Private and Public Sector Differences in Adverse Incidents and Restrictive Practices: Factors That Predicted Service Sector in a National Sample of Forensic Psychiatric Inpatients

Figures & data

Table 1. Participant demographics.

Variable
Age	M = 39.8 years SD = 13.2 Range = 18–79
Sex
Male	N = 183 (79.9%)
Female	N = 46 (20.1%)
Primary psychiatric diagnosis
Psychotic disorder	N = 153 (66.8%)
Affective disorder	N = 16 (7.0%)
Personality disorder	N = 58 (25.3%)
Multiple psychiatric diagnoses
Yes	N = 51 (22.3%)
No	N = 178 (77.7%)
History of ACEs
Yes	N = 167 (75.9%)
No	N = 53 (24.1%)
Mental Health Act (1983) section
None	N = 3 (1.3%)
Civil	N = 74 (32.3%)
Criminal	N = 152 (66.4%)
Length of admission	Mdn = 1–2 years (N = 67) 25th = 4–6 months (N = 37) 75th = 2–3 years (N = 38) Min = Up to 3 months (N = 21) Max = 7+ years (N = 5)
Moved across secure pathway
Yes	N = 64 (27.9%)
No	N = 165 (72.1%)
Provider type
Public sector	N = 99 (43.2%)
Private sector	N = 130 (56.8%)
Security level
Low	N = 140 (61.1%)
Medium	N = 89 (38.9%)
Provider type by security level
Private low secure	N = 89 (38.9%)
Private medium secure	N = 41 (17.9%)
Public low secure	N = 51 (22.3%)
Public medium secure	N = 48 (21.0%)

Table 2. Definitions of restrictive interventions and challenging behaviors.

Restrictive intervention	Definition
Physical intervention	The use of direct physical force to restrict freedom of movement
Restraint (not floor)	Use of taught, hands-on methods of physical restraint while the service user is either standing, sitting, or kneeling
Supine floor restraint	Use of hands-on methods of physical restraint with the service on their back, normally on a floor or bed.
Prone floor restraint	Use of hands-on methods of physical restraint with the service user ‘face down’, normally on a floor or bed
Seclusion	Isolating the service user away from other service users, normally in a designated area, from which they are subsequently prevented from leaving.
Rapid tranquilization	Involves staff administering particular medication when required immediately to manage challenging behavior. This medication can be administered orally, or via an injection.
Challenging behavior	Definition
Verbal aggression toward service users	Shouting, swearing, screaming and generally exhibiting verbal aggression toward other service users.
Verbal aggression toward staff	Shouting, swearing, screaming and generally exhibiting verbal aggression toward staff.
Physical violence toward service users	Punching, biting, kicking, pulling and pushing otherwise causing physical pain or injury to other service users
Physical violence toward staff	Punching, biting, kicking, pulling and pushing otherwise causing physical injury to staff
Sexually inappropriate behavior toward service users	Sexual disinhibition or sexual aggression toward other service users.
Sexually inappropriate behavior toward staff	Sexual disinhibition or sexual aggression toward staff.
Purposeful property damage	Breaking, or otherwise damaging, furniture, fixtures and appliances
Disruptive and/or intimidating behavior	Excessive noise, shouting, antisocial behavior or conduct with disturbs the hospitals therapeutic milieu. Bullying or behavior, which frightens or alarms other service users.
Absconding	Purposefully going absent without permission from the hospital. Not returning from leave as planned.
Illicit Substance misuse	The possession or use of illegal substances
Self-harm	Cutting self, hitting self, biting self, pulling own hair, falling to the floor or banging head
Being a victim of harm	Bullying, extortion, emotional harm from other service users

Table 3. Scoring of frequency and level of harm of patient incidents.

	Scoring
Frequency	0 = None 1 = Once to twice in the last 90 days 2 = Monthly 3 = Weekly 4 = Daily
Level of harm	0 = Not applicable or no harm 1 = Minor harm, injury, or disruption 2 = Major harm, injury, or disruption	Any patient safety incident that had the potential to cause harm Any patient safety incident that resulted in a minor increase in treatment and which caused minimal harm to one or more persons receiving NHS-funded care. Avoidable, permanent harm or impairment of health or damage leading to incapacity, disability or the loss of recovery potential. Avoidable permanent lessening of bodily, sensory, motor, physiologic or intellectual functions.
Severity	Frequency + Level of Harm score (0–6)

Table 4. Differences in frequency of use of restrictive interventions between NHS and private.

