Background: There are a huge variety of risk assessments and nursing assessments in use on acute inpatient wards. These differ a great deal, and seldom lead to more than basic interventions around keeping patients safe. Our review of the research literature and our model of the important factors in conflict and containment generation, suggest some slightly different angles that will help develop viable nursing plans to keep patients safe. This initiative provides some supplementary questions/topics to explore during the nursing assessment on admission, that will assist in the generation of such plans and reduce rates of conflict and containment.

Description: As a supplement to the nursing assessment on admission, and only for patients who have a known history of conflict behaviour on the ward, a 'C & C assessment' will be completed. The additional information secured will be used to contribute a conflict and containment reduction element to the care plan. For those who cannot cooperate on admission, the C & C assessment will be completed on day three or day five of the admission. The assessment topics on the 'C & C assessment' are designed to help with: (i) The identification of triggers to conflict behaviours, for example the behaviours of other patients, the staff, potential stressful events outside hospital, etc. and (ii)      The patients preferences about containment use and what should be avoided.

Experience of use during pilot: More complex than initially envisaged, not fully worked out and requiring significant training. Unpopular among staff as it increased paperwork.

Reflection: This intervention tries to bring together different ideas which are in common circulation with extra content from the Safewards model. Firstly advance directives about preferred containment methods. The difficulty with these seems to be making sure the staff know the patients preferences so that they are actually followed when the circumstances arise. Secondly personal safety plans based on the identification of idiosyncratic triggers for conflict and indicators that it is about to happen. There are some widely different and very good examples of these being used in different places. If you have one please send it to us and we will include it in the links below with a credit to you. Thirdly some additional assessment topics and planning points for conflict avoidance based on the Safewards model.

Background: Our research has shown that a well structured ward, one that is more efficient and effective, has lower rates of conflict and containment. Part of the way the ward staff convey a message about how efficient and effective they are is via the cleanliness and tidiness of the ward. While a tidy ward might not be intrinsically important, it shouts an important message about the staff who work there to everyone who looks. This initiative aims to make the ward more properly reflect the efficiency of the team that works there. In addition, by involving patients it stresses shared responsibility and equality between patients and staff, and gives patients a manageable small role in meaningful contribution to others.

Description:  Regular ‘tidy up’ times are initiated by the nursing staff during which the ward will be tidied up (rubbish cleared, dirty cups and plates returned to kitchen, patients possessions returned to their rooms or bed spaces, leisure equipment put away in cupboards, tables wiped, furniture returned to position, etc.) by nurses and patients (by their choice and on invitation) together, just prior to the end of each shift and before the next shift arrives on duty.
Experience of use during pilot: Already done in many places, a hard sell in those places that don’t already do it.

Background: Some confrontations between patients and staff are ignited by patients not fully understanding how their requests are handled or what actions have already been taken by staff. The waiting, uncertainty, anxiety and stress that can be caused to patients can make their symptoms worse. What may seem a small and trivial matter to the staff might seem a much bigger, more important, or even crucial matter to the patients. The Patient Request Book is a way for us to change the way in which we relate to patients and talk to each other about the many daily requests patients on a ward give to the staff. In addition we anticipate that is should reduce the times that patients give the same request to multiple nurses, or call at the office door to check on progress (both because they fear nothing is being done).

Description: Three times a day the book is taken round the ward by one of the nurses, usually at the beginning of a shift. Patients are asked if there is anything they need or that the staff can do for them. Their requests are logged in the book, and the book is kept in a patient accessible location. From that point nurses log the actions they take to try to fulfil the patient’s request, and attempt to get a satisfactory resolution within the agreed time frame. Some slippage time is to be allowed when agreeing with the patients them how long it will take to get back to them to resolve their request. Patients can check in the book to see what has been done. If the request cannot be met within the time frame, the patient should receive an explanation from the nurse in charge of the shift.

