Safewards Impact in Inpatient Mental Health Units in Victoria, Australia: Staff Perspectives

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.

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.

Exploring safety culture within inpatient mental health units: The results from participant observation across three mental health services

In Australia, acute inpatient units within public mental health services have become the last resort for mental health care. This research explored barriers and facilitators to safe, person-centred, recovery-oriented mental health care in these settings. It utilised participant observations conducted by mental health nurses in acute inpatient units. These units were located in three distinct facilities, each serving different areas: a large metropolitan suburban area in a State capital, a mid-sized regional city, and a small city with a large rural catchment area. Our findings highlighted that, in the three inpatient settings, nurses tended to avoid common areas they shared with consumers, except for brief, task-related visits. The prioritisation of administrative tasks seemed to arise in a situation where nurses lacked awareness of alternative practices and activities. Consumers spent prolonged periods of the day sitting in communal areas, where the main distraction was watching television. Boredom was a common issue across these environments. The nursing team structure in the inpatient units provided a mechanism for promoting a sense of psychological safety for staff and were a key element in how safety culture was sustained.

Medical and surgical nurses' experiences of modifying and implementing contextually suitable Safewards interventions into medical and surgical hospital wards

AIM

To explore general nurses' experiences of modifying and implementing contextually suitable Safewards interventions into medical and surgical hospital wards.

DESIGN

Qualitative action research was used working with nurses as co-researchers.

METHODS

Pre-implementation focus groups were conducted in April 2022 to understand and explore the current strategies nurses utilized to avert, respond to or decrease violence. Following this, two Safewards interventions were modified by the nurses on the wards. Post-implementation focus groups were conducted in October 2022, to explore the nurses' experience of implementing Safewards interventions and the effect on their nursing practice. Data were analysed using Braun and Clarke's framework for thematic analysis.

RESULTS

Three themes emerged from the analysis of the pre-implementation focus groups that reflected the type of violence experienced by these nurses and the context within which they occurred: 'the space is hectic'; 'it can feel like a battlefield'; and 'the aftermath'. These themes encompass the nurses' experience of violence from patients and their visitors. Following the implementation of two modified Safewards interventions, the analysis of the focus groups reflected a change in nursing skills to avert or respond to violence: 'Safewards in action'; 'empathy and self-reflection'; and 'moving forward'.

CONCLUSION

Safewards interventions can be successfully modified and used in general hospital wards and influence nursing practice to manage patient and visitor violence.

IMPLICATIONS FOR THE PROFESSION

In the interests of safety, successful interventions to reduce violence towards general hospital nurses should be a priority for managers and healthcare organizations. Averting, mitigating and managing violence can decrease the negative professional and personal effect on nurses and ultimately improve well-being, job satisfaction and retention rates. Furthermore, decreasing violence or aggressive incidents leads to a safer patient experience and decreased number of nursing errors ultimately improving patient experiences and outcomes. Understanding nurses' experiences of violence and working with them to explore and develop contextually relevant solutions increases their capacity to respond to and avert violent incidents. Contextually modified Safewards interventions offer one such solution and potentially has wider implications for healthcare settings beyond the specific wards studied.

IMPACT

This study addressed the implementation of modified Safewards strategies in medical and surgical wards to prevent violence. Three themes emerged from the analysis of the pre-implementation focus groups that reflected the type of violence experienced by these nurses and the context within which they occurred. Following the implementation of two modified Safewards interventions, the post-implementation focus groups reported positive changes to their practices using the modified resources to prevent violence from patients and their visitors. Mental health interventions, such as those used in the Safewards model can be modified and provide a tool kit of interventions that can be used by medical and surgical nurses.

REPORTING METHOD

This paper has adhered to the COREQ guidelines.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution. WHAT DOES THIS PAPER CONTRIBUTE TO THE WIDER GLOBAL CLINICAL COMMUNITY?: This paper outlines and discusses the action research approach undertaken to work with general hospital nurses to modify mental health nurses' Safewards interventions into their clinical practice. This paper provides evidence of the 'real world' application of Safewards interventions by medical and surgical nurses in general hospital wards. This paper presents qualitative findings based on focus group methods to highlight the narratives of general nurses and their experiences of violence.

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.

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.

