THE SAFEWARDS RANDOMISED CONTROLLED TRIAL Reducing Conflict and Containment on psychiatric wards Lead by Professor Len Bowers

Conflict CONFLICT AND CONTAINMENT Containment PRN medication Coerced IM medication Special observation Seclusion Manual restraint Time out Aggression Rule breaking Substance/alcohol use Absconding/missing Medication refusal Self-harm/suicide

THE SAFEWARDS MODEL FlashpointsConflictContainment Staff modifiers Originating domains Patient modifiers

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

THE SAFEWARDS TRIAL Aim: – Devise a set of the most feasible interventions for inpatient nurses with potentially maximal impact on conflict and containment – Subject those to a rigorous RCT.

298 Generated ideas, started to narrow down to.. 30 Consulted expert nurses and service users, got it down to.. 16 Pilot Study ( 4 Wards (2/2)) took out a further 6 10 To full Trial (31 Wards (16/15)) DEVELOPMENT OF INTERVENTIONS

Experimental intervention (Organisational) Mutual Help Meeting, Clear Mutual Expectations, Soft Words, Talk Down, Know Each Other, Reassurance, Positive Words, Bad News Mitigation, Discharge Messages, Calm Down Methods. (n = 10) + handbook Active 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 FINAL INTERVENTION LIST

MAIN OUTCOMES CONFLICT 14.6% decrease CI 5.4 – 23.5% p = CONTAINMENT 23.6% decrease CI 5.8 – 35.2% p = Mean No. of conflict and containment events/shift

Fidelity check indicated a low take up (38%) of interventions in the time frame. Multiple checking of statistics including removing outliers and modelling for missing data. Does not change results. Disappointing return of staff questionnaires. Turn it around and look as if Wellbeing Intervention makes staff fitter. Still checking. Bottom line – we recommend all 10 interventions are adopted. ADDITIONAL INFO

Trial results first announced NPNR in September 2013 Since then a programme of dissemination both nationally and internationally Initially this was combined with dissemination through social media. In December of 2103, went online DISSEMINATION

9 “International “ presentations ( Europe and Australia) 25 presentations to UK conferences, Universities, Trusts or Wards Facebook Members ( International) 100+ Twitter members ( primarily UK) Definite contact in 31/59 NHS trusts (England) 9 Identified Wards/units in Trusts additional to Trial (9) and Pilot wards (1) 2 non UK (Canada and Holland) 1 Trust has Safewards as a CQUIN or Quality standard for 2014 SINCE SEPTEMBER..

ITS ALL HERE!!!

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