Safewards: the empirical basis of the model and a critical appraisal

An Initial Investigation into Mental Health Clinicians' Aims to Reduce Restrictive Practices

PURPOSE

Internationally, service users and their families have raised concerns about safety in current mental health service delivery. Underfunding and risk-averse management practices are implicated as key challenges. This study aimed to explore initial clinician perspectives on needed changes to reduce restrictive interventions and to improve conditions for service users and staff alike.

MATERIALS AND METHODS

Utilizing a co-operative inquiry approach, this unique study was clinician-led and co-produced by researchers and clinicians. Community and Emergency Department Crisis Mental Health Clinicians (from both nursing and social work backgrounds) explored their use of restrictive interventions, and what they need from policy and resources to change practices. Clinician-researchers collected data across two meetings, subsequently co-conducted a thematic analysis of their reflections in a group setting, and co-produced the write up and reflections of the results.

RESULTS

Seven themes were developed which explored: the holding of risk; over interventions, imperfect solutions; containment seeking; time's importance in the holding of risk; least restrictive environments; and holding risk as an isolating practice. These themes are presented as questions that arose through these discussions, as clinician-researchers reflected on their own practice.

DISCUSSION

The environments where crisis clinicians work are not designed for least restrictive practice, despite these clinicians often find creative and thoughtful solutions to imperfect circumstances.

CONCLUSION

This study models and encourages deep dialogue toward redesigned policy and practices and for future research.

Prevention of Violence in an Acute Psychiatric Unit: Spanish Validation of the Brøset Violence Checklist and Assessment of Its Predictive Capacity for Physical Restraint

BACKGROUND

The management of violence and restrictive practices in acute mental health units poses a challenge for the design of clinical nursing protocols that combine the safety of professionals and the dignified care of patients. Many of the strategies aimed at reducing seclusion and restraint practices include the use of standardised risk assessment instruments, preferably conducted by the nursing staff. Among them, the Brøset Violence Checklist (BVC) is one of the most widely supported tools.

AIM

To conduct the Spanish validation of the BVC and to explore its predictive validity for violence and for the use of restraint.

METHODS

Prospective data from 115 patients consecutively admitted to an acute unit of a general university hospital were gathered to validate the instrument. The role of risk factors for violence such as gender, age, substance use or the involuntariness of the admission was analysed, both in relation to the BVC score and to the need for physical restraint in the short and middle term (72 h and 1 week).

RESULTS

The Spanish version of the BVC maintains its predictive validity for imminent violence and guarantees excellent inter-rater reliability among mental health nurses. The score in the first shift after admission is significantly associated with increased odds of restraint at 72 h (OR = 7.272), and age with decreased odds (OR = 0.903), with no significant effect of the rest of the variables.

DISCUSSION

The BVC is a reliable tool that seems to capture the risk for violence intrinsic to other factors, such as the involuntariness of admission. Its role in the design of non-restraint policies is discussed.

IMPLICATIONS FOR PRACTICE

BVC is a useful and freely available instrument. Its Spanish version opens up its use in the fourth most widely spoken language.

Exploring Individual's Dynamic of Appraisal of Situational Aggression Average Score, Nursing Intervention and the Impact on Aggression

INTRODUCTION

The Dynamic Appraisal of Situational Aggression (DASA) is used to appraise risk of imminent aggression in inpatient mental health settings.

AIM

We investigated whether individual patients' mean DASA scores over multiple consecutive time periods (a rolling DASA mean) improved predictive validity, beyond the ultimate DASA rating, and whether DASA ratings were associated with nursing intervention.

METHOD

Archival data were analysed using cox regression analyses. We investigated the predictive validity of rolling DASA mean models and calculated how many daily DASA ratings generated a mean score with the best model fit. Chi-Squares with Odds Ratios were used to examine the effect of various aggression prevention intervention(s) on aggression means.

RESULTS

Daily DASA ratings had strong predictive validity. Incorporating the ultimate score with the rolling 10-day DASA mean slightly improved prediction. Limit setting was associated with an increased likelihood of aggression for low-risk patients whereas reassurance was associated with increased aggressiveness for those at increased risk of aggression.

DISCUSSION

Daily DASA ratings have strong predictive validity. Considering a 10-day rolling DASA mean in addition to the current day DASA rating may improve prediction.

IMPLICATIONS FOR PRACTICE

DASA ratings can forecast imminent aggression. Additionally, there may be value in considering ratings from the previous 10 days.

The potential for Safewards to reduce restrictive interventions for people arriving to the emergency Department with police for a mental health assessment

Safewards is a complex intervention developed to promote a therapeutic response to minimise conflict and containment in inpatient mental health settings. A pilot study was conducted to adapt Safewards for the emergency department (ED) setting to evaluate its impact on the use of restrictive interventions. This subgroup analysis focusses on patients transported to the ED by police for mental health assessment.

METHOD

A retrospective file audit was conducted using pre and post measures on the use of restrictive interventions following the implementation of Safewards. Demographic and restrictive interventions data were extracted from the hospital databases 12 months before and 6 months after Safewards was implemented. All patients transported to the ED by police for a mental health assessment were included in two regional emergency departments in Victoria, Australia, with over 122,000 presentations per year accredited by the Australasian College for Emergency Medicine.

RESULTS

There were 1379 pre and 543 post attendances accompanied by police. Of these, 85.5% pre and 99.1% post were transported to the hospital under Section 351 of the MHA (2014). Post implementation, there were fewer code grey events (clinical and security responses to unarmed threat) that required restrictive interventions including mechanical or chemical restraint. The number of code grey events in which no restrictive intervention was applied increased from 76.7% to 86.6%. Staff assigned higher triage ratings following the introduction of Safewards. There was a significant reduction in code grey events that used one restrictive intervention after implementing Safewards ED interventions (15.6% versus 7.2%; p=<0.001). Significantly fewer sedative medications were administered to manage behaviour on arrival (20.6% pre versus 9.8% post, p=<0.001).

CONCLUSION

The Safewards ED adaptation may have contributed to a reduction in the use of restrictive interventions in this high-risk subgroup of patients frequently subject to restrictive interventions in the ED. Further research is required to validate the findings from this subgroup analysis.

Nurses' Perspectives on Fostering Therapeutic Relationships While Working With Clients Who Display Conflict Behaviour

Therapeutic relationships are critical in the treatment of mental health disorders. Some clients experiencing mental health disorders display conflict behaviour-for example, suicidal or self-harming behaviour, threats of or actual aggression, and various psychotic behaviours-which presents significant challenges for care professionals. In inpatient mental health units, where interactions with mental health nurses are frequent, managing conflict behaviour is crucial to maintaining care quality and fostering therapeutic progress. This study aims to describe nurses' perspectives on fostering therapeutic relationships while working with clients who display conflict behaviour. Qualitative research was conducted in a specialised treatment setting for such clients by means of individual semi-structured interviews and a focus group interview with nurses. The results show that the nurses' primary focus is on cooperating with clients and colleagues. Regardless of conflict behaviour, nurses consistently invite clients to cooperate. To do so, they must manage their own emotions and expectations, emphasise the clients' responsibility and reduce the opportunities for conflict behaviour. The unit structure helps nurses by reducing ambiguity regarding treatment policies and inconsistencies in nurse-client interactions and allows nurses and clients to experience feelings of safety. To work with conflict behaviour, nurses need to feel valued and supported by their colleagues and have adequate time and resources. In conclusion, this study shows how nurses foster therapeutic relationships with clients who display conflict behaviour by focusing on cooperation, structure and safety.

Review article: Scoping review of interventions that reduce mechanical restraint in the emergency department

OBJECTIVE

Mechanical restraints are known to be associated with many undesirable outcomes in clinical settings. Our objective was to examine the current literature to explore possible interventions that would reduce the use of mechanical restraints in the ED.

