These are ideas we did not develop into full blown interventions. You may find something here useful, some germ of an idea that you can use or adapt to make your ward a safer place. If something from here triggers some action by you, please do let us know via the forum

1

Caringly Vigilant and Inquisitive

Staff should be encouraged to be caringly vigilant and inquisitive, 49 attempted suicides (20% of total staff finds) were stopped because staff took actions such as entering the toilet if a patient was taking a long time, checking on patients when they heard unusual noises etc. Staff could be reminded to do this during handover. This should be mentioned to all new staff as part of their induction, they could also be given some case examples of how this has stopped attempted suicides on the ward. A good question for me is what the behavioural expression of these are. How are they operationalised. Emotional Regulation provides psychological containment, reducing anxiety in the patient and building confidence in the staff. PA is about pleasure and regard and overt dedication to the patient. The gift of time in Felicity Stockwell’s terms. Noticing all the time, being aware of, monitoring, caring about as well as caring for. The opposite of depersonalisation, the opposite of burnout in fact. Kindness, interest in. Again, a three times a day exercise for staff, with points to remember and reflect on? Could we suggest they go somewhere quiet for five minutes to do this, or use five minutes just before their break? Mix with mindfulness stuff?

2

Communicated clarity on leave/discharge

Denial of patients discharge and off-the-ward and not allowing a patients to smoke were found to be events that provoked aggression. Training in the management of these situations and in the ability to set effective structured limits. e.g. about when pts are likely to be discharged, the events/meetings/changes that have to come before discharge, explaining why they are not being discharged/allowed to smoke rather than just an denial? Have a number of set response depending on how close the pt is to discharge.More thought might yield some over arching strategies here - set clear criteria for discharge and communicate them on admission, and at every ward round. Similarly for off ward privilege.

3

Customer care training, or respect guardians

Lessons in etiquette and customer care? Unfailing politeness and respect, despite any behaviour on the part of the patient – need to educate in verbal confrontation skills, and perhaps negotiation skills and strategies – need to go back to some older ideas, complete the de-escalation catalogue, look at Mary Johnson’s older paper.
C&C intervention
Turn up the respect meter. Keep respect at maximum. Max volume respect. Respect broadcast on all channels. A nice phrase with a built in graphic. Could we do a respect ladder, a hierarchy in some way. Much of this is in the infantilisng section of Jane’s work, and is about respect. Mostly etiquette. Forms of address. Names. Please and thank you. Recognition. Little video of knocking at the office door and getting a polite versus non polite response. Also very much about emotional regulation, and not getting frustrated. Not shouting. Not ordering. Not humiliating in front of others. Should be able to find lots of quotes in the City 128 patient interviews. All the equality stuff too. Unfailingly polite. Basic customer service stuff – this must be written down somewhere as well.
Four or five step rule for complaints. Customer relations, complaints
Very impressed with train staff handling of disgruntled passenger. Polite, sympathetic, said what they tried to do, what they couldn’t do, what was outside their control, what options were available, made it easy for them to complain, gave complaints form and hustled to get it as quickly as possible.
There must be books about this, how to set this up, train people in doing this. It’s very simple, and often nurses do it very badly – we are way behind even such ordinary customer managers.
Counselling skills for nurses. The communication styles discussed in 'talking with acutely psychotic people' are basic counselling techniques (and aims): listen without judgement, empathise, establish, keep and respect boundaries (no intrusion), honesty, trust... These are difficult to acquire through reading, they can only be internalised through experience - role play, and supervised interactions are usually the training methods.  
Or re badge this as customer care, or ward etiquette, or increasing respect, ways of showing respect, easing relationships, smoothing interactions, cool runnings.
Appoint a respect guardian amongst the staff and patients. Or a respect watcher to highlight concerns in a helpful way at an early stage, to challenge any slip in standards.
Patients in this study described the nature of verbal abuse from staff as including, threats (for example, being told to behave or a patient would be secluded) or insults (a patient being told they were crazy), or ridiculed (for example, for a physical deformity). Staff should be aware of what they say to patients and how they say it as patients may perceive commands or comments as abusive if said in the wrong way.
Appoint a patient as the respect guardian?

