Safewards: an Introduction.

Keeping everyone as safe as possible is a basic goal for any community. This is as true for hospitals as it is for schools, towns, workplaces or even families. It is also true for psychiatric hospitals.  Keeping everyone as safe as possible also takes thought and effort.

Our research team has been thinking and working on this for years. Recently we tested some ideas on wards and found that they made them significantly safer. We have called this project “Safewards”. This is a description of the thinking behind Safewards.

The Model of Safewards: Some important terms.

To start with, one of the things we wanted to do was to describe why wards could be unsafe at times. This is not easy as wards are busy places with lots going on and are also very different from each other in terms of size, where they are, what resources they have etc. As a starting point, we needed some was of simplifying things. We did this by coming up with a shorthand way of talking about the things we wanted to see reduced across all of the wards.

In Safewards we use the word “Conflict” as shorthand for certain patient behaviours that can result in harm. “Conflict” in Safewards represents such things as: violence; suicide and acts of self-harm; alcohol or drug use, absconding (leaving the ward without permission and missing out on care). It also covers the breaking of basic rules such as refusing to see care workers or smoking in areas that may lead to arguments with staff or other patients.

Of course, it is not only patient behaviours we need to reduce. Staff can use methods of managing wards that, although necessary at times of difficulty, can also be restrictive or coercive. In Safewards we use the word “Containment” as shorthand for the methods staff use to control difficulties on the ward. “Containment” in Safewards represents such things as: extra medication (one-off doses that are only used to sedate or control patients); increased monitoring or observation of patients; restriction placed on patients by moving to a more secure ward or restricting movement on the ward.

What we know about Conflict and Containment is that, even if people are very vigilant, they can feed off each other. We know, for example, that locking wards can and does reduce certain types of harm (absconding), but it can also make other types of harm more likely (self-harm). This is not to say doors should not be locked, but, if they are, wards need to watch that other “conflict” areas are not increased.

model1

 

The Model of Safewards: How it fits together.

We looked at over 1,000 detailed research papers to come up with the model.

The diagram below shows our thinking on how conflict and containment are generated and where staff and patients can reduce them.

Finally, a “model” is really a way of describing complicated things, and this is no exception. It isn’t the be all and end all. There is always more thinking and more debate that will improve our understanding. What we hope it does do is give us a starting point for the debate.

 

sw model

If we take it from the left, the Originating Domains are aspects of the ward that are known to create potential flashpoints. As you will see, we cannot remove these domains as they are part and parcel of ward life. However, the research papers we read pointed to these domains as areas that we need to think about.

Following from the Originating Domains, Flashpoints are times or situations where things could go wrong. This doesn’t mean they will, but means they could.

As Safewards is primarily about what staff can do, we have focused on these. As you can see, the model says that staff can make a difference before there is a flashpoint by being aware of the Originating Domains and getting in there before we have a problem.

They can also make a difference in the way they manage flashpoints and, even if there is conflict, they can still make a difference in how they manage the situation by thinking about what containment to use that won’t make the situation worse.

Safewards Model in a bit more detail:

To dig down a little more, lets start from the Originating Domains, identify potential flashpoints and then consider what staff can do that makes a difference

Originating Domains Flashpoints - Examples Staff Modifiers - Examples
1 Staff Team or Internal Structure Domain

(This is about how staff deal with their own feelings. It’s also about how they support each other to be consistent in setting and keeping to rules and how consistent they are in dealing with patients’ needs. It is also reflected in how much the day to day routine of the ward is geared to being with patients and looking after their needs. This includes making sure the ward is clean and tidy.)
When staff to set limits to patient behaviour.

When staff tell patients information or news that is upsetting.

If there are inconsistencies in staff approach to ward rules.

If staff, for whatever reason, do not address patient requests or needs.
Carefully and compassionately managing times when staff need to ask patients to do something or stop doing something.

Also being able to compassionately break bad news to patients.

Also how well staff work as a team to be consistent and clear.

2 Physical Environment Domain

(The nicer the ward is in terms of good quality furniture, equipment and general décor, the more comfortable patients will feel and the less conflict there is. Wards that have clear viewpoints with few hidden areas are generally safer. This domain also includes staff striking a healthy balance between needing to supervise patients and needing to give periods of privacy.)