METHODS

In this scoping review, we searched online databases Embase, MEDLINE and Cochrane CENTRAL for any studies published between the databases from 1 January 2007 to 19 September 2023. Studies were included if interventions were hospital- or staff-focused and reported measured outcomes before and after the introduction of the intervention. Risk of bias was assessed using the JBI Critical Appraisal Checklist for Cohort Studies.

RESULTS

The search strategy yielded 1937 studies across the three databases, of which 13 studies were extracted and included in the review. Interventions were categorised into four groups: provision of staff training, addition of a de-escalation team, creation of a dedicated unit and introduction of an agitation scale only. Most of the studies saw reduction in restraint rates or time in restraints. Only the two studies that used an agitation scale as a stand-alone intervention saw no significant reduction. Only one study had low risk of bias, whereas the remainder had high risk.

CONCLUSIONS

Evidence supports further exploration of interventions that include: designing an agitation guideline; training staff in assessment, attitudinal and de-escalation skills; addition of a crisis team; and environmental changes in the form of adding a dedicated clinical space. Although these strategies may reduce mechanical restraint in the ED setting, further high-quality studies are needed before definitive conclusions may be drawn.

Understanding the Consumers' Experiences of Safewards: A Qualitative Exploratory Study

Safewards is a model and set of interventions with demonstrated effectiveness in reducing conflict and containment which are associated with negative consumer experiences within inpatient mental health settings. Safewards has been widely adopted internationally as a way of enhancing safety and reducing restrictive practices. Despite this, consumers' experiences of Safewards and its effect on their personal safety are less understood and therefore require further exploration. This qualitative exploratory study sought to explore consumers' experiences of Safewards in acute inpatient mental health units. The Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist was used for reporting purposes. Fifteen consumers across two sites participated in semi-structured focus groups. Thematic analysis generated four themes: (1) engaging consumers in Safewards, (2) consumers supporting each other, (3) interacting and communicating and (4) access, availability and expectations. Participants expressed positive views about Safewards and wanted to be more involved in its day-to-day application. Enhanced consumer involvement in Safewards was associated with improved safety and wellbeing for consumers within acute inpatient mental health units. These findings have the potential to influence practice towards improving the consumers experience of Safewards. This requires an exploration of ways to harness informal consumer supports, recognising that consumers need to spend meaningful time with nurses to feel safe and acknowledging that all forms of restrictive practice have an impact on consumers within acute inpatient environments.

Managing Challenging Behaviour in the Adolescent Inpatient Environment

Frontline clinical staff, typically nurses, are routinely faced with the dilemma of managing challenging, defiant and sometimes unsafe behaviours. Structures of ward rules, regulations and 'behavioural expectations' are often employed in hospital environments in service of regulating these behaviours and ensuring collective well-being. Adolescent inpatient populations, however, pose unique and particularly complex challenges for managing behavioural expectations, given the unique needs and inherent tempestuousness of this developmental period. This article presents a critical review of the existing literature on behavioural expectations for inpatient units, which is largely bereft of adolescent-specific guidelines. Relevant theoretical perspectives are examined that lend understanding to the management of adolescent behaviour. Finally, drawing from neurodevelopmental, attachment and socio-evolutionary theory, guiding clinical principles and recommendations are derived for best practice in managing challenging adolescent behaviour in hospital settings.

Reasons behind the rise in involuntary psychiatric treatment under mental health act 2016, Queensland, Australia - Clinician perspectives

OBJECTIVE

Despite legislative reform to promote less restrictive treatment options, the rates of involuntary psychiatric treatment in Queensland, Australia continue to rise. This paper aims to investigate mental health clinicians' perspectives of reasons behind the high and increasing rates of involuntary psychiatric treatment in Queensland.

METHOD

Qualitative methodology was used to explore clinician perspectives by facilitating two face-to-face focus groups. Purposive sampling was used to select clinicians of multiple disciplines from inpatient and community adult mental health teams. Reflexive thematic analysis was utilised to analyse and interpret data.

FINDINGS

The findings suggested a broad consensus that involuntary treatment is over-utilised in public mental health services. Six main themes were identified, including risk aversion, systemic service deficiencies, lack of voluntary alternatives, increased substance use in the community, legislative and policy shortcomings, and barriers to enacting criteria in the legislation.

CONCLUSION

This paper highlights that legislative reform alone will be ineffective in reducing involuntary psychiatric treatment, and adequate resources, training, policy and culture change are necessary for successful implementation of less restrictive practices. The reforms require reorientation of the implementation of policy, as well as legislation to align the Queensland mental health system within a human rights framework.

Stakeholder perspectives on continuous observation in inpatient psychiatric wards

WHAT IS KNOWN ON THE SUBJECT?: Continuous observation is often used in mental health wards to support the safety of service users, where they will be constantly watched by a member of staff. Evidence suggests that continuous observations may be unhelpful and restrictive, but not enough is known about the practice or the best ways to improve it. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: This evaluation integrates the perspectives of service users, informal carers and staff to explore current continuous observation experiences and inform future improvements. While previous research highlights the importance of therapeutic engagement, this study additionally emphasizes how the observation procedure could be adapted to individual needs. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Continuous observations could be more beneficial if they are therapeutic, proportional to the level of risk and co-developed with the service user, informal carer and staff. Further training about communication could support staff engagement and the observation process could be formalized to ensure regular collaborative reviews.

ABSTRACT

INTRODUCTION: Continuous observation is a frequently used tool to manage high levels of risk on psychiatric wards. However, there is little previous research on its use in practice.

AIM

This qualitative service evaluation aims to explore the continuous observation experiences of service users, informal carers and staff in a local NHS Mental Health Trust, informing suggested future improvements to current practice.

METHOD

Five service users, three informal carers and seven healthcare staff completed semi-structured interviews, which were thematically analysed to create four themes.

RESULTS

Positive interaction and engagement in activities were critical for a therapeutic approach to observations, supporting service users and staff to minimize the unproductive behaviours that can arise. Difficulties balancing safety with privacy could suggest the importance of proportionate and tailored observation procedures for each service user. Ensuring the voices of service users and informal carers remain central to decisions regarding care could further improve the observation experience.

IMPLICATIONS FOR PRACTICE

This study highlights therapeutic, proportionate and co-produced observations as key characteristics to improve practice. Further training and formalization of the observation process could foster cultural changes towards more long-term approaches to risk management.

Medical and surgical nurses' experiences of modifying and implementing contextually suitable Safewards interventions into medical and surgical hospital wards

AIM

To explore general nurses' experiences of modifying and implementing contextually suitable Safewards interventions into medical and surgical hospital wards.

DESIGN

Qualitative action research was used working with nurses as co-researchers.

METHODS

Pre-implementation focus groups were conducted in April 2022 to understand and explore the current strategies nurses utilized to avert, respond to or decrease violence. Following this, two Safewards interventions were modified by the nurses on the wards. Post-implementation focus groups were conducted in October 2022, to explore the nurses' experience of implementing Safewards interventions and the effect on their nursing practice. Data were analysed using Braun and Clarke's framework for thematic analysis.

RESULTS

Three themes emerged from the analysis of the pre-implementation focus groups that reflected the type of violence experienced by these nurses and the context within which they occurred: 'the space is hectic'; 'it can feel like a battlefield'; and 'the aftermath'. These themes encompass the nurses' experience of violence from patients and their visitors. Following the implementation of two modified Safewards interventions, the analysis of the focus groups reflected a change in nursing skills to avert or respond to violence: 'Safewards in action'; 'empathy and self-reflection'; and 'moving forward'.

CONCLUSION

Safewards interventions can be successfully modified and used in general hospital wards and influence nursing practice to manage patient and visitor violence.