An analysis of the barriers and enablers to implementing the Safewards model within inpatient mental health services

Mental health inpatient units can provide a sanctuary for people to recover from mental illness. To support a therapeutic environment, the safety and well-being of service users and staff need protection through reduced conflict and containment rates. The Safewards model identifies 10 interventions to prevent conflict and containment. This paper aims to present barriers and enablers to implementing Safewards by analysing current literature on the Safewards model. It will also compare the Safewards model to New Zealand's Six Core Strategies. In a systematic search of 12 electronic databases following the PRISMA flow chart, 22 primary studies were included in this analysis. JBI tools were used for quality appraisal and deductive content analysis was used to organize and interpret data. Four categories were identified: (a) designing the Safewards interventions and implementation; (b) staff participation and perception of Safewards; (c) healthcare system influences on Safewards implementation; (d) service user participation and perception of Safewards. To support successful Safewards implementation in future practice, this review recommends that Safewards implementation is enabled through robust design of the Safewards interventions and implementation methods; staff participation and positive perception of the Safewards model; a resourced healthcare system that prioritizes Safewards implementation; service user awareness and participation in Safewards interventions. Interactionist perspectives may support the implementation of Safewards. This analysis is limited by research settings mostly being inpatient adult services and inadequate capturing of the service user voice. An ongoing review of barriers and enablers is important for supporting future Safewards implementation.

Sustaining a therapeutic environment within mental health in-patient settings during COVID-19. Results of a Delphi study

AIM

Develop a strengths-based, person-centred, trauma-informed and recovery-oriented framework to mitigate any potential increase in conflict resulting from the implementation of C19 restrictions.

BACKGROUND

Guidance addressing the unique challenges posed by Covid-19 within mental health in-patient settings, including how to support those whose distress may present as behaviour that challenges including violence and self-harm, remains urgently needed.

METHODOLOGY/APPROACH

A Delphi design involving four iterative stages was adopted. Stage 1 involved a review and synthesis of COVID-19-related public health and ethical guidance and a narrative literature review. A formative operational framework was then developed. Stage 2 sought to establish the face validity of the framework through engagement with frontline and senior staff in mental health services in Ireland, Denmark and Netherlands. Stage 3 investigated the content validity of the final framework through a plenary presentation and discussion of the framework at a scientific symposium of the European Violence in Psychiatric Research Group (EViPRG, 2020). Stage 4 sought expert appraisal of the framework using a structured evaluation completed by a panel of eighteen multidisciplinary experts from nine countries, including four academics, six clinicians and eight holding dual clinical/academic appointments to assess content validity.

RESULTS

The guidance adopts the widely advocated approach to support those whose distress may present as behaviour services find challenging in identifying the need for primary, secondary, tertiary and recovery measures. It emphasizes person-centred care while integrating specific Covid-19 public health requirements into service planning. It also aligns with contemporary best practice in in-patient mental health care, incorporating the principles of Safewards, the core values of trauma-informed care, and an explicit on recovery.

CONCLUSION

The guidance developed has face and content validity.

Safewards: An integrative review of the literature within inpatient and forensic mental health units

Mental health inpatient units are complex and challenging environments for care and treatment. Two imperatives in these settings are to minimize restrictive practices such as seclusion and restraint and to provide recovery-oriented care. Safewards is a model and a set of ten interventions aiming to improve safety by understanding the relationship between conflict and containment as a means of reducing restrictive practices. To date, the research into Safewards has largely focused on its impact on measures of restrictive practices with limited exploration of consumer perspectives. There is a need to review the current knowledge and understanding around Safewards and its impact on consumer safety. This paper describes a mixed-methods integrative literature review of Safewards within inpatient and forensic mental health units. The aim of this review was to synthesize the current knowledge and understanding about Safewards in terms of its implementation, acceptability, effectiveness and how it meets the needs of consumers. A systematic database search using Medline, CINAHL, Embase and PsychInfo databases was followed by screening and data extraction of findings from 19 articles. The Mixed Methods Appraisal Tool (MMAT) was used to assess the quality of empirical articles, and the Johanna Brigg's Institute (JBI's) Narrative, Opinion, Text-Assessment and Review Instrument (NOTARI) was used to undertake a critical appraisal of discussion articles. A constant comparative approach was taken to analysing the data and six key categories were identified: training, implementation strategy, staff acceptability, fidelity, effectiveness and consumer perspectives. The success of implementing Safewards was variously determined by a measured reduction of restrictive practices and conflict events, high fidelity and staff acceptability. The results highlighted that Safewards can be effective in reducing containment and conflict within inpatient mental health and forensic mental health units, although this outcome varied across the literature. This review also revealed the limitations of fidelity measures and the importance of involving staff in the implementation. A major gap in the literature to date is the lack of consumer perspectives on the Safewards model, with only two papers to date focusing on the consumers point of view. This is an important area that requires more research to align the Safewards model with the consumer experience and improved recovery orientation.

