Student psychiatric nurses' approval of containment measures: relationship to perception of aggression and attitudes to personality disorder.
Abstract
Difficult and challenging behaviour by inpatients is a feature of acute psychiatric ward life. Different methods are used to contain these behaviours, and there is international variation in which are approved of or used. Previous research suggests that staff attitudes to patients may affect their willingness to use, or choice of, method. The aim of this study was to explore the relationship between approval of containment measures, perception of aggression and attitude to personality disorder. A survey of student psychiatric nurses was conducted, and using three attitudinal questionnaires related to aggression and containment. An association was found between positive attitude to patients and the approval of containment methods that involved nurses being in personal contact with patients. There was evidence that students' attitudes to patients deteriorated over time. The results highlighted the importance of (and linkage between) staffs' feelings of anger and fear towards patients, and their preparedness to use containment measures.
Discussion
"Relationships were found between all three scales, and for one scale a linear trend over duration of training was discovered. However, as with any correlational study, these results are susceptible to a number of different interpretations. Nevertheless, they raise important questions, and suggest new avenues for enquiry."
"The positive link found between attitude to personality disorder and approval of containment was unexpected. The researchers had anticipated that the reverse would be the case, given the evidence for an association between a punitive ideology and negative attitude to personality disorder. However, when these associations are inspected more closely, it can be seen that this positive association is accounted for by strong correlations between APDQ enjoyment and intermittent and continuous observation, and to a lesser degree by correlations with open area seclusion and physical restraint. Perhaps what these containment methods have in common is interpersonal contact with the patient, whereas none of the other methods (e.g. seclusion, time out, mechanical restraint) imply that. Therefore, these correlations may be flowing out of a therapeutic concept of containment, one where the self is wielded in a relationship with the person needing to be contained in order to promote calm and safety."
"The association between high APDQ security and a consideration of containment methods as safe for patients is interesting[...] This link between feelings of personal vulnerability with patients and assessment of containment methods as unsafe for patients (to phrase the correlation the other way round) may be because of anxiety about complaints or untoward incidents, which are a feature of our culture of defensive psychiatry[... A]nxiety may impair the ability to deal with crises, result in an overly rapid deployment of containment measures, and itself be a result of previous violent incidents in which the staff member has been a victim."
"The moralistic judgement and rejection of violence as represented by POAS factor 1 (aggression is unacceptable) was, worryingly, positively related to judgements of containment measures as being safe for staff, perhaps indicating a willingness to use them based upon angry feelings towards patients[...] Some have argued that containment measures are sometimes used, not to promote safety, but to quell patients whose behaviour irritates the staff (Vorselman, 2003)."
"The finding that APDQ enjoyment declined with duration of training was disappointing, and may indicate that mental health nurse training, and its associated exposure to the widespread culture of negativity towards personality disordered patients (Gallop et al., 1989; Morgan and Priest, 1991), are damaging. Our previous studies provide differing evidence. The most recent evidence shows that brief introductory courses have a positive impact (Miller and Davenport, 1996; Bowers et al., 2003); however, our previous interviews of nurses suggested a more ambiguous situation, with some training being positive, and some the opposite (Bowers, 2002)."
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