Safewards – making wards more peaceful places Len Bowers Professor of Psychiatric Nursing and team

Conflict: potentially harmful events Containment: preventing harm Aggression Rule breaking Substance/alcohol use Absconding/missing Medication refusal Self-harm/suicide PRN medication Coerced IM medication Special observation Seclusion Manual restraint Time out Finding a way………

City-128 and manual restraint 136 wards, PCCs six months, c45k On average used once every 5 days Associated with the proportion of patients subject to legal detention, aggressive behaviours, and the enforcement of treatment and detention Greater doctor availability, less use More ethnic minority staff, less use (nul for pts) An effective ward structure of rules and routines was associated with less use

TAWS and manual restraint 16 wards, 5 years PMVA training records and official incident reports Violence increased while staff were absent on the 5 day training course Violence increased following attendance on annual updates focusing on manual restraint rather than de-escalation

CONSEQ and manual restraint 522 random patients, 84 wards, 31 hospitals, first two weeks 13% experienced restraint Physical violence the most frequent precursor, followed by less severe violence, medication refusal, and attempted absconding Most common afterwards: medication, 30% IM, 16% oral prn 1/10 times the restraint ends the events with no further containment action, 1/10 observation, 1/20 seclusion

RIDDORS (Dr L Renwick) 18/12 Riddor reports from 50% MH Trusts Restraint dangerous for nurses as well as patients Biggest single context within which nurses are injured (1/4): Struggle Breaking free After release Full results at NPNR conference in Warwick, September

New Safewards Model: Sources Research program: Absconding; attitudes to PD; City-128; City Nurses; TAWS; CONSEQ; HICON Cross topic literature review: all conflict and containment items; 1181 research studies/papers; 14 people Thinking: ordering, simplifying, reasoning, inspiration; filling in the gaps

Safewards model simple form Flashpoints Conflict Containment Staff modifiers Originating domains Patient Originating domains are categories of aspects of psychiatric wards as social and physical locations, separate from patients normal residences for the provision of 24/7 mental health care on a basis of mixed voluntary and legal coercion, which to the degree they are present or absent can influence the frequency of conflict and/or containment. Staff modifiers are features of the staff as individuals or teams, or ways in which the staff act in managing the patients or their environment, initiating or responding to interactions with patients, that have the capacity to influence the frequency of conflict and/or containment. Patient modifiers are ways in which patients respond and behave towards each other that have the capacity to influence the frequency of conflict and/or containment, and which are susceptible to staff influence. Flashpoints are social and psychological situations arising out of features of the originating domains, signalling and preceding imminent conflict behaviours. Conflict collectively names all those patient behaviours that threaten their safety or the safety of others (violence, suicide, self-harm, absconding etc.). Containment collectively names all the things staff do to prevent conflict events from occurring or seek to minimize the harmful outcomes (e.g. prn medication, special observation, seclusion, etc.).

Six originating domains STAFF TEAM: Internal structure, Rules, Routine, Efficiency, Clean/tidy, Ideology, Custom & practice PHYSICAL ENVIRONMENT: Door locked, Quality, Complexity, Seclusion, PICU/ICA, comfort/sensory rooms, ligature points OUTSIDE HOSPITAL: Visitors, Relatives & family tensions, Prospective –ve move, Dependency & Institutionalisation, Demands & home PATIENT COMMUNITY: Patient-patient interaction, Contagion & discord PATIENT CHARACTERISTICS: Symptoms& demography, Paranoia, PD traits, Depression, insight, Delusions & hallucinations, Irritability/disinhibition, young, male, abused, alcohol/drug use REGULATORY FRAMEWORK: External structure, Legal framework, National policy, Complaints, Appeals, Prosecutions, Hospital policy

Patient-patient interaction PATIENT CHARACTERISTICS PATIENT COMMUNITY Patient-patient interaction Contagion & discord Patient modifiers Anxiety management; Mutual support; Moral commitments; Psychological understanding; Technical mastery; Staff modifiers Explanation/information; Role modelling; Patient education; Removal of means; Presence & presence+ OUTSIDE HOSPITAL Visitors; Relatives & family tensions; Prospective –ve move Dependency & Institutionalisation; Demands & home Stressors PATIENT CHARACTERISTICS Alc/drugs; Depression; insight; delusions; hall.s; young Paranoia, PD traits; Irritability/disinhib; Abused; male; Symptoms& demography Flashpoints Assembly/crowding/activity Queuing/waiting/noise Staff/pt turnover/change Bullying/stealing/ prop. damage Carer/relative involvement Staff modifiers Family therapy Active patient support Psychotherapy & functional analysis; Nursing support & intervention Staff modifiers Pharmacotherapy Bad news; Home crisis; Flashpoints Loss of relationship or accommodation; Argument Independence/identity Flashpoints Exacerbations; Acuity/severity CONFLICT & CONTAINMENT Admission shock; Secrecy; Solitude; Exit blocked Flashpoints Enforced treatment; Admission; Appeal refusal; Exit refused Complaint denied; Compulsory detention; Flashpoints routines, Décor, Maintenance; Clean & Caringly vigilant & inquisitive; Checking tidy; Alternative choices; Respect Staff modifiers Consistent policy; Flexibility; Respect Legitimacy; Compensatory autonomy; Due process; Justice; Respect for rights; Hope; Information giving; Support to appeal; Staff modifiers ignoring Bad news; demand; Limit setting Denial of request; Staff Flashpoints Minor amendments/additions to this version while writing the lit review report. Pie chart expressing proportion of causal contribution? Multiplicity of routes within one sector. Summative, increases likelihood. Hardly ever one single cause of an incident. Add demography? Good for a spinner game? PICU; ICA; comfort/sensoryrooms; ligature points Door locked; Quality; Complexity; seclusion; Features Legal framework; National policy; Complaints; Appeals; Prosecutions; Hospital policy External structure REGULATORY FRAMEWORK PHYSICAL ENVIRONMENT appreciation consistency; Technical mastery; Positive Psychological understanding; Teamwork & Staff anxiety & frustration; Moral commitments; Staff modifiers Ideology; Custom & practice Rules; Routine; Efficiency; Clean/tidy; Internal Structure STAFF TEAM