Safewards Secure: A Delphi study to develop an addition to the Safewards model for forensic mental health services

WHAT IS KNOWN ON THE SUBJECT?: The Safewards model has been introduced to forensic mental health wards with mixed results. Research has identified a need to consider the addition of factors that may be relevant to forensic mental health services to enhance the introduction of Safewards. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: This study elicits factors specific to forensic mental health settings missing from the original Safewards model, which have the potential to enhance nursing care, improve safety and improve adherence to Safewards in a forensic mental health setting. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: This study provides the adaptation required in a forensic mental health setting to enhance the implementation of the Safewards model of care, originally developed to assist nurses to prevent and manage conflict and containment in acute general mental health settings. The development of Safewards Secure has incorporated perspectives from expert Safewards and forensic mental health nurse leaders and healthcare clinicians and is inclusive of consumer and carer perspectives to ensure the model is applicable and broadly acceptable. ABSTRACT: Introduction Safewards is a model designed specifically for acute mental inpatient wards. Research investigating the introduction of Safewards has identified a need to consider factors relevant in forensic mental health services, such as offence and risk issues. Aim To identify adaptations needed to address gaps in the Safewards model to assist forensic mental health nurses to prevent and manage conflict and containment. Method A Delphi study was employed to engage a group of international Safewards and forensic mental health experts (n = 19), to elucidate adaptation of the Safewards model. Results Experts identified necessary elements and reached consensus on key considerations for Safewards interventions. To ensure the Safewards Secure model was robust and developed on a platform of research, all items suggested by Delphi experts were cross-referenced and dependent on empirical evidence in the literature. Discussion This study identified a number of key differences between civil and forensic mental health services, which informed the development of Safewards Secure, an adjunct to the original Safewards model. Implications for Practice The development of person-centred models of nursing care adapted to specific settings, such as forensic mental health, provides a potential solution to preventing and managing conflict and containment, and improving consumer outcomes. Relevance Statement Managing conflict and containment in mental health services remains an ongoing challenge for mental health nurses. Safewards is a model of care designed for acute mental health inpatient settings to prevent conflict and containment. To date, there has been mixed results when introducing Safewards in forensic mental health settings, and reported reluctance and scepticism. To address these issues, this study employed a Delphi design to elicit possible adaptions to the original Safewards model. From this study, Safewards Secure was developed with adaptations designed for forensic services, to enhance the management of conflict and containment, assist implementation and improve consumer outcomes.

A realist evaluation of weighted modalities as an alternative to pro re nata medication for mental health inpatients

Implementing psychosocial approaches into mental health inpatient settings continues to be challenging. This is despite mental health policies prioritizing trauma-informed and recovery-orientated care approaches. This study reports on an interdisciplinary project that implemented and examined the uptake of weighted modalities in a psychiatric inpatient rehabilitation setting. While over-reliance on pro re nata (PRN) medication in these settings has been reported, weighted modalities are a sensory approach that can be self-initiated by consumers as an alternative to use of PRN to manage distress and agitation. A mixed-methods realist approach was used to determine what works, for whom, and in what circumstances weighted modalities were offered by clinicians and used by consumers. Additionally, we were interested in determining whether there was an associated change in PRN use during the trial. Data included in-depth interviews with consumers (n = 12) and clinicians (n = 11), and extraction of PRN medication use preceding, throughout, and following implementation. Statistical analysis revealed a significant increase in PRN rates in the first 3 months of implementation (mean difference from baseline = 29.5, P = 0.047) but a significant decrease in the second three-month period following implementation (mean difference from baseline = -30.7, P = 0.036). Qualitative findings highlighted the key components of successful implementation as being environmental restructuring (availability/accessibility and visibility of weighted modalities) and social influences. Strategies to enhance these components are discussed.

A Systematic Review of the Effectiveness of Safewards: Has Enthusiasm Exceeded Evidence?