Patients being isolated for long periods.

Frustrations when furniture, equipment is broken or not fit for use, or when décor is drab and depressing.

First few days of admission when there can be a sense of shock at the strangeness of the ward

When patients realise the door is locked (if it is) and they have to ask to leave, or are not allowed to leave.
Paying attention to repair and décor needs.

Staff knowing where patients are and making active choices about allowing privacy or supervising.

Staff offering time to patients, being aware of distress and not being frightened of checking if they think someone needs help or is coming to harm.

3 Outside Hospital Domain

(Wards are not cut off from the world. Events and people off the ward have an effect. Money worries, arguments or concerns with family and friends do not disappear with admissions. Drugs and alcohol are available outside of hospital during leave and if a patient absconds. Also, patients are always aware that they will leave the ward eventually and return to the outside world.)

Patients arguing with family and friends

Patient dealing with divorce / bereavement/ illness/ loss.

Patients receiving bad news about people or events off the ward

Crisis at patients or loved one’s home (debt, bills, fire, burglary, threat of eviction etc).
Staff being familiar with and familiar to family and friends.

Staff offering or signposting specific help for family and friends.

Staff being aware of the issues patients have off the ward.

4 Patient Community Domain

(As wards are not immune from tension off the ward, so patients are not immune from tensions from other patients. Feelings can run high on wards were everyone is struggling to cope.)

Patients can be negatively affected by the feelings or behaviour of other patients.

Patients who are anxious or frustrated may find it much harder to deal with other people’s behaviour.
Staff can model caring and understanding in managing difficult feelings or behaviour.

Staff can make sure that patients have a chance to support each other in helpful ways.

5 Patient Characteristics Domain

(Patient Characteristics that are more likely to cause conflict. These fall into 3 groups:

1. A range of possible symptoms, such as paranoia or hallucinations
2. Patients who have difficulties relating to other people.
3. Age, gender, diagnosis, where patents live etc. Certain types of conflict are more likely for different groups. For example, younger men more likely to absconding from care than other groups.

Staff needing to guide patients by asking them to do something or stop doing something.

Staff placing restrictions on patients.

Perceived (or real) loss of liberty.
Staff offering best treatments in a timely manner.

Staff offering explanations about condition.

Compassionately managing those times when staff need to ask patients to do something or stop doing something. (See 1 Staff Team etc, above)

6 Regulatory Framework Domain

(Both staff and patients are bound by legal and managerial policies. The Mental Health Act is law and has to be followed. Many hospital policies are written to ensure all wards stick to the same procedures and often comply with national guidance. This Domain give staff very real power over patients, but also very real responsibilities.)

When the realities of containment under the Mental Health Act cause tensions between patients and staff.

Where staff are seen by patients to be abusing the power they have or not fulfilling their responsibilities.
Staff can be vigilant about ensuring patients have all their rights looked after. This includes giving patients information and helping with appeals or complaints.

Where staff are as flexible as possible to compensate for very real restrictions.

 

What is the point of the model and how does it help?

We are not saying that this model answers all our questions about how to keep people safe on psychiatric wards. As we said above, there is always more to consider. What it does do, we think, is give us a way to begin to understand a very complicated subject.

We also think the the model gives us some ideas about how we can encourage staff and patients on ward to work together to reduce conflict and containment as much as possible. What we haven’t mentioned until this point is that rates of conflict and containment on wards vary a great deal. The wards with the lowest rates can have ten times less. This seems to say that there IS a lot that can be done.

In addition to this, we have also tested out some ideas the model suggested would reduce conflict and containment. Getting these ideas together is a whole other story, but included long conversations with people who had been patients, and people who were staff, about what was possible. Once the ideas were agreed, we took them to real wards and put them through the most rigorous tests possible. The ideas (which were active interventions by staff on the wards) did reduce both conflict and containment by a significant level.* Descriptions of these interventions are on the website. You may have some good ideas yourself!

We hope people will engage with our work. We all need to work together to keep people as safe as possible on psychiatric wards.