IMPLICATIONS FOR THE PROFESSION

In the interests of safety, successful interventions to reduce violence towards general hospital nurses should be a priority for managers and healthcare organizations. Averting, mitigating and managing violence can decrease the negative professional and personal effect on nurses and ultimately improve well-being, job satisfaction and retention rates. Furthermore, decreasing violence or aggressive incidents leads to a safer patient experience and decreased number of nursing errors ultimately improving patient experiences and outcomes. Understanding nurses' experiences of violence and working with them to explore and develop contextually relevant solutions increases their capacity to respond to and avert violent incidents. Contextually modified Safewards interventions offer one such solution and potentially has wider implications for healthcare settings beyond the specific wards studied.

IMPACT

This study addressed the implementation of modified Safewards strategies in medical and surgical wards to prevent violence. Three themes emerged from the analysis of the pre-implementation focus groups that reflected the type of violence experienced by these nurses and the context within which they occurred. Following the implementation of two modified Safewards interventions, the post-implementation focus groups reported positive changes to their practices using the modified resources to prevent violence from patients and their visitors. Mental health interventions, such as those used in the Safewards model can be modified and provide a tool kit of interventions that can be used by medical and surgical nurses.

REPORTING METHOD

This paper has adhered to the COREQ guidelines.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution. WHAT DOES THIS PAPER CONTRIBUTE TO THE WIDER GLOBAL CLINICAL COMMUNITY?: This paper outlines and discusses the action research approach undertaken to work with general hospital nurses to modify mental health nurses' Safewards interventions into their clinical practice. This paper provides evidence of the 'real world' application of Safewards interventions by medical and surgical nurses in general hospital wards. This paper presents qualitative findings based on focus group methods to highlight the narratives of general nurses and their experiences of violence.

Exploring the Safewards Programme to Reduce Restrictive Practices in Residential Aged Care: Protocol for a Pilot and Feasibility Study

INTRODUCTION

Restrictive practice use in residential aged care homes internationally is unacceptably high. Although policies and legislation mandate the reduction or elimination of restrictive practices, there remains a gap in knowledge regarding strategies that have been effective in achieving a sustained reduction in restraint use. There is an urgent need to identify effective and feasible interventions that aged care staff can implement in everyday practice to reduce restraint use. Safewards is an evidence-based programme that has demonstrated effectiveness in reducing conflict and restrictive practice use in inpatient psychiatric settings and has the potential to address the issue of restraint use in aged care homes. This study aims to evaluate the feasibility of Safewards in reducing restrictive practices in residential aged care homes.

METHODS

This pilot and feasibility study will adopt a mixed methods process and outcomes evaluation. Safewards will be implemented in two Australian residential aged care homes. The Reach, Effectiveness, Adoption, Implementation and Maintenance framework will be used to evaluate implementation outcomes. Additionally, the Consolidated Framework for Implementation Research will be used to guide qualitative data collection (including semi-structured interviews with residents/family members, aged care leaders and staff) and explain the facilitators and barriers to effective implementation.

CONCLUSION

This study will provide pilot evidence on the feasibility of the Safewards programme in residential aged care homes. Understanding the processes and adaptations for implementing and evaluating Safewards in residential aged care will inform a future trial in aged care to assess its effectiveness. More broadly, the findings will support the implementation of an international aged care policy of reducing restrictive practices in residential aged care.

PATIENT OR PUBLIC CONTRIBUTION

A person with lived experience of caring for someone with dementia is employed as a Safewards facilitator and is a member of the steering committee. Residents and family members will be invited to participate in the project steering committee and provide feedback on their experience of Safewards.

TRIAL REGISTRATION

ACTRN12624000044527.

Emergency department nurses' learning and evolving perspectives in interacting with patients who self-harm. An explorative interview study of the use of a mobile application

SAFE is a mobile application co-created for and by people who have experienced self-harm, either themselves or as next of kin. This study intended to integrate SAFE into an Emergency Department (ED) to help patients share experiences of self-harm and to support professionals in conducting treatment as usual (TAU). Objective: This study was a part of a Co-operative Inquiry in which a learning intervention was implemented, followed by an interview study exploring ED nurses' reflections and learnings while integrating SAFE into their practice. Methods: Thirteen semi-structured interviews were analysed using reflexive thematic analysis. Results: The nurses imagined that SAFE could be a positive game changer. However, they were hesitant due to uncertainty about the ED context, the value of the app and their skills. Conclusions: Supplying TAU with technology is challenging and future digital solutions must be created in partnership to ensure the solutions are customised to the target group.

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.

De-escalating aggression in acute inpatient mental health settings: a behaviour change theory-informed, secondary qualitative analysis of staff and patient perspectives

BACKGROUND

De-escalation is often advocated to reduce harm associated with violence and use of restrictive interventions, but there is insufficient understanding of factors that influence de-escalation behaviour in practice. For the first time, using behaviour change and implementation science methodology, this paper aims to identify the drivers that will enhance de-escalation in acute inpatient and psychiatric intensive care mental health settings.

METHODS

Secondary analysis of 46 qualitative interviews with ward staff (n = 20) and patients (n = 26) informed by the Theoretical Domains Framework.

RESULTS

Capabilities for de-escalation included knowledge (impact of trauma on memory and self-regulation and the aetiology and experience of voice hearing) and skills (emotional self-regulation, distress validation, reducing social distance, confirming autonomy, setting limits and problem-solving). Opportunities for de-escalation were limited by dysfunctional risk management cultures/ relationships between ward staff and clinical leadership, and a lack of patient involvement in safety maintenance. Motivation to engage in de-escalation was limited by negative emotion associated with moral formulations of patients and internal attributions for behaviour.

CONCLUSION

In addition to training that enhances knowledge and skills, interventions to enhance de-escalation should target ward and organisational cultures, as well as making fundamental changes to the social and physical structure of inpatient mental health wards. Psychological interventions targeting negative emotion in staff are needed to increase motivation. This paper provides a new evidence-based framework of indicative changes that will enhance de-escalation in adult acute mental health inpatient and PICU settings.

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.

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.

Bringing together the World Health Organization's QualityRights initiative and the World Psychiatric Association's programme on implementing alternatives to coercion in mental healthcare: a common goal for action

BACKGROUND

Stakeholders worldwide increasingly acknowledge the need to address coercive practices in mental healthcare. Options have been described and evaluated in several countries, as noted recently in major policy documents from the World Health Organization (WHO) and World Psychiatric Association (WPA). The WHO's QualityRights initiative promotes human rights and quality of care for persons with mental health conditions and psychosocial disabilities. A position statement from the WPA calls for implementation of alternatives to coercion in mental healthcare.

AIMS

We describe the engagement of both the WHO and WPA in this work. We discuss their mutual aim to support countries in improving human rights and quality of care, as well as the differences between these two organisations in their stated goals related to coercion in mental healthcare: the WHO's approach to eliminate coercion and the WPA's goal to implement alternatives to coercion.

METHOD

We outline and critically analyse the common ground between the two organisations, which endorse a similar range of rights-based approaches to promoting non-coercive practices in service provision, including early intervention in prevention and care and other policy and practice changes.

RESULTS

Advocacy and action based on an agreed need to find practical solutions and advances in this area have the power to build consensus and unify key actors.

CONCLUSIONS

We conclude that persons with lived experience, families, mental health professionals and policy makers are now coming together in several parts of the world to work toward the common goals of improving quality, promoting human rights and addressing coercion in mental health services.

Development and evaluation of a de-escalation training intervention in adult acute and forensic units: the EDITION systematic review and feasibility trial

Background

Containment (e.g. physical restraint and seclusion) is used frequently in mental health inpatient settings. Containment is associated with serious psychological and physical harms. De-escalation (psychosocial techniques to manage distress without containment) is recommended to manage aggression and other unsafe behaviours, for example self-harm. All National Health Service staff are trained in de-escalation but there is little to no evidence supporting training's effectiveness.

