Conflict in Context
With mental ill health being such a complex field to work in, guidance to resolve conflict requires that staff understand the difficulties faced by patients. It compels an empathetic way of working where the approach is kind and seeking to reassure, not control; where there is an emphasis on calm, compassionate communication, neutral body language and a willingness to listen. This can be a challenge for some staff who may interpret patient behaviour as deliberately confrontational or threatening, therefore training to help develop a positive and compassionate attitude is essential to reduce conflict and promote patient recovery.
Mental ill health itself is associated with genetics, coping mechanisms, childhood events, an individual’s ability to flourish independently, and environmental factors such as access to shelter, food and warmth. To promote recovery of mental ill health, the delivery of care requires an equally multi-faceted approach. Service provision aimed at improving a patient’s thoughts, feelings and behaviours include psychopharmacology, therapies, and interventions to reduce the impact of stressors in a patient’s home life. At the heart of all this are the therapeutic relationships between patients and staff.
In mental health wards, conflict between patients and staff will arise primarily because of containment, but also as a result of many secondary factors. Evidence shows that the culture of communication between staff, lack of provision of one-to-one support for patients due to pressures, patient dynamics, the physical environment of the ward, history of violence, and events going on in a patient’s home life, are all contributing factors to conflict.
The method which staff use to reduce rising conflict usually determines subsequent use of restrictive practices. For example, where staff react with personal feelings to perceived confrontational or threatening behaviour, a patient may continue to escalate, whereas an approach which is neutral and focused solely on helping the patient cope with their own emotions is likely to be successful in avoiding subsequent use of restrictive practices such as chemical restraint, manual restraint and seclusion.
Although use of these restrictive practices are sometimes compelled to prevent a patient harming themselves or others, such practices are supposed to be used as the very last resort in order to preserve patient dignity, maintain trust between patient and staff, and prevent the reoccurrence of traumatic memories of abuse.
Policy and Legal Context
The inquiry into events at Winterbourne View Hospital and research undertaken by the mental health charity Mind have been pre-emptive in influencing change around the way patient conflict is addressed. A key finding in investigations was that restrictive interventions have been used as punitive measures against patients and not only as last resort measures. Some staff have used physical restraint as an opportunity to ‘get’ patients before patients ‘get’ them. Such findings were pre-emptive in The Mental Health Act Code of Practice being updated in 2015 to offer practice guidance emphasising the need for a reduction in the use of restrictive interventions, including restraint, rapid tranquilisation and seclusion.
To accompany this, the Department of Health (DH) issued Positive and Proactive Care: reducing the need for restrictive interventions. This delivers principles focused on creating a culture of least restrictive practice, with the clear message that care providers should be aiming for proactive, not reactive, care. The document outlines that proactive care should involve full consideration of contextual reasons for a patient’s behaviour.
Influences on patients' patterns of behaviour can include traumatic anniversaries, physical health and a patient’s lack of control over the immediate world around them. Furthermore, exposure to challenging environments where there is widespread behavioural disturbance, as well as blanket rules such as restricted access to S17 leave, activities or cigarette breaks, can contribute towards escalating behaviours.
To best equip staff with the skills to reduce the impact of behavioural triggers, both an understanding of the personal and environmental influence on patient’s behaviour is important. Subsequently, the document encourages participation from commissioners, services, and managers to adopt an approach which empathises with the challenges faced by patients in restrictive settings, and which offers appropriate training for staff in areas such as active listening, self-awareness and compassionate care. Not only will this enable positive therapeutic relationships to be established between patients and staff, but it will create the foundation for successful conflict resolution and, in doing so, reduce the risk of restrictive practices being used.
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