Safewards Workshop

Day 1 

Workshop Day	1
Interventions
•	Know each other
•	Clear mutual expectations
•	Mutual help meeting
•	Bad news mitigation
•	Positive words

Safewards definition of conflict and containment
The Safewards model
•	Sources of evidence for the model
•	Model subject to randomised controlled trial 
•	Data collection process
•	31 wards blind
•	Results: conflict 14.6% decrease, containment 23.6% decrease
–	Strengths: randomised, blind, adequate power, independence of randomisation and analysis
–	Weaknesses: level of cooperation and implementation, nil results from questionnaires  

Task: What is it like on your ward?

What contributes to conflict and containment on your ward?
How does conflict and containment influence your ward?

Conflict and containment rates
•	Rates of conflict and containment vary locally and internationally 
(Bowers et al., 2005a, Nijman et al., 2005)
•	Reasons for these differences provide an opportunity to devise ways to reduce the frequency of risky events - keeping people safer
•	Factors impacting on variability include: 
•	social and physical locations of wards
•	separation from a person’s normal residence
•	provision of 24/7 mental health care
•	mixed voluntary and legal coercion
•	These factors can influence the frequency of conflict and containment
•	Containment methods used in some countries are not used in others 

Key aims of the Safewards model
Six domains that influence or trigger conflict 

Staff can impact all six domains 

Staff modifiers 

Definition
Characteristics of staff or teams or the way staff act in caring for patients or the environment

Potential 
The way staff initiate or respond to interactions can influence the frequency of conflict and containment 

Staff can influence conflict and containment by:
•	reducing or eradicating the originating conflict factors
•	preventing flashpoints
•	cutting the link between the flashpoint and conflict
•	choosing not to use containment when it would be counterproductive
•	ensuring that containment does not lead to further conflict.
Patient modifiers

Definition 
How patients respond and behave towards each other can influence the frequency of conflict and containment. Patients are susceptible to staff influence.

Overview of originating domains 
Staff team domain
Internal structure
Rules, routines, efficiency, clean/tidy, ideology, custom, practice

Staff modifiers
Staff anxiety and frustration, moral commitments (honesty), psychological understanding, teamwork and consistency, technical mastery, positive appreciation, education/training, clinical supervision, model skills, challenge each other, review care provided, focus on flashpoints, finding better ways to manage them (reduce number of rules, pre-empting needs) and set limits

Flashpoints
Denial of request, staff demand, limit setting, bad news, ignoring

Physical environment domain
Better quality environment versus complexity (observation/supervision)

Features 
Door locked, quality of environment, speedy repairs, complexity, seclusion rooms available, PICU, ICA, comfort/sensory rooms, ligature points

Staff modifiers 
Vigilant and inquisitive, checking routines, décor, maintenance, clean and tidy, alternative choices, respect 

Flashpoints 
Secrecy, solitude, admission shock, exit blocked 

Outside hospital domain
Stressors 
Visitors, relatives and family tensions and relationships, missing out, dependency and institutionalisation (absconding), demands and home 

Staff modifiers 
Carer/relative involvement, family therapy, active patient support, awareness, important factors from outside that can influence behaviour on the unit (financial circumstances, support to resolve issues with family and friends, accommodation-checked on/leave to visit)

Flashpoints 
Bad news, home crisis, loss of relationship or accommodation, argument 

Patient community domain
Patient-patient interaction 
Contagion and discord (copying behaviours, impact of others’ behaviour, living with others, meal times and medication times)

Patient modifiers 
Anxiety management, mutual support, moral commitments, psychological understanding, technical mastery

Staff modifiers 
Explanation/information, role modelling, patient education, removal of means, presence and presence+ (getting in early), conflict resolution, pre-emptive reassurance, managing level and fluctuation of activity on the unit

Flashpoints 
Assembly, crowding, activity queuing, waiting, noise, staff/patient turnover or change, bullying, stealing and property damage 