Objectives

Objectives were to: (1) qualitatively investigate de-escalation and identify barriers and facilitators to use across the range of adult acute and forensic mental health inpatient settings; (2) co-produce with relevant stakeholders an intervention to enhance de-escalation across these settings; (3) evaluate the intervention's preliminary effect on rates of conflict (e.g. violence, self-harm) and containment (e.g. seclusion and physical restraint) and understand barriers and facilitators to intervention effects.

Design

Intervention development informed by Experience-based Co-design and uncontrolled pre and post feasibility evaluation. Systematic reviews and qualitative interviews investigated contextual variation in use and effects of de-escalation. Synthesis of this evidence informed co-design of an intervention to enhance de-escalation. An uncontrolled feasibility trial of the intervention followed. Clinical outcome data were collected over 24 weeks including an 8-week pre-intervention phase, an 8-week embedding and an 8-week post-intervention phase.

Setting

Ten inpatient wards (including acute, psychiatric intensive care, low, medium and high secure forensic) in two United Kingdom mental health trusts.

Participants

In-patients, clinical staff, managers, carers/relatives and training staff in the target settings.

Interventions

Enhancing de-escalation techniques in adult acute and forensic units: Development and evaluation of an evidence-based training intervention (EDITION) interventions included de-escalation training, two novel models of reflective practice, post-incident debriefing and feedback on clinical practice, collaborative prescribing and ward rounds, practice changes around admission, shift handovers and the social and physical environment, and sensory modulation and support planning to reduce patient distress.

Main outcome measures

Outcomes measured related to feasibility (recruitment and retention, completion of outcome measures), training outcomes and clinical and safety outcomes. Conflict and containment rates were measured via the Patient-Staff Conflict Checklist. Clinical outcomes were measured using the Attitudes to Containment Measures Questionnaire, Attitudes to Personality Disorder Questionnaire, Violence Prevention Climate Scale, Capabilities, Opportunities, and Motivation Scale, Coercion Experience Scale and Perceived Expressed Emotion in Staff Scale.

Results

Completion rates of the proposed primary outcome were very good at 68% overall (excluding remote data collection), which increased to 76% (excluding remote data collection) in the post-intervention period. Secondary outcomes had high completion rates for both staff and patient respondents. Regression analyses indicated that reductions in conflict and containment were both predicted by study phase (pre, embedding, post intervention). There were no adverse events or serious adverse events related to the intervention.

Conclusions

Intervention and data-collection procedures were feasible, and there was a signal of an effect on the proposed primary outcome.

Limitations

Uncontrolled design and self-selecting sample.

Future work

Definitive trial determining intervention effects.

Trial registration

This trial is registered as ISRCTN12826685 (closed to recruitment).

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 16/101/02) and is published in full in Health Technology Assessment; Vol. 28, No. 3. See the NIHR Funding and Awards website for further award information.

Context

Conflict (a term used to describe a range of potentially unsafe events including violence, self-harm, rule-breaking, medication refusal, illicit drug and alcohol use and absconding) in mental health settings causes serious physical and psychological harm. Containment interventions which are intended to minimise harm from violence (and other conflict behaviours) such as restraint, seclusion and rapid tranquilisation can result in serious injuries to patients and, occasionally, death. Involvement in physical restraint is the most common cause of serious physical injury to National Health Service mental health staff in the United Kingdom. Violence to staff results in substantial costs to the health service in sickness and litigation payments. Containment interventions are also expensive (e.g. physical restraint costs mental health services £6.1 million and enhanced observations £88 million per annum). Despite these harms, recent findings indicate containment interventions such as seclusion and physical restraint continue to be used frequently in mental health settings. Clinical trials have demonstrated that interventions can reduce containment without increasing violence and other conflict behaviours (e.g. verbal aggression, self-harm). Substantial cost-savings result from reducing containment use. De-escalation, as an intervention to manage aggression and potential violence without restrictive practices, is a core intervention. 'De-escalation' is a collective term for a range of psychosocial techniques designed to reduce distress and anger without the need to use 'containment' interventions (measures to prevent harm through restricting a person's ability to act independently, such as physical restraint and seclusion). Evidence indicates that de-escalation involves ensuring conditions for safe intervention and effective communication are established, clarifying and attempting to resolve the patient's concern, conveyance of respect and empathy and regulating unhelpful emotions such as anxiety and anger. Despite featuring prominently in clinical guidelines and training policy domestically and internationally and being a component of mandatory National Health Service training, there is no evidence-based model on which to base training. A systematic review of de-escalation training effectiveness and acceptability conducted in 2015 concluded: (1) no model of training has demonstrated effectiveness in a sufficiently rigorous evaluation, (2) the theoretical underpinning of evaluated models was often unclear and (3) there has been inadequate investigation of the characteristics of training likely to enhance acceptability and uptake. Despite all National Health Service staff being trained in de-escalation there have been no high-quality trials evaluating the effectiveness and cost-effectiveness of training. Feasibility studies are needed to establish whether it is possible to conduct a definitive trial that can determine the clinical, safety and cost-effectiveness of this intervention.

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.

Staff Perspectives in Mental Health Research Regarding Restrictive Interventions: An Australian Scoping Review and Thematic Analysis

Service users and their families have raised concerns about safety in current acute mental health service delivery. Restrictive interventions are routinely used across mental health settings despite increasing awareness of the negative impacts. Underfunding and risk-averse management practices are implicated as key challenges. Utilizing a scoping review and thematic analysis method, this review explored the existing literature of mental health staff perspectives across various settings (including psychiatric wards and emergency departments), focusing on their experience of restrictive interventions. Four themes were developed: 1. Safety (both staff and patient); 2. Barriers to staff reducing their restrictive interventions; 3. Strength in current practice; 4. Recommendations for change. Key gaps in the literature were the limited perspectives of emergency and crisis clinicians (despite these areas being settings where restrictive interventions are utilized) and limited perspectives from allied health disciplines (despite their employment as clinicians in these settings). It also noted a divide between staff and patient safety, as though these concerns are mutually exclusive rather than cooccurring, which is the experienced reality. Advocacy bodies, governments and the media are calling for a reduction in restrictive interventions in crisis settings. This research synthesis proposes that, to achieve this, clinical staff must be involved in the process and their perspectives actively sought and drawn upon to enable reform.

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.

Metacognitive training in the acute psychiatric care setting: feasibility, acceptability, and safety

Patients on acute psychiatric wards desire more psychosocial treatment than they receive, according to recent studies, but evidence-based interventions tailored to this setting are currently lacking. Metacognitive Training for psychosis (MCT) is a flexible, easy-to-administer group therapy that has been adapted to meet this demand (MCT-Acute). Thirty-seven patients with severe mental illness took part in MCT-Acute twice a week during their stay on a locked acute ward and were interviewed before, during, and after the intervention period regarding subjective utility, subjective adverse events, and symptom severity; attendance rates and reasons for absence were recorded. In addition, staff rated adverse events, symptom severity, and functioning (German Clinical Trial Register ID: DRKS00020551). Overall, most patients evaluated MCT-Acute positively and reported symptom stabilization. Staff also reported improvement in functioning. No clinician-rated adverse events related to participation in MCT-Acute were reported. Conducting MCT-Acute is feasible and safe and may contribute to meeting patients', practitioners', and researchers' demands for more evidence-based psychotherapeutic interventions for the acute psychiatric care setting.

Clinical Trial Registration

ID: DRKS00020551, https://drks.de/search/de/trial/DRKS00020551.

