Safewards – making wards more peaceful places

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. Staff modifiers Patient modifiers Originating domains Flashpoints Conflict Containment Safewards modelsimple form

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 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 PATIENT CHARACTERISTICS Stressors Visitors; Relatives & family tensions; Prospective –ve move Dependency & Institutionalisation; Demands & home Symptoms& demography Paranoia, PD traits; Irritability/disinhib; Abused; male; Alc/drugs; Depression; insight; delusions; hall.s; young Flashpoints Assembly/crowding/activity Queuing/waiting/noise Staff/pt turnover/change Bullying/stealing/ prop. damage Staff modifiers Carer/relative involvement Family therapy Active patient support Staff modifiers Pharmacotherapy Psychotherapy & functional analysis; Nursing support & intervention Flashpoints Bad news; Home crisis; Loss of relationship or accommodation; Argument Flashpoints Exacerbations; Independence/identity Acuity/severity CONFLICT & CONTAINMENT Flashpoints Secrecy; Solitude; Admission shock; Exit blocked Flashpoints Compulsory detention; Admission; Appeal refusal; Complaint denied; Enforced treatment; Exit refused Staff modifiers Due process; Justice; Respect for rights; Hope; Information giving; Support to appeal; Legitimacy; Compensatory autonomy; Consistent policy; Flexibility; Respect Staff modifiers Caringly vigilant & inquisitive; Checking routines, Décor, Maintenance; Clean & tidy; Alternative choices; Respect Flashpoints Denial of request; Staff demand; Limit setting Bad news; ignoring Features Door locked; Quality; Complexity; seclusion; PICU; ICA; comfort/sensoryrooms; ligature points External structure Legal framework; National policy; Complaints; Appeals; Prosecutions; Hospital policy REGULATORY FRAMEWORK Staff modifiers Staff anxiety & frustration; Moral commitments; Psychological understanding; Teamwork & consistency; Technical mastery; Positive appreciation PHYSICAL ENVIRONMENT Internal Structure Rules; Routine; Efficiency; Clean/tidy; Ideology; Custom & practice STAFF TEAM

11. Development of interventions

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 = 0.0099)

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. www.safewards.net 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 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 • 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

30. 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