Implementation of the Safewards model in public mental health facilities: A qualitative evaluation of staff perceptions

Implementing Safewards on Children and Young People's Wards: A Process and Outcomes Evaluation

Safewards reduces conflict and containment on adult inpatient wards but there is limited research exploring the model in Children and Young People (CYP) mental health services. We investigated whether Safewards can be successfully implemented on twenty CYP wards across England. A process and outcomes evaluation was employed, utilizing the Integrated Promoting Action on Research Implementation in Health Sciences (i-PARiHS) framework. Existing knowledge and use of Safewards was recorded via a self-report benchmarking exercise, verified during visits. Implementation of the 10 Safewards components on each ward was recorded using the Safewards Organizational Fidelity measure. Data from 11 surveys and 17 interviews with ward staff and four interviews with project workers were subject to thematic analysis and mapped against the four i-PARiHS constructs. Twelve of the 20 wards implemented at least half of the Safewards interventions in 12 months, with two wards delivering all 10 interventions. Facilitators and barriers are described. Results demonstrated Safewards is acceptable to a range of CYP services. Whilst implementation was hindered by difficulties outlined, wards with capacity were able and willing to implement the interventions. Results support the commissioning of a study to evaluate the implementation and outcomes of Safewards in CYP units.

Implementation and use of the Safewards model in healthcare services: A scoping review

Safewards is a multi-intervention mental health nursing model of practice improvement aimed at preventing and reducing conflict and containment. The use of Safewards has now extended beyond mental health settings. Implementation of Safewards has been reported to be challenging and therefore requires an evidence-informed and structured approach. This review's objectives were to: (i) Comprehensively map approaches used to implement Safewards interventions; (ii) Characterise the outcomes measured in Safewards implementation studies; and (iii) Identify the facilitators and barriers to Safewards training and its implementation in practice. All quantitative, qualitative and mixed-methods publications of Safewards, the interventions, evaluations, barriers and facilitators from all healthcare services internationally were included. The Joanna Briggs Institute scoping review and Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping Reviews were used to guide methodology. Data were reported according to the 12 items of the TIDieR. Twenty-seven publications reported the implementation of Safewards. Descriptions were limited for reporting items such as intervention descriptions, materials, resources, specific procedures and processes, modifications made to interventions and delivery of interventions and training. No consistent theoretical implementation framework was reported. Collaboration, leadership, feedback and co-design were strong drivers for staff buy-in, engagement and success for implementation in mental health and acute settings. Transparency, replicability and generalisation require a detailed description of all elements of an intervention being implemented. Without adequate information, only assumptions can be drawn about the clinical governance and process of the implementation and training, and it is difficult to conclude when attempting to replicate the interventions.

Safewards in acute medical/surgical care wards: Capability, Opportunity, Motivation and Behaviour model and Theoretical Domains Framework analysis

BACKGROUND

Safewards is an evidence-based practice improvement model to minimise conflict in inpatient mental health units. There is limited published research on implementing Safewards in acute medical/surgical care wards.

OBJECTIVE

To identify, from nurses' perspectives, barriers, and facilitators to implement four Safewards interventions in acute medical/surgical care wards.

METHODS

This article reports qualitative findings from a funded mixed-method evaluation of the Safewards Acute Care Pilot Project. Six focus group interviews comprising 35 nursing staff from four hospitals in Victoria, Australia were completed between April and October 2022. The semi-structured interview guide included questions developed using the Capability, Opportunity, Motivation and Behaviour model. Data was thematically analysed and mapped to a matrix combining Capability, Opportunity, Motivation and Behaviour model and the Theoretical Domains Framework to elucidate barriers and facilitators to implementing four Safewards interventions in acute medical/surgical care wards.

RESULTS

Three components in the Capability, Opportunity, Motivation and Behaviour model and three Theoretical Domains Framework domains were identified as barriers to the adoption of Safewards in acute medical/surgical care wards. Specific barriers included physical opportunity challenges related to the environmental context and resources domains. The key themes included time constraints and competing priorities; lack of physical space and infrastructure; and poor patient uptake due to lack of understanding. Gaps emerged as a psychological capability barrier within the Theoretical Domains Framework knowledge domain. Additionally, resistance to practice changes was associated with the motivation component of the Capability, Opportunity, Motivation and Behaviour model. Conversely, six TDF domains were relevant to facilitating the implementation of the Safewards interventions: memory, attention, and decision processes; physical skills; social influences; social/professional role and identity; goals; and beliefs about consequences. Key facilitators included the Safewards interventions serving as reminders to focus on compassionate nursing care; nursing staff possessing the skillset for interventions; peer pressure and mandated change; supportive and passionate leadership; presence of champions to drive momentum; belief in nursing staff ownership and expertise for leading implementation; personal commitment to improve work environments and care quality; and the belief that Safewards would improve ward culture.

CONCLUSIONS

Addressing barriers and leveraging facilitators can inform strategies for enhancing staff capability to implement Safewards in acute care wards. Specifically, a tailored, multilayered approach focusing on leadership support, training, resources, patient input, and feedback can promote effective adoption of the Safewards model and adaptation of discrete interventions.

TWEETABLE ABSTRACT

Safewards adaptation: Addressing barriers like resources, space, and patient awareness; leveraging peer modelling and leadership strategies for success.

A participatory and comprehensive intervention to improve violence prevention in two high-risk occupations: effect and process evaluation of a stepped wedge cluster randomised trial

BACKGROUND

Work-related violence committed by clients, patients, and customers represents a major occupational health risk for employees that needs to be reduced.

METHODS

We tested a comprehensive violence prevention intervention involving active participation of both employees and managers in the Prison and Probation Service (PPS) and on psychiatric wards in Denmark. We used a stepped wedge cluster randomised controlled trial design. We measured the degree of implementation of the intervention by registration of fidelity, reach, and dose and used a mixed-effects regression analysis to estimate the effects of the intervention.

RESULTS

We recruited 16 work units for the intervention, but three work units dropped out. The average implementation rate was 73%. In the psychiatric wards, the intervention led to statistically significant improvements in the primary outcome (an increase in the degree to which managers and employees continuously work on violence prevention practices based on their registration and experiences), but none statistically significant improvements in any of the secondary outcomes. In the PPS units, the intervention did not lead to a statistically significant improvement in the primary outcome, but to statistically significant improvements in three secondary outcomes.

CONCLUSION

Most work units were able to carry out the intervention as planned. The intervention showed mixed results regarding the primary outcome. Nevertheless, the results indicate improvements also in the sector where a change in the primary outcome was not achieved. The results point at that a participatory and comprehensive approach could be a viable way of working with violence prevention in high-risk workplaces.

TRIAL REGISTRATION

ISRCTN86993466: 20/12/2017.