Confidentiality: Because the book is accessible to all patients, upon receiving requests, nurses should check that the patient is happy for them to go in the book. Should they decline, their request should be managed through the usual channels for the ward. Respect for patients’ feelings of privacy can be shown through choice of language placed in the Patient Request Book. A request for one to one discussion about being formally detained could be logged, for example, as discussion about ‘legal matters’, similarly a request for the provision of female hygiene products could be logged as ‘various toiletries’.

Experience of use during pilot: More complex than initially envisaged (too many requests throughout day to record, used for other purposes when left on ward), rejected and undermined by staff.

Reflection: Resistance from the staff may have had different sources. Firstly in order not to hear too many requests, or not to engage in conversation about irrational requests, as a means of managing workload. Secondly to avoid contentious emotive requests which cannot be fulfilled, for example ‘I want to be discharged’, thus avoiding the chance of starting a conflict event. Adjusting the intervention to address these underlying problematic issues might make it more successful.

Background: Growing and developing our skills is sometimes difficult in the busy atmosphere of a psychiatric ward. Either we end up learning (and perhaps learning badly) through trial and error, or we get stuck at a certain level, reaching a learning plateau for a long period of time. However psychiatric nursing is something we can always improve and do better at, however many years’ experience we have. Two major ways to improve are to become more conscious of what we are doing right and well (so we can do it more often), and by learning from each other and taking suggestions (so we try new things, or try old things again in a slightly different way or from a different position. This initiative is designed to help you to help each other grow in understanding, knowledge, skills and approaches. Primarily this will be about how we work with patients, but it may also be about how we work with each other. Perfection in psychiatric nursing practice is a goal none of us will ever reach, but one that we should all be continually striving for.

Description: For a defined period of four weeks, during the course of each shift, each nurse on duty will say one thing to increase expertise (suggestions, helpful other options, alternative approaches, what has worked in the past, new and known psychological understandings, etc.) and one thing to express support for (praise for things done well, appreciation for personal skills, sympathy for difficulties experienced and endured, etc.) every other nurse on duty. Care should be taken to do these actions in a genuine and non-stereotyped way, as that would be pointless and undermine the exercise for yourself and others. So, really observe your colleagues on duty, and find something that you really do see, and appreciate it using your own words, in a way that fits with your personality and your relationship with the other person. When receiving such encouragement, be sure to thank the other person, and to allow yourself to accept the praise without internally denigrating it or spoiling it by offsetting it against whatever you feel to be your weaknesses. Similarly, when offering suggestions take care to offer them positively and with humility, otherwise they risk being heard as criticisms. Be tentative, speak about your own experience, and offer them as something the other person might like to try in case it might work for them too. Preface interpretations of patients behaviour with ‘possibly’, ‘maybe’ and ‘perhaps’. Let the other person know that you may be wrong with your suggestion as to different approaches: ‘this might not work, but ….’, or ‘I may to totally wrong about this, but … ‘. When receiving these suggestions, take them in this spirit, even when they have been offered clumsily or were ill timed or poorly phrased. Be open to suggestions from everyone, whatever their position and role. Know that whatever your level of training, everybody has interpersonal skills and observations they can share that may well be helpful to the recipient. Assume (and assume rightly) that we all have much to learn from each other.

Experience of use during pilot: Staff disliked the idea and wouldn’t implement it.

Reflection: This may have the capacity to be really transformative of a team, even the whole multidisciplinary team, if only they have the courage to use it and go for broke!

Background: Occasionally, staff on acute wards have to use forceful means to keep patients or others safe. Although these are avoided as much as possible, sometimes it is necessary to manually restrain a patient, administer medication without their consent, place them in seclusion or transfer them to some form of intensive care. These events can be very traumatic, especially for the patient concerned, but also for the staff. It is often recommended that a debriefing of the patient should take place afterwards, but in our research we have noticed that this seldom happens. Directly after the incident is not a good time, as it would risk reigniting the conflict, or the patient is sedated, or not accessible, or too mentally disturbed and symptomatic. By the next day, a different shift of nurses are on duty, everybody is preoccupied with what is happening now, the new admissions today, the challenges that are occurring on the new shift. This means the incident is forgotten quite quickly as the ward moves on. The patient has no real chance to be guided to learn from what happened, and the staff do not have a chance to learn from knowing the patients point of view. This initiative has been designed to find a workable mechanism by which such debriefs can take place, and the learning be brought to the surface and consolidated. The anticipation is that the learning that takes place will make a repetition less likely, and yield new skills and understandings for the staff and patient.

