Nurse Education Today (2009) 29, 8390

Nurse Education Today

www.elsevier.com/nedt

Comparison in attitudes between nursing and other students in relation to containment measures for disturbed psychiatric patients
Eimear Muir-Cochrane
a

a,*

, Len Bowers

b,1

, Debra Jeffery

Chair of Nursing (Mental Health Nursing), School of Nursing and Midwifery, Faculty of Health Sciences, Flinders University, GPO Box 2100, Adelaide SA 5001, Australia b St. Bartholomew School of Nursing and Midwifery, City University, Philpot Street, London E1 2EA, UK
Accepted 10 July 2008

KEYWORDS
Nursing; Quantitative; Questionnaire; Mental health; Restraint

Summary

Aim: The aim of this study was to compare university student attitudes to containment with that of psychiatric students. Background: Nurses face the potential for aggression and violence in everyday psychiatric nursing practice and as such are by necessity required to employ measures that contain and control patients with difcult or destructive behaviours. Method: The attitudes to containment methods questionnaire was employed to gather data from a sample of non-nursing students (n = 117) and student psychiatric nurses (n = 114) at a UK University between May and September 2002. Data were analysed in SPSS using multivariate analysis of variance. Results: Signicant differences on attitudes to containment measures for the nonnursing students were found for gender, age and if the respondent had known anyone who had been a patient on a psychiatric ward. There was greater approval of physical restraint, IM medication, mechanical restraint and net beds by male respondents who were also more likely to consider containment methods acceptable and dignied. The non-nursing sample approved signicantly less of PRN medication and signicantly more of mechanical restraint and net beds than the student nurses.

* Corresponding author. Tel.: +61 (08) 8201 5907. E-mail addresses: Eimear.muircochrane@inders.edu.au (E. Muir-Cochrane), L.Bowers@city.ac.uk (L. Bowers), debrajanejeffery@ hotmail.com (D. Jeffery). 1 Tel.: +44 20 7040 5824; fax: +44 20 7040 5811. 0260-6917/$ - see front matter Crown Copyright c 2008 Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.nedt.2008.07.002

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E. Muir-Cochrane et al.
Conclusion: The views of non-nursing students differed signicantly, indicating the presence of stereotypical negative views about nurses level of responsibility in providing medical care; a greater acceptance of containment methods considered abhorrent by nursing students; and in contradiction, a lesser approval of the more severe methods of containment that are in current use. Crown Copyright c 2008 Published by Elsevier Ltd. All rights reserved.

Introduction
Despite advances in our understanding of mental illness, physical control mechanisms continue to be used in the management of acutely disturbed psychiatric patients (Meehan et al., 2004). Nurses are faced with the challenge of using a variety of containment measures in their daily work to manage potential or actual violence and to maintain a therapeutic milieu. Containment measures employed in psychiatric in-patient settings include pro re nata (PRN) medication, seclusion, special observation and in some countries, for example USA, the use of physical restraints such as shackles. Any discussion about the use of controlling measures in psychiatry raises strong feelings presumably due to the use of punitive and degrading measures (for example, spinning or dunking patients and the use of straight jackets) employed in the past ( Porter, 1987). Contemporary understandings of the humanitarian, ethical and legal issues associated with the use of containment methods attempt to balance the need for staff to protect the therapeutic milieu of the ward; the greatest good for the greatest number and the rights of the individual, who is acutely disturbed, to the least restrictive environment (Muir-Cochrane, 1996). There is a large body of literature about aggression in health settings and growing literature about the perceptions of aggression by nurses (Needham et al., 2005), as well as the practice of seclusion (Meehan et al., 2004) and mechanical restraints, but attitudes to containment practices in general have not been fully explored in the literature. News media focus on incidents of severe violence by the mentally ill (Paterson, 2006), and the mentally ill are stigmatised and rejected in society (Link et al., 1999). Such attitudes and media coverage may encourage widespread approval of methods used to contain disturbed patients. This study compared university student attitudes to containment with that of psychiatric nursing students using the attitudes to containment methods questionnaire (ACMQ Bowers et al., 2004).

The study
Aims
To compare attitudes of student psychiatric nurses with other students towards containment measures used in psychiatric settings.

Design
A questionnaire survey of university students (excluding nurses) was chosen as an appropriate mechanism to collect data economically and quickly for comparison to a pre-existing reference group of student psychiatric nurses.