Exploring safety culture within inpatient mental health units: The results from participant observation across three mental health services

In Australia, acute inpatient units within public mental health services have become the last resort for mental health care. This research explored barriers and facilitators to safe, person-centred, recovery-oriented mental health care in these settings. It utilised participant observations conducted by mental health nurses in acute inpatient units. These units were located in three distinct facilities, each serving different areas: a large metropolitan suburban area in a State capital, a mid-sized regional city, and a small city with a large rural catchment area. Our findings highlighted that, in the three inpatient settings, nurses tended to avoid common areas they shared with consumers, except for brief, task-related visits. The prioritisation of administrative tasks seemed to arise in a situation where nurses lacked awareness of alternative practices and activities. Consumers spent prolonged periods of the day sitting in communal areas, where the main distraction was watching television. Boredom was a common issue across these environments. The nursing team structure in the inpatient units provided a mechanism for promoting a sense of psychological safety for staff and were a key element in how safety culture was sustained.

Barriers and enablers to the implementation of Safewards and the alignment to the i-PARIHS framework - A qualitative systematic review

Inpatient mental healthcare settings should offer safe environments for patients to heal and recover and for staff to provide high-quality treatment and care. However, aggressive patient behaviour, unengaged staff approaches, and the use of restrictive practices are frequently reported. The Safewards model includes ten interventions that aim to prevent conflict and containment. The model has shown promising results but at the same time often presents challenges to successful implementation strategies. The aim of this study was to review qualitative knowledge on staff experiences of barriers and enablers to the implementation of Safewards, from the perspective of implementation science and the i-PARIHS framework. A search of the Web of Science, ASSIA, Cochrane Library, SCOPUS, Medline, Embase, PsycINFO, and CINAHL databases resulted in 10 articles. A deductive framework analysis approach was used to identify barriers and enablers and the alignment to the i-PARIHS. Data most represented by the i-PARIHS were related to the following: local-level formal and informal leadership support, innovation degree of fit with existing practice and values, and recipients' values and beliefs. This indicates that if a ward or organization wants to implement Safewards and direct limited resources to only a few implementation determinants, these three may be worth considering. Data representing levels of external health system and organizational contexts were rare. In contrast, data relating to local (ward)-level contexts was highly represented which may reflect Safewards's focus on quality improvement strategies on a local rather than organizational level.

Implementation and Adaptation of the Safewards Model in the New Zealand Context. Perspectives of Tāngata Whai Ora and Staff

The safety of service users and staff is paramount in cultivating a therapeutic environment within inpatient mental health units. The Safewards model, originating in the United Kingdom, aims to reduce conflict and containment rates through 10 interventions. This study used participatory action research to explore the perspective of tāngata whai ora and staff regarding the adaptation of the Safewards model to the unique New Zealand context. Such adaptation is critical due to significant health outcome disparities between Māori and non-Māori populations and the disproportionate representation of Māori within mental health services. In adhering to the principles of Te Tiriti o Waitangi, cultural adaptation becomes an imperative obligation. The study utilised qualitative content analysis and thematic analysis, drawing data from focus groups of staff (n = 15) and tāngata whai ora (n = 3). This study describes a New Zealand Safewards model, which must include Te Ao Māori, align with current practices, adapt Safewards interventions and gain acceptance. Organisational change management is pivotal in the integration of this model into nursing practice. The outcomes of this study hold the potential to contribute to the formulation and implementation of a New Zealand Safewards model, while also bearing relevance for the international adaptation of Safewards to culturally diverse countries and healthcare systems.

Reducing violence and aggression: a quality improvement project for safety on an acute mental health ward

Violence and aggression (V&A) are identified as an issue on mental health wards that negatively affect staff, patients, care delivery and safety. This project took place on a male acute mental health ward where V&A are known to be an issue with an average of 21.3 incidences per month in the 6 months preceding the project.The aim was to use QI (Quality Improvement) methodology to reduce incidences of V&A by 20% over a 4-month period. A root cause analysis was completed with staff, previous QI projects and literature on interventions for V&A were reviewed. Two changes were introduced via PDSA (plan, do, study, act) cycles; first was a safewards bundle including a training package, weekly emails and noticeboard displays, the second was safety crosses displayed on the ward.There was a reduction in incidences of V&A across the project, mean weekly incidences reduced from 2.5 at baseline audit to 2.0 at the end of the project. This equates to a 20% reduction in V&A. The project did result in an increase of safewards interventions recorded and staff ratings of ward safety improved. There was a statistically significant correlation found between incidences of V&A and rates of restrictive practices.Further analysis of the 20% reduction did not find a special cause variation, so results may be due to a common cause variation rather than the QI interventions. Safety crosses were not found to have an impact on rates of V&A, it is likely these need to be more embedded into communication about V&A on the ward. Potential confounding patient variables such as illicit drug use and history of V&A as well as staffing should be recorded and monitored in future projects. Recommendations to enhance further change should include regular meetings with both staff and patients to support open communication about the topic.

An analysis of the barriers and enablers to implementing the Safewards model within inpatient mental health services

Mental health inpatient units can provide a sanctuary for people to recover from mental illness. To support a therapeutic environment, the safety and well-being of service users and staff need protection through reduced conflict and containment rates. The Safewards model identifies 10 interventions to prevent conflict and containment. This paper aims to present barriers and enablers to implementing Safewards by analysing current literature on the Safewards model. It will also compare the Safewards model to New Zealand's Six Core Strategies. In a systematic search of 12 electronic databases following the PRISMA flow chart, 22 primary studies were included in this analysis. JBI tools were used for quality appraisal and deductive content analysis was used to organize and interpret data. Four categories were identified: (a) designing the Safewards interventions and implementation; (b) staff participation and perception of Safewards; (c) healthcare system influences on Safewards implementation; (d) service user participation and perception of Safewards. To support successful Safewards implementation in future practice, this review recommends that Safewards implementation is enabled through robust design of the Safewards interventions and implementation methods; staff participation and positive perception of the Safewards model; a resourced healthcare system that prioritizes Safewards implementation; service user awareness and participation in Safewards interventions. Interactionist perspectives may support the implementation of Safewards. This analysis is limited by research settings mostly being inpatient adult services and inadequate capturing of the service user voice. An ongoing review of barriers and enablers is important for supporting future Safewards implementation.

Long-term mental health care in Portugal: A portrait of the first years of activity

INTRODUCTION

In Portugal, a reform to implement Long-term mental health care (LTMHC) started in 2017 allowing patients with severe mental illness receiving psychosocial rehabilitation to regain their autonomy and be reintegrated into their communities.

AIM

To describe the first steps of the Portuguese LTMHC implementation and to assess the relationship between the LTMHC's demand (referrals) and supply (vacancies and occupancy).

METHODS

We conducted a national retrospective observational study to analyse the LTMHC referrals, vacancies and occupancy between mid-2017 (LTMHC establishment) and December 2022. We described and analysed the associated indicators through time and geography, as well as performed a simultaneous regression model to evaluate the relationship between supply and demand.

