Comprehensive Critical Review: Safewards Model in Acute Mental Health

This report presents a critical systematic review of the Safewards Model, focusing on its application within acute mental health units. The study examines the model's background, potential benefits, and aims to assess its effectiveness in reducing conflict and containment, thereby enhancing patient engagement in the recovery process. The review explores the six domains of the Safewards Model (outside hospital, physical environment, patient community, staff team, regulatory framework, and patient characteristics) and the flashpoints that can trigger conflict. The methodology involves a comprehensive search and selection process, including specific inclusion and exclusion criteria, to identify relevant peer-reviewed articles published between 2010 and 2017. The critical appraisal of the selected articles utilizes the CASP systematic review checklist to assess the validity, results, and usefulness of the studies. The report aims to provide evidence-based recommendations regarding the implementation, modification, or alternative models to improve patient outcomes. This study critically reviews the literature that addressed the use of the Safewards Model in Mental Health and its usefulness. It will provide effective recommendations relating to its implementation, modification or a new Model that will help effectively engage patients in acute mental units for better recovery.

Nomthandazo Masuku
SAFEWARDS MODEL
By (Student’s Name)
Professor’s Name
College
Course
Date
1

Nomthandazo Masuku
Background and Potential Benefits of Study
Background
The need to reduce conflict and containment has been a disturbing issue for
many years. Many interventions and models have been attempted to solve this issue
albeit unworking. The absconding by patients, rule breaking, manual restraint, attitude
to containment, compulsory detention and attitude of nurses to patients with mental
disorders have been the backdrops against which these models and intervention have
been tried. Other researchers have also focused their studies on understanding
Safewards Model through aggression, absconding, substance use, medication refusal,
suicide, special observations, coerced medication, manual restraint, seclusion and
mechanical restraint. The overarching finding from these studies point towards the need
for a much stronger model and design a much stronger interventions for the people to
utilize.
It is upon this backdrop that many researchers have recommended the use of
Safewards Model in order to reduce the conflict and containment for effective and
smooth recovery process. The researchers have used Safewards Model and
subsequently produced various ideas for intervention that clearly appreciates the
benefits of this model when used in wards to assist the ward staff decrease levels of
containment and conflicts thereby making their wards safer placers. This is because the
studies have shown that Safewards interventions have generated a significant decrease
in the rate of conflict and reduce the containment rate.
The conflict (self-harm, aggression, absconding, self-harm, medication refusal,
substance use) and containment (as required medication, seclusion, special
2

Nomthandazo Masuku
observation, coerced intramuscular, manual restraint and secular) put patients and staff
at risk of severe harm. The frequency of such events differ across wards, yet there are
few explications as to why this is so, alongside a coherent model is really lacking. This
essay thus proposes a comprehensive critical systematic review of literature that
address the use of Safewards Model in Mental Health to give a detailed explanatory
model of these variations, and sketch the implication for the mechanisms for decreasing
risks alongside coercion on the inpatient wards to inform the required changes in
education, healthcare practice and future research.
Professor Len Bowers and colleagues developed the Safewards Model in the
United Kingdom. This model particularly scrutinizes events referred to as “conflict”
(events which may threaten staff as well as consumers like self-harm, absconding,
suicide and aggression) alongside “containment” (interventions implemented by staff to
avoid a conflict between them and consumers. These may include increased
observation, utilization of medication, as well as using restrictive interventions). Conflict
and containment events can be categorized together (Bowers 2013). This is because
patients that might display one type of the conflict behavior could further display
another. The conflict as well as containment can differ substantially between various
wards and nationally as well as internationally, and types of methods of containment
can further differ significantly. Thus, this Model seeks to offer an explanation on the
differing rates of both containment and conflict as well as provide interventions which
are designed to lessen the risk of the conflict as well as containment incidences taking
place.
3

Nomthandazo Masuku
The model has six domains (see appendix (figure 1 and 2)) that are; outside
hospital, physical environment, patient community, staff team, regulatory framework,
and patient characteristics (Bowers 2013). These 6 domains give rise to flashpoints that
are defined as ‘social as well as psychological context emerging out of the features of
originating domains, signaling as well as proceeding imminent conflict behavior”. Such
flashpoints could trigger conflict that might lead to containment.
The use of containment could cause conflict. The purpose of this model is to
reduce such undesirable interventions (Bowers 2013). The staff interventions can
effectively modify these process by decreasing the conflicts-emerging factors:
preventing flashpoints from emerging; cutting link between flashpoints and conflict;
selecting not to utilize containment; and making sure that containment utilization does
not culminate in further conflicts. It is upon this backdrop that this review will be
important as the model will be systematically described in detail; and clearly shown how
it can be utilized in devising strategies that effectively help promote patient and staff’s
safety.
Potential Benefits (Significance)
This study seeks to evaluate whether using the Safewards Model in acute mental
health units has improved client engagement in promoting recovery. Answering this
research question will have potential implication towards the implementation,
modification and even development of new models to boost the client engagement in
the recovery promotion among the patients in acute mental health units (Price, Burbery,
and Leonard & Doyle 2016).
4