Zero Tolerance for Coercion? Historical, Cultural and Organisational Contexts for Effective Implementation of Coercion-Free Mental Health Services around the World

Coercion of service users/patients when receiving care and treatment has been a serious dilemma for mental health services since at least the 18th century, and the debate about how best to minimise or even eradicate compulsion remains intense. Coercion is now, once again and rightly, at the top of the international policy agenda and the COST Action 'FOSTREN' is one example of a renewed commitment by service user advocates, practitioners and researchers to move forward in seriously addressing this problem. The focus of service improvement efforts has moved from pure innovation to practical implementation of effective interventions based on an understanding of the historical, cultural and political realities in which mental health services operate. These realities and their impact on the potential for change vary between countries across Europe and beyond. This article provides a novel overview by focusing on the historical, cultural and political contexts which relate to successful implementation primarily in Europe, North America and Australasia so that policy and practice in these and other regions can be adopted with an awareness of these potentially relevant factors. It also outlines some key aspects of current knowledge about the leading coercion-reduction interventions which might be considered when redesigning mental health services.

An Integrative Review on Psychiatric Intensive Care

Psychiatric intensive care units (PICUs) provide care and treatment when psychiatric symptoms and behaviors exceed general inpatient resources. This integrative review aimed to synthesize PICU research published over the past 5 years. A comprehensive search in MEDLINE, PsycINFO, PubMed and Scopus identified 47 recent articles on PICU care delivery, populations, environments, and models. Research continues describing patient demographics, and high rates of challenging behaviors, self-harm, and aggression continue being reported. Research on relatives was minimal. Patients describe restrictive practices incongruent with recovery philosophies, including controlling approaches and sensory deprivation. Some initiatives promote greater patient autonomy and responsibility in shaping recovery, yet full emancipatory integration remains limited within PICU environments. Multidisciplinary collaboration is needed to holistically advance patient-centered, equitable, and integrative PICU care. This review reveals the complex tensions between clinical risk management and emancipatory values in contemporary PICU settings. Ongoing reporting of controlling practices counters the recovery movement progressing in wider mental healthcare contexts. However, care innovations centered on patient empowerment and humane environments provide hope for continued evolution toward more liberation-focused PICU approaches that uphold both patient and provider perspectives.

A Call for Transformation: Moving Away from Coercive Measures in Mental Health Care

Coercion is common practice in mental health care [...].

Short-term risk assessment in the long term: A scoping review and meta-analysis of the Brøset Violence Checklist

WHAT IS KNOWN ON THE SUBJECT?: The Brøset Violence Checklist (BVC) has been widely translated and implemented in diverse mental healthcare settings to improve prevention of violence. It is valued as a brief but effective tool in clinical practice. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: This review is the largest and most comprehensive international review of the BVC conducted in the 25+ years since the inception of the instrument in 1995. It integrates findings from existing studies and establishes that the tool has many impressive strengths considering the brief time investment required for completion. The review reveals that the tool has been used in more than 20 different countries around the world in a variety of mental health and other settings as both a risk assessment tool to guide clinical practice and as a formally structured intervention to minimize violence. There is much variation in how the tool is implemented and scored in different services. This variation questions its applicability as a resource and consistency and its use needs attention. This variation in use also limits the conclusions regarding best practices. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: The review supports the use of the BVC as one part of the package for mental health services committed to preventive action aimed at reducing violence and coercion. The review identified that the patient perspective was often absent when completing the BVC, and so this should be considered as an option by services as part of a collaborative philosophy of care.

ABSTRACT

INTRODUCTION: Existing literature on the Brøset Violence Checklist (BVC) is examined in the context of usability, implementation and validity to provide evidence-based recommendations on its application and identify opportunities for future development.

AIM/QUESTION

To identify current knowledge on the BVC and guide clinicians and researchers toward the next steps in using this tool in clinical practice to prevent violence in healthcare settings.

METHOD

A scoping review approach with a meta-analysis supplement was adopted to broadly identify and map available evidence on the BVC and provide specific estimates of predictive validity in different contexts.

RESULTS

Sixty-two studies conducted in 23 countries addressed the implementation of the BVC across various settings. Many studies adapted the original BVC, and the clinical utility was noted as an important feature. A meta-analysis of the original BVC format estimated a pooled area under the curve at 0.83 (95% CI 0.78-0.87) in a subset of 15 studies.

DISCUSSION

The BVC combines high predictive validity and good clinical utility across a wide range of settings and cultures. It should continue to be incorporated into routine practice in mental health services focused on preventing violence and coercion.

IMPLICATIONS FOR PRACTICE

Development of collaborative approaches with service users involved in assessing their own risk of future violence.

Theories for interventions to reduce physical and verbal abuse: A mixed methods review of the health and social care literature to inform future maternity care

Despite global attention, physical and verbal abuse remains prevalent in maternity and newborn healthcare. We aimed to establish theoretical principles for interventions to reduce such abuse. We undertook a mixed methods systematic review of health and social care literature (MEDLINE, SocINDEX, Global Index Medicus, CINAHL, Cochrane Library, Sept 29th 2020 and March 22nd 2022: no date or language restrictions). Papers that included theory were analysed narratively. Those with suitable outcome measures were meta-analysed. We used convergence results synthesis to integrate findings. In September 2020, 193 papers were retained (17,628 hits). 154 provided theoretical explanations; 38 were controlled studies. The update generated 39 studies (2695 hits), plus five from reference lists (12 controlled studies). A wide range of explicit and implicit theories were proposed. Eleven non-maternity controlled studies could be meta-analysed, but only for physical restraint, showing little intervention effect. Most interventions were multi-component. Synthesis suggests that a combination of systems level and behavioural change models might be effective. The maternity intervention studies could all be mapped to this approach. Two particular adverse contexts emerged; social normalisation of violence across the socio-ecological system, especially for 'othered' groups; and the belief that mistreatment is necessary to minimise clinical harm. The ethos and therefore the expression of mistreatment at each level of the system is moderated by the individuals who enact the system, through what they feel they can control, what is socially normal, and what benefits them in that context. Interventions to reduce verbal and physical abuse in maternity care should be locally tailored, and informed by theories encompassing all socio-ecological levels, and the psychological and emotional responses of individuals working within them. Attention should be paid to social normalisation of violence against 'othered' groups, and to the belief that intrapartum maternal mistreatment can optimise safe outcomes.

[The German S3 guidelines on prevention of coercion and treatment of aggressive behavior: from evidence to consensus, from consensus to implementation]

The German S3 guidelines on prevention of coercion: prevention and therapy of aggressive behavior in adults (2018) are cross-sectional guidelines that in addition to medical scientific evidence also touch to a great extent on questions of ethics and law as well as organizational structures of the healthcare system. Accordingly, in addition to the research on evidence, the consensus process also had a strong weighting in the development of the recommendations. The appropriate participation of experts from various fields and their representation in the consensus group was therefore of central importance. Particularly important is the implementation into clinical practice by means of the recommendations for implementation of the German Association for Psychiatry, Psychotherapy and Psychosomatics (DGPPN) for psychiatric wards, psychiatric clinics, and care regions. For psychiatric wards, the recommendations are being evaluated with a multicenter randomized controlled trial (RCT), the PreVCo study.

A descriptive study on the use of restrictive interventions for potentially or actually violent patients in the emergency department

BACKGROUND

Restrictive interventions (chemical, physical, or mechanical restraints) to manage patients who are potentially or actually violent in the emergency department (ED) can be harmful and costly. Non-restrictive interventions are advocated; but this must be preceded with an understanding of patient characteristics that influence their use. A study was conducted to describe the use of restrictive interventions and ascribe it with patient characteristics in the ED.

METHODS

Records from October 2020 to March 2021 in the occupational violence database were used to analyse patient characteristics and restrictive interventions. Logistic regression was used to establish influencing factors of restrictive interventions adjusting for clinically relevant confounders.

