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

SafeVRwards: Designing a complementary virtual reality module to the Safewards framework intended to relax and manage conflict in mental health wards

BACKGROUND

Aggression and negative activation in mental health inpatient units pose significant challenges for both patients and staff with severe physical and psychological ramifications. The Safewards model is an evidence-based conflict-containment framework including 10 strategies, such as 'Calm Down Methods'. As virtual reality (VR) scenarios have successfully enhanced anxiolytic and deactivating effects of therapeutic interventions, they are increasingly considered a means to enhance current models, like Safewards.

OBJECTIVES

The present participatory design investigates the feasibility and user experience of integrating VR therapy as an add-on strategy to the Safewards model, gathering preliminary data and qualitative feedback from bedside staff in an adult inpatient mental health unit.

METHODS

An exploratory within-subjects design combining qualitative observations, self-report questionnaires and semistructured interviews is employed with four nurse champions from the mental health unit at Michael Garron Hospital (Toronto, Canada).

RESULTS

A chronological overview of the design process, adaptations and description of the user experience is reported.

CONCLUSION

'SafeVRwards' introduces VR as a promising conflic-containment strategy complementary to the Safewards model, which can be optimised for deployment through user-oriented refinements and enhanced customisation capacity driven by clinical staff input.

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

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

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TWEETABLE ABSTRACT

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

Exploring the safe environment provided by nurses in inpatient psychiatric wards: A mixed-methods study

INTRODUCTION

Previous research has indicated that community-based mental health services in Iran are restricted, leading to overcrowding in psychiatric wards. This overcrowding has been linked to a range of problems, such as violence, suicide and medical errors. Despite the abundance of research on patient safety, there is still a lack of understanding regarding how mental health nurses (MHNs) create a secure environment within these wards.

AIM

This study focused on exploring a safe environment provided by MHNs in inpatient psychiatric wards at Farshchian (Sina) Hospital, Hamadan, Iran.

METHOD

An explanatory mixed-methods study was conducted. Initially, the Safe Environment Scale was distributed to all MHNs (n = 48) working in three wards at Farshchian (Sina) Hospital to evaluate the current status. The scale measured two dimensions, and descriptive statistics were used to analyse the collected data. Subsequently, 20 MHNs were selected for semi-structured interviews using purposeful sampling at the same hospital to interpret and fill gaps in the quantitative findings. The data collected from the interviews were analysed using conventional content analysis.

RESULTS

The perception and engagement of MHNs in creating a safe environment in the inpatient psychiatric wards were found to be at a medium level, according to the Safe Environment Scale (mean ± SD, 14.67 ± 4.18 and 85.27 ± 17.57, respectively). The qualitative study identified several categories in the results, including 'Hyper-vigilance to safety and security environment', 'Therapeutic communication gap', 'Nurse burnout', 'Staff safety and security need' and 'Environmental safety hazards'.

DISCUSSION

MHNs employ a hyper-vigilant strategy to guarantee a secure atmosphere within psychiatric wards. However, this approach may inadvertently impede the establishment of a safe environment and even diminish MHNs' perception and involvement in its maintenance.

IMPLICATIONS FOR MENTAL HEALTH NURSING

According to our research, it appears that MHNs need to improve their education and training in order to successfully implement the vigilance strategy for establishing a secure environment. Additionally, it is essential for them to prioritize therapeutic communication with patients, as this plays a vital role in promoting a safe environment within inpatient psychiatric wards.

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

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

Staff Perceptions on the Effectiveness of GRiP-S, a New Approach to Clinical Supervision Incorporating Safewards: An Interpretive Phenomenological Analysis

This study explored the impact of an innovative approach to clinical supervision for mental health nurses which integrates Safewards, named Group Reflective integrated Practice with Safewards - GRiP-S. Qualitative data was collected through 10 individual semi-structured interviews with nursing staff who had participated within the clinical supervision approach. Interviews provided insights into the nursing staff's perception and experience of the clinical supervision approach. Through interpretive phenomenological analysis six themes emerged (i) illuminating embodied practice of Safewards, (ii) building confidence through empowering connections, (iii) creating a culture of positive change, (iv) identifying internal motivation for and external barriers to supervision engagement, (v) navigating a global pandemic, and (vi) the transformative role of reflection. Findings demonstrated that the GRiP-S approach assisted mental health nurses' adoption of Safewards interventions in practice, while supporting the development of a cohesive staff team. The impact of COVID-19 within the study setting was addressed and nurses identified how the Safewards model assisted in navigating challenges during this time. Findings further supported prior research on the role of the supervisor and supervisee relationship. This study supports the integration of Safewards within reflective clinical supervision for mental health nursing staff to assist in Safewards fidelity and nursing staff personal and professional development.

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.

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Safety Performance in Acute Medical Care: A Qualitative, Explorative Study on the Perspectives of Healthcare Professionals

Healthcare professionals need specific safety performance skills in order to maintain and improve patient safety. The purpose of this study is to get a deeper understanding of healthcare professionals’ perspective in acute care on the topic of safety performance. This study was conducted using a qualitative approach. Healthcare professionals working in nursing were interviewed using semi-structured interviews. Using content analyzing, categories were identified which present aspects of safety performance; subcategories were developed deductively. A total of 23 healthcare professionals were interviewed, of which 15 were registered nurses, five were nursing students and three were pedagogical personnel. Nine (39.1%) were <30 years old, 17 (73.9%) were female, and 9 (39.1%) had a leadership function. Results highlight the importance of safety performance as a construct of occupational health rather than of patient safety, and the role of the organization, as well as the self-responsibility of healthcare professionals. Healthcare professionals should be more conscious of their role, have a deeper understanding of the interaction of individual, team, patient, organization and work environment factors.