Description: The day after any significant containment incident on the ward (specifically, a manual restraint, a coerced IM injection, seclusion, or transfer to Psychiatric Intensive Care or use of an Intensive or Extra Care Area or equivalent) the Nurse in Charge, after consulting the nursing notes/records, is to approach the patient involved and: (i) Apologise. Explain that the staff are sorry it got to that point, and that it was not the outcome the staff wanted, but the staff goal is to keep everyone safe. (ii) Ask how the patient perceived matters and what happened, and ask for suggestions on how the same outcome can be avoided in future. The results of this interview to be noted in the nursing notes and discussed at handover. If the patient concerned has been transferred to an onsite PICU or equivalent, the Nurse in Charge should seek to visit there and conduct the debriefing interview. On the shift the incident occurs, nurses are to note in the ward diary, task book or equivalent, for the next day, that the patient debriefing is to take place. So that oncoming nurses know that the interview is to be conducted that day, and can check it off once done.

Experience of use during pilot: Confused with regular debrief, central idea (apologising to patients) more complex and perhaps justifiably resisted in some circumstances.

Background: There are many reasons behind some patients' refusal of medication. One of these reasons is the sense of pressure and coercion around medication taking, and the feelings of disempowerment and humiliation that go along with them. We might not be able to give patients as much choice as they like about what or how much medication they take. However it is possible to expand their choices around the actual taking of medication in other ways, and these might reduce their resistance to taking it.

Description: Increased patient choices around medication consumption are to be provided for those who are reluctant to take it. These patients can be offered choices about: (i) When to take the medication (first or the last person to be offered their medication); (ii) What type of drink they take it with (the ward will provided with a range of alternatives which have been checked as suitable by a MH Trust chief pharmacist). This option is only for those patients taking psychiatric medications. Some drinks can interact with other drugs for physical health problems, and these medications should therefore ideally be taken with water. (iii) What type of container the drink is provided in (the ward will provided with a range of alternatives, in addition to hot and cold drinks held on the ward). (iv) A choice of sweets/snacks for after consumption, to take the taste away (the ward will provided with a range of alternatives); (v) Where they take the medication (in the clinic room, in their room, outside in the courtyard, in the kitchen – whatever locations the ward provides); (vi) Referral to the Pharmacist for further discussion/information; (vii) Referral to the medical team for prescription of alternative preparations (tablets, liquid, fastmelt) or alternative times of consumption (morning vs. midday vs. night).

Experience of use during pilot: There were logistical difficulties for the researchers in terms of keeping the wards supplied with drinks and sweets. In addition it was hard for wards to restrict the drinks/sweets only to those who were difficult are taking medication. Finally, on some of the wards, sad to say, the staff consumed the drinks.

The next interventions are those that were on our original shortlist. These were not selected by our service user and carer group or by our professional expert advisory groups. If you choose to implement these, you will need to give them more thought, adjustment and preparation:

Background: Patients who feel cared for and appreciated are more likely to cooperate with the staff. Unwittingly, some of the small things we do convey a contrary message. For example, when we come onto the ward to go on duty, the first people we speak to and greet are our fellow staff members, and we completely ignore the patients. On top of this, much of our conversation with patients is driven by necessity rather than by choice, and is often negative. ‘Please don’t do that’, ‘please come with me to see the doctor’, ‘breakfast time’ etc., so many orders and commands in comparison to the briefer times we have to sit down with patients and really chat. This intervention is a small, easy thing to do that starts the shift with a positive message to the patients from all of the staff.

