BackgroundAcute psychiatric inpatient wards experience high levels of conflict behaviour (e.g. violence, absconding, self-harm) which are managed by containment methods (e.g. restraint, seclusion, time out, sedation). Most previous studies have only examined one or two conflict and containment events, therefore little is known about their sequence, and what the common pathways of events are for patients.

Aims To identify conflict behaviours exhibited by patients, containment methods used by staff, the order of these events and the characteristics of patients involved in them.

MethodWe collected information about the first two weeks of admission from the case notes of 522 patients (with their consent). Patients were recruited from 84 wards in 31 psychiatric hospitals across Southern England. A range of background information was also collected on each patient. Mental Health Research Network Clinical Studies Officers assisted with data collection.

Results The most common conflict behaviour was verbal aggression which was displayed by half of patients at least once during their first two weeks of admission. Refusing to eat, refusing to

see workers, aggression against objectsand physical violence were each displayed at least 200 times during the two week period (see Figure 1). The least common behaviours were refusing to drink, suicide attempts and substance misuse (all less than 10% of patients).

The most common containment measure used by staff was PRN (or ‘as required’) medication which was used for two thirds of patients (Figure 2). De-escalation techniques (verbally calming a patient) and intermittent observation (regular, timed checks on a patient) were also frequently used (over half the sample received these interventions at least once). The least frequently used method of containment was placing a patient in seclusion (isolating a patient in locked room).

Emerging findings include:

Coerced IM medicationReceived by one in ten patients, usually in response to aggression and medication refusal. Manual restraint was used on half of occasions. Coerced IM medication brought most crises to an end.

Self-harmIncidents tended to occur early in admission. Absconding, medication refusal and non-compliance were frequent precursors. Incidents were typically managed with PRN medication and de-escalation.

Seclusion & time outThere was significant variation in rates of seclusion between hospitals. Seclusion and time out were used with similar patients & in similar circumstances. Outcomes for the management of physical violence were also comparable.

Constant special observationUsed on admission in half of cases, but typically preceded by absconding, violence or self-harm. Other containment, especially intermittent special observation, was often tried first. Most episodes involved other interventions, such as de-escalation and extra medication.

AuthorsLen BowersLen.Bowers@kcl.ac.uk

Duncan StewartDuncan.Stewart@kcl.ac.uk

AcknowledgementThis report presents independent research commissioned by the National Institute for Health Research (NIHR) under its Programme Grants for Applied Research scheme (RP-PG-0707-10081) and supported by the NIHR Mental Health Research Network. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health.

Understanding the sequenceof conflict & containment events: CONSEQ

Figure 1: Common conflict behaviours

0 200 400 600 800 1000 1200 1400

Refusing to go to bedDemanding PRN medication

Self-harmAbsconding

Attempting to abscondRefusing to attend to hygiene

Refused PRN medicationPhysical violence

Refusing to see workersAggression against objects

Refusing to eatRefused regular medication

Verbal aggression

Frequency

Figure 2: Containment methods

0 200 400 600 800 1000 1200 1400 1600 1800 2000

Seclusion

Sent to intensive care

Show of force

Coerced IM medication

Constant observation

Restrained

Time out

Intermittent observation

De-escalation

PRN medication

Frequency