Sample
The sample consisted of non-nursing students attending lectures (n = 117), between May and June 2005, at one UK University. This included groups of students at every stage of the university process from undergraduate to postgraduate and from a variety of academic subjects. All students asked to participate consented to do so. After data collection, if the students required it, the researcher spent time with the students discussing the issues and emotions which had been raised by the research. The modal age group was 2029 years old, and 61% were male. The reference group, consisted of all student psychiatric nurses attending lectures (n = 114), between June and September 2002, for a three-year training programme leading to registration as qualied psychiatric nurses, at the same UK University as the student sample. This included groups at every stage of the training process, from new starters through to those nearing nal qualication. All students asked to participate consented to do so. The modal age group was under 30 years of age, and 61% were female. An analysis of this sample has been reported in more detail in a previous paper (Bowers et al., 2004).

Comparison in attitudes between nursing and other students in relation to containment

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Data collection methods

The attitude to containment measures questionnaire (ACMQ, Bowers et al., 2004) was used. This questionnaire names, denes and pictures 11 methods of containment and asks respondents to rate each method for acceptability, efcacy, safety for staff, safety for patients, dignied for patients and preparedness of the respondent to use that method. The questionnaire is accompanied by denitions of each method, coupled with photographs of its use. Ratings are via a ve point Likert scale, ranging from strongly disagree (1) to strongly agree (5). For each containment method, ratings of overall approval were obtained by summing each individuals ratings of its acceptability, efcacy, etc., producing 11 method-specic scores in total. Overall ratings of containment as a whole (i.e. all methods together) were obtained by summing all scores to produce an efciency score, all for acceptability to produce and acceptability score, etc., producing six types of approval score. Physical restraint was dened as physically holding the patient, preventing movement, whereas mechanical restraint was dened as the use of restraining straps, belts or other equipment to restrict movement. The questionnaire was adapted slightly for the non-nursing sample to provide slightly clearer descriptions of some of the containment methods. PRN medication was altered to extra medication. The sentence of greater intensity than that which any patient normally receives was removed from the description for intermittent observation and constant observation. Two questions were also added: Do you know anyone who has been a patient in a psychiatric ward? and Have you ever visited or seen inside a psychiatric ward? The information and instructions on how to complete the questionnaire were also adapted to make it more intelligible to people with no work experience of psychiatry.

Data analysis
Data from both samples was entered into SPSS v12 for analysis. The non-nursing cohort was rst examined utilising descriptive statistics to compare their approval of different methods. Independent samples t-tests were then used to assess whether previous experience of psychiatry was associated with differences in scores for the non-nursing questionnaire. The non-nurses were then compared to the nursing sample using multivariate analysis of variance, with age and gender entered as xed factors to control for differences in the age and gender composition of the two samples. Wilks Lambda was used to test for overall differences between the two samples, and for age and gender effects (Wilks, 1932). Differences between the two samples in the approval of individual containment methods were described using estimated marginal means (what the means would have been with no age and gender differences between the two samples). Bonferroni adjustments were made for multiple comparisons when assessing the signicance of differences between the two samples in approval of individual containment methods. Partial etasquared is reported as an indicator of effect size for these results (SPSS, 1997).

Results
The non-nursing cohort
For the non-nursing sample, the means and standard deviations of the attitude to containment scores are provided in Table 1. Intermittent observation, constant observation and time out are the measures which receive the highest method-specic approval ratings, whilst net beds, PRN medication, and mechanical restraint receive the lowest. Seclusion and IM medication (used in the UK) are almost as disapproved of as mechanical restraint and net beds (not used in the UK). Signicant differences on attitudes to containment measures for the non-nursing students were found for gender, age and if the respondent had known anyone who had been a patient on a psychiatric ward. There was greater approval of physical restraint (t = 2.68, df = 115, p = 0.008), IM medication (t = 2.33, df = 115, p = 0.021), PICU (t = 2.74, df = 115, p = 0.007), mechanical restraint (t = 4.09, df = 115, p = 0.000) and net beds (t = 3.66, df = 115, p = 0.000) by male respondents who were also more likely to consider containment methods

Ethical considerations
Ethical approval was obtained from the Senate Ethics Committee of City University, and permission to approach students to invite them to participate in the research was given by the Dean of the School. Students were provided with information about the study and informed that their participation was purely voluntary, the questionnaire was anonymous and they were free to withdraw without prejudice, at any stage of the data collection phase of the study.