Description: When coming onto the ward for the first time for the day (as long as they are not late!), each member of staff will go around the public areas of the ward and: 1. Greet every available and awake patient by name; 2. Say hello and introduce themselves to any new patients, expressing a welcome; and 3. Give a personal compliment to every patient, share with them some personal item of news, or offer some time to chat or otherwise spend time with them later during the shift. All this before entering the nursing office or seeking out other staff members to greet and exchange news with. Especial care should be taken to make sure that less popular, quieter and more difficult patients are equally included in this ritual, and that it is carried out genuinely and with a good heart. Additional care needs to be taken that compliments are socially appropriate for gender and age relationships. Older people are more likely to misinterpret compliments as being patronised, and the opposite gender may interpret them as flirtatious. It is possible to use a few words of greeting to patients in a group, and select individual members to make individual comments too, choosing the most reserved and withdrawn difficult/disliked ones. Make sure you don't disturbed those who are asleep. It will feel false and forced at first, but your task is to do it and make it real. Adapt it to yourself and your personal style. You may think this will take a lot of time, but our experience shows it can be done in just a few minutes.

Background: It is not always easy to communicate to patients who are ill our genuine concern for their welfare and our interest in making them satisfied, happy and relaxed with their inpatient experience. In order to communicate this better to patients, this initiative ensures that they are asked formally, on a regular and repetitive basis, and by a person of some nursing seniority, whether there is anything more that we can do for them. In addition, it presents a useful opportunity to assess patients' degree of wellbeing.

Description: At a suitable point during every nursing shift (including the night shift), the Nurse in Charge will walk around the ward and speak to every patient, asking the three 'S' questions: SATISFACTION Are you satisfied with everything on the ward? SAFETY Do you feel safe? STRIVE TO PLEASE Is there anything more we can do for you? As a matter of good practice, the opportunity should be used to observe and assess patients, with appropriate follow up actions.

Background: The patients who are admitted to our wards often have poor social networks, few friends, and little contact with their family. The low self-esteem engendered by this, and by the stigma of being considered mentally ill, can add to tension, irritability, and the likelihood that they will behave in a difficult fashion on the ward. On top of this, patients who behave in a difficult way are hard for us to like. Their behaviour gets in the way of us seeing their positive qualities, and our negative reaction to them makes further disruptive behaviour more, rather than less, likely. However when we positively appreciate patients, it builds up their self-esteem and it helps us build a more productive relationship with them. This initiative is designed to help the ward team focus on the positives and strengths of the patients, and to express that appreciation in the form of a small gift.

Description: The ward will be provided with a crate of small presents for patients (small sweet items [regular and diabetic], decorative items, soaps and perfumes, etc.), with cards (including some birthday cards) and wrapping paper. All the gifts have been checked for safety and appropriateness by a group of inpatient nursing experts. Each new patient will be offered a nicely wrapped gift and a card a week into their ward stay by a staff member. This gift should be based on the staff member's understanding of what might make the particular patient happy, based on what they have learned about that person. If possible, the gift should be given by the patients named nurse, but if not, by the person on duty who has the best relationship with that particular patient. The gift should be accompanied by a card, which should be signed by the available staff. The card should contain at least one handwritten message saying what the staff like, admire and appreciate about the patient concerned. This message can be reiterated when the gift is given to the patient. An additional gift should be given on patients' birthday, if this occurs during their admission. Birthday cards are also included in the crate of necessary resources for this initiative.

Background: In our interviews of patients in many research studies, we have found that patients are not always clear about the guidelines for leaving the ward. Perhaps these were never explained or communicated to them, because sometimes it was assumed that people would know, or that patients would tell each other. Sometimes, when they are explained on admission, the patient has not been in a suitable state to absorb them. Often people need to have things repeated before they truly learn or absorb them. Staff can also be confused about who is allowed to leave the ward, on what basis, for how long, to go where. And about who has to stay. That confusion and lack of clarity is easily conveyed to patients in the way we answer their questions. These sorts of confusions can lead to patients unwittingly getting into trouble and conflict with staff, including about leaving the ward and absconding. Use of a signing in and out book clarifies expectations, and provides a leaving ritual during which nurses can explain the those expectations and patients can make a commitment about when they are coming back. The presence of the book also makes more visible the process of trying to leave without permission.