Safewards is intended to be an evidence-based approach to reduce levels of conflict and containment in mental health inpatient settings. A systematic review was carried out to examine whether Safewards is effective in reducing conflict and containment events; and improving ward climate. Searches for articles evaluating the implementation of Safewards was conducted using PsycINFO, PubMed, Web of Science, Cochrane Library and CINAHL. Thirteen studies were included for review after applying inclusion and exclusion criteria. The Quality Assessment Tool for Studies with Diverse Designs (QATSDD) was used to assess study quality and the majority of studies (N = 7) were rated as "moderate" quality. Whilst there is evidence to suggest that Safewards is effective for reducing conflict and containment in general mental health services, there is insufficient high-quality empirical evidence to support its effectiveness in settings beyond this. Further research using robust methodological designs with larger, more representative samples is required in order for the effectiveness of Safewards to be established across the range of contexts in which it is currently being applied.

Effect of Safewards on reducing conflict and containment and the experiences of staff and consumers: A mixed-methods systematic review

Safewards is an internationally adopted framework that provides interventions to reduce conflict and containment in healthcare settings. This systematic review evaluated the effect of Safewards on conflict and containment events in inpatient units and the perceptions of staff and consumers. Quantitative, qualitative, and mixed-methods studies were considered for inclusion. Following the Joanna Briggs Institute methodology, two reviewers independently screened, appraised, and extracted data. Qualitative data were synthesized using inductive-thematic analysis. Quantitative and qualitative data were integrated with a convergent-segregated approach and presented in tabular and narrative format. A search of 13 databases and grey literature yielded 14 studies of variable methodological quality. Four studies reported reduced rates of conflict and one study reported reductions that were not statistically significant. Six studies reported reductions in rates of containment, three studies found no statistical significance and one study reported statistically significant reductions at follow-up. Staff and consumers in four studies reported an improved experience of safety. Three themes were developed as follows: (i) therapeutic hold, cohesion, support and the environment, (ii) conflict, containment and the experience of safety, and (iii) the complexities of adapting and embedding change. This review found most staff and consumers reported Safewards improved therapeutic relationships, cohesion, and ward atmosphere. Staff and consumers reported improved ward atmosphere, leading to consumer-centred, recovery-oriented care. Safewards improved the experience of safety from the perspective of staff and consumers when combined with ongoing training, leadership and time for consolidation. While results are promising they should be used cautiously until more robust evidence is established.

Exploring factors that influence success when introducing "The Safewards Model" to an acute adolescent ward: A qualitative study of staff perceptions

Problem

The Safewards’ model identifies factors that can lead to conflict and addresses these factors, using ten interventions, within inpatient mental health wards aiming to reduce “conflict and containment.” The Department of Health (2014) and Care Quality Commission (2017) supported the use of Safewards to reduce restrictive practice across all mental health settings in the UK, but its application to adolescent mental health remains relatively unexplored. This study therefore aims to address the research question: “What are the factors influencing the success of ten Safewards’ interventions when implemented onto an acute adolescent ward?”

Methods

Eight healthcare assistants and two nurses who had attended Safewards’ training participated in semi‐structured interviews four months after Safewards was introduced to an acute adolescent ward. The interviews were transcribed verbatim and analyzed using thematic analysis. Data analysis was conducted inductively by developing data‐driven themes.

Findings

Many of the factors influencing Safewards’ success in adolescent mental health (e.g., acuity; dependence on nonregular staffing; lack of leadership and operating procedures) paralleled the evidence found in adult services.

Conclusions

This study contributes new information by implementing “mutual help” and “calm down” principles with adolescents, as well as discussing barriers of operational procedures and benefits of patient involvement.

It's a little bit like prison, but not that much: Aboriginal women's experiences of an acute mental health inpatient unit

This research aimed to gain an understanding of the acute mental health inpatient experience as described by Aboriginal women during admission. It recorded for the first time the words of Aboriginal women within the inpatient unit, including their perceptions of factors which may promote or impede a culturally safe environment. Eleven Aboriginal women inpatients gave interviews before discharge from the inpatient unit. Five Aboriginal Reference Group (ARG) members with experience of the inpatient unit also gave interviews, adding 'insider-outsider' perspectives. Interviews were recorded, transcribed, entered into NVivo software, and analysed inductively to raise codes and develop themes. Five interconnecting themes emerged: Social Context: life experience preceding, shaping, and following admission; Connection: with kin, community, and culture. Control: self-determination, legally and physically curtailed; Caring: actions promoting reconnection and self-determination; Communication: conveying caring and supporting agency, reconnection, and return to community. Findings reflected inpatient issues reported in previous studies, adding insights into the cultural concerns of Aboriginal women and offering practical clinical implications for culturally secure service delivery in an inpatient setting. Existing literature offered a basis for developing the model offered here for transcultural interaction for recovery in an inpatient setting. Attention to these findings can enhance Aboriginal women's inpatient experience and promote further research. The article complies with the COREQ-32 checklist for describing qualitative studies.