RESULTS

There were 1,192 referrals to the LTMHC, of which 99 (8.3%) were made for childhood and adolescence structures. The maximum support residence (RAMa, 'Residência de apoio máximo'), designed for patients with higher disabilities, had the highest number of referrals. Additionally, since the opening of vacancies in different institutions, residential structures became quickly saturated. On the other hand, domiciliary services were those with the lowest occupancy. Our estimates support that the vacancies (supply) are induced by the referrals (demand), and referrals are also related to the location of LTMHC facilities.

CONCLUSION

LTMHC is still in the initial stage of development in Portugal, and it is expected to receive financial support through the Recovery and Resilience Programme. According to the occupancy rates and referrals made, residential structures seem to be a priority, being also important to explore the partial use of domiciliary services. The geographical distribution of vacancies can also be a concern, considering the important proximity to the community in LTMHC.

Using the Theoretical Domain Framework to understand what helps and hinders the use of different sensory approaches in Australian psychiatric units: A survey of mental health clinicians

BACKGROUND/AIM

Although sensory approaches are recommended to relieve distress and agitation and reduce the use of seclusion and restraint, many Australian psychiatric units have struggled to sustain their practice. The aim of this study was to investigate the barriers and enablers influencing the use of different sensory approaches across one health region in Australia and to obtain recommendations for strategies to improve their use.

METHOD

This cross-sectional survey was informed by the Theoretical Domain Framework. Likert scale questions considered barriers and enablers to the use of non-weighted sensory interventions, weighted modalities, sensory rooms, and sensory assessments/plans. Open-ended questions explored participant concerns and recommendations to improve the use of sensory approaches.

RESULTS

Participants (n = 211) were from nursing, allied health, medical, and peer support staff across inpatient psychiatric units. Factors most frequently identified as enablers for using sensory approaches were beliefs of positive benefits to consumers (e.g. decreasing distress and agitation); belief it was within the staff's role; and knowledge of the approaches. Limited time was the most common identified barrier. Factors statistically associated with more frequent use were knowledge, skills, confidence, availability, and easy access to sensory tools/equipment. Only 30% of participants were concerned about potential risks of sensory approaches, with this risk mitigated through adequate supervision and thorough risk assessment. Recommendations to improve practice included improved access to, and maintenance of, equipment, more training, and increased staffing.

CONCLUSION

This study revealed how barriers and enablers vary for different sensory approaches and how these factors impact their frequency of use in psychiatric units. It provides insights into staff recommendations to improve the use of sensory approaches in one health region in Australia. This knowledge will lead to the development of implementation strategies to address identified barriers and improve the use of sensory approaches in psychiatric units.

Planning for Change: Co-Designing Implementation Strategies to Improve the Use of Sensory Approaches in an Acute Psychiatric Unit

Implementing sensory approaches in psychiatric units has proven challenging. This multi-staged study involved qualitative interviews (n = 7) with mental health care staff in an acute psychiatric ward to identify the local factors influencing use of sensory approaches, and co-design implementation strategies with key stakeholders to improve their use. Using framework analysis, results revealed that the use of sensory approaches were hindered by: inadequate access to sensory resources/equipment; lack of time; lack of staff knowledge; and belief that sensory approaches are not effective or part of staff's role. To address identified barriers a systematic theory-informed method was used to co-design implementation strategies to improve the use of sensory approaches.

Models, frameworks and theories in the implementation of programs targeted to reduce formal coercion in mental health settings: a systematic review

Introduction

Implementation models, frameworks and theories (hereafter tools) provide researchers and clinicians with an approach to understand the processes and mechanisms for the successful implementation of healthcare innovations. Previous research in mental health settings has revealed, that the implementation of coercion reduction programs presents a number of challenges. However, there is a lack of systematized knowledge of whether the advantages of implementation science have been utilized in this field of research. This systematic review aims to gain a better understanding of which tools have been used by studies when implementing programs aiming to reduce formal coercion in mental health settings, and what implementation outcomes they have reported.

Methods

A systematic search was conducted using PubMed, CINAHL, PsycINFO, Cochrane, Scopus, and Web of Science. A manual search was used to supplement database searches. Quality appraisal of included studies was undertaken using MMAT-Mixed Methods Appraisal Tool. A descriptive and narrative synthesis was formed based on extracted data. Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines were followed in this review.

Results

We identified 5,295 references after duplicates were removed. Four additional references were found with a manual search. In total eight studies reported in nine papers were included in the review. Coercion reduction programs that were implemented included those that were holistic, and/or used professional judgement, staff training and sensory modulation interventions. Eight different implementation tools were identified from the included studies. None of them reported all eight implementation outcomes sought from the papers. The most frequently reported outcomes were acceptability (4/8 studies) and adaptation (3/8). With regards to implementation costs, no data were provided by any of the studies. The quality of the studies was assessed to be overall quite low.

Discussion

Systematic implementation tools are seldom used when efforts are being made to embed interventions to reduce coercive measures in routine mental health care. More high-quality studies are needed in the research area that also involves perspectives of service users and carers. In addition, based on our review, it is unclear what the costs and resources are needed to implement complex interventions with the guidance of an implementation tool.

Systematic review registration

[Prospero], identifier [CRD42021284959].

[Long Term Evaluation of the Implementation of the Safewards Model - Results of a Follow-Up-Study Among Patients and Staff in Acute Psychiatric Wards]

OBJECTIVE

Evaluation of long-term effects of the implementation of the Safewards Model (SM) among staff and patients in acute psychiatry in Germany.

METHOD

Assessment of ward atmosphere, job satisfaction, fidelity, and coercive interventions in 2 locked wards directly before and 15 months after implementation of the SM.

RESULTS

Ward atmosphere was assessed significantly better after implementation, job satisfaction was still above-average at both times, coercive interventions declined significantly in one ward, fidelity and degree of implementation were still high.

CONCLUSIONS

The implementing of the SM in locked wards in acute psychiatry can also have positive effects in long run.