4

Clinical supervision

Structured clinical supervision. Lunch and supervision together, as a group, with lunch provided
Paid for by the researchers.
Sandwiches and cake and soup and bread
Logistical problems about supply and place
Supervisor nominated by the staff. And trained by us.
Intervention bus to meet inside
OR Provide clincial supervision to ward nurses based on a specific structure related to the working model, train a cadre of clinical supervisors from volunteers/seniors
Staff support group: Fortnightly staff support meetings whereby WM and any staff members meet to offer help/advice/show of team support for any issues. This might also increase positive morale.
[Difficult to implement in addition to usual supervision?]

5

Compliment first

Staff to compliment/say something positive about patient upon first interaction of their shift. This fits into technical mastery and positive appreciation. Staff should compliment patients as much as possible so that patients feel they are being noticed and appreciated. Could we provide a thesaurus, a set of hints, possible compliments, ways to deliver them? With due care to avoid being perceived as patronising. {the fixed time might detract from them being seen as genuine]

6

Recall positives to self

A recent experimental psychological study has showed that positive thoughts strengthens emotional resilience during challenging times. Therefore, at the end of each shift, staff could be recall at least 3 positive things that happened during their shift, perhaps recount them to the oncoming shift? Closely related to 'positive handovers' and could be merged.

7

Containment review

Containment review: Introduce routine monitoring systems - as a tool for assessing levels of C&C and reflecting on variations within hospitals and improve reviews and local policy making.   Some US interventions have publicised this type of info in an effort to encourage competition between wards to reduce containment use. Perhaps prescribed structured reviews or review documents to be completed at handover or at ward rounds - containment reviews, or avoidance planning, crisis management, crisis plans, safety review. Alternatively could be a hospital wide review committee. Link to debriefing (staff). External drive to hold it formally, and expose reasoning to view in the eyes of others, are both likely to be important elements. mandating within the ward - it probably already is but doesn't happen.
[Too prescriptive to work]

8

Mutual help

Important "what to do if…" scenario posters e.g. "if you see/strongly suspect that another patient is self-harming, immediately inform a member of staff" or "if a patient collapses…" etc

9

New patient induction

Have an induction for all newly admitted patients which clarifies ward rules, where limits are set as well as highlighting the consequences of rule breaking. Greater awareness and understanding of the ward rules may reduce the number of aggressive indicidents that occur as a result of being denied. Looking at the mutual expectations poster on admission? Made part of the mutual expectations?

10

Timetable

Provide timetable with detailed routine. The second intervention could be a full and accurate timetable. Not just activities, but meal times, medication rounds, when people are expected to be up and when asleep (this should have a rationale on the rules too, regarding diurnal reversal and ill effects). With punctuality being important and a display of efficiency. Tidy up times added. Offering help with up and out of bed. The necessity of daily activity for psychological well being. Exercise program.

11

Recipe book

Increase technical mastery, provide a recipe book of response skills and phrases culled from all possible sources. Need to tackle anger provoking and irritating situations as well as fear provoking ones.

12

Social mood control

Raise the general mood on the ward and pleasant emotions through gifts, nice suprises, positive feedback, refreshments, being entertaining, humour. Set the mood early in the day, and safeguard against aversive events. Particularly manage waking up and getting up. Good mood naturally rises throughout the morning, and we should try to enhance that process. Bad mood rises at night and we should try to control that. Recognise effort and achievements, pay compliments, notice small advancements or changes, smiles, generosity, mutual support amongst patients. maybe also this is why positive inter staff interaction IS important. To charge the battery. To garsp the positive mood and take it outside the office onto the ward.
This incorporates lots of other more detailed interventions.

