Safewards – making wards
more peaceful places
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………

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
• 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
• 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)
• 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
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 model
simple form
Flashpoints Conflict Containment
Staff
modifiers
Originating
domains
Patient
modifiers

Six originating domains
1. STAFF TEAM: Internal structure, Rules, Routine, Efficiency,
Clean/tidy, Ideology, Custom & practice
2. PHYSICAL ENVIRONMENT: Door locked, Quality, Complexity,
Seclusion, PICU/ICA, comfort/sensory rooms, ligature points
3. 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

PHYSICALENVIRONMENTOUTSIDE
HOSPITAL
PATIENT COMMUNITY
PATIENT
CHARACTERISTICSREGULATORY
FRAMEW
ORK
STAFFTEAM
Patient-patient interaction
Contagion & discord
InternalStructure
Rules;Routine;Efficiency;Clean/tidy;
Ideology;Custom&practice
Features
Doorlocked;Quality;Complexity;seclusion;
PICU;ICA;comfort/sensoryrooms;ligaturepoints
Sym
ptom
s&
demography
Paranoia,PD
traits;Irritability/disinhib;Abused;male;
Alc/drugs;Depression;insight;delusions;hall.s;young
Stressors
Visitors;Relatives&
familytensions;Prospective–vemove
Dependency&
Institutionalisation;Demands&
home
Externalstructure
Legalframework;Nationalpolicy;Complaints;
Appeals;Prosecutions;Hospitalpolicy
Staffmodifiers
Staffanxiety&frustration;Moralcommitments;
Psychologicalunderstanding;Teamwork&
consistency;Technicalmastery;Positive
appreciation
Staff modifiers
Explanation/information; Role modelling;
Patient education; Removal of means;
Presence & presence+
Staffmodifiers
Caringlyvigilant&
inquisitive;Checking
routines,Décor,Maintenance;Clean&
tidy;Alternativechoices;Respect
Staffmodifiers
Carer/relativeinvolvement
Familytherapy
Activepatientsupport
Staffm
odifiers
Pharmacotherapy
Psychotherapy&
functionalanalysis;
Nursingsupport&
intervention
Patient modifiers
Anxiety management; Mutual support; Moral commitments;
Psychological understanding; Technical mastery;
Flashpoints
Denialofrequest;Staff
demand;Limitsetting
Badnews;
ignoring
Flashpoints
Assembly/crowding/activity
Queuing/waiting/noise
Staff/pt turnover/change
Bullying/stealing/
prop. damage
Flashpoints
Secrecy;Solitude;
Admissionshock;
Exitblocked
Flashpoints
Exacerbations;
Independence/identity
Acuity/severity
Flashpoints
Compulsorydetention;
Admission;Appealrefusal;
Complaintdenied;
Enforcedtreatment;
Exitrefused
Flashpoints
Badnews;Homecrisis;
Lossofrelationshipor
accommodation;
Argument
CONFLICT
CONTAINMENT
&
Staffm
odifiers
Dueprocess;Justice;Respectforrights;Hope;
Informationgiving;Supporttoappeal;
Legitimacy;Compensatoryautonomy;
Consistentpolicy;Flexibility;Respect

Development of interventions

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

• 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
The Safewards Trial

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 channel on Youtube

Safewards on Twitter
Currently 301 followers, including CEOs and DoNs

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

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

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

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
• 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

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