Getting a grip on Safewards: The cross impact of clinical supervision and Safewards model on clinical practice

The Safewards model is used across various mental health settings to reduce incidents of conflict and containment and its efficacy in reducing the use of seclusion and restraint, improving patients' experiences of care, and enhancing safety within clinical settings is well documented (Bowers, Journal of Psychiatric & Mental Health Nursing, 21, 2014, 499). However, there are barriers to successful implementation, including level of staff buy-in (Baumgardt et al., Frontiers in Psychiatry, 10, 2019, 340; Price et al., Mental Health Practice, 19, 2016, 14). This mixed-method study assessed the impact of adopting a Safewards model within a clinical supervision framework in an approach, named Group Reflective integrated Practice with Safewards (GRiP-S), which integrates Safewards theory within the clinical supervision framework. Both quantitative and qualitative data were collected using the questions derived from the Manchester Clinical Supervision Scale -26© (Winstanley & White, The Wiley International Handbook of Clinical Supervision. John Wiley & Sons Ltd, 2014). A total of 67 surveys and eight interviews were completed by nursing staff. Overall, the results showed that the GRiP-S approach improves the implementation of Safewards and nurses' clinical practice. Nursing staff satisfaction with clinical supervision and Safewards improved post GRiP-S pre-GRIP-S- 69.54 (SD 16.059); post-GRIP-S 71.47 (SD 13.978). The survey also identified nursing staff's perception of GRiP-S in the restorative and formative domains of clinical supervision improved. The restorative mean score pre-GRiP-S was 28.43 (SD 5.988) and post-GRiP-S 29.29 (SD 3.951). The formative mean score pre-GRiP-S was 20.10 (SD 5.617) and post-GRiP-S 20.63 (SD 13.978). The qualitative results further explained the satisfaction levels and the changes seen in perception domains. The GRiP-S approach reported (i) improved therapeutic relationships and patient centred care, (ii) improved staff communication and teamwork, (iii) barriers to GRiP-S engagement, and (iv) assistance with the change process. The results indicate that the GRiP-S approach had a positive impact on Safewards delivery and supports ongoing change of practice.

Sensory approaches in psychiatric units: Patterns and influences of use in one Australian health region

BACKGROUND/AIM

Australian guidelines and policies recommend the use of sensory approaches in mental health care. Nevertheless, many Australian psychiatric units report difficulty sustaining these approaches. To inform efforts to close the gap between recommendations and practice, the aim of this study was to understand the patterns of use of sensory approaches and what demographic and clinical factors influence their use, across one health region in Queensland, Australia.

METHODS

Using a cross-sectional survey design, a custom-designed questionnaire was distributed via email and in paper form to health professionals and peer support workers working in acute, secure, and community care psychiatric units across one health region. Information on demographics and the use of various sensory interventions was gathered utilising both open-ended and Likert scale questions.

RESULTS

Useable questionnaires were collected from 183 participants from various disciplines (77% nursing). The majority reported using sensory approaches with a limited number of consumers, and almost 9% never used the approach. Activity-based sensory interventions and sensory equipment were most often used, whereas sensory assessments, sensory plans, and sensory groups were least used. Sensory interventions were mainly used to reduce consumer anxiety and agitation and to assist with emotional regulation. Factors positively correlated with frequency of use for all interventions were discipline (occupational therapy); working in an acute inpatient unit; and training in sensory approaches. Age was negatively correlated with frequency of use only for weighted modalities.

CONCLUSIONS

This study revealed that sensory approaches were used by most staff though with a limited proportion of consumers in psychiatric units in one large metropolitan health service. It provides insights into the factors influencing frequency of use, highlighting the importance of training in sensory approaches and access to occupational therapists. With this knowledge, we can work towards closing the gap between recommendations and the practice of sensory approaches.

Safewards: An integrative review of the literature within inpatient and forensic mental health units

Mental health inpatient units are complex and challenging environments for care and treatment. Two imperatives in these settings are to minimize restrictive practices such as seclusion and restraint and to provide recovery-oriented care. Safewards is a model and a set of ten interventions aiming to improve safety by understanding the relationship between conflict and containment as a means of reducing restrictive practices. To date, the research into Safewards has largely focused on its impact on measures of restrictive practices with limited exploration of consumer perspectives. There is a need to review the current knowledge and understanding around Safewards and its impact on consumer safety. This paper describes a mixed-methods integrative literature review of Safewards within inpatient and forensic mental health units. The aim of this review was to synthesize the current knowledge and understanding about Safewards in terms of its implementation, acceptability, effectiveness and how it meets the needs of consumers. A systematic database search using Medline, CINAHL, Embase and PsychInfo databases was followed by screening and data extraction of findings from 19 articles. The Mixed Methods Appraisal Tool (MMAT) was used to assess the quality of empirical articles, and the Johanna Brigg's Institute (JBI's) Narrative, Opinion, Text-Assessment and Review Instrument (NOTARI) was used to undertake a critical appraisal of discussion articles. A constant comparative approach was taken to analysing the data and six key categories were identified: training, implementation strategy, staff acceptability, fidelity, effectiveness and consumer perspectives. The success of implementing Safewards was variously determined by a measured reduction of restrictive practices and conflict events, high fidelity and staff acceptability. The results highlighted that Safewards can be effective in reducing containment and conflict within inpatient mental health and forensic mental health units, although this outcome varied across the literature. This review also revealed the limitations of fidelity measures and the importance of involving staff in the implementation. A major gap in the literature to date is the lack of consumer perspectives on the Safewards model, with only two papers to date focusing on the consumers point of view. This is an important area that requires more research to align the Safewards model with the consumer experience and improved recovery orientation.

Current State of Research on Coercion in Mental Health: Umbrella Review Protocol

In recent years, international organizations, professionals, and representatives of mental health service users have expressed the need to regulate, limit, and even eliminate coercive measures in psychiatric treatment. The main objective of the current review is to provide a comprehensive synthesis of existing evidence on coercion in mental health care through a protocol for an umbrella review of systematic reviews. This protocol was designed according to the Joanna Briggs Institute guide for methodological development, conduct, and reporting of umbrella reviews. To minimize bias in the process, two independent reviewers selected the studies to be included, extracted, and synthesized; analyzed the data; and assessed risk of bias of each review. The review protocol was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols guidelines. This review offers a comprehensive compilation of systematic reviews on coercion developed to date. Coercion causes adverse physical and psychological effects and is an emotional stressor for individuals with psychiatric diagnoses and health care workers. Characterization of coercion across care settings, its impact on clinical outcomes, the perception of those involved, and how coercion could be reduced will also be discussed. [Journal of Psychosocial Nursing and Mental Health Services, xx(xx), xx-xx.].

Effect of Safewards on reducing conflict and containment and the experiences of staff and consumers: A mixed-methods systematic review

Safewards is an internationally adopted framework that provides interventions to reduce conflict and containment in healthcare settings. This systematic review evaluated the effect of Safewards on conflict and containment events in inpatient units and the perceptions of staff and consumers. Quantitative, qualitative, and mixed-methods studies were considered for inclusion. Following the Joanna Briggs Institute methodology, two reviewers independently screened, appraised, and extracted data. Qualitative data were synthesized using inductive-thematic analysis. Quantitative and qualitative data were integrated with a convergent-segregated approach and presented in tabular and narrative format. A search of 13 databases and grey literature yielded 14 studies of variable methodological quality. Four studies reported reduced rates of conflict and one study reported reductions that were not statistically significant. Six studies reported reductions in rates of containment, three studies found no statistical significance and one study reported statistically significant reductions at follow-up. Staff and consumers in four studies reported an improved experience of safety. Three themes were developed as follows: (i) therapeutic hold, cohesion, support and the environment, (ii) conflict, containment and the experience of safety, and (iii) the complexities of adapting and embedding change. This review found most staff and consumers reported Safewards improved therapeutic relationships, cohesion, and ward atmosphere. Staff and consumers reported improved ward atmosphere, leading to consumer-centred, recovery-oriented care. Safewards improved the experience of safety from the perspective of staff and consumers when combined with ongoing training, leadership and time for consolidation. While results are promising they should be used cautiously until more robust evidence is established.