RESULTS

Of the N = 1276 potentially or actually violent patients, 70 % received restrictive interventions. Chemical restraint was common, with 1 in 2 patients receiving either oral medication or intramuscular injection. Probability of restrictive interventions were higher in patients who were intoxicated [(adjusted odds ratio (aOR) 3.48, 95 % confidence interval (CI) 1.675-7.21)], had high triage score (aOR 2.084, 95 % CI 1.094-3.96), and were in the ED involuntarily (aOR 1.494, 95 % CI 1.105-2.020).

CONCLUSION

The results reveal the need for multifaceted approaches that limit the presentations of, and minimise restrictive interventions among, potentially or actually violent patients.

Systematic literature review of the use of Staff Attitudes to Coercion Scale (SACS)

Objective

Staff's attitudes to the use of coercion may influence the number of coercive interventions employed and staff willingness to engage in professional development projects aimed at reducing the use of coercion itself. The Staff Attitude to Coercion Scale (SACS) was developed to assess the attitudes of mental healthcare staff to the use of coercion in 2008 and has been employed subsequently. This global study systematically reviews and summarizes the use of the scale in research.

Methods

Seven databases were searched for studies using SACS in articles published in peer reviewed journals and gray literature. In addition, researchers who have asked for permission to use the scale since its development in 2008 were contacted and asked for their possible results. Extracting of data from the papers were performed in pairs of the authors.

Results

Of the 82 identified publications, 26 papers with 5,838 respondents were selected for review. A review of the research questions used in the studies showed that the SACS questionnaire was mostly used in studies of interventions aimed at reducing coercion and further explain variation in the use of coercion.

Conclusion

SACS is, to our best of knowledge, the only questionnaire measuring staff's attitudes to the use of coercive interventions in mental health services. Its widespread use indicates that the questionnaire is perceived as feasible and useful as well as demonstrating the need for such a tool. However, further research is needed as the relationship between staff attitudes to coercion and the actual use of coercion remains unclear and needs to be further investigated. Staff attitudes to coercion may be a prerequisite for leaders and staff in mental healthcare to engage in service development and quality improvement projects.

"My life isn't my life, it's the systems": A qualitative exploration of women's experiences of day-to-day restrictive practices as inpatients

WHAT IS KNOWN ON THE SUBJECT?: Sometimes someone needs to be in hospital because they are struggling with their mental health and need some extra support but being in hospital can also be a difficult experience. There are a lot of restrictions in place in hospital, like locked doors, rules to follow and not much choice about what happens to you. Other research has found that these restrictions can feel difficult and stressful for people and so more research is needed about this. We wanted to know what being in hospital felt like for women in particular. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: We interviewed women who were in hospital because of their mental health about what it was like for them in hospital. The women told us that they felt powerless while they were in hospital. They sometimes felt like they were being punished and this could affect their mood and could lead to them hurting themselves. They also said that they were not always listened to by staff, and they found it difficult being away from their family and friends while they were in hospital. The women also told us that being in hospital could sometimes help them to feel safe. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Women should be looked after in hospital in a way that helps them to feel in control of what happens to them. They should be supported to be able to go outside the hospital on leave, to keep in touch with their family and friends, and they should be listened to by staff. A project called "safewards" has suggested some ways for helping to make hospital wards safer. They have suggested that everyone should be clear about what the rules are when they go into hospital and ways that staff could communicate more clearly with the people they are working with. Our research supports using these techniques. ABSTRACT: Introduction Inpatient care often involves restrictive interventions such as seclusion and restraint and restrictive practices that limit the person's freedom, rights and daily activities. Restrictive practice has not been the explicit focus in previous research; however, it often appears as an important theme, with participants identifying it can have a detrimental effect on their well-being. More research specifically on this topic in an inpatient setting is, therefore, needed. Women might be particularly vulnerable to adverse effects of restrictive practices compared to men as women generally occupy less powerful positions in society and more often experience abuse. Aims The study aimed to explore women's experiences of routine restrictive practices in mental health inpatient settings. Methods Twenty-two women who were currently inpatients on mental health wards were interviewed about their experiences of restrictive practices in hospital. Interviews were analysed using thematic analysis. Results An overarching theme emerged of powerlessness. Four key sub-themes were also identified: restrictions perceived as punitive, having no voice, impact of restrictions on relationships and restrictions providing safety and support. Discussion Although restrictive practices were found to provide the women with a sense of safety, they were also found to impact upon the women's well-being, leading to increases in self-harm and over-reliance on restrictions. Implications for practice This research highlights the importance of gender-informed inpatient services for women that foster independence, empowerment and allow women to have their voices heard. Safewards interventions such as clear mutual expectations and soft words could contribute to mitigating the impact of restrictive practices.

Aggression in mental health care: Opportunities for the future-A qualitative study on the challenges when defining and managing aggression across inpatient disciplines

WHAT IS KNOWN ON THE SUBJECT?: Aggression towards caregivers is a global phenomenon in mental health care. Although attempts have been made to define aggression, there is no globally accepted definition. Discrepancies in defining aggression can lead to differences in judgement and a sub-par management of aggression. The fact that different disciplines work together in mental health care makes it an even more pressing matter as no research was found regarding a multidisciplinary definition of aggression. Currently, coercive measures, such as isolation, sedation or restraints, are the most common ways of managing aggression. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Mental healthcare nurses and psychologists defined aggression by previous experiences, and they also agree that there are no alternatives in managing aggression when non-coercive techniques do not work. Several opportunities and examples of best practice were given by the participants, but the consensus was that caregivers are in need of alternatives when they are face to face with acute aggression. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: It is vital for residential units to agree on a definition of aggression and acute aggression. It is our belief that this can aid them in preventing and de-escalating aggression as well as diminishing the use of coercive measures. Further primary research exploring the opportunities of non-coercive techniques, a multidisciplinary approach and the relationship between a workplace culture normalizing aggression and the mental well-being of healthcare workers is also needed.

ABSTRACT

INTRODUCTION: Aggression by patients against healthcare workers is a global recurring phenomenon in mental health care. Discrepancies in defining aggression can lead to differences in judgement, which in turn causes difficulties in managing aggression. The multidisciplinary nature of mental healthcare makes a standardized definition an even more pressing matter. No studies, however, were found exploring the way different disciplines approach the definition of aggression. Although traditional methods of managing aggression rely on coercive methods, current research favours the use of non-coercive measures.

AIM

The aim of this study was to explore the different ways mental healthcare nurses and psychologists define and manage aggression in a residential unit.

METHOD

A qualitative research design was used, consisting of interviews and focus groups. Transcripts were analysed using a reflexive thematic approach.

RESULTS

Three major themes were found: (1) approaches towards defining aggression, (2) experiencing aggression and (3) managing aggression: the need for alternatives.

DISCUSSION

In this study, aggression is defined by how aggression has been experienced, both mental health nurses and psychologists agree that there are no alternatives in managing aggression when non-coercive techniques do not work. Aggression is considered an integral part of the job indicating an "aggression-tolerating" workplace.

IMPLICATIONS FOR PRACTICE

Three implications for practice were identified: (1) It is vital for residential units to agree on a broad-based definition of aggression, (2) further primary research exploring the opportunities of non-coercive techniques and a multidisciplinary approach is crucial and (3) the relationship between a workplace culture normalizing aggression and the mental well-being of healthcare workers also needs further study.

National Strategies to Reduce the Use of Coercive Measures in Psychiatry in Denmark - A Review of Two Decades of Initiatives

Coercive measures are a major infringement of the autonomy of psychiatric patients and no medical justification exists for applying mechanical restraint (MR) to these patients currently. Knowledge regarding how preventive strategies affect the use of MR is limited. This paper aimed to understand the link between the initiatives taken by national authorities and the practical implications to MR reduction. Policy texts and the number of coercive measures used in two decades were reviewed. Trends were discussed with five experts with real-life experience and suggestions were obtained regarding how to end the use of mechanical restraint in mental health care settings.

