Development of a model to predict security incidents in high secure psychiatric care. An investigation into ward culture and physical environment

It has been suggested that environmental factors and the organisational culture of a forensic service hold the key to predicting and preventing incidents. However, little empirical research addresses this. This thesis aimed to develop a model that explains which factors of culture and environment impact security incidents in secure care. This can then be used in practice to aid the prediction and management of security incidents. The thesis includes four studies. A systematic literature review of 41 studies and 5 inquiries found that staff characteristics, patient interactions, the physical environment and meaningful recreation were linked to security incidents. It also highlighted a focus on aggressive incidents and a lack of research in high secure psychiatric settings. The second study of the thesis aimed to address these issues. Interviews were conducted with six security staff in high secure psychiatric services to gather detailed information about security incidents in this setting. It was found that aspects of ward culture, such as patient relationships, application of rules, engagement in activity and injustice were perceived to be associated with incidents. However, these factors were not linked to actual incident data in this study. Therefore, the third study aimed to do this. It used questionnaires to assess the perceptions of ward culture of 73 patients and 157 staff members. Record based data was used to assess if these perceptions were associated with the number of incidents on a ward. The study found that lower levels of support from staff and other patients was related to greater numbers of threat and substance incidents. In addition, levels of inappropriate behaviours were higher on wards where patients felt less involved in the service. Finally, this thesis explored the theory that the interpersonal style of staff and perceived fairness may explain why staff-patient relationships and involvement in the service were associated with incidents. Engagement in meaningful activity and the physical environment were also investigated in the final study. Using the same methodology as study three, the final study assessed the perceptions of 151 staff members and 62 patients. It found that higher levels of aggressive and non-aggressive incidents were associated with controlling interpersonal style of staff, lower perceived fairness, and fewer patients involved in off-ward activities. The perception of fair treatment and the number of patients involved in off-ward activities mediated the link between staff interpersonal style and security incidents. Based on these results, the McKenna model of security incident prediction was created. This highlights the features of wards, which increase the likelihood of security incidents. It is proposed that the model can be used to highlight wards in high secure services that are at risk of having high levels of security incidents