Exploring factors that influence success when introducing "The Safewards Model" to an acute adolescent ward: A qualitative study of staff perceptions

Problem

The Safewards’ model identifies factors that can lead to conflict and addresses these factors, using ten interventions, within inpatient mental health wards aiming to reduce “conflict and containment.” The Department of Health (2014) and Care Quality Commission (2017) supported the use of Safewards to reduce restrictive practice across all mental health settings in the UK, but its application to adolescent mental health remains relatively unexplored. This study therefore aims to address the research question: “What are the factors influencing the success of ten Safewards’ interventions when implemented onto an acute adolescent ward?”

Methods

Eight healthcare assistants and two nurses who had attended Safewards’ training participated in semi‐structured interviews four months after Safewards was introduced to an acute adolescent ward. The interviews were transcribed verbatim and analyzed using thematic analysis. Data analysis was conducted inductively by developing data‐driven themes.

Findings

Many of the factors influencing Safewards’ success in adolescent mental health (e.g., acuity; dependence on nonregular staffing; lack of leadership and operating procedures) paralleled the evidence found in adult services.

Conclusions

This study contributes new information by implementing “mutual help” and “calm down” principles with adolescents, as well as discussing barriers of operational procedures and benefits of patient involvement.

Measuring Staff Attitudes to Coercion in Poland

Introduction: Coercion can be defined as the use of force to limit a person's choices. In Poland, coercive measures may tend to be overused. However, there is limited information regarding the attitudes of nurses toward coercion in psychiatric settings and the factors influencing any decisions to use coercion. Aims: To validate the Staff Attitudes to Coercion Scale (SACS) for a group of psychiatric nurses and psychiatrists, to compare the said with the original Norwegian SACS version, and to compare nurses' attitudes with those displayed by psychiatrists. A second aim was to understand the relationship between self-efficacy and attitudes to coercion. Method: We surveyed 351 psychiatric nurses and psychiatrists rating SACS and GSES (General Self Efficacy Scale). We validated the SACS factor structure using confirmatory principal component factor analysis, calculated the internal consistency of subscales, and analyzed the test-retest reliability and face validity of the subscales themselves. Further, we analyzed the differences in attitudes toward coercion between nurses and psychiatrists, as well as whether there was an association between GSES and the SACS subscales. We compared the means on the SACS items between three countries-Germany, Norway, and Poland. Results: The confirmatory factor analysis of the Polish version of SACS found the same factor structure with three factors as was displayed in the original Norwegian SACS, except that one item was loaded on another factor. Internal consistency was acceptable for the factors on coercion as security and the coercion as offending, and unacceptable for the factor on coercion as treatment. Test-retest reliability was excellent for all the three subscales. Face validity was high for the factor coercion as security, partly present for coercion as offending, and not present for coercion as treatment. The subscale Coercion as Treatment was rated significantly higher by nurses than by psychiatrists, but there was no difference for the two other subscales. There was no significant association between the General Self-Efficacy Scale and any of the SACS subscales. The biggest differences in attitudes toward forms of coercion was noted between Poland and Germany. Discussion: The three-factor structure of SACS was the best solution for the Polish nurses and psychiatrists. The attitudes toward coercion differed between the two groups, but a low correlation was computed for the SACS subscales and self-efficacy. There is a cultural diversity visible amongst the three countries examined. Reduction in the use of coercion is a priority worldwide. More knowledge about the process involved in using coercive measures may contribute to this. The use of coercive interventions may harm patients and threaten patients' rights. Thus, education is needed for pre-service and in-service nurses alike.

Contextual Barriers and Enablers to Safewards Implementation in Victoria, Australia: Application of the Consolidated Framework for Implementation Research

Background: Safewards is a complex psychosocial intervention designed to reduce conflict and containment on inpatient mental health units. There is mounting international evidence of the effectiveness and acceptability of Safewards. However, a significant challenge exists in promising interventions, such as Safewards, being translated into routine practice. The Consolidated Framework for Implementation Research (CFIR) provides a framework through which to understand implementation in complex health service environments. The aim was to inform more effective implementation of Safewards using the CFIR domains and constructs, capitalizing on developing an understanding of variations across wards. Method: Seven Safewards Leads completed the Training and Implementation Diary for 18 wards that opted in to a trial of Safewards. Fidelity Checklist scores were used to categorize low, medium and high implementers of Safewards at the end of the 12-week implementation period. Results: Qualitative data from the diaries were analyzed thematically and coded according to the five CFIR domains which included 39 constructs. Twenty-six constructs across the five domains were highlighted within the data to have acted as a barrier or enabler. Further analysis revealed that six constructs distinguished between low, medium, and high implementing wards. Discussion: Our findings suggest that for implementation of Safewards to succeed, particular attention needs to be paid to engagement of key staff including managers, making training a priority for all ward staff, adequate planning of the process of implementation and creating an environment on each inpatient unit that prioritize and enables Safewards interventions to be undertaken by staff regularly.

Everyday comforting practices in psychiatric hospital environments: A design anthropology approach

WHAT IS KNOWN ON THE SUBJECT

Comfort as a conceptual and lived experience is essential in psychiatric hospital contexts and for overall mental health wellbeing. Comfort is a valuable aspect when designing hospitals and built environments for psychiatric care.

WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE

This article presents the results from a Design Anthropology study at four Psychiatric Units co-located in a newly built regional hospital based on 126 ethnographic interviews with staff, within which 63 participants mentioned the importance of comfort in generating environments conducive to wellbeing. An in-depth qualitative understanding of comforting practices, as emergent forms of everyday care. These may receive less attention within more established interventions from organisational models of care (e.g., Safewards) and might appear to be implicit gestures of courtesy. However, they contribute to meaningful encounters and contribute to individual and organisational wellbeing in psychiatric care.

WHAT ARE THE IMPLICATIONS FOR PRACTICE

This paper builds on comfort theories and demonstrates implications for practice through ethnographic examples. Comfort, often unnoticed until it is absent, needs to be maintained through continuous "small" but intentional acts of care. These constitute a finely tuned repertoire of everyday comforting practices of care at psychiatric contexts. Corridors and doors are presented as spaces where people have brief interactions that can contribute to everyday comforting experiences. Comfort is discussed in dialogue with existing literatures from psychiatric nursing, healthcare building design and design anthropology. Implicit and improvised practices of care that foster comforting environments have vital potential to support institutionally endorsed models of care (e.g., Safewards). The article proposes that design has a dual role for comforting environments in psychiatric care; (a) through the practice of architectural design and (b) through the practices of staff when creating everyday comforting interactions for wellbeing.