Description: A large book and pen will be left in a public place appropriate to the ward concerned, either close to the front door or outside the nursing office. All those entering and leaving the ward (staff, and patients, excluding those making deliveries) at any time sign themselves in and out on a fresh page for each day. Patients who leave the ward are requested to get a nurse to countersign their departure. On leaving, ask the patient to sign the book, reminding them of the time they are due back.

Background: While some patient aggression can be easily understood, for example anybody might get irritated and annoyed with the restrictions placed on them when they are in a psychiatric ward, others are not so easily understood. Assaults can appear to come 'out of the blue' or entirely unpredictably. On these occasions, research has shown that the suspicions and paranoia of patients are an important factor. Many patients can be suspicious of staff. They may not fully understand why they have been brought into hospital and they might feel this is unjustified. They may have difficulty interpreting what goes on around them, and in confusing situations paranoid interpretations are more readily elicited. Whatever their primary diagnosis, they may to some degree a personality that perceives the world as a place that is very hostile to them, and filled with people who mean them harm one way or another. This perception can be built on powerful childhood experiences. Or they may be more formally paranoid, experiencing auditory hallucinations telling them they are at serious physical risk from the people around them, or delusional beliefs that are permeated with personal threat. The ward is a difficult environment for people with paranoid and persecutory beliefs. Some of their usual coping mechanisms are not open to them. For example, the most commonly used coping mechanism and to stay at home and steer clear of any social gathering or place (shops, pubs, public transport) where there are many strange people around, or to avoid enclosed spaces. These strategies are not easily possible on the ward, although we can make some adjustments such as allowing patients to spend more time alone or to eat alone. However we can capitalise on two other coping mechanisms used by patients – making friends/compliance, and seeking help/protection. All these things mean that patients can respond in unanticipated and extremely hostile ways, when they feel under threat. Even though in reality the reverse is the case, and all those around them seek their benefit. For the suspicious person, being threatening and aggressive towards others is a way of coping, a way of making their potential persecutors more wary. Using this initiative will help staff modify their approach to, and behaviour around such patients so as to minimise the risk of assaults occurring.

Description: How to behave in the vicinity of paranoid or potentially paranoid patients: DISTANCE Never suddenly encroaching on the patient’s space; VISIBILITY Never converse with others behind the patients back or where they cannot see if that can be avoided; DON’T LOOK Never stare at the patient or gaze in their direction; EXPLANATIONS Give extra explanations about whatever is going on and what conversations with others are about. Approaching a paranoid or potentially paranoid patient: HAIL Greet first from a distance; ORIENTATION Orient to place and person. Say who you are and what your role is (even if you think the patient should already know this), remind the patient that they are on a ward, give the name of the ward and the hospital and how long they have been there, if necessary; REASON Say what you would like to talk to them about and why; REPETITION Repeat these facts until you are sure the patient has understood them to some degree; PERMISSION Request permission to approach the patient, and only do so with their consent. Secure acknowledgement before action, or alternatively try to talk from a greater distance than usual. Certain things follow from these principles. For example, caution should be taken not to walk suddenly into rooms without warning, particularly private places like the patients bedroom. A sense of awareness needs to be developed around how paranoid patients might view the simplest of procedures, and how to make sure that negative interpretations are avoided as much as possible. Furthermore, some assaults between patients are based on paranoid misinterpretations, therefore the staff need to set an example about how to approach and deal with such patients in a safe manner. Many patients will follow the staff example, and if not, they can be advised and instructed on how to go about doing so. Patients will often avoid one of their number who is paranoid, however this will only be possible to a certain degree on a ward. Psychiatric wards tend not to be very spacious.

Background: The ward can be a confusing place for patients. All kinds of reasons lead to someone being admitted, and their ability to understand the process is affected by their psychiatric symptoms. If this is their first admission, they may not know what to expect at all. If they have been admitted before, they may have more accurate expectations, but they may also have picked up many false or only partially correct notions about what the ward is for and how it operates. This initiative aims to clarify some of these things and convey some key messages within the first few minutes of a patient arriving on the ward. Putting these messages up front and first will heighten their importance and influence the way everything is subsequently perceived and responded to. The messages are designed to bolster mutual respect and mutual help – between patients and other patients as well as between staff and patients. A ward community where everyone is seeking to assist and help everyone else is a collaborative and cooperative venture. Within such an atmosphere, conflict is much less likely.

