Safewards: An integrative review of the literature within inpatient and forensic mental health units

Abstract

Mental health inpatient units are complex and challenging environments for care and treatment. Two imperatives in these settings are to minimize restrictive practices such as seclusion and restraint and to provide recovery‐oriented care. Safewards is a model and a set of ten interventions aiming to improve safety by understanding the relationship between conflict and containment as a means of reducing restrictive practices. To date, the research into Safewards has largely focused on its impact on measures of restrictive practices with limited exploration of consumer perspectives. There is a need to review the current knowledge and understanding around Safewards and its impact on consumer safety. This paper describes a mixed‐methods integrative literature review of Safewards within inpatient and forensic mental health units. The aim of this review was to synthesize the current knowledge and understanding about Safewards in terms of its implementation, acceptability, effectiveness and how it meets the needs of consumers. A systematic database search using Medline, CINAHL, Embase and PsychInfo databases was followed by screening and data extraction of findings from 19 articles. The Mixed Methods Appraisal Tool (MMAT) was used to assess the quality of empirical articles, and the Johanna Brigg’s Institute (JBI’s) Narrative, Opinion, Text‐Assessment and Review Instrument (NOTARI) was used to undertake a critical appraisal of discussion articles. A constant comparative approach was taken to analysing the data and six key categories were identified: training, implementation strategy, staff acceptability, fidelity, effectiveness and consumer perspectives. The success of implementing Safewards was variously determined by a measured reduction of restrictive practices and conflict events, high fidelity and staff acceptability. The results highlighted that Safewards can be effective in reducing containment and conflict within inpatient mental health and forensic mental health units, although this outcome varied across the literature. This review also revealed the limitations of fidelity measures and the importance of involving staff in the implementation. A major gap in the literature to date is the lack of consumer perspectives on the Safewards model, with only two papers to date focusing on the consumers point of view. This is an important area that requires more research to align the Safewards model with the consumer experience and improved recovery orientation.

Are principles of recovery-oriented practice evident in staff and service user perspectives on seclusion?

“…Further, Muir-Cochrane et al (2018) and Jansen et al (2022) highlighted the moral distress experienced by frontline staff who face these dilemmas while being aware of a growing societal expectation to avoid restrictive practices and engage in recovery-oriented practices. Findings from this study and other research (Mullen et al, 2022) emphasise the active role that staff and systems play in the co-production of social situations. They suggest that revised practices could support the partial reconciliation of seclusion and recovery, where the seclusion is deemed necessary.…”

“…These findings should be considered in the context of increasing calls for reductions in restrictive practices in mental health settings (Muir-Cochrane et al , 2018) and the evidence for negative outcomes associated with these practices (Butterworth et al , 2022). In addition, models such as Safewards (Mullen et al , 2022) and trauma-informed approaches (Bloom and Farragher, 2013; Ross, 2020) offer alternatives to harmful restrictive practices. Despite this, seclusion remains a part of AMH services, with evidence of on-going support among clinical staff (Happell and Harrow, 2010; Van der Merwe et al , 2013), indicating that efforts to minimise or eliminate it may face significant barriers.…”

“…One of the main counterpoints to the use of seclusion highlighted in the literature is the importance of recovery-oriented approaches to AMH (Mullen et al , 2022). A review of qualitative studies of seclusion and restraint by Hawsawi et al (2020) highlights the need for more recovery-oriented care.…”

Barriers and enablers to the implementation of Safewards and the alignment to the i‐PARIHS framework – A qualitative systematic review

“…The complexity of Safewards makes it context-dependent, that is, what system it is used within, how it may perform differently depending on different implementation strategies, and how it may have different effects on different persons involved (Booth et al, 2016). Previous literature reviews on Safewards have focused on examining the effectiveness of reducing conflict and containment (Finch et al, 2022;Mullen et al, 2022;Ward-Stockham et al, 2022), improving ward climate (Finch et al, 2022), nurses' perspectives on adopting and implementing Safewards and consumers' needs (Mullen et al, 2022), and the perceptions of staff and consumers (Ward-Stockham et al, 2022). The results showed that Safewards could provide evidence for reducing restrictive practices.…”

“…Previous literature reviews on Safewards have focused on examining the effectiveness of reducing conflict and containment (Finch et al, 2022; Mullen et al, 2022; Ward‐Stockham et al, 2022), improving ward climate (Finch et al, 2022), nurses' perspectives on adopting and implementing Safewards and consumers' needs (Mullen et al, 2022), and the perceptions of staff and consumers (Ward‐Stockham et al, 2022). The results showed that Safewards could provide evidence for reducing restrictive practices.…”