Six domains identify the key influences over conflict and containment rates: the patient community, patient characteristics, the regulatory framework, the staff team, the physical environment and outside hospital. The outermost ring summarises the key features within those domains that can give rise to conflict and containment events. The next ring indicates the patient modifiers, what patients can do together that influences the way in which the features of the six domains give or do not give rise to conflict and containment events. The next ring indicates the staff modifiers in a similar fashion. Where arrows exist between this ring and the outmost one, they indicate that staff also have the power to directly modify or alter the features of the domains so as to reduce the risk of conflict or containment events. The innermost ring identifies the flashpoints most closely related to the domains within which they sit, flashpoints being those events or social circumstances that are most likely to trigger a conflict or containment event in the very short term. Conflict and containment are in the centre of the model, linked by a bi-directional arrow representing the fact that while conflict can trigger containment, containment use can itself trigger conflict.
The internal structure of the ward is asserted by the staff team, and is composed of the rules of patient conduct, the daily and weekly routine as to what happens when and where, and the overall ideology asserted by the staff either overtly or implicitly by their behaviour as to the purpose of the ward and what it offers to patients. Also included in internal structure are the efficacy and efficiency with which that ideology is put into practice as shown by the timely and responsive way the ward as an organisation for delivering inpatient care operates. One common and highly visible signifier of an efficient organisation is overall cleanliness and tidiness, hence its inclusion here. Finally, the custom and practice amongst the staff team as to what happens when patients behave in ways incompatible with or disruptive of the internal structure also forms part of this domain, as choice of containment method is highly locally determined and very variable between wards, hospitals and countries.
- Staff anxiety and frustration, or rather the degree to which staff can regulate their normal emotional responses to the disruptive and behaviour of patients that threatens the internal structure of the ward. Staff anxiety accentuates patient anxiety and self-control ability, as well as hindering the nurses ability to respond in the most effective and socially skilled way. Staff frustration and anger has the capacity to amplify patient anger, or alternatively trigger catastrophic loss of self-esteem, either of which responses can trigger further or more extreme conflict behaviours.
- Moral commitments, particularly to honesty (even when it was difficult or costly), bravery (being willing to confront patients and risk violence when necessary), equality (demonstrating through a variety of ways a lack of superiority), nonjudgmentalism (eschewing large scale moral valuation of the patient), universal humanity (expression of an inclusive picture of the human race and a valuing of people despite their diversity), and individual value (an appreciation of the value of the individual person).
- Psychological understanding, meaning being able to deploy a range of alternative explanations for the difficult behaviour of patients, derived from psychological models, studies, or psychotherapeutic approaches, instead of judging patients to be morally bad and worthy of punishment. These psychological understandings thus generate different ways for staff to respond to such behaviours, as well as aiding with emotional self-regulation.
- Teamwork and consistency refers to the way in which the staff support each other practically and psychologically so as to aid emotional regulation, specifically in allowing ventilation of emotions 'off stage' and in sharing the burden of face to face contact with challenging patients. In addition the team produces consistency in asserting and applying the internal structure to patients, consistency over time, between nurses and between patients. This aids in legitimising the internal structure in the eyes of patients, supporting self-control, and dampening any sense of injustice and therefore anger.
- Technical mastery refers to the range, depth and quantity of social and interpersonal skills and responses available to the staff in order to deal with patient challenges to the internal structure, including bringing comfort to the distressed and the de-escalation of those becoming agitated, as well as skilled exercise of power and control.
- Positive appreciation indicates the degree to which the staff like and enjoy being with patients, affording them respect, compassion and companionship.
- The two way arrows indicate that in the case of the staff team domain, the internal structure itself is under the control of the staff, who determine the content of the rules and routines, or who operate efficaciously or not. Therefore the domain itself can be regarded as a staff modifier.
The flashpoints for internal structure are those moments where power and influence are exercised by staff, either when denying or refusing a patients request, asking a patient to do (or stop doing) something, communicating unwelcome news to a patient about a staff decision taken elsewhere, or when ignoring patients overt or implicit requests for assistance or support.