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E. Muir-Cochrane et al. acceptable (t = 2.58, df = 115, p = 0.011), dignied (t = 4.06, df = 115, p = 0.000) or would be prepared to use them (t = 2.74, df = 115, p = 0.007). As there were very few numbers in the under 20 and 4049 age groups, the groups were collapsed into two smaller groups of under 30 and 30 years and older. The 30+ age group considered containment to be more effective than the under 30 age group (t = 2.93, df = 115, p = 0.004). If a respondent had known anyone who had been a patient on a psychiatric ward then they were less likely to consider containment methods dignied for the patient (t = 1.98, df = 115, p = 0.050). No differences were found between those who had visited a psychiatric hospital and those who had not.

Std. Dev Std. Dev Mean

Sum total approval Prepared to use

0.97 1.16 0.76 1.08 0.91 1.06 0.89 1.01 0.97 1.12 0.95 3.22 3.15 3.98 2.86 3.65 2.92 3.30 2.88 3.68 2.42 3.34 0.83 0.92 0.73 0.96 0.92 0.89 0.85 0.97 0.92 1.07 0.83 3.27 2.91 4.01 2.99 3.56 2.84 3.48 2.91 3.82 2.84 3.59

17.50 18.81 23.68 17.93 21.81 17.88 20.93 17.65 22.19 16.10 20.93 36.30 5.41 35.53 6.83

Safe for patient

Mean

Std. Dev

Mean

1.72 4.16 3.21 4.49 3.87 4.23 3.55 4.16 3.99 4.67 3.89

Nurses and non-nurses compared

Fig. 1 displays the means approval scores of different containment methods by the two groups (corrected for age and gender differences between samples). Any overall rating above the horizontal reference line indicates overall approval, any below overall disapproval. Non-nursing students opinions were less differentiated between containment methods, with overall approval scores ranging from 16 to 24 in comparison to the psychiatric nursing students range of 1124. Using multivariate analysis of variance to control for age and gender effects in the two different samples, there were signicant differences between student nurses and the non-nursing sample. These are summarised in Table 2. There were signicant overall differences between the non-nurses and the mental health student nurses (Wilks Lambda = 0.63, F(11,201) = 10.39, p < 0.001), and by age (Wilks Lambda = 0.71, F(33,593) = 1.60, p = 0.009) in the approval of different containment methods, but there was no difference by gender. Two interaction terms were also signicant, age x gender (Wilks Lambda = 0.73, F(11,201) = 1.5, p = 0.022) and gender x sample (student nurses versus non-nurses) (Wilks Lambda = 0.90, F(11,201) = 1.93, p = 0.038). There were no signicant differences between student nurses and the non-nursing students in assessment of efcacy, acceptability, safety, etc. of the containment measures as whole. The non-nursing sample approved signicantly less of PRN medication (p < 0.001) and signicantly more of mechanical restraint (p = 0.001) and net beds (p < 0.001) than the student nurses. A trend toward lesser approval of seclusion was also present (p = 0.059).

Safe for staff

Std. Dev

0.92 0.94 0.83 0.84 0.90 0.91 0.72 0.93 0.99 0.96 0.92 1.00 1.04 0.85 0.98 0.84 0.95 0.85 0.96 1.00 0.97 0.96 0.84 0.97 0.66 0.96 0.80 1.01 0.77 1.03 0.73 1.01 0.82 2.46 3.39 4.15 2.90 3.86 2.81 3.68 2.72 3.98 2.35 3.72 0.67 0.87 0.82 0.93 0.75 0.87 0.75 0.93 0.74 1.05 0.78 PRN medication Physical restraint Intermittent observation Seclusion Time out IM medication PICU Mechanical restraint Constant observation Net bed Open area seclusion 2.53 3.60 3.82 2.95 3.42 3.57 3.53 3.38 3.88 3.06 3.56 2.43 2.66 3.85 2.42 3.87 2.32 3.28 2.23 3.55 2.01 3.52 3.59 3.06 3.88 3.78 3.44 3.39 3.64 3.47 3.28 3.40 3.16

Mean attitude to containment measures scores for the non-nursing sample

Std. Dev

Dignied

Acceptability

Std. Dev

Std. Dev

Efcacy

Mean

Summed total score

Table 1

37.30

4.02

36.06

Mean

4.54

32.19

Mean

5.05

38.08

Mean

4.67

Comparison in attitudes between nursing and other students in relation to containment

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Figure 1

Comparison chart of nurses and non-nurses, with reference line for neutral opinion.