Description: The admitting nurse to convey the following messages to newly arrived patients, in their own words:

PURPOSE - What the ward is for (keeping everyone safe, treating mental illness, assessing what help is needed, giving physical healthcare and help with everyday living);

PARTNERSHIP - The staff want to work with patients to help and support them, and their help is needed to do this;

SUPERVISION - Everyone has to watch over each other to keep all safe and well

MUTUAL SUPPORT - Everyone here supports and helps each other to get better and ready to go home

EXPECTATIONS - Bullying, abuse, drug or alcohol use and theft not tolerated, as these make people mental illness worse and get in the way of us helping each other [if the ward has a poster of mutual expectations, these can be shown to the new patient and explained to him/her

AVAILABILITY - Let the staff know if you are scared or upset; if you or someone else needs urgent help, shout; and if you need something from the nursing staff and can't find someone available on the ward, please knock at the office door (but do be aware that sometimes things get very busy, and nurses are not usually available during handover

Background: One of the major tasks of acute inpatient care is to keep people safe. This includes preventing them from harming themselves or attempting suicide. Research repeatedly shows that the places where these events take place are the private areas of the ward (bedrooms, bathrooms, toilets) and the most common times for these events to occur is in the late afternoon or evening. This initiative increases checking of these areas so that patients can be found at an early stage or be dissuaded from trying to harm themselves by the knowledge that someone is likely to come along. In addition, as a side effect, it makes staff more available to patients, increases everyone's sense of safety, and provides opportunity for brief interactions between staff and patients.

Description: During a shift, each member of nursing staff is to check all bedrooms, bathrooms and toilets twice per shift, at random times. Staff not included in the handover are to carry out one round of such checks while the handover is taking place. Night staff are also to do two rounds of checks, at random times but before midnight or before regular patient checking during sleep commences.

Background: Occasionally, staff on acute wards have to use forceful means to keep patients or others safe. Although these are avoided as much as possible, sometimes it is necessary to place a patient on constant observation, manually restrain them, administer medication without their consent, place them in seclusion or transfer them to some form of intensive care. These events can be very traumatic, especially for the patient concerned, but also for the staff. Perhaps because none of us like doing these things, we tend not to think about them as much as we should. However there has been quite a lot of research where patients have been interviewed afterwards, and we know quite a bit about how they feel during observation, seclusion and the like. Consideration of these feelings gives some hints about how we can carry out the forms of containment in a better and more respectful manner. This initiative details how this might be done.

Description of Respectful containment: Constant observation: Patients have mixed feelings – being under constant observation made them feel irritated, punished, treated like a prisoner, distressed by lack of privacy, isolated, degraded, and coerced; however sometimes it also made them feel safe, understood, accepted, and reduced anxiety and suicidal thoughts. To minimise the negative reactions: Be polite, respectful and personal. Offer as many choices as possible – what would they like to do while observed, is there anything they would like help with that they could do together (make bed, tidy room, do some laundry) or assist others (play a game with another patient, help tidy the ward, clean some dishes, tidy the kitchen, participate in groups, chat to another patient), where do they want the nurse to sit (which side), do they want the nurse to be silent or chat, etc. Explain the reason for the constant observation is not punishment, but to keep the patient safe. Give information on how and when it will be reviewed, and who has authority to discontinue it. To maximise the positive reactions: Carry out the observation thoroughly and rigorously (this will reassure the patient and potentially decrease their anxiety. Off the opportunity for a more in depth one to one talk about the things that are bothering them.

