Safewards making wards more peaceful places
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Safewards – making wards more peaceful places. Len Bowers Professor of Psychiatric Nursing and team. Conflict: potentially harmful events. Containment: preventing harm. Aggression Rule breaking Substance/alcohol use Absconding/missing Medication refusal Self-harm/suicide.

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Safewards making wards more peaceful places

Safewards – making wards more peaceful places

Len Bowers

Professor of Psychiatric Nursing

and team

Conflict potentially harmful events
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………

City 128 and manual restraint
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

Taws and manual restraint
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

Conseq and manual restraint
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

Riddors dr l renwick
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

New safewards model sources
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

Safewards model simple form










Safewards modelsimple form

Six originating domains
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

Safewards making wards more peaceful places


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+




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




Staff/pt turnover/change


prop. damage

Staff modifiers

Carer/relative involvement

Family therapy

Active patient support

Staff modifiers


Psychotherapy & functional analysis;

Nursing support & intervention


Bad news; Home crisis;

Loss of relationship or











Secrecy; Solitude;

Admission shock;

Exit blocked


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


Denial of request; Staff

demand; Limit setting

Bad news;



Door locked; Quality; Complexity; seclusion;

PICU; ICA; comfort/sensoryrooms; ligature points

External structure

Legal framework; National policy; Complaints;

Appeals; Prosecutions; Hospital policy


Staff modifiers

Staff anxiety & frustration; Moral commitments;

Psychological understanding; Teamwork &

consistency; Technical mastery; Positive



Internal Structure

Rules; Routine; Efficiency; Clean/tidy;

Ideology; Custom & practice


The safewards trial final intervention list
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 trial
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

Main outcomes
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)

Safewards on twitter
Safewards on Twitter

Currently 301 followers, including CEOs and DoNs

Safewards on facebook
Safewards on Facebook

732 international members, daily posts

Www safewards net

4,714 people have paid 8,324 visits to this site (so far)

Www safewards net the forum – the forum

Safewards is popular
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

Safewards making wards more peaceful places

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

Safewards at a personal level
Safewards at a personal level motivated. It's really got our team talking.

“I myself, however, have incorporated the interventions into every aspect of my nursing care, and the results are fantastic”

Summary motivated. It's really got our team talking.

  • 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



  • Join the forum, get support and help each other!

  • Meet the challenge, personal and professional

Safewards making wards more peaceful places

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.