Design features that reduce the use of seclusion and restraint in mental health facilities: a rapid systematic review

Increasing efforts are being made to prevent and/or eliminate the use of seclusion and restraint in mental health facilities. Recent literature recognises the importance of the physical environment in supporting better outcomes in mental health services. This rapid review scoped the existing literature studying what physical design features of mental health facilities can reduce the use of seclusion and physical restraint.

DESIGN

A rapid review of peer-reviewed literature.

METHODS

Peer-reviewed literature was searched for studies on architectural design and the use of restraint and seclusion in mental health facilities. The following academic databases were searched: Cochrane Library, Medline, PsycINFO, Scopus and Avery for English language literature published between January 2010 and August 2019. The Joanna Briggs Institute's critical appraisal tool was used to assess the quality of included studies.

RESULTS

We identified 35 peer-reviewed studies. The findings revealed several overarching themes in design efforts to reduce the use of seclusion and restraint: a beneficial physical environment (eg, access to gardens or recreational facilities); sensory or comfort rooms; and private, uncrowded and calm spaces. The critical appraisal indicated that the overall quality of studies was low, as such the findings should be interpreted with caution.

CONCLUSION

This study found preliminary evidence that the physical environment has a role in supporting the reduction in the use of seclusion and restraint. This is likely to be achieved through a multilayered approach, founded on good design features and building towards specific design features which may reduce occurrences of seclusion and restraint. Future designs should include consumers in a codesign process to maximise the potential for change and innovation that is genuinely guided by the insights of lived experience expertise.

Consumers living with psychosis: Perspectives on sexuality

Mental health clinicians work within a recovery framework that is rights based and emphasizes positive and respectful approaches to working with mental health consumers. Mental health nurses' practice is also predicated on holism and inclusiveness, yet consumers' sexuality is sometimes neglected and rights in this area overlooked. Also overlooked is sexuality as an area for investigation, particularly from a consumer perspective, even though it constitutes part of consumers' broader remit of sexual health. This paper reports findings from a case study where consumers were asked about their ability to negotiate and sustain sexual expression while residing in a long-stay mental health rehabilitation facility. There were three main findings. First, the physical space of the facility, inclusive of consumers' bedrooms, was policed by mental health clinicians with ongoing intrusions into consumers' privacy, which inhibited their sexual expression. The creation of barriers to sexual expression is counter to polices that promote recovery. Second, consumers reported significant medication-related weight gain which negatively affected their self-image and sexual sense of self. Third, the consumers spoke about their sexuality in ordinary, everyday language devoid of any hallmark of psychosis. This highlights the importance of relating to consumers about their sexuality and sexual needs from a humane rather than technical framework. Further, it foregrounds the relational aspect of the mental health nurses' role rather than the technical aspect. Yet sexuality is a topic that is often neglected, indicating that an upskilling of the mental health nursing workforce is required, to strengthen communication and relationship skills.

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

BACKGROUND

A lack of safety experienced by patients and staff in acute psychiatric units is a major concern and containment methods used to manage conflict have the potential to cause harm and upset to both staff and patients. To ensure safety for all, it is highly desirable to reduce levels of conflict and containment and the Safewards model is an evidence-based model aimed at reducing conflict and containment rates by improving nurse-patient relationships and safety.

METHODS

The aim of this study was to explore mental health nurses' experience of the introduction and practice of three Safewards interventions; reassurance, soft words and discharge messages. A qualitative descriptive research design utilising a purposive sample (n = 21) of registered psychiatric nurses (n = 16) and managers (n = 5) in an acute psychiatric unit in Ireland. Following a 12-week implementation of Safewards, three focus groups were conducted, two with nursing staff and one with nurse managers. Data were analysed using Braun and Clarke thematic analysis framework which supported the identification of four themes: introducing Safewards, challenges of Safewards, impact of Safewards and working towards success.

RESULTS

The findings indicate that the process of implementation was inadequate in the training and education of staff, and that poor support from management led to poor staff adherence and acceptance of the Safewards interventions. The reported impact of Safewards on nursing practice and patient experience were mixed. Overall, engagement and implementation under the right conditions are essential for success and while some participants perceived that the interventions already existed in practice, participants agreed Safewards enhanced their communication skills and relationships with patients.