13

Education alc/drugs

Alcohol and drug reduction interventions, education, posters, a specific campaign perhaps, or brief motivational interviewing interventions. Education on substance/alcohol use? Posters? Prescriobed discussions with patients? How does the new model encompass this issue? [Easy to do, but not sure it would be of much help during an admission]

14

Activitipedia

Provide a manual, handbook or encyclopedia to group activity session ideas. Provision of an activity bank/encyclopedia with session plans and stuff to print off to run it, plus lists of equipment etc. Provide and activity trolley, with necessary equipment in crates, etc. and list of suggestions, art materials, a play station and games, etc. All these things have to have a direction, a purpose, that staff can articulate to patients. Assessment, social skill, co-operation with others, concentration, mood, change of pace, etc. Provide with crates or a trolley with kit for activities, with PS3, or incorporate Star Wards as part of the package? Provide modular activity crates with insrtuctions and equipment inside

15

No-react

Training sessions on how not to respond angrily or in fear. The key to emotional regulation is through the handling of verbal abuse. Stress inoculation, anxiety management, anger control, fear control. Exposure to a video of someone shouting abuse at you. Pre identification of hurtful insults and a plan on how to respond to each one - identify your own known vulnerabilities

16

Antibullying policy

Anti-bullying policy, regaular inviations to report bullying, clear statements that it would not be tolerated and is unnacceptable, effective prevention of threat and fear. Lower tension and reduce incidents. [How would the pts/staff reported as bullies be approached? Could this potentially cause more conflict - especially if those reported did not agree/felt wrongly accused.][Could this cause more bullying if patients make things up about one another? How would staff determine the truth and deal with events?]

17

Collate positives/strengths

Aggressive pts found to have self-serving ToM bias (view of themselves more positive that how they rate others' view of themselves). Positive appreciation - get staff and other pts to rate their perception of other pts - list of positive adjectives to describe others that they could keep. May improve the perception of how others view them - which may lead to less aggressive behavior. Could be put ona   special card - my strengths as others see them? Could we provide lists of potentyial adjectives - a thesaurus from which people could pick the most appropriate?

18

Debrief: staff

Staff debriefing sessions 3 days after a violent incident to focus on staff member's thoughts and emotional reactions to the event (emotional regulation) - implementation (along with the SOAS) was associated with a decrease in assaults over the 3 year study period.
Peer support program for staff - Following incidents of violence and aggression staff are supported by peer support workers who enable staff to speak about their experience and gain emotional support. Flannery and colleagues found that the peer support program led to a reduction in violent and aggressive incidents on the study wards.   After team discussion: Evidence not that convincing - how does peer support affect patient behaviour?   Could offer telephone support. One member of staff a month should be assigned a role of peer support for colleagues who have encountered violence and aggression. This staff member will be responsible for simply making sure the staff victim is ok. That is, one an incident has occured, the peer support staff member will ask the staff victim if they are ok or if they want to discuss the incident and offer them support if and when they need it. This may not generate a great deal of work for nurses as the act of simply asking to make sure the staff victim is ok might be sufficient support for some nurses. This may also help to generate team building.
Primary purpose to achive psychological understanding?

19

De-stress advice

Providing staff a DVD/booklet/podcast on how to de-stress, relaxation techniques/advice and increase their cognitive/emotional self-management ability after their shifts end and they go home (fits into emotional regulation)

20

Patient newsletter

Wards could devise a patient newsletter which could feature activities such a crosswords or Sudoku to curb boredom and patients and staff could come up with a name, submit articles, recipes, photographs, art work etc. This only needs to be a basic A4 document but the collaborative working between staff and patients to create something that the whole ward can enjoy might be a nice way to encourage positive appreciation on both sides.

21

Request free times

Request free times: Serious incidents reported early morning and at lunch time - busy time lots of rule following/requests. Clear routine/timetable in place around these times (poster on the wall) so staff and patients know exactly what is going to happen and what is expected of them (effective structure). Or reschedule the staff activity? More analysis needed of what exactly happens when, but core idea of giving staff request free times could be a good rule. This could be made part of the request system, and is at the very least implied by it.