Patient characteristics domain
Symptoms and demography 
•	Symptoms: paranoia-defensive aggression/absconding, specific delusions, depression-suicide attempts/irritability, use of substances, irritability or disinhibition
•	Personality traits: features of ASPD, instrumental aggression
•	Demographic: particularly being younger and male

 Staff modifiers 
Pharmacotherapy, psychotherapy and functional analysis; nursing support and intervention; enhance choices, freedom and control over circumstances; develop mutually respectful partnership; therapeutic community; authoritarianism-counterproductive; CBT; social skills training; TIC responses; choices over how to respond.
Only a few people account for the majority of aggressive incidents, therefore:
•	change responses after the first event to avoid subsequent events
•	target therapeutic interventions

Flashpoints 
Exacerbations, independence, identity, acuity, severity

Regulatory framework domain
External structure 
Legal framework, national policy, complaints, appeals, prosecutions and hospital policy 

Staff modifiers 
With the exception of hospital policy, these modifiers are not under staff control (RRI); however, the way they are carried out can be. 
Procedural justice, respect for rights, hope, information giving, support to appeal, legitimacy, compensatory autonomy, consistent policy, flexibility, effective complaints process, policy targeted at RRI, choices (such as more activities, meals, snacks), intervene to address hopelessness and self-stigmatisation.

Flashpoints 
Compulsory detention, admission, appeal refusal, complaint denied, enforced treatment and exit refusal 

What this model adds to practice
•	Includes patient-patient interaction
•	Identifies that staff response to patient characteristics can have an impact
•	Acknowledges the regulatory framework and that action can be taken at higher policy levels
•	Incorporates influences from outside hospital

Safewards interventions
The Safewards interventions are a set of prevention and intervention strategies developed to correspond to diverse flashpoints identified in the model.

Know each other
Background

•	Good therapeutic relationships between staff and patients are the foundation of effective care.
•	Gives patients and staff information about each other so they can find common areas of interest
•	Provides topics for conversation 
•	Shares information within the team to help engage the patient

Aims

•	Build stronger relationships between patients and between patients and staff
•	Enhance patients’ coping skills
•	Improve difficult behaviour
•	Help patients feel comfortable and reassured and increase social interaction
•	Nurture equality while maintaining safety
…making conflict less likely 

Task: Getting to know each other 
Where did you grow up? 
How many children in your family? 
What was one of your childhood hobbies? 
What was your biggest challenge growing up? 
What was your first job?
Information collected 
What information do we generally collect about patients?
•	It is usually negative and often focuses on: 
–	past psychiatry history of illness
–	disabilities
–	admissions
•	Little of the information collected provides a basis for relationship building
Task: What non-controversial information might you wish to share? 

Examples of non-controversial information

•	Qualifications
•	Years of experience working in mental health
•	Hospitals and various locations worked
•	Previous jobs
•	Hobbies and interests
•	Favourite TV program and reasons
•	Favourite film and why
•	Favourite book and why
•	Preferred music genre
•	What bad advice have you taken?
•	What bad advice have you given?
•	What is your top life tip?

Know each other in practice
•	On admission, ask the patient and their carers questions that will help to produce a profile of the patient and include: 
–	key background info
–	likes and dislikes
–	favourite things
–	quotes
–	beliefs
•	These can be conversation triggers for staff
•	Add a graphic or picture of the patient’s choice

 Know each other in practice
•	Produce a ‘know each other folder’ for all staff and patients on the ward. 
•	Use the know each other templates or modify and create your own.

