Safewards – making wards more peaceful places

Len Bowers

Professor of Psychiatric Nursing

and team

Conflict: potentially harmful events

• 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

Containment: preventing harm

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

1. Research program: Absconding; attitudes to PD; City-128; City Nurses; TAWS; CONSEQ; HICON

2. Cross topic literature review: all conflict and containment items; 1181 research studies/papers; 14 people

3. Thinking: ordering, simplifying, reasoning, inspiration; filling in the gaps

Safewards modelsimple form

Flashpoints Conflict Containment

Staffmodifiers

Originatingdomains

Patientmodifiers

Six originating domains1. STAFF TEAM: Internal structure, Rules, Routine, Efficiency,

Clean/tidy, Ideology, Custom & practice2. PHYSICAL ENVIRONMENT: Door locked, Quality, Complexity,

Seclusion, PICU/ICA, comfort/sensory rooms, ligature points3. OUTSIDE HOSPITAL: Visitors, Relatives & family tensions,

Prospective –ve move, Dependency & Institutionalisation, Demands & home

4. PATIENT COMMUNITY: Patient-patient interaction, Contagion & discord

5. PATIENT CHARACTERISTICS: Symptoms& demography, Paranoia, PD traits, Depression, insight, Delusions & hallucinations, Irritability/disinhibition, young, male, abused, alcohol/drug use

6. REGULATORY FRAMEWORK: External structure, Legal framework, National policy, Complaints, Appeals, Prosecutions, Hospital policy

PHYS

ICA

L EN

VIR

ON

MEN

TO

UTS

IDE

HO

SPIT

AL

PATIENT COMMUNITY

PATIEN

T CH

AR

AC

TERISTIC

SR

EGU

LATO

RY FR

AM

EWO

RK

STAFF TEAM

Patient-patient interactionContagion & discord

Internal StructureRules; Routine; Efficiency; Clean/tidy;

Ideology; Custom & practice

Feat

ures

Doo

r loc

ked;

Qua

lity;

Com

plex

ity;

secl

usio

n;

PIC

U; I

CA

; com

fort/

sens

oryr

oom

s; li

gatu

re p

oint

s

Symptom

s& dem

ography

Paranoia, P

D traits; Irritability/disinhib; A

bused; male;

Alc/drugs; D

epression; insight; delusions; hall.s; young

Stre

ssor

s

Vis

itors

; Rel

ativ

es &

fam

ily te

nsio

ns; P

rosp

ectiv

e –v

e m

ove

Dep

ende

ncy

& In

stitu

tiona

lisat

ion;

Dem

ands

& h

ome

External structure

Legal framew

ork; National policy; C

omplaints;

Appeals; P

rosecutions; Hospital policy

Staff modifiersStaff anxiety & frustration; Moral commitments;

Psychological understanding; Teamwork & consistency; Technical mastery; Positive

appreciation

Staff modifiersExplanation/information; Role modelling;Patient education; Removal of means;

Presence & presence+

Sta

ff m

odifi

ers

Car

ingl

y vi

gila

nt &

inqu

isiti

ve; C

heck

ing

rout

ines

, Déc

or, M

aint

enan

ce; C

lean

&

tidy;

Alte

rnat

ive

choi

ces;

Res

pect

Staf

f mod

ifier

s

Car

er/re

lativ

e in

volv

emen

t

Fam

ily th

erap

y

Act

ive

patie

nt s

uppo

rt

Staff modifiers

Pharm

acotherapy

Psychotherapy &

functional analysis;

Nursing support &

intervention

Patient modifiersAnxiety management; Mutual support; Moral commitments;

Psychological understanding; Technical mastery;

FlashpointsDenial of request; Staffdemand; Limit setting

Bad news;ignoring

FlashpointsAssembly/crowding/activity

Queuing/waiting/noiseStaff/pt turnover/change

Bullying/stealing/prop. damage

Flas

hpoi

nts

Sec

recy

; Sol

itude

;

Adm

issi

on s

hock

;

Exi

t blo

cked

Flashpoints

Exacerbations;

Independence/identity

Acuity/severity

Flashpoints

Com

pulsory detention;

Adm

ission; Appeal refusal;

Com

plaint denied;

Enforced treatm

ent;

Exit refused

Flas

hpoi

nts

Bad

new

s; H

ome

cris

is;

Loss

of r

elat

ions

hip

or

acco

mm

odat

ion;

Arg

umen

t

CONFLICT

CONTAINMENT

&

Staff m

odifiers

Due process; Justice; R

espect for rights; Hope;

Information giving; S

upport to appeal;

Legitimacy; C

ompensatory autonom

y;

Consistent policy; Flexibility; R

espect

Development of interventions

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

• 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

The Safewards Trial

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

There's been a real buzz on the ward, I think people really

get it.

It's common sense and it makes you think about what you do and how that helps

It's really good to see so many people so enthusiastic and

motivated. It's really got our team talking.

This could potentially flip everything on it’s head and make things much better

It’s not rocket science and it makes so much sense. It’s simple.

Very interesting. It’s basic stuff that is actually useful and raises questions for us about actions and interventions

It’s nice to see people buzzing from this and

so motivated

This is our chance as a team to think about what we do and start to try new approaches together

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/mentalhealthnursinglen.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/mentalhealthnursinglen.bowers@kcl.ac.uk