Safewards – making wards
more peaceful places
Len Bowers
Professor of Psychiatric Nursing
and team
Containment:
preventing harm
Conflict: potentially
harmful events
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Aggression
Rule breaking
Substance/alcohol use
Absconding/missing
Medication refusal
Self-harm/suicide
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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
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 model
simple form
Staff
modifiers
Patient
modifiers
Originating
domains
Flashpoints
Conflict
Containment
Six originating domains
1. STAFF TEAM: Internal structure, Rules, Routine, Efficiency,
Clean/tidy, Ideology, Custom & practice
2. PHYSICAL ENVIRONMENT: Door locked, Quality, Complexity,
Seclusion, PICU/ICA, comfort/sensory rooms, ligature points
3. 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
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+
Flashpoints
Assembly/crowding/activity
Queuing/waiting/noise
Staff/pt turnover/change
Bullying/stealing/
prop. damage
CONFLICT
&
CONTAINMENT
Denial of request; Staff
demand; Limit setting
Bad news;
ignoring
Flashpoints
Staff anxiety & frustration; Moral commitments;
Psychological understanding; Teamwork &
consistency; Technical mastery; Positive
appreciation
Staff modifiers
Rules; Routine; Efficiency; Clean/tidy;
Ideology; Custom & practice
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
Selected final
interventions
Full Trial Jan-June
2013
• Feedback questionnaires
• Focus groups
• Dropped 6 of the most
practically difficult and disliked
interventions
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
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
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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 really good to see so
many people so
enthusiastic and
motivated. It's really got
our team talking.
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
This is our chance as a
team to think about what
we do and start to try
new approaches together
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 common sense and it
makes you think about what
you do and how that helps
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:
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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