22

A patient's day

Day/week/month in the life of a patient i.e. same idea as above but may would help staff to understand the patient better. This should increase help to increase positive appreciation and may also better their psychiatric philosophy [Prefer a proper 'patient summary' which could be updated as a front page to notes][will patients be well enough to do this? Other mediums could be considered like painting ect?]

23

Eliminate

Proscribe eradicate some forms of containment - locked doors, seclusion?

24

Frustrations box

A sealed 'frustrations box' which staff could drop notes of paper into (anonymously or not) which describe their frustrations and barriers to providing effective care. Such a tool would be useful as it would encourage staff to voice their frustrations in an easy and quick manner by writing/typing whatever they want without having to fill out forms or going through other channels to voice their frustrations, many of which might need the staff member to wait for (which might put them off, or might cause them to forget). It also might make them feel better knowing that they have voiced it. Ward managers could then on a weekly basis read these frustrations/barriers and address them. [May lead to more problems when discussed and it may be obvious who made the comment. ]

25

Patient diaries

Asking patients to keep a reflective diary of the conflicts they have been involved so they can privately and uniquely express how a conflict started, was resolved (or not), what they might had done differently, and how they feel.

26

Prescribing praise

Prescribe minumum doses of praise. Praise. Prescribe minimum doses of praise. To be given out with the medication? Might solve meds refusal a bit too. Praise and compliments and smiles. Got to be done really and with sincerity. Get patients to be positive to each other too? Needs the same lexicon as the positive handovers. needs to be focused especially on the most ill and obnoxious patients. [need to avoid being patronising]

27

Article club

A book club where staff and patients can all read the same material over a week or so (maybe a short story, an newspaper or magazine article or a poem for time restrictions sake). The materials could be made available at the nurses desk or somewhere central so that anyone interested in reading it (even if they don't later feel like participating in the discussion) can take part. This could encourage engagement and interaction between staff and patients and provides an extra activity for patients on the ward. A meeting could be arranged at regular intervals, every week or two weeks where the literature can be discussed and new litterateur chosen. [Might be hard to find relevant material to pitch at the right level for all taking into consideration ability, languages, interests etc.]

28

Maximise choice

Go the extra mile for detained patients - can resolve the detention, but do everything else to make them comfortable. Choice of bed. Choice of bedding. Personal TVs. Food preferences. Drink preferences. Music, TV, recreation preferences. Do washing for them. Get personal items from home. Be creative and responsive to their requests. Communicate your genuine support and cocnern for them, even in the face of anger and irritation. Kindness. Patience. Empathy. Absorb anger, don't reflect it. Calm. etc. [Will this level of care be kept up for the duration of the admission? ]

29

Self analysis

Create a self analysis tool to assess strengths and weakness, ponder own moral commitments and scale of values, assess own skills repertoire, psychological understandings, indentify what situations evoke irritation or anxiety, ect. Prior to training. Almost like a pre therapy questionnaire we used to use at Brindle House. With a scoring system, perhaps? And no requirement to share. [Should be shared with supervisor to develop goals?][To what end?]

30

Family interventions

If there are tensions and stresses at home, work with the whole family unit to resolve them. [Inquiry about family, engage with family etc][dependent on the family]

31

Interaction targets

Targets for patient-staff 1:1 time, especially for 1st week of admission (e.g. one per day).   Definition of min duration and content range probably required. This is pretty much already mandated.

32

Intermittent observation

Introduce more intermittent observation [Needs to be more defined- for which patients, for what purpose?]

