BackgroundAcute psychiatric wards manage patients whose actions may threaten safety (conflict). Staff act to avert or minimise harm (containment). The Safewards model enabled the identification of ten interventions to reduce the frequency of both.ObjectiveTo test the efficacy of these interventions.DesignA pragmatic cluster randomised controlled trial with psychiatric hospitals and wards as the units of randomisation. The main outcomes were rates of conflict and containment.ParticipantsStaff and patients in 31 randomly chosen wards at 15 randomly chosen hospitals.ResultsFor shifts with conflict or containment incidents, the experimental condition reduced the rate of conflict events by 15% (95% CI 5.6–23.7%) relative to the control intervention. The rate of containment events for the experimental intervention was reduced by 26.4% (95% CI 9.9–34.3%).ConclusionsSimple interventions aiming to improve staff relationships with patients can reduce the frequency of conflict and containment.Trial registrationIRSCTN38001825.

Accessible summaryRates of violence, self-harm, absconding and other incidents threatening patients and staff safety vary a great deal by hospital ward. Some wards have high rates, other low. The same goes for the actions of staff to prevent and contain such incidents, such as manual restraint, coerced medication, etc.The Safewards Model provides a simple and yet powerful explanation as to why these differences in rates occur.Six features of the inpatient psychiatric system have the capacity to give rise to flashpoints from which adverse incidents may follow.The Safewards Model makes it easy to generate ideas for changes that will make psychiatric wards safer for patients and staff.AbstractConflict (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. 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. This paper proposes a comprehensive explanatory model of these differences, and sketches the implications on methods for reducing risk and coercion in inpatient wards. 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. These domains give risk to flashpoints, which have the capacity to trigger conflict and/or containment. 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. 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.

It is estimated that in a 12 month period at the hospital in this study a nurse would have a one in 10 chance per year of receiving any kind of injury as a result of patient aggression. Despite the predominance of verbal over physical aggression, the fear generated from working in such an environment and a difficulty in understanding the causes of patient aggression may motivate staff to manage aggressive incidents with physical methods such as seclusion and restraint on a frequent basis.

L. A review and meta-analysis of the patient factors associated with psychiatric in-patient aggression.Objective: To combine the results of earlier comparison studies of inpatient aggression to quantitatively assess the strength of the association between patient factors and i) aggressive behaviour,ii) repetitive aggressive behaviour. Method: A systematic review and meta-analysis of empirical articles and reports of comparison studies of aggression and non-aggression within adult psychiatric in-patient settings. Results: Factors that were significantly associated with in-patient aggression included being younger, male, involuntary admissions, not being married, a diagnosis of schizophrenia, a greater number of previous admissions, a history of violence, a history of self-destructive behaviour and a history of substance abuse. The only factors associated with repeated in-patient aggression were not being male, a history of violence and a history of substance abuse. Conclusion: By comparing aggressive with non-aggressive patients, important differences between the two populations may be highlighted. These differences may help staff improve predictions of which patients might become aggressive and enable steps to be taken to reduce an aggressive incident occurring using actuarial judgements. However, the associations found between these actuarial factors and aggression were small. It is therefore important for staff to consider dynamic factors such as a patient's current state and the context to reduce in-patient aggression. Summations• Psychiatric in-patients who are younger, male, admitted involuntarily, not married, have a diagnosis of schizophrenia, have a greater number of previous admissions, a history of violence, a history of self-destructive behaviour and a history of substance abuse were more likely to be aggressive than non-aggressive during their stay.• Psychiatric in-patients who are female and have a history of substance abuse or a history of violence were more likely to be repetitively aggressive than aggressive once during their stay. Considerations• The associations between patient characteristics and aggression were small suggesting that other factors may be helpful in predicting aggression.• There were significantly high levels of heterogeneity across the articles entered into most of the metaanalyses.• A relatively small number of comparison studies were found relative to the number of publications on in-patient aggression suggesting that this is an underused study design.

This is the accepted version of the paper.This version of the publication may differ from the final published version. to ascertain those factors most strongly associated with verbal aggression, aggression towards objects and physical aggression against others. High levels of aggression were associated with a high proportion of patients formally detained under mental health legislation, high patient turnover, alcohol use by patients, ward doors being locked, and higher staffing numbers (especially qualified nurses). The findings suggest that the imposition of restrictions on patients exacerbates the problem of violence, and that alcohol management strategies may be a productive intervention. Permanent repository linkInsufficient evidence is available to draw conclusions about the nature of the link between staffing numbers and violence.3

This review underscores the influence that staff have in making in-patient psychiatric wards safe and efficacious environments.

The study illustrates why some patients view their involuntary hospitalisation positively, whereas others believe it was wrong. This knowledge could inform the development of interventions to improve patients' views and treatment experiences.

Acute psychiatric wards experience high levels of conflict behaviours (violence, absconding, self-harm, rule breaking and medication refusal) by patients. These events cause stress and injury to staff and patients. Their management through containment methods (e.g. sedation, restraint, seclusion) is contentious, and nurses are ambivalent about their use. The aim of this study was to reduce conflict and containment on two acute psychiatric wards through changes in nurses' beliefs, attitudes and practices. Two 'City Nurses' were employed to work with two acute wards for 1 year, assisting with the implementation of changes according to a working model of conflict and containment generation, itself based on previous research. Evaluation was via before-and-after measures. Statistically and clinically significant decreases in conflict occurred, with falls in aggression, absconding and self-harm. Ward atmosphere improved and nurse-patient interaction rates increased. There was no significant change in containment method use. Significant reductions in aggression, absconding and self-harm can be achieved on acute psychiatric wards. However, it does not appear that containment can be reduced, even through large reductions in conflict.