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THE SAFEWARDS RANDOMISED CONTROLLED TRIALReducing Conflict and Containment on psychiatric wards
Lead by Professor Len Bowers
Conflict
CONFLICT AND CONTAINMENT
Containment• PRN medication• Coerced IM medication• Special observation• Seclusion• Manual restraint• Time out
• Aggression• Rule breaking• Substance/alcohol use• Absconding/missing• Medication refusal• Self-harm/suicide
THE SAFEWARDS MODEL
Flashpoints Conflict Containment
Staffmodifiers
Originatingdomains
Patientmodifiers
PHYSIC
AL
ENVIR
ON
MEN
TO
UTS
IDE
HO
SPIT
AL
PATIENT COMMUNITY
PATIEN
T CHARACTER
ISTIC
SREG
ULA
TORY FR
AM
EWO
RK
STAFF TEAM
Patient-patient interactionContagion & discord
Internal StructureRules; Routine; Efficiency; Clean/tidy;
Ideology; Custom & practice
Feat
ure
s
Doo
r lo
cked
; Qua
lity;
Com
plex
ity;
secl
usio
n;
PICU; I
CA;
com
fort
/sen
sory
room
s; li
gatu
re p
oint
s
Sym
ptom
s& d
emog
raphy
Paranoia, PD traits; Irritability/disinhib; Abused; m
ale;
Alc/drugs; Depression; insight; delusions; hall.s; young
Str
esso
rs
Visi
tors
; Rel
ativ
es &
fam
ily ten
sion
s; P
rosp
ectiv
e –v
e m
ove
Dep
ende
ncy
& In
stitu
tiona
lisat
ion;
Dem
ands
& h
ome
External stru
cture
Legal framew
ork; National policy; C
omplaints;
Appeals; Prosecutions; 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
Sta
ff m
odifi
ers
Car
er/r
elat
ive
invo
lvem
ent
Fam
ily the
rapy
Activ
e pa
tient
sup
port
Staff
mod
ifiers
Pharmacotherapy
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
Secr
ecy;
Sol
itude
;
Adm
issi
on s
hock
;
Exit
bloc
ked
Flashpoin
ts
Exacerbations;
Independence/identity
Acuity/severity
Flashpoin
ts
Com
pulsory detention;
Admission; Appeal refusal;
Com
plaint denied;
Enforced treatment;
Exit refused
Flas
hpoi
nts
Bad
new
s; H
ome
cris
is;
Loss
of r
elat
ions
hip
or
acco
mm
odat
ion;
Argu
men
t
CONFLICT
CONTAINMENT
&
Staff
modifi
ers
Due process; Justice; R
espect for rights; Hope;
Information giving; Support to appeal;
Legitimacy; C
ompensatory autonom
y;
Consistent policy; Flexibility; R
espect
THE SAFEWARDS TRIAL
Aim:– Devise a set of the most feasible interventions
for inpatient nurses with potentially maximal impact on conflict and containment
– Subject those to a rigorous RCT.
DEVELOPMENT OF INTERVENTIONS
Experimental intervention (Organisational)Mutual Help Meeting, Clear Mutual Expectations, Soft Words, Talk Down, Know Each Other, Reassurance, Positive Words, Bad News Mitigation, Discharge Messages, Calm Down Methods. (n = 10) + handbook
Active 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
FINAL INTERVENTION LIST
MAIN OUTCOMES
CONFLICT14.6% decreaseCI 5.4 – 23.5%
p = 0.004
CONTAINMENT23.6% decreaseCI 5.8 – 35.2%
p = 0.001
• Fidelity check indicated a low take up (38%) of interventions in the time frame.
• Multiple checking of statistics including removing outliers and modelling for missing data. Does not change results.
• Disappointing return of staff questionnaires.
• Turn it around and look as if Wellbeing Intervention makes staff fitter. Still checking.
• Bottom line – we recommend all 10 interventions are adopted.
ADDITIONAL INFO
• Trial results first announced NPNR in September 2013
• Since then a programme of dissemination both nationally and internationally
• Initially this was combined with dissemination through social media.
• In December of 2103, www.safewards.net went online
DISSEMINATION
• 9 “International “ presentations ( Europe and Australia)
• 25 presentations to UK conferences, Universities, Trusts or Wards.
• 500+ Facebook Members ( International)
• 100+ Twitter members ( primarily UK)
• Definite contact in 31/59 NHS trusts (England)
• 9 Identified Wards/units in Trusts additional to Trial (9) and Pilot wards (1)
• 2 non UK (Canada and Holland)
• 1 Trust has Safewards as a CQUIN or Quality standard for 2014
SINCE SEPTEMBER..
ITS ALL HERE!!!
WWW.SAFEWARDS.NET
