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Safewards: Increasing safety on psychiatric inpatient wards

1. Summary of the impact

Ensuring the safety of patients and staff is a major challenge for psychiatric hospital management and nursing practice. Incidents of aggression, restraint and seclusion must be reduced, to create safe recovery and work environments. To address some of these difficulties, King’s College London developed a model of causative factors affecting safety levels on psychiatric wards and showed that the Safewards approach based on this model was effective. Safewards has since been widely implemented in whole, or part, across NHS mental health wards in the UK and in multiple hospitals worldwide. In England it is recommended in National Institute for Health and Care Excellence (NICE) guidance, and several other countries also recommend it in their policy frameworks (e.g. Australia, Belgium, Denmark, Finland). It has also been extended beyond psychiatric wards into novel areas including youth justice centres and community care homes.

2. Underpinning research

The number of adults admitted annually to mental health inpatient services has risen over the last ten years, which has increased the risk of conflict in these highly pressured and challenging environments, both between patients, and between patients and staff. The frequency of conflict (aggression, violence, self-harm, absconding, substance use) and containment (medication, physical restraint, seclusion, special observation) varies between psychiatric inpatient wards, with few explanations as to why. A coherent model for dealing with conflict and containment was lacking. PI Bowers recognised the importance of reducing conflict and containment, which can put patients and staff at serious risk of harm, whilst at City of London University (City). He assembled a collaboration of researchers from King’s, the Royal College of Psychiatrists, London NHS trusts, UCL and City, to explore this, and moved to King’s in 2010 to develop an extensive and comprehensive research programme.

King’s researchers examined practices in acute inpatient psychiatric care to establish aspects of conflict and containment. King’s researchers carried out a series of systematic reviews of over 1,100 papers and identified that dynamic factors such as a patient’s current state and context were important contributors to aggression, alongside factors relating to the patients themselves (e.g. 1). A factor analysis of nurses’ records in 2012 (522 patients, 84 wards, 31 hospitals) revealed six patterns of conflict behaviour in patients related to containment methods. A second separate analysis revealed three factors relating to containment methods: those which are “serious and intrusive”, those that diffuse situations, and those relying on observation (2). King’s researchers also found three conflict and containment events, which occurred much more frequently than other events; namely verbal aggression, PRN (or “as needed” medication), and de-escalation. Transitions between these were also more common than between other events, and they named them the “Minimal Triangle” (3). Data for (2) and (3) were gathered 2009 - 2010 while Bowers was at City, and analyses were carried out after he moved to King’s in 2010. leadership and has

King’s researchers developed and piloted a suite of interventions called the Safewards Model. King’s Safewards Model proposes 6 domains which can give rise to flashpoints triggering conflict and/or containment. These domains are: the staff team, the physical environment, factors outside hospital, the patient community, patient characteristics and the regulatory framework. The model identified that staff interventions can modify these processes, reducing conflict and the need for containment, and is unique in its recognition that care staff’s use of containment, even when motivated by the desire to prevent future conflict, can actually cause the conflict to occur. King’s described this dynamic model systematically and showed how understanding its central principles can inform strategies that promote the safety of patients and staff, leading to a healthier work and recovery environment (4).

In developing the model approximately 300 ideas for interventions to reduce rates of conflict and containment which had been identified in evidence reviews (e.g. 1) were rated and consolidated by King’s researchers. Service users, carers and expert professionals were consulted before selecting 16 potential interventions for pilot testing, following which 6 were dropped, and improvements made to the remaining 10.

King’s researchers led on testing Safewards in a single blind cluster randomised controlled trial (RCT) on 31 wards at 15 hospitals. This RCT demonstrated that Safewards produced a 15% decrease in the rate of conflict and a 26% decrease in the rate of containment (5), and showed that where Safewards is implemented, patients and staff will be safer, and less likely to be subject to (or need to use) risky and unpleasant containment methods.

3. References to the research

  1. Bowers. L., Alexander. J., Bilgin, H., Botha, M., Dack, C., James, K., Jarrett, M., Jeffery, D., Nijman, H., Owiti, J.A., Papadopoulos, C., Ross, J., Wright, S., & Stewart. D. (2014) Safewards: the empirical basis of the model and a critical appraisal. Journal of Psychiatric and Mental Health Nursing, 21(4): 354-364.

  2. Ross, J, Bowers, L., & Stewart, D. (2012) Conflict and containment events in inpatient psychiatric units. Journal of Clinical Nursing, 21(15-16): 2306-2315.

  3. Bowers, L, James, K, Quirk, A, Wright, S, Williams, H & Stewart, D. (2013). Identification of the "minimal triangle" and other common event-to-event transitions in conflict and containment incidents. Issues in Mental Health Nursing, 34(7): 514-523.

  4. Bowers, L., (2014). Safewards: A new model of conflict and containment on psychiatric wards. Journal of Psychiatric and Mental Health Nursing, 21(6): 499-508.