33

Managaerial appreciation

Random visits from high-level Trust directors who come in and encourage staff members to keep doing their jobs well and provide positive appreciation. This is something that happened which I read about in the timeline logs (for the transition analysis work) and was seen as a very positive thing by ward manager. Organised visits to the experimental wards from Trust directors who have the specific agenda to positively appreciate the intervention work being carried out

34

Reading preferences

Ask pts what reading material (newspapers, magazines etc) they would like to have in the ward during their stay so that these can be made available (to increase pt choices and freedoms). Give every patient their preferred newspaper, delivered in the morning?

35

Who I am

Reframing the self: The nursing role, parental role, team ideology; Remoralisation, reawakening and eliciting public commitment to moral values, aiding the construction of a moral identity with appropriate self evaluations and self statements; Eschewing judgmentalism, black and white thinking, punitive ideology, superiority and power
Recall who and where you are: All the anger defence mechanisms identified in the DSPD book, create acronym to help people remind themselves when self-monitoring

36

Staff to pupil

Staff to offer patients the chance to teach them something (e.g. a language, poetry, musical instrument etc) so that staff's positive appreciation of them increases

37

A nurses' day

Day/week/month in the life of a nurse/ward manager/etc i.e. short reflective diary-like document that would help increase pts' understanding and positive appreciation for staff members. This should also serve to help other staff members understand their colleague better, thus increasing team-building and positive appreciation. After team discussion: Getting people to read it is the problem.   Could add some info of this kind to staff photos usually displayed at reception. [risk of burdening patients with staff problems. Would work better for staff to staff.]

38

Office restriction

One in one out rule for the nurisng office, to force more interaction with patients and reduce staff-staff chit chat [might decrease morale] [One in one out rule for the nurisng office, to force more interaction with patients and reduce staff-staff chit chat]

39

Open doors

In the context of Tighten wraparound security; Maximise door visibility; Adequate staff numbers; One exit only; Secure garden area [Depends on existing ward design]

40

Personal recognition

Ensure that birthdays and other important personal days are not ignored. What other days? [Name days][anniversaries, religious festivals. National celebrations such as the world cup or royal wedding might be nice to get the whole ward involved.]

41

Personal recognition

Display patient artwork/other productions in the nursing office and/or around the ward. - One idea could be to run a regular patient work presentation group where staff/pts present their work to the group
- Another idea is to start a patient artwork portfolio book which can be placed in the day room.
- Dressing up the walls in wards with artwork may have feasability issues as the NHS buildings that contain the wards are contracted from private companies who would likely charge high fees for any such maintenance being carried out.
Panel boards: As painting/decorating directly onto a ward's walls have feasability issues (as wards are contracted from private companies who would likely charge high fees), using panel boards would get around this problem. These are large thin wooden boards that are attached to the walls that can be decorated and then easily removed and replaced when necessary.

42

Nurses support OT

Nurses to support OT sessions when OT staff members are ill or in low supply (part of increased staff activity). But this is generally done anyway, except where there are major team problems anyway [should always be done except in exceptional circumstances]

43

Esteem enhancement

Printed bite-sized information (in the staff offices) that help to remind nurses (and other staff members) why mental health nursing is as important as general nursing. This might aid in reducing the negative impact on self- and professional-esteem that might be being caused by the public view of mental health nursing as less valuable/important than other forms of nursing.

44

Ideology documenttation

Ideology nursing model through documentation. How to develop ideology. Need to merge ethics with goals to describe process of work on acute wards, including the rules and activities. Perhaps specify assessment areas and what should be on care plans? Revamping the old nursing model nursing process approach.

45

Patient ratings

Positive appreciation, technical mastery, teamwork skill (and other domains) patient scoring of staff members. Ward managers can review these statistics and talk to staff about ideas on increasing their technical mastery (for e.g.) during supervision [Not enough time for potential benefits to kick in?][Could have negative effect on staff morale and burnout if comments and scores are bad…'why do I bother!']

