1. Safewards: Model refresher

2. Conflict Containment Safewards definition of conflict and containment Events that threaten staff or patient safety, including verbal abuse, physical aggression to others, self-harm, suicide and absconding Things staff do to prevent events or minimise harmful outcomes, including use of extra sedating medication, special observation, restraint and seclusion

3. Task: How have you been using Safewards in practice? 1. Explain the relationship between conflict and containment 2. Identify opportunities where nurses can intervene 3. Generate ideas for change that have the potential to reduce conflict and containment

4. Task: Name the six domains 6. Outside hospital Flashpoint 5. Physical environment 4. Staff team 3. Regulatory framework 2. Patient characteristics 1. The patient community Definition: Social and psychological situations arising out of features of the originating domains, signaling and preceding imminent conflict behaviours Domains

5. 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

6. Patient Characteristics Staff modifiers CONFLICT CONTAINMENT & Staff modifiers Patient Community Outside Hospital Physical Environment Staff Team Regulatory Framework

7. Can you give examples from practice for the following? Reducing or eradicating the conflict originating factors Preventing flashpoints from arising Cutting the link between the flashpoint and conflict Choosing not to use containment when it would be counterproductive Ensuring that the use of containment does not lead to further conflict Patient modifier examples

8. Summary of the model Originating domains Flashpoints Conflict Containment Patient modifiers Staff modifiers

9. Task: Spin the Safewards model

10. Task: Pin the intervention on the Safewards model

11. Overview of originating domains

12. Staff team domain Internal structure Rules, routines, efficiency, clean/tidy, ideology, custom, practice Staff modifiers Staff anxiety and frustration, moral commitments (honesty), psychological understanding, teamwork and consistency, technical mastery, positive appreciation, education/training, clinical supervision, model skills, challenge each other, review care provided, focus on flashpoints, finding better ways to manage them (reduce number of rules, pre-empting needs) and set limits Flashpoints Denial of request, staff demand, limit setting, bad news, ignoring

13. Physical environment domain Better quality environment versus complexity (observation/supervision) Features Door locked, quality of environment, speedy repairs, complexity, seclusion rooms available, PICU, ICA, comfort/sensory rooms, ligature points Staff modifiers Vigilant and inquisitive, checking routines, décor, maintenance, clean and tidy, alternative choices, respect Flashpoints Secrecy, solitude, admission shock, exit blocked

14. Outside hospital domain Stressors Visitors, relatives and family tensions and relationships, missing out, dependency and institutionalisation (absconding), demands and home Staff modifiers Carer/relative involvement, family therapy, active patient support, awareness, important factors from outside that can influence behaviour on the unit (financial circumstances, support to resolve issues with family and friends, accommodation-checked on/leave to visit) Flashpoints Bad news, home crisis, loss of relationship or accommodation, argument

15. Patient community domain Patient-patient interaction Contagion and discord (copying behaviours, impact of others’ behaviour, living with others, meal times and medication times) Patient modifiers Anxiety management, mutual support, moral commitments, psychological understanding, technical mastery Staff modifiers Explanation/information, role modelling, patient education, removal of means, presence and presence+ (getting in early), conflict resolution, pre-emptive reassurance, managing level and fluctuation of activity on the unit Flashpoints Assembly, crowding, activity queuing, waiting, noise, staff/patient turnover or change, bullying, stealing and property damage

16. Patient characteristics domain Symptoms and demography 1.Symptoms: paranoia-defensive aggression/absconding, specific delusions, depression-suicide attempts/irritability, use of substances, irritability or disinhibition 2.Personality traits: features of ASPD, instrumental aggression 3.Demographic: particularly being younger and male Staff modifiers Pharmacotherapy, psychotherapy and functional analysis; nursing support and intervention; enhance choices, freedom and control over circumstances; develop mutually respectful partnership; therapeutic community; authoritarianism-counterproductive; CBT; social skills training; TIC responses; choices over how to respond. Only a few people account for the majority of aggressive incidents, therefore: 1.change responses after the first event to avoid subsequent events 2.target therapeutic interventions Flashpoints Exacerbations, independence, identity, acuity, severity

17. Regulatory framework domain External structure Legal framework, national policy, complaints, appeals, prosecutions and hospital policy Staff modifiers With the exception of hospital policy, these modifiers are not under staff control (RRI); however, the way they are carried out can be. Procedural justice, respect for rights, hope, information giving, support to appeal, legitimacy, compensatory autonomy, consistent policy, flexibility, effective complaints process, policy targeted at RRI, choices (such as more activities, meals, snacks), intervene to address hopelessness and self-stigmatisation. Flashpoints Compulsory detention, admission, appeal refusal, complaint denied, enforced treatment and exit refusal

18. Task: Reviewing the Safewards model and concept What questions do you have about the Safewards model? What did you find difficult to explain? Where might further information be useful?

19. Minister of Health Consumer group Psychiatrists CEO Len Bowers Safewards Prepare a two-minute presentation to sell the value and benefits of Safewards to a person or group Task: Selling the model and benefits

20. Task: Selling the Safewards model The Minister of Health The Minister has been in office for less than two weeks and is trying to understand the new initiatives that have been funded to determine which she will continue to support in light of her pre-election commitments. You have been chosen to present Safewards to the Minister. Victorian AMA Psychiatrists Group It has been bought to the attention of the AMA that a group of nurses is introducing an initiative called Safewards. Recently the AMA was approached by one of the services looking for support and participation by their psychiatrists. The AMA knows very little about Safewards. You have been chosen to present to the CEO of the AMA and AMA’s lead psychiatrist. Scenarios

21. Task: Selling the Safewards model CEO The CEO has heard about Safewards from others outside the service but is interested to know more from an independent source. He is wondering if it has a place in your service. You have been chosen to present to the CEO. Consumer group Some consumers have noticed changes on the ward and are wondering what Safewards is all about and how it will affect them. You have been chosen to present to the consumer group. Professor Len Bowers Len and his team are visiting Melbourne to hear how their model is being applied in the Victorian context. He is concerned there might be some changes in the theory and practice. You have been chosen to present. Scenarios

22. Task: Role play

23. Safewards feedback Paste in some feedback from staff, patients and family here about the impact Safewards has had to date

24. Task: Fidelity comments to consider Professor Len Bowers has made some comments in relation to Safewards - discuss these statements as a group If your intervention doesn’t alter any of the ‘staff modifiers’ identified in the Safewards model, then it isn’t a Safewards intervention, and it probably won’t do anything to make your ward a safer place, even though it might make it nicer in other ways. Although many Safewards interventions can be done creatively, that doesn’t mean anything creative or arty is a Safewards intervention. None of the interventions will work if you and your team don’t actually do them!