  5. Bowers, L., James, K., Quirk, A., Simpson, A., SUGAR (Service User and carer Group for Research)., Stewart, D. and Hodsoll, J. (2015). Reducing conflict and containment rates on acute psychiatric wards: The Safewards cluster randomised controlled trial. International Journal of Nursing Studies, 52(9): 1412–1422

4. Details of the impact

King’s research has contributed to making psychiatric units safe places, where any conflict that may arise can be dealt with in a way that is humane and fair, with containment used as an absolute last resort. King’s research has also ensured that staff should feel safer at work.

Safewards is recommended in the UK by government and healthcare bodies.

King’s research informed the 2015 National Institute for Health and Care Excellence (NICE) Guideline NG10: ‘Violence and aggression. Short-term management in mental health, health and community settings’ (King’s researcher Bowers was a Guideline development group member). Safewards was identified as one of only two conflict and containment management interventions shown to be effective via a randomised controlled trial, and Safewards is mentioned multiple times throughout the Guideline as notable, evidenced, and implemented in many hospitals [A1].

Safewards is also recommended in the 2015 report ‘Positive and Proactive Care: reducing the need for restrictive interventions’ by the then Department of Health as follows: “The Safewards model has demonstrated significant effectiveness in achieving reductions in incidents of conflict and the use of physical restraint, seclusion and rapid tranquillisation in acute UK mental health settings….. all providers should consider the implications of the Safewards model to their context” [A2 p22]. Safewards was also promoted through the Department of Health’s Positive and Safe Champions newsletter in 2015 [A3].

In NHS England (NHSE), the Commissioning for Quality and Innovation (CQUIN) framework supports improvements in the quality of services and the creation of new, improved patterns of care. In MH3 CQUIN, Reducing Restrictive Practices within Adult Low & Medium Secure Services, Safewards is recommended: "Increase positive ward culture by developing conflict reduction practice-based initiatives e.g. positive handovers (Safewards)" [A4 p3]. Safewards has also been recommended by the Head of Quality Improvement Taskforce for Children and Young People inpatient services (Mental Health, Learning Disability and Autism) at NHSE [A5].

The Care Quality Commission (CQC) has repeatedly endorsed Safewards in various reports, e.g. in 2014 it stated “We welcome the new Safewards model” [A6 p49]; and in a report in 2017 stated “quality improvement techniques and evidence-based approaches such as Safewards can help support staff to change their practice” [A7 p1]. The CQC also stated that their biggest concern in mental health was safety, naming Safewards in another 2017 report as a “good initiative to embrace a culture of safety” [A8 p82].

The National Insititue for Health Research (NIHR) also highlighted Safewards in its 2018 report Forward Thinking, targeted at mental health commissioners and provider organisations, saying: “it had many strengths, and a demonstrable impact on conflict and containment rates. Decreased conflict means fewer injuries from violence, suicide and self-harm” [A9 p18].

King’s researchers responded to the real and pressing need to address the issue of managing conflict and containment with swift and strategic rollout of the Safewards model. Having developed a model with strong evidence of effectiveness (4,5) it was immediately disseminated. King’s researchers swiftly went beyond traditional academic publications and conference presentations to reach practitioners quickly, to protect as many staff and patients as possible. A website was launched in 2013, making the Safewards interventions freely and easily available to all, with no registration requirement. It has since been translated into German, Turkish, Dutch, Finnish, Danish, Polish, and Spanish, with thousands of international visitors every year [B1]. Each component part of the approach is presented separately in a way that is practical and comprehensive. In the year Dec 16 2019 – Dec 16 2020, the website had 71,286 users, 69,849 of whom were new, from countries across the world including Germany, Australia, and the USA [B2]. King’s researchers set up dedicated social media channels for practitioners to support, advise and learn from one another including Twitter @Safewards (over 4,000 tweets and 4,700 followers), Youtube where 37 training videos created by King’s researchers are freely available and have had over 31,000 views in total, and Facebook (membership of a dedicated Facebook group is 8,000+ members, predominantly healthcare workers) [B3]. King’s research staff supported the Safewards rollout with meetings and local launch events with leading nurses, managers and influential figures worldwide [B4]. The Safewards team have not only made available a comprehensive and easy to implement set of tools to increase safety on psychiatric units via their website, but in their online forums have also fostered a growing and supportive community of healthcare staff committed to working together to provide advice and guidance to improve standards of care [B1].

Safewards has been widely implemented across England and the UK. Safewards was deliberately made freely available without registration via the website in order to minimise barriers and maximise take-up. This means there is no firm number of how many trusts and teams have implemented Safewards. However, we are aware of implementation in South London & Maudsley, Greater Manchester Mental Health (GMMH), Sussex Partnership, Lincolnshire Partnership, West London, Worcestershire, Kent, Berkshire, Derby, Leicester, Oxleas, Merseycare, Fife, and Cumbria, Northumberland and Tyne and Wear (CNTW). Examples include, in GMMH 58 wards have adopted the Safewards philosophy and practice [C1, C2]; and in Sussex Partnership since Safewards was implemented there has been a 63% decrease in seclusion, 45% decrease in restraints, and a 53% decrease in use of rapid tranquilisation medication [C3]. In CNTW all wards within the Trust utilise Safewards, resulting in restraint down 23%, seclusion down 21% and staff assault reduced by 18% [C4]. We are also aware that private UK providers such as Cygnet Healthcare, Elysium and Priory Group are using Safewards.