Nurses' attitudes towards the use of physical restraint in psychiatric care: A systematic review of qualitative and quantitative studies

WHAT IS KNOWN ON THE SUBJECT?: Application of physical restraint is a common practice to protect service users and staff in psychiatric care. Nurses' attitudes towards physical restraint and its influencing factors in psychiatric settings in different countries are variable. Previous reviews include studies on different coercive methods, making it difficult to differentiate attitudes specific to physical restraint. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Nurses' attitudes were marked by negative feelings and moral conflict towards the use of physical restraint and consider it a necessary nursing intervention and a last resort. The barriers for restraint-free environment practice included contextual demand, lack of knowledge on restraint and lack of alternatives to restraint. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Nurse educators should develop and evaluate related educational training programmes to promote the development of alternative effective skills in handling violence instead of physical restraint. Policy makers should develop strategies to remove the barriers to a restraint-free environments. ABSTRACT: Introduction Physical restraint is common in psychiatric care; nurses' attitudes are crucial as nurses often implement the procedure. Previous reviews include studies exploring coercive methods but do not specifically focus on physical restraint. Aims This integrated mixed-method systematic review aimed to examine nurses' attitudes towards the use of physical restraint in psychiatric care and the factors influencing these attitudes. Methods Six databases were searched from 2000 to 2021. Thematic integrative analysis was used to synthesize the data. Results Ten studies were included. Five themes encapsulate nurses' attitudes towards physical restraint: "emotional responses," "moral conflicts," "ensuring safety for all," "a necessary nursing intervention" and "a last resort." Three themes were identified for factors influencing attitudes: "contextual demands," "level of knowledge" and "alternatives to restraint." Discussion Nurses' attitudes were marked by negative feelings and moral conflict towards the use of physical restraint. However, nurses applied physical restraint as an ordinary nursing intervention. Educational interventions and the leadership role may facilitate the change of current practice to a restraint-free environment. Implications for Practice Mental health nurses should work to remove the barriers to restraint-free environment and develop effective skills that can be used as alternatives to physical restraint.

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.

Shared understanding of resilient practices in the context of inpatient suicide prevention: a narrative synthesis

Background

The prevailing patient safety strategies in suicide prevention are suicide risk assessments and retrospective reviews, with emphasis on minimising risk and preventing adverse events. Resilient healthcare focuses on how everyday clinical practice succeeds and emphasises learning from practice, not from adverse events. Yet, little is known about resilient practices for suicidal inpatients. The aim of the study is to draw upon the perspectives of patients and healthcare professionals to inform the conceptual development of resilient practices in inpatient suicide prevention.

Methods

A narrative synthesis was conducted of findings across patients and healthcare professionals derived from a qualitative case study based on interviews with patients and healthcare professionals in addition to a systematic literature review.

Results

Three sub-themes categorise resilient practices for healthcare professionals and for patients hospitalised with suicidal behaviour: 1) interactions capturing non-verbal cues; 2) protection through dignity and watchfulness; and 3) personalised approaches to alleviate emotional pressure. The main theme, the establishment of relationships of trust in resilient practices for patients in suicidal crisis, is the foundation of their communication and caring.

Conclusion

Clinical practice for patients hospitalised with suicidal behaviour has characteristics of complex adaptive systems in terms of dynamic interactions, decision-making under uncertainty, tensions between goals solved through trade-offs, and adaptations to patient variability and interpersonal needs. To improve the safety of patients hospitalised with suicidal behaviour, variability in clinical practice should be embraced.

Trial registration

https://doi.org/10.1136/bmjopen-2016-012874

Opinions and experiences of nursing students about evaluating the sexual health of individuals with mental disorders: A qualitative study

PURPOSE

To explore the views and experiences of nursing students about evaluating the sexual health of individuals with mental disorders.

DESIGN AND METHODS

A phenomenological approach was used. The purposeful sampling method gathered 11 nursing students. Data were collected in-depth interviews, which were analyzed using Colaizzi's method of data analysis.

FINDINGS

The findings were grouped under three themes: Barriers to sexual health evaluation, lack of supervision and knowledge, and increasing personal growth.

PRACTICE IMPLICATIONS

Barriers to sexual health evaluation need to be determined. Educators and clinicians should supervise students during clinical placement. Learning holistic care is an opportunity to increase personal growth.

Non-coercive techniques for the management of crises in mental health settings in Germany—a narrative review

Coercion is common in mental health care settings in Germany. At the same time, considerable efforts are undertaken to reduce and ultimately abolish coercive interventions. Need adapted treatment, open door policies, and moving away from the biomedical model of mental illness can contribute to non-coercive care. WHO's QualityRights Training can be used to advance knowledge about and adherence to human rights standards in institutions, and to transform institutions to a non-coercive approach. Advance care decisions can make sure that will and preferences prevail in situations when capacity is questioned. However, a radical overhaul of legislation would be required to abolish coercive mental health care in Germany.

Safewards Secure: A Delphi study to develop an addition to the Safewards model for forensic mental health services

WHAT IS KNOWN ON THE SUBJECT?: The Safewards model has been introduced to forensic mental health wards with mixed results. Research has identified a need to consider the addition of factors that may be relevant to forensic mental health services to enhance the introduction of Safewards. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: This study elicits factors specific to forensic mental health settings missing from the original Safewards model, which have the potential to enhance nursing care, improve safety and improve adherence to Safewards in a forensic mental health setting. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: This study provides the adaptation required in a forensic mental health setting to enhance the implementation of the Safewards model of care, originally developed to assist nurses to prevent and manage conflict and containment in acute general mental health settings. The development of Safewards Secure has incorporated perspectives from expert Safewards and forensic mental health nurse leaders and healthcare clinicians and is inclusive of consumer and carer perspectives to ensure the model is applicable and broadly acceptable. ABSTRACT: Introduction Safewards is a model designed specifically for acute mental inpatient wards. Research investigating the introduction of Safewards has identified a need to consider factors relevant in forensic mental health services, such as offence and risk issues. Aim To identify adaptations needed to address gaps in the Safewards model to assist forensic mental health nurses to prevent and manage conflict and containment. Method A Delphi study was employed to engage a group of international Safewards and forensic mental health experts (n = 19), to elucidate adaptation of the Safewards model. Results Experts identified necessary elements and reached consensus on key considerations for Safewards interventions. To ensure the Safewards Secure model was robust and developed on a platform of research, all items suggested by Delphi experts were cross-referenced and dependent on empirical evidence in the literature. Discussion This study identified a number of key differences between civil and forensic mental health services, which informed the development of Safewards Secure, an adjunct to the original Safewards model. Implications for Practice The development of person-centred models of nursing care adapted to specific settings, such as forensic mental health, provides a potential solution to preventing and managing conflict and containment, and improving consumer outcomes. Relevance Statement Managing conflict and containment in mental health services remains an ongoing challenge for mental health nurses. Safewards is a model of care designed for acute mental health inpatient settings to prevent conflict and containment. To date, there has been mixed results when introducing Safewards in forensic mental health settings, and reported reluctance and scepticism. To address these issues, this study employed a Delphi design to elicit possible adaptions to the original Safewards model. From this study, Safewards Secure was developed with adaptations designed for forensic services, to enhance the management of conflict and containment, assist implementation and improve consumer outcomes.

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.].

