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

2. 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………

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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.).

9. 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

10. 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

11. Development of interventions
Generated ideas
July 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

12. 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

19. 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

20. 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 = )

21. Safewards channel on Youtube

22. Safewards on Twitter
Currently 301 followers, including CEOs and DoNs

23. Safewards on Facebook
732 international members, daily posts

24.
4,714 people have paid 8,324 visits to this site (so far)

25. www.safewards.net – the forum

26. 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

27. 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

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

29. 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
Join the forum, get support and help each other!
Meet the challenge, personal and professional

30. This is independent research funded by the National Institute for Health Research (NIHR) under its Programme Grants for Applied Research programme (RP-PG ) 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.