Paste an example of a know each other form filled out from someone in your service here
Know each other fidelity

•	Staff sharing personal information with staff, or giving information to patients to emphasise power differences and unbalanced relationships.
•	Staff showing who they are to each other in front of patients

Task: Create your know each other implementation plan

Background and aims
Background
Some difficult and challenging behaviours are due in part to lack of clarity about how patients are expected to behave or lack of consistency about what the expectations are.
Aims
•	Create an egalitarian social unit
•	Set clear standards for staff and patients
•	Hold people to account 
•	Build consistency and predictability while allowing flexibility
•	Clarify staff-patient relationships so staff can be consistent
•	Ensure patients understand their obligations and those of staff

Task: Examples of clear expectations 

This can particularly affect those who:
•	aren't thinking clearly
•	are distracted by psychotic thinking or are preoccupied
•	have difficulty interpreting communication
•	experience changes in mood 
•	have a distorted view of world and others
•	have history of trauma

Mutual expectations for consideration
•	General expectations
•	The staff
•	Excluded items
•	Property
•	Places

Role of the clear mutual expectations lead 

•	Ensure clear mutual expectations meetings occur
•	Communicate meeting results in a visible manner e.g. posters
•	Ensure the clear mutual expectations are discussed:
–	if you're the admitting nurse, show the information/poster and explain its contents
–	if you are on duty when a person is admitted, remind the admitting nurse to refer to the clear mutual expectations
–	at handover, ask whether the poster has been shown and explained to new patients

Clear mutual expectations fidelity
•	Codifying rules for patients so staff have an easier time telling patients what to do
•	A pretty poster or mission statement to point to when things get tricky

Task: Create your clear mutual expectations implementation plan
Mutual help meeting
Background 

•	The ward is a social community and a powerful engine to help patients, shape their behaviour and progress towards discharge
•	The help that patients give each other is highly valued 
•	The giving of help between patients offers the giver:
•	a socially valued role
•	the chance to make a meaningful contribution
•	the potential to improve their self-esteem 

Aims
•	Strengthen an existing mechanism highly valued by patients

•	Give patients a valued role and public recognition

•	Build patient self-esteem

•	Increase mutual support

•	Establish values, understanding and social skills
Task:  Invaluable mutual support

Think of an example where patient-patient mutual support has been invaluable on your ward
Conflict
About half of all inpatient aggression arises from patient behaviour or patient-patient interaction.

 Conflict can be reduced if patients:
•	positively appreciate each other
•	contain their own emotional reactions to each other’s behaviour
•	uphold behavioural expectations

This will contribute to reduced levels of
 conflict. 

Mutual help meeting 

Description 

•	A voluntary meeting of all patients and staff on duty
•	Ideally first thing in the morning
•	Preferably every day (not less than 3 per week)
•	Follows a structured agenda 
•	Discusses how everyone can help each other 
•	Once all the points are covered the meeting is closed 
•	Does not have to be chaired by a staff member

Agenda
•	Round of thanks: All patients and staff can individually thank anyone, present or not present, for anything they have done for them since the last meeting. Everyone is free to comment. 

•	Round of news: Staff explain recent events on the ward that might be confusing or distressing. Assist patients and staff to psychologically understand each other’s behaviour. Ask everyone to watch over each other, keep each other safe, and call for help if they are worried.

•	Round of suggestions: Everyone has a chance to offer suggestions about each other.

•	Round of requests and offers: Patients discuss how others in the ward can help them.

Examples of offers and requests 
•	Share knowledge and experience about care and services 
•	Support each other in practical tasks
•	Encourage each other to take part in structured activities
•	Accompany each other on walks or activities 
•	Play games such as cards or table tennis
•	Discuss current affairs 
•	Spend time with people
•	Share coping strategies, such as relaxation techniques 
•	Make a drink for someone
•	Sit next to someone at meal times 
•	Say good morning
•	Ask how someone else is feeling 
•	Listen to music or watch TV with someone and talk about it afterwards 

Specific staff roles
•	Hold the first meeting and explain the purpose
•	Attend the meetings as often as possible
•	Prepare contributions and offer support in advance 
•	Ensure the agenda is covered and everyone has an opportunity to speak
•	Offer suggestions about how patients can help each other if there is difficulty generating ideas
•	Offer advice on expression of mutual respect and positive appreciation between patients and assist in understanding each other’s behaviour 
•	Accurately describe any recent potentially distressing events on the ward