46

Team photo

Put a 'team photo' in the office. This may help increase feeling of team support and morale. Plus, the act of getting the team together for a group photo might boost, at least temporarily, boost morale and feelings of team support. Could get this done professionally. [Difficult to get the team together at one time]

47

Feedback to managers

Staff to rate their line managers, as telling a manager what you think of him or her through constructive feedback is likely to make employees feel less stressed and happier: "Research presented at a BPS conference found that the relationship between staff and line managers was the most commonly reported cause of stress in the workplace. When bosses received feedback from their staff, they were more likely to change their style and be seen as more effective, a study of 150 managers found...Managers who did not receive any feedback were less likely to change their management behaviour" [anonymous? relationship strain?]

48

Support for patients on leave

Phone calls from the ward staff, arrange visits from home treatment teams

49

Breathing exercise

Another simple emotional regulation exercise: Staff to imagine the air entering and leaving through the heart area or the center of your chest for 15 seconds during the times they are experiencing negative emotions. Inlcude in Blue Book? In order to do this people would have to self monitor regularly, notice themselves, be aware of themselves and then of others. Combat busyness and distraction. Could they be asked to reflect every hour as an exercise? Then given a nmenonic of claming things to do? {Practice reguarly (maybe not everytime they experience negative emotions as this might not be cery feasible) 'noticing thoughts' Defusion techniques from negative/nonfunctional thoughts ...Rename to mindfulness?]

50

Personal music

Find out on admission assessment (perhaps through a questionnaire) what music patients enjoy listening to (from specific artists to genres). Subsequently, provide patients with mp3 players (e.g. cheap iPod nanos) with music loaded on to them that patients will individually enjoy. This might alleviate boredom and also help with de-escalating patients after an incident has occured.

51

Supervision

How to use supervision effectively, learning and getting personal benefit. Contracting. Alternative means other than one to one. Supervisee responsibility.

52

Thought stopping

Loving the symptomatic and problematic patient. Inducing anti-TAWS. Transforming frustration and anxiety into love. But how? CBT thought stopping techniques for ANTS about patients, eg. Attention seeking, behavioural not symptomatic, personality disordered really, shouldn't be rewarded for bad behaviour. Reflect and become self-aware of discomfort and avoidance.

53

Improve visibility

Environment improvement: install vision panels in doors of all patient rooms (this was associated with decreased conflict and containment in transition analysis). Is the mechanism for this through staff anxiety reduction?

54

Team cohesion

Teamworking - consistency, mutual support, communications. Awareness and response. Predict, prevent and plan. Monitor and stay in touch. Lesson on how to achieve consistency. Team building event. Nothing here about how to build teams. Is there a team building literature?

55

Managed transfers

Where patients are moved between wards they should be given an opportunity to visit the ward and understand why they are being moved and what the therapeutic purpose is. This would also be an opportunity for them to meet with the nurses and doctors on the ward which may decrease feelings of agitation and anxiety once they actually move to the ward. Research reveals that violence and aggression are more frequent in the first few days of being transferred to a new ward.

56

Shipshape

Organise ward cupboards and stock, and the ward office. A place for everything, and everything in its place. Ship shape. Could have an experienced admin worker go in and help the staff and ward manager to do this

57

Define purpose

Provide ideology paper material as a skeleton and work out a ward purpose with the staff, giving them back some good posters with commissioned art work. Create the overarching ideology, or define it, an exercise to be prescribed, perhaps with a framework to build upon, devlop or agree, put on a poster and promulgate on the ward, through leaflets. At close of project, share across the sample, or even write up as a study in its own right. Provide a statement of purpose of acute inpatient care. Easy to promulgate, but how do you get buy-in, get people to agree to it togetehr and commit to it, when they have the leadership, or it lies outsdie the research field? They could define their own as an exercise, but it might be unrealistic wishful thinking, ratehr than research based pragmatism.

58

Double time

More ill, more time. Research found that forensic patients with a higher overall disturbance in social behaviour were more likely to be aggressive in order to reduce social distance and seek attention. This suggests that staff should spend more quality time with these patients compared to the less profoundly disturbed patients. But not in a reactive way. Double time? 2 x 10 mins per shift for the most ill, or 4 x 5 mins?