ABSTRACT

INTRODUCTION: Creating a comforting environment is essential for delivering psychiatric care. While healthcare organisations explicitly implement care models and adapt the physical environment, attention to staff's implicit everyday practice is limited.

AIM

Developing a design anthropology approach tailored specifically to the research site, we examine the social and physical environment to unpack how staff integrate both-implicit comforting interventions, and the explicit measures taken by the organisation-into their everyday practices of psychiatric care.

METHOD

Design and sensory ethnography, using extended observations and "walking tours" were undertaken with 126 staff members. A thematic analysis was conducted on all visual and audio material.

RESULTS

Staff's everyday implicit care practices and situated design decisions provide a comforting environment for patients, visitors and staff.

DISCUSSION

Implicit practices combine with an explicit organisational model of care to achieve a comforting environment. The value of design anthropology to uncover these dynamics is emphasized. Comforting practice involving implicit gestures of courtesy, which are infrequently addressed within organisational models of care (e.g., Safewards), are foregrounded.

IMPLICATIONS FOR PRACTICE

Explicit models of care have clear value in generating comfort; however, psychiatric hospital care also benefits from less visible modes of delivering comfort through everyday practices. By acknowledging both explicit and implicit modes of comfort, we can better understand how care models and psychiatric cultures of care are nurtured. Continuous "small" but intentional acts of care (e.g., brief interactions in corridors and at doors) constitute a finely tuned repertoire of everyday comforting practices.

Conceptual framework for a comprehensive competence in managing challenging behaviour: The views of trained instructors

WHAT IS KNOWN ON THE SUBJECT?: There is body of knowledge available about the harms associated with restrictive interventions used in behaviour management, service users' perceptions of the use of restraints, and staff competence in behaviour management. The staff perspective has been studied in terms of staff exposure, responses to and prevention of aggression, staff-related factors associated with service user aggression, and staff attitudes and perceptions towards violence. The definitions of competence in behaviour management provided in training interventions are fragmented and based on unilateral measurements. Training interventions with the purpose of enhancing staff competence in behaviour management are organized regularly, yet there is a lack of clarity on how effective these interventions are. Inadequate conceptual understanding of behaviour management can weaken the effectiveness of these interventions. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Our study produced new knowledge by providing a preliminary conceptual framework that can be used to comprehensively describe and assess competence in managing challenging behaviour and to cover safely the whole care process. Humane care and ethical sensitivity should be the premises of interaction with people in distress. We also pointed out the needs for conceptual clarification of the concepts of confidence, support and restraint. We provide important new insight into the leadership and cultural issues of behaviour management that is relevant for patients, staff members and healthcare organizations. We found that staff members do not consider service user safety and workplace safety as opposing issues. Further, we provide new perspectives for prevention, the risk assessment process and effective communication in the context of behaviour management. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: A comprehensive understanding of the competences related to behaviour management will foster universal definitions for "support" and "restraint," which can then be used to ensure that the best practices are used for behaviour management. Organizational culture and participative leadership on behaviour management should be developed with a special focus on safety issues, common understanding of comprehensive competence, risk assessment and prevention, views regarding the use of restraints, and teamwork. ABSTRACT: Introduction Previous research concerning staff views of behaviour management has not considered instructors' views. The definitions of competence in behaviour management are fragmented, which can undermine the effectiveness of training interventions. Aim/Question This study aimed to describe Finnish and British Management of Actual or Potential Aggression instructors' perceptions of safety and behaviour management-related competences and create a conceptual framework for comprehensive competence. Method An explorative-descriptive qualitative approach with purposive sampling (N = 22), semi-structured interviews and abductive content analysis. Results Conceptual framework of comprehensive competence in managing challenging behaviour includes five categories-knowledge, skills, attitude, confidence and ethical sensitivity-and 21 subcategories. Competent staff and supportive leadership ensured safety, while inconsistent risk management culture, the health and behaviour of service users, and inadequate staff orientation endangered safety. Discussion The study produced new knowledge of safety issues and competences from the perspective of the instructors who deliver behaviour management training. Implications for practice Competence to manage challenging behaviour should be developed based on our conceptual framework to provide an effective and safe training. Prevention, the risk assessment process, alternative communication, and the definitions of "confidence," "support" and "restraint" should all be sufficiently addressed in future training.

Mental health nurses experience of the introduction and practice of the Safewards model: a qualitative descriptive study

BACKGROUND

A lack of safety experienced by patients and staff in acute psychiatric units is a major concern and containment methods used to manage conflict have the potential to cause harm and upset to both staff and patients. To ensure safety for all, it is highly desirable to reduce levels of conflict and containment and the Safewards model is an evidence-based model aimed at reducing conflict and containment rates by improving nurse-patient relationships and safety.

METHODS

The aim of this study was to explore mental health nurses' experience of the introduction and practice of three Safewards interventions; reassurance, soft words and discharge messages. A qualitative descriptive research design utilising a purposive sample (n = 21) of registered psychiatric nurses (n = 16) and managers (n = 5) in an acute psychiatric unit in Ireland. Following a 12-week implementation of Safewards, three focus groups were conducted, two with nursing staff and one with nurse managers. Data were analysed using Braun and Clarke thematic analysis framework which supported the identification of four themes: introducing Safewards, challenges of Safewards, impact of Safewards and working towards success.

RESULTS

The findings indicate that the process of implementation was inadequate in the training and education of staff, and that poor support from management led to poor staff adherence and acceptance of the Safewards interventions. The reported impact of Safewards on nursing practice and patient experience were mixed. Overall, engagement and implementation under the right conditions are essential for success and while some participants perceived that the interventions already existed in practice, participants agreed Safewards enhanced their communication skills and relationships with patients.

CONCLUSION

The implementation of Safewards requires effective leadership and support from management, mandatory training for all staff, and the involvement of staff and patients during implementation. Future research should focus on the training and education required for successful implementation of Safewards and explore the impact of Safewards on nursing practice and patient experience.

Overcoming barriers to implementing ward-based psychosocial interventions in acute inpatient mental health settings: A meta-synthesis

BACKGROUND

The culture of acute mental health wards is often dominated by medical models of care despite some patient dissatisfaction with care in these settings and a demand for increased access to psychosocial interventions. Research has found that psychosocial interventions can improve a number of patient and staff outcomes, however, implementation within these settings is often challenging.

OBJECTIVES

The aim of this review was to provide a comprehensive synthesis of the barriers and facilitators to implementing psychosocial interventions on acute wards, in order to develop a list of recommendations for embedding psychosocial interventions within the ward culture in acute settings.

METHODS

Databases were systematically searched using search terms related to acute mental health wards and psychosocial intervention implementation from inception to December 2019. Thirty-nine studies (forty-three papers) that explored the implementation of psychosocial interventions on adult acute mental health wards using qualitative methods met inclusion criteria. Data relating to barriers and facilitators to implementing psychosocial interventions extracted from the results sections of the papers were synthesised using the COM-B model.

