New prospects for peace on the wards

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………

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

Implications of the Safewards Model

• Causality is complex with multiple, overlapping and interacting factors involved

• No single miracle answer to the problems of conflict and containment

• Some causal factors are outside the control of ward staff, some are outside the control of anybody

• There will be no complete answer to the problems of conflict and containment

• Strengths: identifies patient modifiers; ideas engine• Weaknesses: over-inclusive; biased to own research

Development of interventions

• Included: Generic acute wards, PICUs, Triage, Assessment, Treatment. • Excluded: forensic, elderly, CAMHS or other speciality• Excluded: wards with two or more of the following conditions – acting ward

manager, locum consultant psychiatrist, nursing vacancy rate > 30%• 2 randomly chosen wards at each of 15 randomly chosen hospitals in SE

England (42 eligible hospitals in consenting Trusts within 100 km central London)

• One Trust declined to participate, 7 hospitals excluded following selection due to planned reconfigurations/ward closures

• At each hospital, wards randomly allocated to experimental or control conditions

• All randomisation and analysis independent

The Safewards Trial- the sample -

• Single blind Cluster Randomised Controlled Trial• 8 weeks baseline data collection, 8 weeks implementation, 8 weeks

outcome data collection• Wards and researchers only informed of allocation 2 weeks before

implementation started• 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- design -

The 10 Safewards Interventions

Clear Mutual Expectations

13/35

Soft Words

15/35

Reassurance

Mutual Help Meeting

18/352015 Melbourne Cup

Bad News Mitigation

Positive Words

Calm Down Methods

Discharge Messages

Talk Down

Know Each Other

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 Trialresponse rates and completion

• Preparation: manager contacts and hospital visits started 8 months before trial

• One hospital with 3 wards, = 31 wards• 31 wards made it all the way through (no drop outs)

– Events and changes (+delayed changes, SLaM, CNWL)– Reactance, difference/individuality

• 564 staff gave signed consent (88%)• 8,368 PCCs returned (53.6% of total possible)• 2,704 additional questionnaires completed (62%

baseline, 44% outcome)• All questionnaires scanned and then double checked

CONFLICT14.6% decreaseCI 5.4 – 23.5%

p = 0.004

CONTAINMENT23.6% decreaseCI 5.8 – 35.2%

p = 0.001

Main outcomes

Sensitivity analysis

• Dropping wards with serious changes– Change from acute to assessment, results still significant– Fire and several ward moves, results still significant

• Dropping wards with <20%, <30% and <40% data return rate in outcome phase, all results still significant

• Dropping outlier ward with high rate of conflict at baseline (m15 vs 5) results still significant

• Testing missing data bias – passed with flying colours– Affirms value and validity of PCC as top research instrument

Questionnaires

• WAS: no differences, either group, on oo, sc, pc• APDQ: both groups improved over time on three

subscores - security, acceptance, enthusiasm (following or leading?)

• SHAS – both groups improved over time on one minor subscore – needs function

• SF-36 The control ward staff improved on their physical health relative to the experimental ward staff. There were not changes in staff mental health

Fidelity to the interventions(by ward)

• Researcher checklist (outcome period):• Experimental m 38%, sd 8, range 27-54%, n=271• Control m 90%, sd 9, range 69-99%, n=209

• End of study questionnaire:• Experimental m 89%, sd 11, range 62-100%, n=79• Control m 73%, sd 19, range 39-100%, n=74

Formal economic analysis

• Staff time (alone) saved via Safewards: £88,384 pa (95% CI £88,096 - 88,725) at 2013 prices = €110,261, = Canadian $176,473

• £63,915 conflict reduction, £24,470 due to less use of containment

• Cost of implementing Safewards £4,951 per year = € 6,176, = Canadian $12,331

Strengths & Limitations

• Strengths:– Randomisation, blindness, control

intervention, adequate power, independence of randomisation and analysis

• Weaknesses:– Modest level of cooperation and

implementation from ward staff, null result for questionnaires

Safewards is popular

• 15 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 (Australia), $1 million for Safewards implementation and evaluation. Also Brisbane, Tasmania, Darwin

• Hospitals in the Netherlands (Rotterdam), New Zealand (Dunedin, Christchurch), Canada (Ontario, Abbotsford), Iceland (Reykjavik), Finland (Helsinki), Turkey (Istanbul), etc.

UK Policy (& Tasmania)

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

Why do it?: Strong fit with nursing identity

Patients ‘get it’ and love it“This meeting has been empowering as has enabled people to use skills and qualities which may sometimes get lost as a result of admission to hospital. It has enabled us to take a lead in supporting each other; hospital sometimes lends itself to processes which are done to or for us so this meeting brings more balance. The helping each other meeting has helped to reduce some of the fear which is felt upon admission and has led to people feeling more embraced within the ward community straight away and gives time to verbalise and talk about admission from a peer perspective. Through the meeting we are sharing understanding and support from people who may share similar experiences and perspectives of being patients within the ward. Helping each other is something which everyone does and is a natural part of ward life; through giving this a formal forum we have opened it up to all of the ward community.” Mark, Avocet Ward

Some Safewards implementers and their activities

Safewards channel on Youtube

Circa 12k views

Safewards on Twitter

Currently 1000+ followers, including CEOs and DoNs

Safewards on Facebook

2,200+ international members, daily posts

Safewards on LinkedIn

200+ members

www.safewards.net

32k people have paid 55k visits to this site (so far)

Levels of engagement with Safewards

• Implement the 10 research proven interventions, with regular renewal as a permanent commitment

• Do that, plus add selected interventions from the top list of 30, with the same commitment to permanence and renewal

• Do both of those, plus add additional interventions from the even longer original list – again with permanence and renewal

• Devise your own interventions based on the Safewards model. Implement them, audit them, share them with others, publish your results. Plus doing all the above.

• WHAT IS YOUR AMBITION?

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• 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