Development of interventions Generated ideas July 2008- Feb 2011 298 ideas based on model, our programme of research and lit review Refined list of interventions Team ratings Selected top 30 Consulted expert nurses and service users Two groups of expert nurses and ward managers Rate feasibility SUGAR Pilot study (2012) 16 interventions Four wards in East London Conflict declined on experimental wards, containment no change Selected final interventions Feedback questionnaires Focus groups Dropped 6 of the most practically difficult and disliked interventions Full Trial Jan-June 2013

The Safewards Trial - final intervention list - Experimental intervention (organisational): clear mutual expectations, soft words, talk down, positive words, bad news mitigation, know each other, mutual help meeting, calm down methods, reassurance, discharge messages (n = 10) + handbook Control intervention (wellbeing): desk exercises, pedometer competitions, healthy snacks, diet assessment and feedback, health and exercise magazines, health promotion literature, linkages to local sports and exercise facilities

The Safewards Trial 2 randomly chosen acute/picu/triage wards at each of 15 randomly chosen hospitals (42 eligible hospitals in consenting Trusts within 100 km central London). At each hospital, wards randomly allocated to experimental or control conditions 8 weeks baseline data collection, 8 weeks implementation, 8 weeks outcome data collection Wards and their staff blind as to which was the experimental and which the control intervention until after the study Primary outcomes: conflict and containment via PCC Secondary outcomes: WAS, APDQ, SHAS, SF-36, LoS, economic Fidelity: researcher checklist and end of study questionnaire Process and reaction to change: observational reports from researchers

Main outcomes CONFLICT: 14.6% decrease in comparison to the control wards (CI 5.4 – 23.5%, p = 0.004) CONTAINMENT: 23.6% decrease in comparison to the control wards (CI 5.8 – 35.2%, p = 0.0099)

Safewards channel on Youtube

Safewards on Twitter Currently 301 followers, including CEOs and DoNs

Safewards on Facebook 732 international members, daily posts

www.safewards.net 4,714 people have paid 8,324 visits to this site (so far)

www.safewards.net – the forum

Safewards is popular 17 MH Trusts have made a commitment to implement Safewards across acute wards and other areas Safewards team has had contact with 37 MH Trusts Nursing management association for psychiatric hospitals in Germany, ditto Switzerland, the Nursing association for adherence therapy and 5 hospitals € for translation of website and materials State of Victoria, $2 million for Safewards implementation and evaluation

It’s not rocket science and it makes so much sense. It’s simple. It's really good to see so many people so enthusiastic and motivated. It's really got our team talking. It’s not rocket science and it makes so much sense. It’s simple. It’s nice to see people buzzing from this and so motivated There's been a real buzz on the ward, I think people really get it. This could potentially flip everything on it’s head and make things much better It's common sense and it makes you think about what you do and how that helps This is our chance as a team to think about what we do and start to try new approaches together Very interesting. It’s basic stuff that is actually useful and raises questions for us about actions and interventions

Safewards at a personal level “I myself, however, have incorporated the interventions into every aspect of my nursing care, and the results are fantastic”

Summary A brand new, large scope explanatory model has been formulated: the Safewards Model Its test, the Safewards RCT, has had a positive outcome We recommend that inpatient nurses implement these interventions Complementary to Starwards, which we also recommend Compatible with, and enhances AIMS accreditation There are lots of resources to help you on the web: youtube safewards channel twitter feed www.facebook.com/groups/safewards/ www.safewards.net Join the forum, get support and help each other! Meet the challenge, personal and professional www.kcl.ac.uk/mentalhealthnursing len.bowers@kcl.ac.uk

This is independent research funded by the National Institute for Health Research (NIHR) under its Programme Grants for Applied Research programme (RP-PG-0707-10081) and supported by the NIHR Mental Health Research Network. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health. www.kcl.ac.uk/mentalhealthnursing len.bowers@kcl.ac.uk