Male subjects approved signicantly more of mechanical restraint (p = 0.016) than female subjects, with a trend towards greater approval of compulsory IM medication (p = 0.09). Male subjects were more prepared to use containment (p = 0.007), and exhibited a trend towards considering containment in general signicantly more effective (p = 0.051).

Discussion
The high levels of approval of less restrictive forms of containment (intermittent observation, constant observation and timeout) were acknowledged by both cohorts of students, and reect a generally libertarian societal attitude. The less differentiated opinions of non-nurses on containment methods perhaps indicates that they felt less strongly one way or the other, or were more reluctant to make an assessment about things with which they were unfamiliar. In this case some of the differences between the two sets of scores may be due to these less extreme attitudes as expressed by non-nurses. However examination of Figure 1 demonstrates that the differences were deeper than this. There were some methods for which there is a real disjunction between the nurses and nonnurses. PRN medication was both more disapproved of by the non-nurses than coerced IM medication, and much more disapproved of than the comparison group of nurses. This was the rst item to be rated on the ACMQ, and its low rating by the nonnurses might be due to a degree of shock with being faced with the reality of psychiatric care. However much worse appears in the media, both ctional and non-ctional. Feedback from the researcher collecting the data (DJ) was that subjects responded adversely to the idea of powerful psychotropic medication being administered at the discretion of nurses, rather than doctors.

Interactions
Examination of the charts of the estimated marginal means for individual containment method scores showed that the age x gender signicant interaction was due to rising approval rates of mechanical restraint in males over 39 years old in the non-nurses and males over 49 in the student nurses, coupled with a lowered approval rates for females over 39 years old for both samples. The gender x sample signicant interaction was due to a more approval of net beds by male compared to female non-nurses and a less approval by male compared to female student nurses. There was also a signicant gender x source interaction with regard to approval on mechanical restraints. Both male non-nurses and male student nurses have greater approval of mechanical restraint than their female counterparts, but with male non-nursing students having greater approval than male student nurses. Female student nurses, however, had greater approval of mechanical restraint than female non-nursing students.

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Table 2

Estimated marginal means and tests of between subjects effects Non-nursing versus MH nursing students Non MH F nursing nursing Sig. Partial g
2

Age group Under 3039 4049 50 and F 30 over 20.85 18.53 23.14 18.28 22.83 17.34 21.02 15.76 21.66 13.41 20.28 37.99 36.09 30.82 37.21 35.98 35.03 20.22 19.02 23.82 18.28 22.34 19.45 21.81 15.61 23.08 13.55 20.56 39.34 37.21 30.97 38.00 35.94 36.30 20.19 16.95 25.52 17.17 22.66 18.08 21.73 15.40 18.20 14.72 20.64 38.40 35.22 29.39 37.51 35.21 34.92 19.37 21.25 23.25 22.88 24.25 22.75 23.03 20.85 25.63 9.37 21.53 43.25 39.55 36.08 41.84 37.06 38.42 Sig. Partial g
2

Gender Male Female F Sig. Partial g2

PRN medication Physical restraint Intermittent observation Seclusion Time out Compulsory IM PICU Mechanical restraint Continuous observation Net bed Open area seclusion Efcacy total Acceptability total Dignied total Safe for staff total Safe for patients total Prepared to use total

17.24 17.86 24.70 16.75 22.17 18.02 21.05 17.50 20.17 16.33 20.88 38.20 35.14 30.47 38.52 35.82 34.85

22.54 19.17 23.53 20.02 23.35 19.61 22.25 15.47 22.75 10.94 20.46 40.02 37.79 31.76 37.93 35.97 36.59

68.88 <0.001 0.246 0.30 0.582 0.001 1.40 3.61 0.74 0.19 0.77 11.64 1.91 0.238 0.007 0.059 0.390 0.663 0.381 0.001 0.017 0.004 0.001 0.004 0.052

2.50 0.061 0.034 0.51 0.674 0.007 1.60 0.191 0.022 1.28 0.63 2.34 0.42 2.86 0.282 0.594 0.075 0.740 0.038 0.018 0.009 0.032 0.006 0.039

21.04 19.50 19.41 17.81 24.83 23.23 19.06 23.30 20.05 22.27 17.80 18.17 22.39 17.81 21.20 14.89