Manual restraint: Patients feel a combination of anger, fear and panic, and restraint risks reawakening memories of previous distressing or abusive events. To minimise the negative reactions: Be polite and respectful even in the face of extreme verbal abuse and the patient's attempts to hurt, punch, kick or otherwise assault you or the other nurses. Continue verbal de-escalation while the patient is being held, and remain emotionally neutral – no anger and no fear. Keep the patient oriented. Remind them who they are, that they are in hospital, remind them who your are, what the ward is and for, and remind them of previously established adult to adult relationships (e.g. my name is Dave, I'm a nurse, you'll remember I took you for a walk out the shops yesterday and we talked about football, etc). Express reluctance to continue and the wish to release the patient as soon as possible. Say exactly what the patient has to do in order to be released (e.g. be still for 5 full minutes, engage in talking calmly about what is happening, reach agreement about what is to happen next, perhaps further talking in a quiet place, taking oral prn medication, agreeing to spend time in a quiet room voluntarily, undergoing constant observation for a fixed time period, etc.). Reassure the patient that you will take care of their safety, that you don't want to cause them any pain, and that you are monitoring their physical condition, especially their breathing. Try to engage them in some calming deep breathing exercises and basic relaxation.

Seclusion: Patients feel angry or upset, lonely or abandoned, humiliated, worthless, depressed, punished, trapped and bored. Only a few patients feel calmer and safer in seclusion, for the majority the experience is predominantly negative. To minimise the negative reactions: Be polite and respectful even in the face of extreme verbal abuse and the patient's attempts to damage to seclusion room. Feelings of fear and anxiety can be allayed by supportive observation, reassurance, and company from outside the door, if it is not safe for staff to enter the room. Steps should be taken to always reassure patients that they will remain supervised, and that the seclusion will be of limited duration. Humiliation can be addressed through enhanced respect towards the patient, providing information about how they can complain or appeal. Depression can be tackled via a positive staff attitude towards the future, the description of positive goals, talk of recovery and discharge (of others seen in seclusion), and an affirmation that the staff do not hold grudges about disruptive behaviour. If the patient is bored, music, radio, newspapers, magazines etc., could be provided – although if the patient is bored the question should be raised as to whether they need to remain in seclusion. Say exactly what the patient has to do in order to be released (e.g. be calm and non abusive for 20 full minutes, engage in talking calmly about what is happening, reach agreement about what is to happen next, perhaps further talking in a quiet place, taking oral prn medication, agreeing to spend time in the seclusion room voluntarily with the door open, undergoing constant observation for a fixed time period, etc.).

Coerced IM medication: Feelings reported are predominantly negative, with fear being the most prominent, followed by anger and helplessness. It is rated by patients in England as the least acceptable form of containment, and on wards where it is used a lot, patients are more negative about all other containment methods. To minimise the negative reactions: Always offer an oral prn equivalent first. Although basic, in fraught situations this is not always done. Be polite and respectful even in the face of extreme verbal abuse and aggression. Reassure patients that they will be looked after by qualified nursing staff, will be well supervised and monitored, and will come to no harm. Try to engage them in some calming deep breathing exercises and basic relaxation.

Background: The admission of a new patient is a tense time for everyone. For the patient concerned, it may be admission, possibly unwillingly, to a totally new environment, full of unknown people, whilst they are cognitively and emotionally compromised in their ability to socially adjust. For the staff, it means a lot of extra administrative and other work, coupled with anxiety about the unpredictability of an unknown patient (or a known patient with a history of risky behaviour). For the patients in the ward, the experience is somewhat the same. They worry about how the new person is going to behave, how friendly he or she will be, and they have to adjust to the new person's interpersonal style and way of going about things. This initiative is designed to speed and smooth the adjustment of all parties to the presence of a new person on the ward, whilst at the same time affirming mutual help as a key value of the ward community.

Description: On admission each patient is introduced to a 'buddy', a patient nearing discharge, who can introduce the new patient to the ward, its layout, the routines, and to other patients. The 'buddy' can also offer friendly support and companionship. Those patients who are too disturbed to make use of the help offered by a 'buddy' when first admitted, could have one allocated a day or two after admission. The benefits are that the common culture of mutual support will be highlighted at an early stage in the patients stay, and their entry into the patient community will be eased. Any sense of isolation or feeling lost will be minimised. The mutual introduction may allay existing patients' fears about the new patient, and the 'buddy' will benefit from a meaningful contribution to the care of someone else. Lower stress all round will reduce the risks of conflict. Occasionally new friendships may be formed by the process, extending the social networks of patients on discharge. Patients who pose a serious risk to others may not be suitable for this scheme, as givers or recipients.

