Title: Reducing Conflict and Containment in Psychiatry
Funder: Department of Health (England)

Abstract: This programme aims to deliver a significant reduction in aggression and other disruptive behaviour through evidence based interventions. It will improve health outcomes, provide greater patient and staff safety, reduce injuries and staff sickness, create better staff morale, address concerns about ethnic minority care and improve the patient experience of acute psychiatric care. The disturbed behaviour of acute psychiatric inpatients, and the way that behaviour is managed, arouse considerable concern and have serious financial implications. Aggression can result in injuries, sometimes severe, to other patients or to staff, causing staff absence and hampering the efficiency of the psychiatric service. Absconding is linked to negative outcomes, invokes time consuming bureaucratic procedures, disrupts treatment, and causes staff anxiety. Self-harm or suicide attempts by patients also cause injuries and medication refusal disrupts treatment, hinders patient recovery and extends length of stay. The ways in which these behaviours are managed by staff are contentious and emotive, and there is little evidence or agreement about their efficacy. In this proposal we call behaviour that puts patients and others at risk 'conflict', and staff management procedures (e.g. 'as required' medication, seclusion, special observation, intensive care, manual restraint, and enforced medication) 'containment'. The aim of the programme is to discover what staff factors influence the frequency of conflict and containment, and to derive and rigorously test methods to reduce it. Previous research has tended to look at these events and behaviours on an individual basis. When there has been research, or trials of ways to reduce their frequency, these have been aimed at the individual types of conflict or containment, and have used less rigorous evaluation methodologies. Our previous research shows that these behaviours are related in intricate ways, and that future investigations need to take this into account. Our previous research includes several large-scale studies, some before and after trials, modelling and conceptual work. That research led to the development of a working model of staff factors in the generation of conflict and containment, formulated in 2001. Some of our more recent studies have shown that the model needs to be refined, prior to forming a basis for more rigorous and large-scale clinical trials. With this programme, we propose to build on this body of work by, in sequence, (i) confirming and extending the working model, (ii) deriving feasible interventions, and (iii) testing those interventions in a rigorous, adequately powered trial. In order to extend the model, we propose three projects. First, from two previous studies we have very large datasets. We will exploit these using multilevel modelling, structural equation modelling, and time series analysis in order the learn more about the relationship between conflict, containment and other factors. Second, we propose to complete a comprehensive international literature review looking at the evidence on staff factors in conflict and containment across all types of events. Third, we will collect data on conflict and containment from a representative sample of patients in three regions in order to investigate the sequence of events for patients. We will use the findings from these studies to revise our model and devise interventions to reduce conflict and containment. In order to test these interventions, in the second half of the programme, following a feasibility study and pilot, we will conduct an adequately powered cluster Randomised Controlled Trial. Research staff will be embedded in NHS structures and activities related to acute inpatient care at national and local levels, engaging in dissemination of research results, advising on service improvement and policy development. Collaborative public involvement will be structured throughout the programme, utilising innovative internet based methods developed locally.


Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES;7.3 MANAGEMENT AND DECISION MAKING
Health categories: MENTAL HEALTH