Type of restrictive intervention	Mean rank	U	Z	Observed p	Adjusted alpha
Overall restraint score	Public = 113.07 Private = 134.87	6321.5	−2.882	.004	.007*
Seclusion	Public = 107.8 Private = 120.47	7146.0	2.860	.004	.008*
Supine floor restraint	Public = 107.8 Private = 118.6	6903.0	2.678	.007	.01*
Physical intervention	Public = 106.1 Private = 121.0	7217.5	2.520	.012	.013*
Restraint (not floor)	Public = 109.3 Private = 119.4	7000.5	2.104	.035	.017
Rapid tranquilization	Public = 112.4 Private = 117.0	6691.5	.972	.331	.025
Prone floor restraint	Public = 114.5 Private = 115.4	6486.5	.873	.383	.05

U: Mann–Whitney’s U statistics; z: standardized test statistic, *: statistically significant after adjusting for alpha inflation, p <.05.

Table 5. Differences in frequency/severity of patient incidents between NHS and private.

Type of incident	Mean rank	U	z	Observed p	Adjusted alpha
Overall incident score	Public = 94.3 Private = 130.7	8481.5	4.136	<.001*	.004*
Self-harm	Public = 99.2 Private = 127.0	7997.5	3.702	<.001	.004*
Purposeful property damage	Public = 99.9 Private = 126.5	7933.0	3.608	<.001	.005*
Physical violence toward staff	Public = 98.2 Private = 127.8	8103.5	3.891	<.001	.005*
Physical violence toward patients	Public = 102.2 Private = 124.7	7699.5	3.210	.001	.006*
Verbal aggression toward staff	Public = 101.5 Private = 125.3	7772.5	2.782	.005	.006*
Verbal aggression toward patients	Public = 103.0 Private = 124.1	7622.5	2.539	.011	.007
Disruptive and/or intimidating behavior	Public = 104.1 Private = 123.32	7516.5	2.319	.020	.008
Sexually inappropriate behavior toward patients	Public = 107.8 Private = 120.5	7150.5	2.136	.033	.01
Victim of harm	Public = 107.2 Private = 120.9	7203.0	1.852	.064	.013
Absconding	Public = 112.8 Private = 116.7	6656.5	.633	.527	.017
Sexually inappropriate behavior toward staff	Public= 112.8 Private = 116.7	6653.0	.575	.565	.025
Illicit substance misuse	Public = 113.8 Private = 116.0	6558.5	.315	.753	.05

U: Mann-Whitney’s U statistics; z: standardized test statistic; *: statistically significant after adjusting for alpha inflation, p <.05.

Table 6. Prevalence of patient characteristics between NHS and private sector services.

Patient characteristic	Public (%)	Private (%)	X^2	V	Observed p	Adjusted alpha
Personality disorder	Yes = 14 (14.1) No = 85 (85.6)	Yes = 44 (33.8) No = 86 (66.2)	11.538	.224	<.001	.006*
Multiple diagnoses	Yes = 12 (12.1) No = 87 (87.9)	Yes = 39 (30.0) No = 91 (70.0)	10.378	.213	.001	.007*
Moved across secure pathway	Yes = 36 (36.4) No = 63 (63.6)	Yes = 28 (21.5) No = 102 (78.5)	6.134	.164	.013	.008
Sex	Male = 84 (84.8) Female = 15 (15.2)	Male = 99 (76.2) Female = 31 (23.8)	2.647	.108	.104	.01
Mental Health Act section	None = 1 (1.0) Civil = 25 (25.3) Criminal = 73 (73.7)	None = 2 (1.5) Civil = 49 (37.7) Criminal = 79 (60.8)	4.235	.136	.120	.013
Affective disorder	Yes = 4 (4.0) No = 95 (96.0)	Yes = 12 (9.2) No = 118 (90.8)	2.330	.101	.127	.017
History of ACEs	Yes = 77 (80.2) No = 19 (19.8)	Yes = 90 (72.6) No = 34 (27.4)	1.722	.066	.189	.025
Psychotic disorder	Yes = 65 (65.7) No = 34 (34.3)	Yes = 88 (67.7) No = 42 (32.3)	.105	.021	.746	.05

X²: Pearson Chi-sqaure; V: Cramer’s V; *: statistically significant after adjusting for alpha inflation, p <.05.