CONCLUSION

The implementation of Safewards requires effective leadership and support from management, mandatory training for all staff, and the involvement of staff and patients during implementation. Future research should focus on the training and education required for successful implementation of Safewards and explore the impact of Safewards on nursing practice and patient experience.

How does the environment influence consumers' perceptions of safety in acute mental health units? A qualitative study

AIMS AND OBJECTIVES

To explore how the physical and social environment of acute mental health units influences consumers' perception and experience of safety.

BACKGROUND

Acute mental health units are places in which consumers should feel safe. Not all consumers, however, feel safe in this environment. Little is known about what contributes to consumers' feelings of safety in this setting.

DESIGN

The study used a qualitative descriptive design, influenced by naturalistic enquiry. Data were analysed using thematic analysis and are reported according to the COREQ checklist.

METHODS

Fifteen people who had experienced admission to an acute mental health unit were individually interviewed.

RESULTS

Having a supportive environment enhanced consumers' perception and experience of safety. A supportive environment was experienced when consumers had privacy, felt safe from other consumers and had meaningful activities to participate in within the acute mental health unit. In contrast, having their privacy breached by other consumers made participants feel unsafe. Many participants were fearful of other consumers, and felt unsafe and unable to protect themselves. Lack of meaningful activities led to boredom and contributed to consumers feeling unsafe.

CONCLUSIONS

Personal spaces should address consumers' privacy needs without compromising staff access. Staff presence enhances consumers' feelings of safety, but this need can be heightened when consumers are unable to alert staff when they feel unsafe. Meaningful activities link consumers to their lives outside of the hospital and can enhance recovery.

RELEVANCE TO CLINICAL PRACTICE

Understanding how the acute unit environment is perceived by consumers can assist nurses and managers to promote feelings of safety among consumers. Feeling safe can, in turn, optimise recovery.

Safewards: Changes in conflict, containment, and violence prevention climate during implementation

Since its development, there has been growing utilization of the Safewards package of interventions to reduce conflict and containment in acute mental health wards. The current study used the opportunity of an implementation of Safewards across one large metropolitan local health district in New South Wales Australia to evaluate change. Specific aims of the study were to measure, for the first time in Australia, changes in shift-level reports of conflict and containment associated with Safewards introduction, and to measure any association with change in the violence prevention climate using a tool validated for use in the current study setting. Eight of eleven wards opted-in to participating in Safewards. Implementation was conducted over a period of 24 weeks (4-week preparation, 16-week implementation, and 4-week outcome phases). Conflict and containment were measured using the Patient-Staff Conflict Checklist Shift Report and violence prevention climate using the VPC-14. From 63.2% response rate, the mean (SD) reported conflict and containment incidents per shift fell from 3.96 (6.25) and 6.81 (5.78) to 2.94 (4.22) and 5.82 (4.62), respectively. Controlling for other variables, this represented reductions of 23.0 and 12.0%, respectively. Violence prevention climate ratings did not change. Safewards was associated with significant improvements in all incidents of conflict and containment, including the most severe and restrictive types, and this was largely unaffected by outcomes measure response rate, shift or weekday/weekend reporting, or number of ward beds. Safewards is increasingly justified as one of very few interventions of choice in adult, acute mental health services and should be widely utilized.

'Only ever as a last resort': Mental health nurses' experiences of restrictive practices

Nurses play a crucial role in the implementation of restrictive practices such as seclusion and restraint. Restrictive practices have been widely recognized as harmful practices and efforts to reduce their use have been in place for several years. While some reductions have been achieved, more information and insight into the perspectives and experiences of front-line mental health nursing staff is required if further changes are to be realized. Sixty-five respondents participated in an online survey to investigate Australian mental health nurses' personal experiences and opinions regarding restrictive practices. Analysis revealed restrictive practices as a complex, contested and challenging area of practice. Analysis of data revealed five main ways that restrictive practices were framed by respondents. These were as follows: as a response to fear; to maintain safety for all; a legacy of time and place; the last resort; and, a powerful source of occupational distress. In addition, findings revealed the need to support staff involved in restrictive practices. This need could be satisfied through the implementation of procedures to address post-restrictive distress at all levels of the organization. Ensuring an optimal work environment that includes appropriate staffing, availability of supportive education and structured routine debriefing of all episodes of restrictive practice is critical in achieving further reductions in seclusion and restraint.