Safewards: a new model of conflict and containment on psychiatric wards

Abstract

Accessible summaryRates of violence, self-harm, absconding and other incidents threatening patients and staff safety vary a great deal by hospital ward. Some wards have high rates, other low. The same goes for the actions of staff to prevent and contain such incidents, such as manual restraint, coerced medication, etc.The Safewards Model provides a simple and yet powerful explanation as to why these differences in rates occur.Six features of the inpatient psychiatric system have the capacity to give rise to flashpoints from which adverse incidents may follow.The Safewards Model makes it easy to generate ideas for changes that will make psychiatric wards safer for patients and staff.AbstractConflict (aggression, self-harm, suicide, absconding, substance/alcohol use and medication refusal) and containment (as required medication, coerced intramuscular medication, seclusion, manual restraint, special observation, etc.) place patients and staff at risk of serious harm. The frequency of these events varies between wards, but there are few explanations as to why this is so, and a coherent model is lacking. This paper proposes a comprehensive explanatory model of these differences, and sketches the implications on methods for reducing risk and coercion in inpatient wards. This Safewards Model depicts six domains of originating factors: the staff team, the physical environment, outside hospital, the patient community, patient characteristics and the regulatory framework. These domains give risk to flashpoints, which have the capacity to trigger conflict and/or containment. Staff interventions can modify these processes by reducing the conflict-originating factors, preventing flashpoints from arising, cutting the link between flashpoint and conflict, choosing not to use containment, and ensuring that containment use does not lead to further conflict. We describe this model systematically and in detail, and show how this can be used to devise strategies for promoting the safety of patients and staff.

Interventions following a high violence risk assessment score: a naturalistic study on a Finnish psychiatric admission ward

“…The use of restrictive methods has been widely debated [4] and various attempts have been made to reduce the use of seclusion and restraint in psychiatric nursing [31–33]. The use of coercive methods has been reported to impair the therapeutic alliance [4, 34], as patients often consider the use of coercive methods as a form of punishment [35, 36] and see them as negative interventions [34, 37].…”

Nursing Staff Factors Contributing to Seclusion in Acute Mental Health Care – An Explorative Cohort Study

“…Several initiatives for reducing coercion and for improving quality of care have started in the recent years, e.g., the High Intensive Care model in the Netherlands (Mierlo van, Bovenberg, Voskes, & Mulder, 2013) and Safewards internationally (Bowers, 2014;Bowers et al, 2014). Both initiatives emphasize the importance of the interaction between nurses and patients.…”

Cross-national mixed-methods comparative case study of recovery-focused mental health care planning and co-ordination in acute inpatient mental health settings (COCAPP-A)

“…These include work to develop standards and to accredit wards, 92 guidance to help service commissioners, 93 action by charities to promote good practice 94 and research to put hospital-based mental health nursing on a more evidence-based footing. 95 However, there is little direct policy focus on inpatient services despite this being the site of treatment for elevated mental distress and consuming significant resources. Although there has arguably been a renewed interest in mental health policy of late, 96 inpatient care has largely been neglected or sidelined in attempts to achieve greater efficiencies elsewhere in the system.…”

“…Staff in Across sites staff were aware of the policy drivers to provide a greater focus on recovery and to provide respectful, compassionate, dignified care and to improve quality. Staff gave examples which embedded recovery and reflected a post-Francis culture (reference to policy highlighted above) l A variety of initiatives to improve inpatient services were described by staff across the six sites; this included audit using the Royal College of Psychiatrists' AIMS, 92 the Productive Ward initiative, 188 Bright Charity's Star Wards, 94 Safewards, 95 Quality Improvement programmes 189 and support from housing workers/peer support workers l Some staff spoke about localised changes in care plan templates l An initiative which was creating more pressure in the short term in one site was the introduction of a Section 136 room. In this case concerns were raised about the impact that this had on staffing on the ward DOI: 10.3310/hsdr05260 HEALTH SERVICES AND DELIVERY RESEARCH 2017 VOL.…”