Professor Len Bowers
Professor of Psychiatry, Kings College London
Len Bowers is a qualified psychiatric nurse with clinical and managerial experience in acute inpatient and community care. He now leads a team of researchers investigating this issue at the Institute of Psychiatry, has completed more than £4 million of grant funded research and has authored over a hundred peer reviewed publications. Speaking regularly at international conferences, Len has advised the UK Government on policy issues and contributed to policy guidelines on psychiatric nursing practice.
Presentation Topic: Safewards: Making Wards More Peaceful Places
Len Bowers focusses on why psychiatric wards are not all the same. He highlights that some experience ten times more adverse incidents, violence, self-harm etc., than others. He discusses the difference in wards and use the Safewards Model to explain how this can happen, and what we can do to help all our wards become quieter, calmer, more peaceful and safer places – for the patients and the staff.
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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
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.
14.
15.
16.
17.
18.
19. • 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
20. 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)
26. 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
27. 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
28. Safewards at a personal level
“I myself, however, have incorporated
the interventions into every aspect of
my nursing care, and the results are
fantastic”
29. 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
30. 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
Editor's Notes
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.).
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?