Below is the most basic form of the Safewards Model, which summarises the factors influencing rates of conflict and containment on wards, and explains why some wards have ten times as much conflict and containment than others, even though they are in the same hospital and admit the same sorts of patients. By conflict we mean all those patient behaviours that threaten their safety or the safety of others (violence, suicide, self-harm, absconding etc.), and by containment we mean all the things staff do to prevent those events from occurring or seek to minimize the harmful outcomes (e.g. PRN medication, special observation, seclusion, etc.). Our model indicates that there are a set of conflict originating factors that can give rise to specific flashpoints which can then trigger a conflict incident. The model also indicates that containment is in a dynamic reciprocal relationship with conflict, and that sometimes the use of containment can itself give rise to conflict rather than successfully prevent it. Finally, the model shows that staff can influence rates of conflict and containment on their wards at every level: by reducing or eradicating the conflict originating factors; by preventing flashpoints from arising out of them; by cutting the link between the flashpoint and conflict, i.e. the flashpoint occurs but does not lead to a conflict event; by judiciously choosing not to use containment on occasions when it would be counterproductive; and by ensuring that containment use does not lead to further conflict when it is used.

sw model

Not shown in the simplified diagram above is that conflict originating factors arise out of six domains, and each of these domains provides for differing flashpoints and therefore differing ways for staff to intervene in order to promote greater safety and decreased containment. The following table provides a summary of these:

Domain/originating factors Flashpoints Staff modifiers
Staff team or Internal Structure: Rules; Routines; Efficiency, Clean/tidy; Ideology, custom & practice Denial of request; Staff demand; Limit setting; Bad news; Ignoring Staff anxiety & frustration; Moral commitments; Psychological understanding; Teamwork & consistency; Technical mastery; Positive appreciation
Physical environment: Door locked; Quality; Availability of seclusion; Rooms; PICU or comfort/chill/sensoryrooms Complexity of layout; Hidden areas; Private areas Caringly vigilant & inquisitive; Checking routines
Outside hospital: Visitors; Relatives & family tensions; Prospective negative move; Dependency & Institutionalisation; Demands & home Bad news; Home crisis; Loss of relationship or accommodation; Argument Carer/relative involvement; Family therapy; Active patient support
The patient community or patient-patient interaction: Contagion & discord Assembly/crowding/activity; Queuing/waiting/noise; Staff/pt turnover/change; Bullying/stealing/property damage Explanation/information; Role modelling; Patient education; Removal of means; Presence & presence+
Patient characteristics, symptoms & demography: Paranoia, PD traits; Irritability/disinhibition; Abused; Male; Alcohol/drugs; Depression; Insight; Delusions; Hallucinations; Young Exacerbations; Independence/identity; Acuity/severity Pharmacotherapy; Psychotherapy; Nursing support & intervention
Regulatory framework or external structure: Legal framework; National policy; Complaints; Appeals; Prosecutions; Hospital policy Compulsory detention; Appeal refusal; Complaint denied; Enforced treatment Due process; justice; respect for rights; Information giving; Support to appeal; Legitimacy

 

The table above summarises a great deal of information about all the different ways in which both conflict and containment can arise, due to widely varying factors. To take just one example a rule that a patient cannot have, say, sharp objects in their property while they are on the ward, can give rise to an occasion on which they ask for some and are told no by the staff. If handled poorly by the staff, in a disrespectful fashion, against a background of previous inconsistent answers, this may prompt verbal aggression from the patient or worse. For internal structure, staff have some control over the content of the originating factor, therefore over whether flashpoints are likely to occur and whether those flashpoints are likely to turn into an adverse incident. The physical environment is less malleable to staff, but how they work within that environment to deliver care and supervision is very much within their control. What happens outside the hospital within the patient’s network of friends and family may not be alterable by staff, but staff can make sure they know about potential stressors, tensions and demands, and intervene quickly when these become acute or upsetting. Similarly, staff can act to shape and modify patients’ interactions and responses to each other, by fostering a positive and non judgmental approach through a variety of ways. Staff cannot choose a patient’s symptoms or the contents of their delusions, however they can deliver good treatment in a supportive and low stress environment, promoting quick recovery. Efficient and effective treatment for mental illness is a conflict reducing measure. Finally, while the framework of the mental health act cannot be changed, the manner in which it is used by staff, and way in which power is exerted, can have a significant impact on how much conflict is generated.

It is clear from this model that no single small intervention is going to solve all problems and eliminate all conflict and containment. What is required is action on a multitude of different fronts. Even then, some of the conflict originating factors are obdurate realities, such as mental illness, legislation, etc. Nevertheless staff do have considerable power and influence over conflict and containment rates by the way in which they respond to these and other conflict generating factors.