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Prof. Len Bowers, Kings College. Restraint Reduction Conference Keynote 27th June '14

  1. Safewards – making wards more peaceful places Len Bowers Professor of Psychiatric Nursing and team
  2. 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………
  3. 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
  4. 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
  5. 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
  6. 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
  7. 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
  8. Safewards model simple form Flashpoints Conflict Containment Staff modifiers Originating domains Patient modifiers
  9. 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
  10. 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
  11. Development of interventions
  12. 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
  13. • 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
  14. 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)
  15. Safewards channel on Youtube
  16. Safewards on Twitter Currently 301 followers, including CEOs and DoNs
  17. Safewards on Facebook 732 international members, daily posts
  18. 4,714 people have paid 8,324 visits to this site (so far)
  19. – the forum
  20. 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
  21. 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
  22. Safewards at a personal level “I myself, however, have incorporated the interventions into every aspect of my nursing care, and the results are fantastic”
  23. 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 – – • Join the forum, get support and help each other! • Meet the challenge, personal and professional
  24. 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.

Editor's Notes

  1. Originating domains are categories of aspects of psychiatric wards as social and physical locations, separate from patients normal residences for the provision of 24/7 mental health care on a basis of mixed voluntary and legal coercion, which to the degree they are present or absent can influence the frequency of conflict and/or containment. Staff modifiers are features of the staff as individuals or teams, or ways in which the staff act in managing the patients or their environment, initiating or responding to interactions with patients, that have the capacity to influence the frequency of conflict and/or containment. Patient modifiers are ways in which patients respond and behave towards each other that have the capacity to influence the frequency of conflict and/or containment, and which are susceptible to staff influence. Flashpoints are social and psychological situations arising out of features of the originating domains, signalling and preceding imminent conflict behaviours. Conflict collectively names all those patient behaviours that threaten their safety or the safety of others (violence, suicide, self-harm, absconding etc.). Containment collectively names all the things staff do to prevent conflict events from occurring or seek to minimize the harmful outcomes (e.g. prn medication, special observation, seclusion, etc.).
  2. Minor amendments/additions to this version while writing the lit review report. Pie chart expressing proportion of causal contribution? Multiplicity of routes within one sector. Summative, increases likelihood. Hardly ever one single cause of an incident. Add demography? Good for a spinner game?