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The Safewards Randomised Controlled trial

The Safewards Randomised Controlled trial. Reducing Conflict and Containment on psychiatric wards. Lead by Professor Len Bowers. Conflict and containment. Containment. Conflict. Aggression Rule breaking Substance/alcohol use Absconding/missing Medication refusal Self-harm/suicide.

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The Safewards Randomised Controlled trial

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  1. The Safewards Randomised Controlled trial Reducing Conflict and Containment on psychiatric wards Lead by Professor Len Bowers

  2. Conflict and containment Containment Conflict • Aggression • Rule breaking • Substance/alcohol use • Absconding/missing • Medication refusal • Self-harm/suicide • PRN medication • Coerced IM medication • Special observation • Seclusion • Manual restraint • Time out

  3. Staff modifiers Patient modifiers Originating domains Flashpoints Conflict Containment The safewards model

  4. PATIENT COMMUNITY Patient-patient interaction Contagion & discord Patient modifiers Anxiety management; Mutual support; Moral commitments; Psychological understanding; Technical mastery; Staff modifiers Explanation/information; Role modelling; Patient education; Removal of means; Presence & presence+ OUTSIDE HOSPITAL PATIENT CHARACTERISTICS Stressors Visitors; Relatives & family tensions; Prospective –ve move Dependency & Institutionalisation; Demands & home Symptoms& demography Paranoia, PD traits; Irritability/disinhib; Abused; male; Alc/drugs; Depression; insight; delusions; hall.s; young Flashpoints Assembly/crowding/activity Queuing/waiting/noise Staff/pt turnover/change Bullying/stealing/ prop. damage Staff modifiers Carer/relative involvement Family therapy Active patient support Staff modifiers Pharmacotherapy Psychotherapy & functional analysis; Nursing support & intervention Flashpoints Bad news; Home crisis; Loss of relationship or accommodation; Argument Flashpoints Exacerbations; Independence/identity Acuity/severity CONFLICT & CONTAINMENT Flashpoints Secrecy; Solitude; Admission shock; Exit blocked Flashpoints Compulsory detention; Admission; Appeal refusal; Complaint denied; Enforced treatment; Exit refused Staff modifiers Due process; Justice; Respect for rights; Hope; Information giving; Support to appeal; Legitimacy; Compensatory autonomy; Consistent policy; Flexibility; Respect Staff modifiers Caringly vigilant & inquisitive; Checking routines, Décor, Maintenance; Clean & tidy; Alternative choices; Respect Flashpoints Denial of request; Staff demand; Limit setting Bad news; ignoring Features Door locked; Quality; Complexity; seclusion; PICU; ICA; comfort/sensoryrooms; ligature points External structure Legal framework; National policy; Complaints; Appeals; Prosecutions; Hospital policy REGULATORY FRAMEWORK Staff modifiers Staff anxiety & frustration; Moral commitments; Psychological understanding; Teamwork & consistency; Technical mastery; Positive appreciation PHYSICAL ENVIRONMENT Internal Structure Rules; Routine; Efficiency; Clean/tidy; Ideology; Custom & practice STAFF TEAM

  5. The safewards trial • Aim: • Devise a set of the most feasible interventions for inpatient nurses with potentially maximal impact on conflict and containment • Subject those to a rigorous RCT.

  6. Development of Interventions

  7. Final intervention list Experimental intervention (Organisational) Mutual Help Meeting, Clear Mutual Expectations, Soft Words, Talk Down, Know Each Other, Reassurance, Positive Words, Bad News Mitigation, Discharge Messages, Calm Down Methods. (n = 10) + handbook Active Control intervention (Wellbeing) desk exercises, pedometer competitions, healthy snacks, diet assessment and feedback, health and exercise magazines, health promotion literature, linkages to local sports and exercise facilities

  8. Main outcomes Mean No. of conflict and containment events/shift CONFLICT 14.6% decrease CI 5.4 – 23.5% p = 0.004 CONTAINMENT 23.6% decrease CI 5.8 – 35.2% p = 0.001

  9. Additional info • Fidelity check indicated a low take up (38%) of interventions in the time frame. • Multiple checking of statistics including removing outliers and modelling for missing data. Does not change results. • Disappointing return of staff questionnaires. • Turn it around and look as if Wellbeing Intervention makes staff fitter. Still checking. • Bottom line – we recommend all 10 interventions are adopted.

  10. Dissemination • Trial results first announced NPNR in September 2013 • Since then a programme of dissemination both nationally and internationally • Initially this was combined with dissemination through social media. • In December of 2103, www.safewards.netwent online

  11. Since September.. • 9 “International “ presentations ( Europe and Australia) • 25presentations to UK conferences, Universities, Trusts or Wards. • 500+ Facebook Members ( International) • 100+ Twitter members ( primarily UK) • Definite contact in 31/59 NHS trusts (England) • 9 Identified Wards/units in Trusts additional to Trial (9) and Pilot wards (1) • 2 non UK (Canada and Holland) • 1 Trust has Safewards as a CQUIN or Quality standard for 2014

  12. Its all here!!!www.safewards.net

  13. To have more detailed presentation for your trust • Geoff.brennan@kcl.ac.uk

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