The features of the physical environment influencing conflict and containment rates include its quality (better quality environments evoke greater care, are more comfortable and express greater respect for patients) and complexity (more difficult to observe environments make supervision by the staff harder, and supervision suppresses suicidal impulses and enhances self-control). Other features of the physical environment relate more directly to containment, for example whether the door to the ward is locked to patients trying to exit, whether a seclusion room is available, or a psychiatric intensive care unit.
The staff modifiers of these features include the maintenance of the environment, such as speedy repairs, frequent redecorations, regular furniture replacement. including the staff's own respect for the physical environment and caring attention to it, as well as keeping the environment clean and tidy so that it looks its best. Other staff modifiers reflect the degree to which the physical environment can be adjusted to patient choices regarding colour and decoration, from choices of bed coverings and curtains through to the availability of posters and the potential for personalising bedrooms or bed spaces. A further element of staff modifiers are the ways in which staff adjust the way they operate so as to provide good patient supervision, from the use of checking routines through to being caringly vigilant and inquisitive. This refers to the staff taking an interest in patients, observing them, responding to indications of distress, and/or noticing their absence; being inquisitive to the degree that they will respond to unusual noises or unsatisfactory responses, and inquire into what is going on in an assertive manner.
Flashpoints include patient secrecy or solitude, spaces and times in which the lack of staff supervision allows the surfacing and acting upon of suicidal or self-harming instincts, or which allow abuse or bullying between patients. The degree of admission shock experienced by patients is also likely to be increased if the ward is in a deteriorated and unkempt condition. The point at which the exit is discovered to be locked may prompt either anger/resistance, or a slump in self-esteem and potential self-harm.
Stressors from outside hospital largely relate to the patients friends, family or home. Contact with friends and family, if hostile, argumentative or upsetting in other ways (for example the patients absence from important events, or an expressed need for support from the patient that cannot be provided, or the conveying of bad news of some sort such as illness, death or other loss) can give rise to distress and conflict behaviours. Some relationships with family members may be toxic or extremely stressful for patients, for example demanding parents who show no understanding of the effects of mental illness, or a major relationship with a partner which is breaking down, financial and childcare agreements after divorce, or childcare difficulties, poor bonding or even abuse and the involvement of social services. Contact with friends and family can occur via phone, email, social networking channels, letters or during visits. Other stressors from outside hospital relate to home and accommodation, for example there might be requirements for home care that that patient has difficulty in coping with while in hospital, such as bills, repairs, maintenance, as well as worries about burglary during their absence. Alternatively moves of accommodation are common during an admission, and if that move is to a less desirable place in the eyes of the patient, as discharge approaches, stress and conflict behaviour is more likely.
Staff modifiers relate to acquiring and developing a fully rounded knowledge of the patients friends and family network, coupled with an appreciation of the meaning, nature and significance for the patient of his or her relationships with them. Such full knowledge allows either the effective involvement of friend and relatives in care provision, or a fully therapeutic approach to dealing with any problems or issues, potentially involving a range of different therapeutic approaches, from parenting training, through marital or couple therapy, through to family therapy provision. Active patient support in these relationships by the staff, assisting them to manage and regulate them, offers further possibilities for modification of their potential to lead to conflict behaviour on the ward.
Flashpoints include the occurrence of an argument with a friend or family member, receipt of bad news from outside hospital, a loss or disappointment on the part of the patient, a home crisis of some sort (fire, burglary, actual or threatened loss of tenure, major reminders of bills and indebtedness).
Conflict arising from the patient community has its roots in contagion or discord. Contagion arises either because patients copy the disruptive or risky behaviour of each other, or because such behaviour on the part of other patients arouses anxiety and uncertainty, triggering certain conflict behaviours as coping mechanisms or defences. Alternatively the anxiety aroused may lead to more frequent or intense psychiatric symptoms which themselves give rise to further conflict behaviours. The other origin of conflict in the patient community is discord between patients, who are essentially living in close proximity with others they did not choose, and whose behaviour can be difficult, unpredictable, irritating or obnoxious.
In this case there are patient modifiers which influence whether contagion or discord actually give rise to conflict behaviour, and these parallel the staff modifiers relating to internal structure. For example a patient's ability to regulate their own normal emotional responses of anxiety and frustration towards the behaviour of their fellow patients, their psychological understanding of such behaviour in order to avert judgement and condemnation, their technical; mastery of social skills and repertoire of graceful social responses, their moral commitments to honesty, equality, and the degree to which the patients on the ward, as a group, offer each other mutual support in tolerating the difficult behaviours of those who at any one time are extremely disruptive.