Management of Accidental Succinylcholine Ingestion: Navigating Uncharted Waters

Accidental oral ingestion of intravenous drugs is rare and under-reported, which may lead to serious morbidity and worsen the outcome for the patient. Though oral ingestion of sedatives and opioid drugs is reported, literature regarding the ingestion of muscle relaxants and subsequent management is limited. We report an interesting case of oral intake of 10 ml (500 mg) of injection Succinylcholine, a depolarizing muscle relaxant, by a psychiatric patient awaiting electroconvulsive therapy (ECT) in the pre-procedure room. We hereby report the subsequent sequence of events along with the suggested recommendations to be followed in the case of such an eventuality. To the best of our knowledge, this is the first case report of oral ingestion of a depolarizing neuromuscular blocking drug and its subsequent consequences.

De-escalation of conflict in forensic mental health inpatient settings: a Theoretical Domains Framework-informed qualitative investigation of staff and patient perspectives

Background

Violence and other harms that result from conflict in forensic inpatient mental health settings are an international problem. De-escalation approaches for reducing conflict are recommended, yet the evidence-base for their use is limited. For the first time, the present study uses implementation science and behaviour change approaches to identify the specific organisational and individual behaviour change targets for enhanced de-escalation in low and medium secure forensic inpatient settings. The primary objective of this study was to identify and describe individual professional, cultural and system-level barriers and enablers to the implementation of de-escalation in forensic mental health inpatient settings. The secondary objective was to identify the changes in capabilities, opportunities and motivations required to enhance de-escalation behaviours in these settings.

Methods

Qualitative design with data collection and analysis informed by the Theoretical Domains Framework (TDF). Two medium secure forensic mental health inpatient wards and one low secure mental health inpatient ward participated. 12 inpatients and 18 staff participated across five focus groups and one individual interview (at participant preference) guided by a semi-structured interview schedule informed by the TDF domains. Data were analysed via Framework Analysis, organised into the 14 TDF domains then coded inductively within each domain.

Results

The capabilities required to enhance de-escalation comprised relationship-building, emotional regulation and improved understanding of patients. Staff opportunities for de-escalation are limited by shared beliefs within nursing teams stigmatising therapeutic intimacy in nurse-patient relationships and emotional vulnerability in staff. These beliefs may be modified by ward manager role-modelling. Increased opportunity for de-escalation may be created by increasing service user involvement in antipsychotic prescribing and modifications to the physical environment (sensory rooms and limiting restrictions on patient access to ward spaces). Staff motivation to engage in de-escalation may be increased through reducing perceptions of patient dangerousness via post-incident debriefing and advanced de-escalation planning.

Conclusions

Interventions to enhance de-escalation in forensic mental health settings should enhance ward staff’s understanding of patients and modify beliefs about therapeutic boundaries which limit the quality of staff-patient relationships. The complex interactions within the capabilities-opportunities-motivation configuration our novel analysis generated, indicates that de-escalation behaviour is unlikely to be changed through knowledge and skills-based training alone. De-escalation training should be implemented with adjunct interventions targeting: collaborative antipsychotic prescribing; debriefing and de-escalation planning; modifications to the physical environment; and ward manager role-modelling of emotional vulnerability and therapeutic intimacy in nurse-patient relationships.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40359-022-00735-6.

A Systematic Review of the Effectiveness of Safewards: Has Enthusiasm Exceeded Evidence?

Safewards is intended to be an evidence-based approach to reduce levels of conflict and containment in mental health inpatient settings. A systematic review was carried out to examine whether Safewards is effective in reducing conflict and containment events; and improving ward climate. Searches for articles evaluating the implementation of Safewards was conducted using PsycINFO, PubMed, Web of Science, Cochrane Library and CINAHL. Thirteen studies were included for review after applying inclusion and exclusion criteria. The Quality Assessment Tool for Studies with Diverse Designs (QATSDD) was used to assess study quality and the majority of studies (N = 7) were rated as "moderate" quality. Whilst there is evidence to suggest that Safewards is effective for reducing conflict and containment in general mental health services, there is insufficient high-quality empirical evidence to support its effectiveness in settings beyond this. Further research using robust methodological designs with larger, more representative samples is required in order for the effectiveness of Safewards to be established across the range of contexts in which it is currently being applied.

The contagiousness of memes: containing the spread of COVID-19 conspiracy theories in a forensic psychiatric hospital

COVID-19 has transformed healthcare service provision. In addition to the spread of a virus, there has been an equally concerning emergence and spread of conspiracy theories. Such theories can threaten societal cohesion and adherence to the necessary public health guidance. In a forensic in-patient setting, such difficulties can be amplified. In this paper, we outline the key theory in relation to the development and spread of conspiracy theory memes. We propose primary, secondary and tertiary level responses to tackle the possible generation and spread of harmful conspiracies in the forensic in-patient setting. We consider this to be important, as there is a risk that such beliefs could affect patients' mental health and, in extremis, undermine physical health efforts to reduce the spread of COVID-19.

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.

Youths' Perceptions Of The Relation Between Alcohol Consumption And Risky Sexual Behaviour in the Western Cape, South Africa: A Qualitative Study

The purpose of this study is to explore the factors that youth identify as contributing to alcohol consumption, and more specifically its relation to risky sexual behaviour among youth. We employed an exploratory qualitative method using focus group discussions with 34 young people between the ages of 18-25-years-old in low socio-economic status communities in the Western Cape province of South Africa. Data were analyzed thematically utilizing Braun and Clarke's (2006) six-step thematic analysis process. We identified two thematic domains pertaining to alcohol consumption and risky sexual behaviour, namely individual and social factors, each comprising three themes. The individual factors thematic domain comprises intrapersonal influences, employment and educational attainment; while the social factors thematic domain includes interpersonal influences, social influences, and hope for the future. Youth living in low socio-economic status communities were thought to be at greater risk of alcohol misuse and subsequent risky behaviour, given the political and social history of marginalisation, systematic oppression, and social inequality. To address alcohol use and risky sexual behavior among youth, we recommend interventions with adolescents, parents or guardians, and the community. More specifically, interventions aimed at adolescents should focus on the transition to young adulthood. Interventions with parents should focus on their role in modelling and potentially regulating alcohol consumption. Finally, community interventions should centre on drinking behaviors, levels of drinking, what constitutes harmful drinking, and how to identify when treatment and recovery support is likely to be required.

Containment and therapeutic relationships in acute psychiatric care spaces: the symbolic dimensions of doors

BACKGROUND

There is an increasing trend of door locking practices in acute psychiatric care. The aim of the present study was to illuminate the symbolic dimensions of doors in Greek mental health nurses' experiences of open and locked working spaces.

RESULTS

A sequential mixed-method designexplored the experiences of nurses working in both open and locked psychiatric acute care units. Participants experiences revealed four types of doors related to the quality of recovery-oriented care: (a) the open door, (b) the invisible door, (c) the restraining door, and (d) the revolving door. Open doors and permeable spacesgenerated trust and facilitated the diffusion of tension and the necessary perception of feeling safe in order to be involved in therapeutic engagement. When the locked unit was experienced as a caring environment, the locked doors appeared to be "invisible". The restraining doors symbolized loss of control, social distance and stigma echoing the consequences of restrictingpeople's crucial control over spaceduring the COVID-19 pandemicin relation toviolence within families, groups and communities. The revolving door (service users' abscondence/re-admission) symbolised the rejection of the offered therapeutic environment and was a source of indignation and compassion fatigue in both open and locked spaces attributed to internal structural acute care characteristics (limited staffing levels, support, resources and activities for service users) as well as 'locked doors' in the community (limited or no care continuity and stigma).

CONCLUSIONS

The impact of COVID-19 restrictions on people's crucial control of space provides an impetus for erecting barriers masked by the veil of habit and reconsidering the impact of the simple act of leaving the door open/locked to allow both psychiatric acute care unit staff and service users to reach their potential.