RESULTS AND CONCLUSIONS

We conclude that to address barriers to the implementation of psychosocial interventions, services should provide clear information to patients regarding the benefits of engagement, and additional training for staff. A shift in ward culture is required and can be achieved through the recruitment of empathic implementers, together with providing staff with protected time for delivery of psychosocial interventions with clear accountability for intervention delivery through the provision of clearly defined roles.

An evaluation of a video magnification-based system for respiratory rate monitoring in an acute mental health setting

CONTEXT

One of the most important goals of inpatient psychiatric care is to provide a safe and therapeutic environment for both patients and staff. A small number of aggressive or agitated patients are difficult to sedate, even after multiple doses of sedating antipsychotics. Adverse effects can result in harm to the patient and staff and that observations are conducted without touching the patient.

AIM

This study aims to determine if motion magnification can improve the feasibility of non-contact respirations monitoring over a video feed.

METHODS

Registered nurses were invited to view seven pairs of pre-recorded footage of healthy volunteers and count the number of breaths that they observe over a period of one minute for each. One of the paired videos was unprocessed and the other magnified the motion of chest rise and fall.

RESULTS

Nursing observation of respirations showed an improvement in reduction of count error from 15.7 % to 1.5 % after video magnification of respiratory movement. Nurses also stated that viewing the processed video was much easier to make their observations from.

CONCLUSION

It is possible to use magnified video to monitor respirations of patients during circumstances where it is potentially difficult to obtain. Further observational studies should be conducted on a larger scale with this type of technique and is urgently needed to inform practice.

Reducing aggression in psychiatric wards using Safewards-A Polish study

PURPOSE

To reduce the use of mechanical restraints, Safewards was introduced to a ward in a psychiatric hospital in Poland.

DESIGN AND METHODS

Three aspects of Safewards were applied for 8 months. The comparison time period was the same time frame of the previous year.

FINDINGS

Restraint use dropped by 24%, and the number of patients restrained dropped 34%. The duration of restraint remained at 2.8 days per episode.

PRACTICE IMPLICATIONS

Simple techniques aimed at promoting positive interactions between staff and patients can reduce the frequency of restraints.

Involving mental health consumers in nursing handover: A qualitative study of nursing views of the practice and its implementation

Nursing handover occurs between shifts and is an important means of communication and information exchange around consumer care. The involvement of consumers in nursing handover, known as 'bedside handover', is well established within general health settings and promotes a patient-centred approach to care. Bedside handover represents an opportunity for mental health settings to consolidate recovery-oriented principles, albeit with some unique challenges in the way that involving consumers in nursing handover is implemented. This qualitative descriptive study explores the views of nursing staff and nursing managers about involving consumers in nursing handover and the process of implementation across five mental health inpatient units in Australia. The study took place in a local health district covering regional and rural areas of New South Wales that had issued a directive to implement bedside handover. The consolidated criteria for reporting qualitative research (COREQ) checklist was applied to this study. Six focus groups were held with nursing staff (n = 22), and eleven individual interviews were undertaken with nursing managers to explore their perceptions of bedside handover and its implications for nursing practice. The data were analysed using thematic analysis. Data from focus groups and interviews were analysed separately and then combined to generate three themes: (i) the mental health context is different; (ii) protecting consumer privacy and confidentiality; and (iii) it might make things worse. The findings provide insights into both the challenges, and the process of involving consumers in nursing handover within mental health settings and provides guidance for future implementation.

Health Care Management Models for the Evolution of Hospitalization in Acute Inpatient Psychiatry Units: Comparative Quantitative Study

BACKGROUND

Mental health disorders are a problem that affects patients, their families, and the professionals who treat them. Hospital admissions play an important role in caring for people with these diseases due to their effect on quality of life and the high associated costs. In Spain, at the Healthcare Complex of Zamora, a new disease management model is being implemented, consisting of not admitting patients with mental diseases to the hospital. Instead, they are supervised in sheltered apartments or centers for patients with these types of disorders.

OBJECTIVE

The main goal of this research is to evaluate the evolution of hospital days of stay of patients with mental disorders in different hospitals in a region of Spain, to analyze the impact of the new hospital management model.

METHODS

For the development of this study, a database of patients with mental disorders was used, taking into account the acute inpatient psychiatry unit of 11 hospitals in a region of Spain. SPSS Statistics for Windows, version 23.0 (IBM Corp), was used to calculate statistical values related to hospital days of stay of patients. The data included are from the periods of 2005-2011 and 2012-2015.

RESULTS

After analyzing the results, regarding the days of stay in the different health care complexes for the period between 2005 and 2015, we observed that since 2012 at the Healthcare Complex of Zamora, the total number of days of stay were reduced by 64.69%. This trend is due to the implementation of a new hospital management model in this health complex.

CONCLUSIONS

With the application of a new hospital management model at the Healthcare Complex of Zamora, the number of days of stay of patients with mental diseases as well as the associated hospital costs were considerably reduced.

Patient safety in inpatient mental health settings: a systematic review

OBJECTIVES

Patients in inpatient mental health settings face similar risks (eg, medication errors) to those in other areas of healthcare. In addition, some unsafe behaviours associated with serious mental health problems (eg, self-harm), and the measures taken to address these (eg, restraint), may result in further risks to patient safety. The objective of this review is to identify and synthesise the literature on patient safety within inpatient mental health settings using robust systematic methodology.

DESIGN

Systematic review and meta-synthesis. Embase, Cumulative Index to Nursing and Allied Health Literature, Health Management Information Consortium, MEDLINE, PsycINFO and Web of Science were systematically searched from 1999 to 2019. Search terms were related to 'mental health', 'patient safety', 'inpatient setting' and 'research'. Study quality was assessed using the Hawker checklist. Data were extracted and grouped based on study focus and outcome. Safety incidents were meta-analysed where possible using a random-effects model.

RESULTS

Of the 57 637 article titles and abstracts, 364 met inclusion criteria. Included publications came from 31 countries and included data from over 150 000 participants. Study quality varied and statistical heterogeneity was high. Ten research categories were identified: interpersonal violence, coercive interventions, safety culture, harm to self, safety of the physical environment, medication safety, unauthorised leave, clinical decision making, falls and infection prevention and control.

CONCLUSIONS

Patient safety in inpatient mental health settings is under-researched in comparison to other non-mental health inpatient settings. Findings demonstrate that inpatient mental health settings pose unique challenges for patient safety, which require investment in research, policy development, and translation into clinical practice.

PROSPERO REGISTRATION NUMBER

CRD42016034057.