Safewards has been implemented internationally. In the state of Victoria, Australia, $2.4 million has been invested in Safewards implementation for 58 mental health units initially, with a second phase expected to include emergency departments and acute medical units [D1], and Safewards Victoria is now a recognised resource in the National Quality Health Standards [D2]. In Denmark Safewards has been implemented in around half of all mental health units, reducing forced sedation and mechanical restraints [D3]. In Tasmania [D4], Finland [D5], and Belgium [D6], Safewards interventions are either recommended or are being actively implemented in hospitals in order to drive quality improvements in mental health inpatient care.

Safewards benefits both patients and staff. Less conflict results in fewer injuries and less violence towards staff. Less containment is better for staff as well as patients (5). There are other benefits. Patient Iris reports “it has certainly helped and supported me, to be seen as Iris, and not the badly behaved person I am so often seen as… this wonderful human way of working with very distressed and vulnerable people” [E1]. Paul Sams, Service User Project Coordinator says ”as a former service user I am particularly impressed with the opportunities these interventions offer patients to have a voice in the ward environment” [E2]. The benefits of Safewards for patients and staff are recognised by NHSE [A5] and the Royal College of Nursing, who says “the most important part of Safewards is that patients and their families ‘get it’ and love it” [E3]. Head of Nursing for Acute Care at Sussex Partnership reports that Safewards “has helped the team move away from an “us and them” mentality that previously existed…creating a ward community that is collaborative and safe” [C3].

The unique dynamism of Safewards has enabled the model to be implemented within health and social care settings beyond psychiatry. Care in Mind runs residential care homes in England for young people, and introduced Safewards for Safehomes in March 2015. They report that it has had “an overwhelmingly positive impact. The model allows for a more therapeutic relationship between staff and young people. In fact, in many ways, it allows the young people in our care to see the staff as more human” [F1]. In CNTW NHS Foundation Trust, as well as Adult Acute Services, Safewards has been rolled out across Children’s services, Older People’s services, Psychiatric Intensive Care Units, Forensics, Mother and Baby units, Autism and Learning Disability services, and more recently within community based servies [C4]. In Tasmania Safewards is one of the actions committed to in the Government’s long-term plan for mental health 2015-25, and as well as in healthcare settings, it is being implemented in the Youth Justice sector, where it is known as Safecentres [F2].

5. Sources to corroborate the impact

[A] Sources to corroborate the inclusion of Safewards in UK guidelines and recommendations

A1 NICE guideline NG10: Violence and aggression: short-term management in mental health, health and community settings 2015

A2 Department of Health report: Positive and Proactive Care 2015

A3 Department of Health Positive and Safe Champions Newsletter 2015

A4 MH3 CQUIN

A5 Testimonial from Salli Midgley, NHS England

A6 Care Quality Commission report 2014: Monitoring the Mental Health Act report 2014

A7 Care Quality Commission report 2017: Mental Health Act, A focus on restrictive intervention reduction programmes in inpatient mental health services

A8 Care Quality Commission report 2017: The state of health care and adult social care in England 2016/2017

A9 NIHR Forward Thinking report 2018

[B] Evidence from Safewards website and social media

B1 Safewards website

B2 Safewards website analytics

B3 Social media screenshots (x3)

B4 Selection of photographic evidence from Safewards Facebook group, which as of Dec 2020 had over 8,000 members.

[C] Corroborating evidence from NHS trusts of UK uptake of Safewards

C1 Greater Manchester Mental Health testimonial

C2 Greater Manchester Mental Health announcement of launch of Safewards

C3 Sussex Partnership testimonial

C4 Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust testimonial

[D] Corroborating international uptake of Safewards

D1 Evidence of Safewards roll out in Australia roll out (x2)

D2 Australia rollout testimonial

D3 Denmark rollout testimonial

D4 Tasmanian Government, Department of Health and Human Services report: Rethink Mental Health, Better Mental Health and Wellbeing, a Long-Term Plan for Mental Health in Tasmania 2015 - 2025

D5 Testimonnial from Tampere University, Finland

D6 Belgium Hoge Gezondheidsraad report 2016: Conseil Supérieur de la Santé, Aborder et gérer les conflits et pratiquer des interventions sous contrainte dans les soins de santé mentale

[E] Corroborating evidence from patients and professionals on benefits of Safewards

E1 Service user Iris Benson testimonial

E2 Service user Paul Sams testimonial

E3 Testimonial from Catherine Gamble, Professional Lead for Mental Health, Royal College of Nursing

[F] Corroborating evidence from those using Safewards in settings beyond psychiatric wards

F1 Care in Mind, Safewards for Safehomes

F2 Tasmania Safecentres presentation 2020

Additional contextual information

Grant funding

Grant number Value of grant
RP-PG-0707-10081 £1,959,924