Safewards intervention refresher: 
Reassurance

Background – stigma and fear
•	Patients are affected by stereotypes, stigma and the media
•	They may perceive fellow patients as strange or frightening 
•	They may be sure that they pose no threat to others, but are not sure about the threat other patients pose to them
•	Fears may be overlaid with paranoid ideation or delusions

•	Stigma and fear could produce a powerful motivation to abscond or be defensively aggressive
•	Any confrontation between patients or between patients and staff, even if verbal, can raise the anxiety of patients to unbearable levels
•	These reactions partly explain why one event triggers another and why if there is one significant incident on the ward, a second is more likely to occur

Background – contagion
•	Contagion arises either because patients copy other’s disruptive or risky behaviour or because such behaviour by other patients arouses anxiety and uncertainty, triggering conflict behaviours as coping mechanisms or defenses
•	Increased levels of anxiety may lead to more frequent or intense psychiatric symptoms, which give rise to further conflict behaviours

Aims

This intervention seeks to reduce the risk of 'contagion' between patients by allaying the anxieties that occur in stressful circumstances 

Task: What do we do that might cause anxiety?

•	Saying: 
•	‘You’re not allowed to smoke’
•	‘I’m busy now, I’ll see you later’
•	‘I’m not your nurse’
•	‘We’ll talk about that later’

•	Chaotic nurses station
•	Inconsistency – patients find the nurse who will give the right answer
•	Strict visiting hours
•	Asking too many questions – especially about a patient’s history
•	Withholding information, such as results  or plans
•	Early discharge
•	Changeable decisions 
•	Doors slamming
•	Medication time screamed out through the ward
•	Restrictive interventions
•	Group approaching a patient
•	Room searches 
•	Fear of consequences if tell real feelings
•	Fear that feelings will be associated with illness
•	Locked doors – not allowed to leave ward
•	Constantly check on patients 

Potential anxiety provoking incidents 
Loud shouting/property damage/aggression - provokes fear, anxiety, stress and agitation that can lead to defensive aggression, absconding, withdrawal and disengagement from therapeutic activities 

Self-harm - may provoke copycat acts, can be distressing provoke anger or fear of one’s own internal impulses 

Absconding - may suggest the idea to others

Intoxication - provokes fear and anxiety about unpredictable behaviour

Show of force - such as transferring a patient to high dependency, can undermine patient confidence in staff, make people feel vulnerable or bullied, provoke anger and/or fear and may be re-traumatising 

Task: Using reassurance on our ward
Task: Processes for reassurance
What processes do we have in place to assist with reassurance?
Are we consistent with reassurance?
How do we know who might be in need of reassurance?
Any suggestions to strengthen this intervention?
 
Reassurance long term implementation
•	Periodically remind staff to maintain awareness and act upon it
•	Include reassurance as an agenda item during handovers
•	Develop other mechanisms to overcome the inattention that eventually follows a routine practice

Reassurance fidelity

•	Telling patients things will be fine when they come to the office door and express a worry
•	Gossiping about other patients who may exhibit challenging behaviour

Reassurance adjustments
CAMHS	Simplify explanations and lower expectations of understanding
Forensic	None
Older people	None where message can be understood and retained