General staff roles
•	Prepare the room
•	Gather patients and staff
•	Keep the meeting directed to its task - stop it from drifting
•	Encourage good contributions through positive feedback
•	Reframe negative contributions
•	Listen and be attentive
•	Model mutual respect
•	Enable everyone to contribute
•	Seek information and opinions and provide information 
•	Clarify and summarise for others
•	Suggest compromises and settlements

Getting organised

When and where it will be held?
Who could we get assistance from?
When do we start?
How will we inform staff about the meeting and their role?
How could the meeting be advertised?
Create a log book which is to be kept in a communal area

What to expect
•	Only a few people will participate initially
•	Attendance will grow as the meeting is held regularly and is talked about
•	Even with only a few people the meeting can be productive
•	Attendees can consider how they can help others who aren't attending
•	Small things can be important to people

Mutual help meeting fidelity

•	A forum for complaints and suggestions from patients about what the staff or hospital should do or for staff to give news to patients
•	Another group in the ward where staff quote Yalom and have a debrief while patients go back to bed

Task:  Create your mutual help meeting implementation plan
Bad news mitigation
Background
•	Some people leave the unit impulsively and in anger following unwelcome news 
•	Bad news from home can also cause conflict.
•	Bad news can include death in the family, termination of a relationship with intimate partner, loss of tenancy, burglary, illness in the family, childcare issues
•	The resulting stress and distress can then be acted out on the unit in increased irritability, aggression, violent incidents and absconding 
Aims
•	Help us notice flashpoints rapidly and act fast to provide psychological and social support, before distress turns into conflict
•	Cut connection between a flashpoint and conflict
•	Recognise the possible impacts of bad news
•	Increase people’s sense of being known as human beings
•	Increase people’s feelings of being supported by others and not being alone with their problems
Task: Bad news scenarios
•	What have you found helpful when working with people who have received bad news?
•	What has not been helpful?
 Bad news mitigation in practice
•	Be aware of occasions and events that might trigger angry or upset reactions
•	At handover, discuss as a team and share knowledge to predict who might receive unwelcome news and how support will be offered
•	Work with the multidisciplinary team (MDT) to express bad news empathically or intercept after it has happened
•	Maintain awareness of what is going on through regular one-on-one contact with the patient
•	Know everyone’s general demeanor 

Bad news mitigation in practice 
•	Be aware of signs of distress/upset/unhappiness - ask if anything is the matter, particularly after phone calls or visits

•	Find a quiet place, give the person time to express their feelings

•	Acknowledge their frustration, express sympathy and empathy

•	Make a friendly gesture, offer a cup of tea or snack

•	Answer any questions honestly, giving time, attention and respect

•	Show you are receptive to concerns - use listening techniques (make eye contact, ask about concerns, use open ended questions, such as ‘Tell me more…’) 
	
Bad news mitigation in practice 
•	Find out how much people understand about care decisions and correct any misconceptions 
•	Frame treatment in positive way
•	Some people may not be able to absorb all information – follow up to assess emotional state and understanding 
•	Shock and anger accompanying bad news can create confusion and hinder understanding. This may be compounded by illness or medication
•	Help the person understand decisions, acknowledge feelings. This can improve relationships and make aggression, self-harm and absconding less likely 
•	Be responsive and respectful of a person’s views

Role of the intervention lead 

Make sure these two questions are considered by the team at handover: 

•	Has anyone received any bad news over the past shift? If they have, how can we support them? 

•	Is anyone likely to receive bad news during the coming shift, and if so, how are we going to manage that? 

Bad news mitigation fidelity
•	A way of protecting patients from life or threatening them with consequences or assuming how they will feel
•	Attaching the phrase ‘I am sorry to let you know’ when we tell patients they cannot have something they desperately want

Task: Create your bad news mitigation implementation plan
Positive words
Background and aims
Background
At handover the focus is often on behaviour that is difficult or presents risks to the patient or others. Focusing on this behaviour may promote a negative perception of patients, rather than a balanced view of strengths and ways of working with a person. 