59

Prescribe patience

Prescribe patience. Patience as alternative to no frustration or frustration control.
Pre-patience. Patience is derived from realistic expectations and targets, which are themselves based up accurate assessment of capability and a good understanding of the experience and reality of mental illnesses.
Post-patience. Following violent assault etc. Again psychological understanding of behaviour and incapacity.
Just another word for psychological understanding, whioch should be the primary purpose of the staff debrief?

60

Problem to opportunity

Is it possible to diminish the personal salience of troublesome patient behaviour. Help people get some distance from their roles, so that what happens in itneractions with patients doesn’t have the capacity to threatening them so much. Stick and stones etc. Or increase the view and range of potential benefits - not just wages, but also personal and moral development.

61

Realistic risk

Attack the danger distortion with a realistic assessment of facts and risks. Could be done for all the conflict behaviours, based on the lit review work.

62

Tagged staff

A coloured-coded tag which attaches to the staff's item of clothing (e.g. belt) that patients can easily see. A yellow tag (for example) would signify that the staff member was available for any patient request, a red tag would signify that the staff member is moderately busy and can only deal with urgent requests, and a blue tag would signify that the staff member is too busy to deal with any requests at the current time. The rationale would be to preempt patients' requests being denied as they would know before needing to actually ask whether the staff member is available to help them or not. This would also reduce the instances of 'escalatory denials' (ie. staff saying 'no' to a request in a manner that upsets or agitates the patient). It may also save staff members time from having to explain each time that they are not free. This fits into the 'effective structure' element of the working model. After team discussion: Possibly too easy to ignore patients or interaction with them. Eg better to inform patients (nicely!) that too busy to deal with a request, but will sort it by such and such a time? Note this is doen in SLAM for medication giving - using a tabard. The alternative is to always have someone who IS available, and marked as so. Usually this means the office occupant, but could be otherwise. [not sure it would stop patients from asking. ]

63

Talker

Nominate a talker during manual restraint. Violent people can shut down, can’t hear what is being said – is this true.
Why can’t our staff continue to de-escalate during restraint – existing takes take total concentration. There needs to be a non-involved talker. Perhaps works better in forensics, or does it – certainly can do in high secure. Appoint a separate talker who has no restraint responsibility. Either that or use the security guard approach. This is a really difficult issues.

64

Understanding symptoms

Lessons on diagnosis, but to concentrate on patients perspective equally. How they see the world.

65

Bad ward

Describe the opposite. Describe the bad ward, the opposite ward, the high conflict and high containment ward. That will make everyone laugh. But then ask the audience how much this is true of their own ward. Include in Blue Book?

66

Discharge thanks

Staff to write a thnak you letter or convery a positive message to the patient on discharge. Could be provided with a set of cards for this. Something to read when you get home.

67

More staff in evening

Increased staffing levels in the evening: Several papers report a variation in rates of self harm during the day, with a peak in the evening (20:00-23:00). It is unclear why this is the case, however if staff were made aware that this is a difficult time for some patients, and were availiable to support patients experiencing difficult feelings this may reduce the episodes of self harm. [and more activities]

68

Peace and quiet

Keeping quiet, reducing frenetic actvity, maintaining calm and peaceful atmosphere, quiet control, walking slowly, talking quietly, tv turned down low.

69

Depression & transition ideintification

Screen all patients for depression, know them well enough to understand what is a potentially negative transition for them, then ameliorate it if it exists.

70

Triangle of choices

An anger management assessment tool and "Triangle of Choices" have assisted patients in identifying and managing feelings of frustration and anger. Since their inception 1 year ago, the implementation of documented alternatives to restraints has increased, and use of most restrictive measures has decreased.

