpoints, which have the capacity to trigger conflict and/or containment. This Safewards Model depicts six domains of originating factors: the staff team, the physical environment, outside hospital, the patient community, patient characteristics and the regulatory framework. This paper proposes a comprehensive explanatory model of these differences, and sketches the implications on methods for reducing risk and coercion in inpatient wards. The frequency of these events varies between wards, but there are few explanations as to why this is so, and a coherent model is lacking. Conflict (aggression, self-harm, suicide, absconding, substance/alcohol use and medication refusal) and containment (as required medication, coerced intramuscular medication, seclusion, manual restraint, special observation, etc.) place patients and staff at risk of serious harm.
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