Background: Cognitively compromised, distracted and depressed patients might find it difficult to see that the staff really do care about them and their progress to discharge. They might find it harder to notice expressions of that care and concern, more difficult to understand them and take them on board. A slight increase in expressed care will therefore communicate that to them somewhat better. Moreover, we know two things. Firstly that staff's positive appreciation of patients is linked to lower conflict with them. Secondly, that the more we act in the way we desire, the more we come to genuinely experience the emotions that we are acting or slightly exaggerating. Together these two things mean that this initiative will lead to reductions in the frequency of conflict.

Description: A simple, small thing to do. End every interaction with patients with an expression of care, concern and warmth, in a genuine way. Each nurse needs to find their own way of doing this, but those ways might include: a warm smile; eye contact; caring expression; a couple of words of encouragement; perhaps saying 'I will be thinking off you', or 'I'm going to try and figure out a way to help'. Whatever is chosen , it should be consonant with the nurses interpersonal style, be a little more expressive than usual, and be carried out with all patients, including especially those with whom the relationship is poor or who are disliked.

Background: As caring staff we always strive to be kind to the patients we care for. Kindness is therefore an intrinsic part of our jobs and our working life. Sometimes it can get a bit loss in the rush of events and business which is the acute psychiatric ward. In addition, it is something we get paid for, a fact that patients also know. This 'getting paid for it' paradoxically undermines the very thing that the kindness represents – the valuing of the patient. Our colleagues are potentially even more neglected, they may also not always be aware of how much we care for them. In this initiative, we are seeking to reaffirm and demonstrate to patients and our colleagues that we genuinely care for them.

Description: Staff to perform a minimum of two random acts of kindness or generosity per week, one for patients and the other for each other. These acts should involve doing slightly more for someone than is necessary, something you didn't really have to do, proverbially expressed as 'going the extra mile'. Acts of kindness might include: finding something for someone, bringing something in for them, finding out come information for them, choosing to spend some extra time with them, bring in a small gift (fruit, biscuits, homemade cake), etc.

Background: Acute psychiatric wards can be very busy places. There is much to do every day, the phone rings continuously, the patients are asking for different things all the time. There is medication to give out, meals to be served, tasks to be done, new patients to be admitted, etc. All this rush and bustle means that we seldom have time to reflect upon the impact of the work on us, or to monitor what we are feeling in response to the behaviours of patients around us. Not being conscious of these effects leaves us vulnerable to acting on emotions we were barely aware we had until the reaction occurs. Sometimes those reactions are not the ones we would have preferred or have chosen if we could have approached them in a different state of mind. This initiative is designed to give us a little time to think in a structured way about our emotional responses to the patients on the ward, and therefore to give us greater choice in how we respond and behave towards them.

Description: Each member of staff, by prior arrangement with the rest of the nursing team on duty, to go to a room on the ward by themselves for 10 minutes during each shift. During that time they should: (i) Take some deep breaths and practice some relaxation techniques; (ii) Think about the shift so far, and consider whether any patient's behaviour has increased their anxiety, or led to feelings of frustration and irritation, however slight. Then to generate a couple of alternative ways to respond to these patients or their behaviours in a positive way, and to just let the negative emotional response go. (iii) Consider which patients currently on the ward they like the least, then spend some time thinking about why, and whether they can understand the patients in some other way that will portray them as more likeable. Further points for reflection could include: Think of each of the patients on the ward. Am I really hearing them, really looking at them, really noticing their state, body language, tone of voice, apparent mood. Am I attending to them or have they become objects, things in the ward? Am I just seeing them, or am I encountering them as human beings? Who have I not spoken to today? Who have I not seen at all? Can I even recall the names of everyone who is on the ward currently, could I list them?