Aims
•	Balance the budget – know the strengths as well as the problems
•	Set an optimistic start to every shift
•	Change staff relationship assumptions
•	Even out the implied power and status differential

Handover in practice 
Primary role  
•	Only time the nursing team gets together to discuss each patient 
•	The meeting has a critical organisational function – discussion of key risks, new patient admissions

Safewards approach to handover
•	Balance the natural tendency to focus on issues and negative aspects of patient behaviour
•	Say something positive about each patient at handover
•	When difficult or disruptive behaviour is described, offer a possible psychological explanation  
•	Overall, promote a positive appreciation of patients to reduce the likelihood of further conflict
•	Refer to the document Understanding unsafe and risky patient behaviour, which can help in building psychological explanations

Task: Being positive

Think of a scenario in your workplace:
•	What positive thing could you say about the patient’s behaviour? 
•	What positive quality could you draw attention to?
•	What did you do that was positive in supporting the patient?
Research group and service team suggestions
•	Refer to past achievement, including before admission/illness
•	Engaging with an activity 
•	Demonstration of coping 
•	Making a contribution or demonstrating patience 
•	Something the patient has enjoyed
•	Expression of interest in something
•	Visits and phone calls that went well
•	A positive aspect to behaviour
•	Endurance and courage
•	Coping with things better
•	Having a good conversation 

Role of the intervention leads 

•	In every handover, remind the person doing the handover to ask the following questions:
–	What is the positive message about this patient? 
–	Why do we think the patient might have behaved in that way?

•	Give every staff member a copy of Understanding unsafe and risky patient behaviour
•	Use Understanding unsafe and risky patient behaviour to interpret patient behaviour on the ward for others on the team 

Task: Identifying positive and negative words
A few more…. 
ABLE,   ACCEPT – ACCEPTANCE – ACCEPTABLE – ACCEPTED -ACCEPTING,   ACTION,   ACTIVATE,   ACTIVE,   ADD,   ADDITION,   ADMIRABLE,   
ADORABLE,   ADVANTAGE,   AFFIRM,   AGELESS,   AGREE,   AGREEABLE,   AID,   AIM,   
ABUNDANCE,   ACCOUNTABILITY,   ACCOMPLISHMENT – ACCOMPLISH,   ACCURACY,   ACHIEVEMENT ACHIEVE,   ACKNOWLEDGEMENT,   ADAPTABILITY,   ADVENTURE – ADVENTUROUS,   AGILITY,   ALERTNESS,   AMBITION,   ANTICIPATION,    APPRECIATE – APPRECIATION – APPRECIATIVE,   ASSERTIVENESS – ASSERTIVE,   ATTENTIVENESS,   AUDACITY,   AWARE – AWARENESS,   AUTHENTIC – AUTHENTICITY,   ABRACADABRA,   ATTRACTION,   ALLOW – ALLOWING,   AFFECTION – AFFECTIONATE,   ABSORBED,   ALERT,   AMAZED,   AWED,   ANIMATED,   ARDENT,   
AMAZING,   AWESOME,   AROUSED,   ASTONISHED,   AMUSED,   AIR,   ALOHA,   ADORE,    ADMIRE,   ADMIRABLE,   ALLURE,    ANGEL – ANGELIC,    ALTRUISM – ALTRUISTIC,   ABOUNDING,   ABSOLUTE, ACCESSIBLE,   ACCLAIMED,   ACCOMMODATE – ACCOMMODATED – ACCOMMODATION – ACCOMMODATING,    AMPLE, 
Positive words fidelity
Task: Examples of negative words and phrases
What are some of the negative words and phrases that are overused in your setting?

What might be some alternatives you could use?

Video: The power of words
Task: Create your positive words implementation plan