3.49 0.063 0.016 1.81 0.180 0.008 2.71 0.101 0.013 0.47 0.68 2.90 0.87 5.91 0.495 0.412 0.090 0.353 0.016 0.002 0.003 0.014 0.004 0.027

0.168 0.009

0.98 0.405 0.014 0.86 0.462 0.012 0.22 0.880 0.003 0.96 0.415 0.013 0.67 0.573 0.009 1.93 0.126 0.026 1.01 0.390 0.014 0.21 0.892 0.003 0.69 0.558 0.010

21.95 21.34 13.48 13.01 21.64 19.64 40.46 38.02 37.69 35.62 32.41 30.01 39.12 37.24 36.94 34.87 38.17 33.52

0.24 0.627 0.001 0.15 0.699 0.001 2.59 0.109 0.012 3.85 0.051 0.018 2.26 0.135 0.010 2.93 0.088 0.014 1.76 0.186 0.008 1.85 0.176 0.009 7.48 0.007 0.034

18.41 <0.001 0.080 0.44 0.507 0.002 0.42 2.57 0.01 2.06 0.02 0.51 0.519 0.002 0.110 0.012 0.911 0.000 0.153 0.010 0.879 0.000 0.475 0.002

E. Muir-Cochrane et al.

Comparison in attitudes between nursing and other students in relation to containment Non-nurses responded much more mildly to the idea of the Net bed than did nurses. Net beds, or cage beds, as they are sometimes known, have been widely used in Eastern Europe, and widely criticised. The Czech Republic in particular has come under some international pressure to stop the use of these devices (BBC, 2004), with the famous childrens author J.K. Rowling becoming involved in the campaign (Rowling, 2004), and their abolition being a criterion for the Czech Republics accession to the European Union. UK psychiatric nursing students clearly shared this abhorrence in a way that the non-nursing students did not. The non-nursing students put net beds in the same bracket at they put seclusion and PRN medication, both of which are widely used in the UK. Even mechanical restraint was more approved of by the non-nurses, whilst the oating of the idea it might be reintroduced into psychiatry caused an intense media debate recently (Guardian, 2005). Non-nursing students can probably be taken as representative to some degree of the general public in relation to knowledge about, and attitudes to psychiatry. These ndings therefore imply that, were the UK general public to be more widely aware of current practice in the management of disturbed patients, they would both criticise the use of medication and seclusion, whilst at the same time nding psychiatric professionals strong feelings of abhorrence towards the use of mechanical devices neither comprehensible nor acceptable. Previous analysis of the student nurses data (Bowers et al., 2004) showed that they did not go through a process of acquiring strong negative opinions about mechanical restraint and net beds, but entered nursing with those negative evaluations that stayed the same throughout training. In conjunction with these ndings from non-nurses, this indicates that abhorrence towards mechanical restraint is not a product of enculturation to the institution of psychiatry, but that psychiatry attracts workers who are more likely to have those negative evaluations to start with. Student nurses may have different moral and personality characteristics that lead them to pursue a career in psychiatric nursing. Furthermore, if the non-nurses views are representative in some way of wider public views, we may hypothesise that this does not happen in countries where mechanical restraint is widely used (i.e. selective recruitment of disapprovers does not occur or those more approving are drawn into psychiatry), or that similar people are recruited into psychiatry in those countries, but are encultured into acceptance of mechanical restraint/net beds. Either way this raises important practical and moral questions for those countries

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(most of the world) where mechanical restraint is used. Respondents knowledge of someone who had been a patient on a psychiatric ward decreased their acceptance of containment methods as dignied. Interestingly however, having been to a psychiatric ward had no effect on respondents attitudes suggesting that personal involvement or knowledge of someone with a mental illness was the potent inuence. This is supported by research that found an association between positive attitudes to patients and the approval of containment methods that involved nurses being in personal contact with patients (Bowers et al., 2007). Across both groups, men believed containment to be more effective, Mechanical Restraint to be better, and declared themselves more prepared to use containment, in comparison to women. This greater male approval suggests containment use is linked to gender roles and greater aggression in males (Mischel et al., 2004). Approximately onethird of nurses working in acute psychiatry are male, suggesting that gender may have a signicant impact on the care delivered to patients. As older males show even greater levels of containment approval, this either indicates a gradual growth in conservatism with age, or reects a cohort effect, with younger cohorts of men expressing their gender in a less aggressive manner. The interactions between age and gender in this dataset are complex, and may reect the effects of changing cohorts, change of views with age, wider social trends, or a combination of all three.