71

Ackowledgement

Having a 'staff member of the week/month' award (with some sort of financial reward attached) based on patients' anonymous survey ratings of staff members. This may motivate all of the staff members to do their jobs better, which could in turn positively impact on conflict and containment. one idea might be to have three members per month nominated by WM, and the patients vote for their winner. Certificate and/or voucher as reward? Positive practice of the month award (selected by ward manager). This will reward staff for positive practice, and teach staff good examples of positive practice (organisational support element) [Not sure how reinforcing money is - what is the evidence? Think the acknowledgement be enough and more feasible. More power if examples of the positive practice are discussed with team during meeting.][What would motivate the patients to take part?]

72

Emotion tags

Emotion tags/labels to be made available for patients to use. This would allow patients to explicitly announce how they are feeling to others which may be useful to staff for knowing quickly and accurately how patients are feeling, and in providing a consistent reminder that patient x is angry/sad etc. [some pts (staff) may have alexithymia and therfefore unable to label their emotions. This in itself may lead to frustration/aggression. Worth screening for and designing intervention for these pts?][Might also provide a constant reminder to patients that they are angry.
Need some sort of intervention by staff if they notice the patient constantly wearing the badge or this may increase patient frustration/conflict if feel like emotions are being ignored.]

73

Inter-patient clarity

Clarity between patients. Excessive and extreme clarity, between patients too. Extra personal space. Talk before approach. Orientation to place and person. Redoubled politeness and respect. Train patients in these approaches. This is the paranoid patient plan applied to inter patietn interactions.

74

Selective activation

Research found that (forensic) patients who were more socially withdrawn used aggression as a means of resisting involvement in activities and securing social isolation. Depressed patients, however, were found to behave aggressively in order to attract attention and reduce social distance. Thus, staff should be learn to differentiate from these two types of patients, and, work with them differently according to their type: for social withdrawn pts, pts should not be pushed into activity as much as 'depressed' patients, who instead should be more strongly encouraged. This may only be applicable to forensic settings though. (fits into 'technical mastery' and maybe 'teamwork skill')

75

Staggered timetable

Staggering activities on the ward to avoid periods that are overly busy (such as in the mornings where there is change of shift, breakfast, washing all going on at once). Patients whose cognitive functioning is impaired might perceive this activity as overwhelming, excessive and aversive. Runs counter to predictable schedule, though.

76

Wireless headphones

Wireless headphones for all to watch TV, making the ward quieter and less stimulating. But would reduce the social interaction around watching

77

Our history

Plea to nursing ethics, professional conduct, and historical figures. If not figures then the nurses at specific hospitals at specific times. Reclaim our achievements from the names like Connolly, etc. Part of the moral speech?

78

Reduce self-stigma

Reduction of self-stigma i.e. feelings of shame, guilt, and inferiority due to their mental illness. This is important as previous research has shown that there is a link between self-stigma, self-esteem and psychological health (Link et al, 2001; Berge & Ranney, 2005; Yen et al, 2005). Self-stigma reduction techniques could take the form of reading material that focuses on explaining what self-stigma is, unconditional self-acceptance (Ellis, 1994; Dryden, 2001) (i.e. pts accepting themselves as fallible human beings), and challenging frequent specific beliefs about stigma.

79

Targeted support

Regularly assessing staff social support levels and working with the particular staff members who feel they lack such support. What sort of working with?

80

Orientation

Orientation maps - maps of the ward with stickers saying 'you are here'. Signs in large lettering

81

Lockable storage

Provide keys, lockers and security cabinets for valuables, to reduce thefts and thus arguments between patients

82

Past patient visitors

Ask patients who have been discharged and have recovered to come back and visit the ward staff. This will help staff humanise their current patients. This can be problematic when past patients come in and cause trouble. Also generate dependency and foster institutionalism. [Might be nice for them to talk to the patients on the ward to and answer questions about life on the ward and how they coped with it. ]

83

Hair care

Free onsite barbering/hairdressing sessions (feeling freshly groomed increase dignity and may increase self-efficacy)