The need for a coherent model for dealing with conflict and containment

This work first started with Professor Len Bowers assembling researchers from King’s, the Royal College of Psychiatrists, London NHS (National Health Service) trusts, UCL and City, University of London, to explore the variations between conflict and containment on individual wards. In 2010, this developed into an extensive and comprehensive research programme, which initially looked at the practices in acute inpatient psychiatric care to establish aspects of conflict and containment.

King’s researchers carried out a series of systematic reviews that indicated several factors, such as managing the physical environment, or staff not explaining the ward structure to patients, were important contributors to increased conflict, alongside factors relating to the patients themselves. They also realised the patterns of conflict behaviour in patients corelated with the use of containment methods by staff. In other words, while patient conflict could lead to staff containment, it is also the case that staff use of containment can lead to patient conflict.

In response to those findings, a team led by Professor Bowers and Professor Alan Simpson developed and piloted a suite of interventions to address these issues. This team included expert inpatient staff service users and carers and was hugely assisted by the Service User (and Carer) Group Advising Research (SUGAR).

The Safewards Model

King’s Safewards Model highlights six factors that can lead to "flashpoints” - precursors or triggers for conflict and/or containment.

These six factors are: the staff team, the physical environment, factors outside hospital, the patient community, patient characteristics and the regulatory framework. The model hypothesised that wards that reduced and or managed flashpoints better had less conflict and containment.

From the model approximately 300 ideas for interventions to reduce or manage flashpoints, which had been identified in evidence reviews, were rated, and consolidated by King’s researchers. Service users, carers and expert professionals were consulted before selecting 16 potential interventions for pilot testing. Following the pilot, which showed promising results, the wards involved advised on the 10 interventions they felt were both practical and achievable within the average acute ward setting.

This dynamic model systematically showed how understanding its central principles can inform strategies that promote the safety of patients and staff, leading to a healthier work and recovery environment.

Implementing Safewards across England and the UK

The Safewards website was launched in 2013 and it has made the model’s interventions freely and easily available to all, with no registration requirement. This was deliberately done to minimise barriers and maximise take-up. This means there is no clear number of how many trusts and teams have implemented Safewards. It is also clear that wards other that acute inpatient units were interested in the interventions.

However, King’s researchers are aware of implementation in many organisations across the UK including NHS Trusts such as South London & Maudsley, Greater Manchester Mental Health (GMMH), Sussex Partnership, Lincolnshire Partnership, West London, Worcestershire, Kent, Berkshire, Derby, Leicester, Oxleas, Merseycare, Sheffield, Midlands Partnership, Cumbria Northumberland and Tyne and Wear (CNTW), Tees, Esk and Wear Valleys (TEWS), as well as Fife and Boarders NHS Trust in Scotland, Health Boards in Wales and five Health and Social Care Trusts in Northern Ireland. Many independent providers in the UK have also implemented Safewards in their services.

One PICU unit in Sussex Partnership NHS Trust subsequently reported that they had recorded a 63% decrease in seclusion, 45% decrease in restraints, and a 53% decrease in use of rapid tranquilisation medication following Safewards implementation. In CNTW all wards within the Trust utilise Safewards as part of a Trust led Positive & Safe Strategy called Talk 1^st. In its second year, Talk 1^st reported that restraint was down 23%, seclusion down 21% and staff assault reduced by 18% across the Trust.

Additionally, Safewards has been implemented in Canada, Holland, Germany, Austria, Switzerland, Sweden, Norway, Finland, Malta, Ireland, The Czech Republic, Slovakia, and Spain. In Germany, Austria and Switzerland, a network of Safewards implementors has driven the uptake across multiple services. This has also been the case in Sweden and the Czech Republic.

In Tasmania, Finland, and Belgium Safewards interventions are either recommended or are being actively implemented in hospitals to drive quality improvements in mental health inpatient care. In 2019 the Ministry of Health of the Republic of Indonesia sent a team of doctors and nurses to the UK to learn about Safewards for use in their services.

Many of these international colleagues have contributed to the Safewards website material being translated into German, Turkish, Dutch, Finnish, Danish, Polish, Czech, and Spanish, with thousands of international visitors to website every year. In 2023, the British Council provided funding for the material to be translated into Chinese as part of a bigger implementation project.