Limitations
Some caution must be expressed about the representativeness and durability of the ndings. For the student nurse sample, only half the sample pool of student nurses participated in the study (mainly due to non- or late attendance at classes, rather than refusal to participate), and there maybe a degree of non-response bias in the results. For the non-nursing students, data collection occurred in May and June, when many students had already completed their studies for that year.

Conclusions
The views of non-nursing students differed signicantly from those of nursing students, in ways that indicated (a) the presence of stereotypical negative views about nurses level of responsibility in providing medical care; (b) a greater acceptance of containment methods considered abhorrent by

90 nursing students (mechanical restraint and net beds); and (c) in contradiction, a lesser approval of the more severe methods of containment that are in current use (physical restraint and seclusion). The rejection of mechanical restraint by UK psychiatric professionals is due to the selective recruitment of people with such views, rather than an impact of enculturation to psychiatry as an institution. Disapproval of Mechanical Restraint is not a feature of UK culture as a whole. Personal involvement with the mentally ill reduces approval of containment by non-nurses, whereas the male gender role is associated with greater approval. Further exploration is warranted to explore wider social and cultural trends and their effect on attitudes of the general public towards the mentally ill and how they are treated.

E. Muir-Cochrane et al.
ization process: the case of containment methods for disturbed patients. Nurse Education Today 24, 435442. Bowers, L., Simpson, A., Alexander, J., Ryan, C., Carr-Walker, P., 2007. Student psychiatric nurses approval of containment measures: relationship to perception of aggression and attitudes to personality disorder. International Journal of Nursing Studies 44 (3), 349356. Guardian, 2005. Call for restraint to tackle violent mental health patients. <http://www.guardian.co.uk/medicine/story/ 0,,1404144,00.html> (viewed 1.12.2006). Link, B.G., Phelan, J.C., Bresnahan, M., Stueve, A., Pescosolido, B.A., 1999. Public conceptions of mental illness: labels, causes, dangerousness, and social distance. American Journal of Public Health 89 (9), 13281333. Meehan, T., Bergen, H., Fjeldsoe, K., 2004. Staff and patient perceptions of seclusion: has anything changed? Journal of Advanced Nursing 47 (1), 3338. Mischel, W., Shoda, Y., Smith, R.E., 2004. Introduction to Personality: Towards an Integration. John Wiley and Sons, New Jersey, USA. Muir-Cochrane, E., 1996. An investigation into nurses perceptions of secluding patients on closed psychiatric wards. Journal of Advanced Nursing 23, 555563. Needham, I., Abderhalden, C., Halfens, R., Dassen, T., Haug, H., Fischer, J., 2005. The effect of a training course in aggression management on mental health nurses perceptions of aggression: a cluster randomised controlled trial. International Journal of Nursing Studies 42 (6), 649655. Paterson, B., 2006. Newspaper representations of mental illness and the impact of the reporting of events on social policy: the framing of Isabel Schwarz and Jonathan Zito. Journal of Psychiatric and Mental Health Nursing 13 (3), 294300. Porter, R., 1987. Mind Forgd Manacles: A History of madness in England from the Restoration to the Regency. Athlone, London. Rowling, J.K., 2004. J.K. Rowling Ofcial Site: cage beds. <http:// www.jkrowling.com/textonly/en/links_cb.cfm> (viewed 1.12. 2006). SPSS, 1997. SPSS Advanced Statistics 7.5. Chicago, USA, SPSS Inc. Wilks, S., 1932. Certain generalizations in the analysis of variance. Biometrika 24, 471494.

Acknowledgements
LB was responsible for the study conception and design, EMC and LB were responsible for the drafting of the manuscript. DJ performed the data collection and DJ & LB data analysis. Funding N/A, administrative support N/A. LB provided statistical expertise. EMC and LB made critical revisions to the paper. LB supervised the study.

References
British Broadcasting Corporation, 2004. Czech mans week in a cage. <http://news.bbc.co.uk/1/hi/programmes/crossing_ continents/3873123.stm> (viewed 1.12.2006). Bowers, L., Simpson, A., Alexander, J., Ryan, C., Carr-Walker, P., 2004. Cultures of psychiatry and the professional social-

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