Safewards Impact in Inpatient Mental Health Units in Victoria, Australia: Staff Perspectives

Introduction: Mental health professionals working in acute inpatient mental health wards are involved in a complex interplay between an espoused commitment by government and organizational policy to be recovery-oriented and a persistent culture of risk management and tolerance of restrictive practices. This tension is overlain on their own professional drive to deliver person-centered care and the challenging environment of inpatient wards. Safewards is designed to reduce conflict and containment through the implementation of 10 interventions that serve to improve the relationship between staff and consumers. The aim of the current study was to understand the impact of Safewards from the perspectives of the staff. Methods: One hundred and three staff from 14 inpatient mental health wards completed a survey 12 months after the implementation of Safewards. Staff represented four service settings: adolescent, adult, and aged acute and secure extended care units. Results: Quantitative results from the survey indicate that staff believed there to be a reduction in physical and verbal aggression since the introduction of Safewards. Staff were more positive about being part of the ward and felt safer and more connected with consumers. Qualitative data highlight four key themes regarding the model and interventions: structured and relevant; conflict prevention and reducing restrictive practices; ward culture change; and promotes recovery principles. Discussion: This study found that from the perspective of staff, Safewards contributes to a reduction in conflict events and is an acceptable practice change intervention. Staff perspectives concur with those of consumers regarding an equalizing of staff consumer relationships and the promotion of more recovery-oriented care in acute inpatient mental health services.

Consumer Perspectives of Safewards Impact in Acute Inpatient Mental Health Wards in Victoria, Australia

Background: Inpatient mental health wards are reported by many consumers to be custodial, unsafe, and lacking in therapeutic relationships. These consumer experiences are concerning, given international policy directives requiring recovery-oriented practice. Safewards is both a model and a suite of interventions designed to improve safety for consumers and staff. Positive results in reducing seclusion have been reported. However, the voice of consumers has been absent from the literature regarding Safewards in practice. Aim: To describe the impact of Safewards on consumer experiences of inpatient mental health services. Method: A postintervention survey was conducted with 72 consumers in 10 inpatient mental health wards 9-12 months after Safewards was implemented. Results: Quantitative data showed that participants felt more positive about their experience of an inpatient unit, safer, and more connected with nursing staff. Participants reported that the impact of verbal and physical aggression had reduced because of Safewards. Qualitatively, participants reported increased respect, hope, sense of community, and safety and reduced feelings of isolation. Some participants raised concerns about the language and intention of some interventions being condescending. Discussion: Consumers' responses to Safewards were positive, highlighting numerous improvements of importance to consumers since its implementation across a range of ward types. The findings suggest that Safewards offers a pathway to reducing restrictive interventions and enables a move toward recovery-oriented practice.

Using interventions to reduce seclusion and mechanical restraint use in adult psychiatric units: an integrative review

The aim of this integrative review was to describe interventions aimed at reducing seclusion and mechanical restraint use in adult psychiatric inpatient units and their possible outcomes. CINAHL, MEDLINE, PsycINFO and Medic databases were searched for studies published between 2008 and 2017. Based on electronic and manual searches, 28 studies were included, and quality appraisal was carried out. Data were analysed using inductive content analysis. Interventions to proactively address seclusion were environmental interventions, staff training, treatment planning, use of information and risk assessment. Interventions to respond to seclusion risk were patient involvement, family involvement, meaningful activities, sensory modulation and interventions to manage patient agitation. Interventions to proactively address mechanical restraint were mechanical restraint regulations, a therapeutic atmosphere, staff training, treatment planning and review of mechanical restraint risks. Interventions to respond to mechanical restraint risks included patient involvement, therapeutic activities, sensory modulation and interventions to manage agitation. Outcomes related to both seclusion and mechanical restraint reduction interventions were varied, with several interventions resulting in both reduced and unchanged or increased use. Outcomes were also reported for combinations of several interventions in the form of reduction programmes for both seclusion and mechanical restraint. Much of the research focused on implementing several interventions simultaneously, making it difficult to distinguish outcomes. Further research is suggested on the effectiveness of interventions and the contexts they are implemented in.

Patients' experiences of assessment and detention under mental health legislation: systematic review and qualitative meta-synthesis

BACKGROUND

Understanding patient experiences of detention under mental health legislation is crucial to efforts to reform policy and practice.

AIMS

To synthesise qualitative evidence on patients' experiences of assessment and detention under mental health legislation.

METHOD

Five bibliographic databases were searched, supplemented by reference list screening and citation tracking. Studies were included if they reported on patient experiences of assessment or detention under mental health legislation; reported on patients aged 18 years or older; collected data using qualitative methods; and were reported in peer-reviewed journals. Findings were analysed and synthesised using thematic synthesis.

RESULTS

The review included 56 papers. Themes were generally consistent across studies and related to information and involvement in care, the environment and relationships with staff, as well as the impact of detention on feelings of self-worth and emotional state. The emotional impact of detention and views of its appropriateness varied, but a frequent theme was fear and distress during detention, including in relation to the use of force and restraint. Where staff were perceived as striving to form caring and collaborative relationships with patients despite the coercive nature of treatment, and when clear information was delivered, the negative impact of involuntary care seemed to be reduced.

CONCLUSIONS

Findings suggest that involuntary in-patient care is often frightening and distressing, but certain factors were identified that can help reduce negative experiences. Coproduction models may be fruitful in developing new ways of working on in-patient wards that provide more voice to patients and staff, and physical and social environments that are more conducive to recovery.

DECLARATION OF INTEREST

None.

Preventing and Reducing Coercive Measures-An Evaluation of the Implementation of the Safewards Model in Two Locked Wards in Germany

Introduction: Aggression and violence are highly complex problems in acute psychiatry that often lead to the coercive interventions. The Safewards Model is an evidence-informed conflict-reduction strategy to prevent and reduce such incidents. The aim of this study was to evaluate the implementation of this model with regard to coercive interventions in inpatient care. Materials and Methods: We evaluated outcomes of the implementation of the Safewards Model in two locked psychiatric wards in Germany. Frequency and duration of coercive interventions applied during a period of 10 weeks before and 10 weeks after the implementation period were assessed through routine data. Fidelity to the Safewards Model was assessed by the Organization Fidelity Checklist. Results: Fidelity to the Safewards Model was high in both wards. The overall use of coercive measures differed significantly between wards [case-wise: χ² (1, n = 250) = 35.34, p ≤ 0.001; patient-wise: χ² (1, n = 103) = 21.45, p ≤ 0.001] and decreased post-implementation. In one ward, the number of patients exposed to coercive interventions in relation to the overall number of admissions decreased significantly [χ² (1, 182) = 9.30, p = 0.003]. Furthermore, the mean duration of coercive interventions overall declined significantly [U(55,21) = -2.142, p = 0.032] with an effect size of Cohen's d = -0.282 (95% CI: -0.787, 0.222) in that ward. Both aspects declined as well in the other ward, but not significantly. Discussion: Results indicate that the implementation of the Safewards interventions according to the model in acute psychiatric care can reduce coercive measures. They also show the role of enabling factors as well as of obstacles for the implementation process.