The staff modifiers are thus largely about how the staff support and help patients respond positively to each other. Role modelling of equanimity and of skilled responses to challenging behaviour potentially equips those patients who witness it with greater skills. Giving explanations about behaviour and information of psychiatric symptoms and conditions (including formal education packages) fosters patients' psychological understanding of each other. In addition, the possibility of copycat events can sometimes be prevented by the immediate removal of the means to carry them out, for example removal from the ward of all plastic bags following patient's attempted suicide using one. The presence of staff and their good relationships with patients (presence+) allows intervention at an early stage of potential arguments, with diplomatic negotiation or other action averting irritations that may otherwise later turn into violence.
As the origins of conflict in this domain are contagion and discord, flashpoints include any occasion on which patients are brought into close proximity with each other, so any assembly, joint activity or crowding on the ward prompts interactions that can be difficult, induce misunderstandings between patients, or foster the witnessing by other patients of conflict. Those misunderstandings may be further fosters if communication between patients is made more challenging by the stress of queuing or waiting, or by a high level of noise making hearing more difficult. Bullying, stealing and property damage between patients are also incendiary and likely to lead to conflict if not managed or dealt with. Finally staff and patient turnover increases anxiety and uncertainty in the patient community, making conflict more likely.
A large variety of patient characteristics can give rise to conflict behaviour, and these fall into three groups:
- Symptoms, for example paranoia resulting in defensive aggression or absconding, specific delusions motivating irrational behaviours, auditory hallucinations such as voices instructing the patient to behave in certain ways, depression leading to suicide attempts or irritability, or use of alcohol or drugs resulting in irritability or disinhibition.
- Personality traits, perhaps especially features of antisocial personality disorder leading to instrumental aggression, or borderline personality disorder linked to self-harm.
- Demographic features, particularly being younger and male.
The staff modifiers of this are therefore the delivery of the most effective and efficient treatments, which may involve pharmacotherapy and/or psychotherapy. The speedy resolution of symptoms means reduced risks of conflict behaviour. One specific version of psychotherapy would be the functional analysis of conflict behaviours the patient does exhibit, coupled with the appropriate behaviour treatments to extinguish them. Finally general nursing support and intervention in terms of responding to patient symptoms, providing reassurance, minimising the impact of those symptoms of patients’ behaviour, all provide opportunities to reduce the risk of conflict behaviours occurring.
Relevant flashpoints in this domain include exacerbations or sudden increases or expressions of severe symptoms or illness, or any occasions on which patient freedom, liberty and independence are curtailed - issues of particular salience to young men and sensitive for those with personality disorder traits. In this way the flashpoints of the patient characteristics domain link to those already described under the staff team domain.
The external structure of the ward includes those constraints on patient behaviour dictated largely from outside the ward itself. These range from the operations of the mental health act and the coerced detention of patients in hospital against their will (resulting in patient hostility, anger, aggression and absconding), through national policy on mental health care as it impinges upon patients' journey through the psychiatric system (what is or is not provided and under what conditions, treatment, accommodation, financial benefits.), to hospital policies around complaints, appeals and prosecutions of patients for assaults or other criminal behaviour.
With the exception of hospital policy, which may be influenced by the staff delivering direct care on the wards, the rest of these things are not under staff control. However the way in which they are executed can be modified by the staff. Respect for patient rights, attention to due process, the provision of accurate information particularly in relation to appeals and advocacy, expressions of hope and positive planning for the future, support in utilising the complaints process, all enhance the patient perceived legitimacy of the external structure, reducing the frustration and hopelessness that can lead to conflict behaviours. Increasing the liberty or choices of patients in areas where this is still possible may also compensate for restrictions have to be applied.
Flashpoints in this domain are those moments in which power is exercised by the psychiatric system, potentially resulting in aggressive rebellion or collapse of self-esteem and depression on the part of patients. These include the refusal to allow a patient to leave the hospital, the enforcement of treatment, and the failure of a complaint or appeal. These moments being the patient’s situation into sharp relief and can trigger conflict behaviours.