Nomthandazo Masuku
If the research finds out that the model has improved consumer engagement, it
would be recommended for mental health units as this will be beneficial since it will
have helped decrease any form of conflict and restrictive containment methods that only
serve to derail the recovery process of the patients in acute mental health units (Price,
Burbery, Leonard and Doyle 2016).
On the other hand, the research will have potential benefits by identifying some
key limitations of Safewards and suggest the required adjustment or modification that
will boost its usage for promoting recovery (Parish 2013). The research might also
reach a finding that the Model itself is effective as it is but the process of implementation
may have not been well understood and hence focus on the ways to improve Safewards
for better outcomes (Price, Burbery, Leonard and Doyle 2016). Finally, the study will be
of great potential where it reaches a conclusion that Safewards is not the best Model in
this context and goes on to recommend the implementation of new Model to substitute
Safewards Model (Price, Burbery, Leonard and Doyle 2016).
5

Nomthandazo Masuku
Aim:
The real aim is to critically review the literature that addressed the use of the
Safewards Model in Mental Health. The comprehensive critical review of literature is
done to understand the usefulness of Safewards Model in mental health. To do this, the
focus will be on whether the reviewed literature highlight the effectiveness of limitation
of this model on the basis of implementation and usage. The success of this model in
clinical health will be examined on the basis of whether it has enhanced patient
engagement and the corresponding effect of such an engagement to recovery process.
This well provide effective recommendations relating to its implementation, modification
or a new Model that will help effectively engage patients in acute mental units for better
recovery.
Purpose:
The main purpose of this study is to evaluate the success of Safewards Model in
terms of its ability to engage the patients in acute mental units by looking at how the
issues of conflict and containment are either reduced or increased even after the
implementation of the Safewards Model. This will be beneficial in informing the future
Model or the implementation and modification necessary to make Safewards Model to
be more effective (Price, Burbery, Leonard & Doyle 2016). By so doing, a
recommendation will be offered that will propose the adoption and implementation of the
Safewards Model so as to promote consumer engagement and hence better recovery.
Research Question
 Has using the Safewards Model in acute mental health units improved client
engagement in promoting recovery?
6

Nomthandazo Masuku
Systematic Critical Review
The researcher used the critical review to appraise various articles in the
literature. The aim of the critical-review was to validate that the researcher had lengthily
investigated the literature as well as critically evaluated the quality of such literature.
The critical review extends beyond the mere description to include the analysis degree
as well as the conceptual innovation. Unlike traditional literature reviews that merely
introduces a topic, summarize the main ideas and providing certain illustrative instance
which lacks reliability, critical systematic review guarantees reliability by recording how
primary studies were sought as well as selected and how such studies were analyzed to
generate their conclusions. It helps the readers to be able to judge whether each of the
relevant literature is probably to have been found as well as how the quality of a given
study is assessed. The systematic review remains transparent regarding they generate
conclusions. This is important because it avoids misrepresentation of knowledge base
by evaluating each study to make clear its relevance and quality. It helps confirms that
the review authors have taken the necessary steps to decrease distortions and
inaccuracies. The systematic review also uses a protocol that sets out how the review is
conducted prior to actual review to reduce bias by minimizing the influence the results
might have over the being overly influenced by review procedures. The systematic
review also entails exhaustive searches to obtain as much as feasible of the relevant
study to reduce bias by ensuring that conclusions are never overly influenced by most
reachable study. The methods of systematic review are also made explicit to allow
users of review to know if they can trust the findings of the review as readers can easily
judge how well the review has been undertaken. The systematic review also involves
7

Nomthandazo Masuku
potential users of the systematic review to ensure that the research is relevant by
setting advisory cohorts are set up with representation from all user groups. The
findings of the systematic review remains solid as the results of sound research are
synthesized effectively. This helps generate clear as well as easily reachable messages
regarding the reliable evidence existing on a topic. This is done by appraisal of each
study and pooling its results which imply that conclusions can be effectively drawn
regarding the direction of the evidence in its entirety.
Search, Retrieval, and Selection
The researcher used the critical review process to search for the relevant articles
about Safewards Model. To begin my search, I first identified the key terms and phrases
that could help me get the required and relevance articles. Some of the key terms
identified were: Safewards Model; Implementation of Safewards Model; Importance of
Safewards Model; Success of Safewards Model; Conflicts and Restrictive Containment
Application of Safewards Model; and Challenges to Safewards Model Implementation.
After this identification of key terms, I brainstormed on specific search engines that
could helped me get the required articles. I came up with a list of few search engines
including Google, Yahoo and Bing. Further, I selected some data bases that could
enable me get the required information and came up with a list of key databases: The
York Research Database; PubMed; Cochrane Library; Popline; TOXNET; CINAHL Plus
and EMBASE to enable me obtain the relevant articles and retrieved (Goulet, Larue &
Dumais 2017).
The inclusions and exclusion criteria was based on a number of considerations.
First, I was looking at the current and updated articles. Based on this criteria, only the
8

Nomthandazo Masuku
peer-reviewed article published between 2010 and 2017 would be included and any
article published before 2010 was excluded. The other criteria was based on whether
the article was academic article (peer reviewed) journal. Thus once I had gotten an
article, I had to check whether it is a peer-reviewed before including it or discarding it.
Another inclusion and exclusion criteria was based on the relevance of the article to my
topic. I had to read through the conclusion and recommendation sessions of each article
to grasp and a glance whether it would help me advance the aim of this study. Only
those articles that helped me understood the use, success and importance of
Safewards Model were included. Based on the above exclusion and inclsion criteria, I
managed to identify only seven key important articles and selected them for the review
out of the thirty articles that were retrieved and appraised effectively. The articles then
formed the basis for my literature review which then informed the findings and
subsequent evidence-based discussion of this paper.
Critical Appraisal
The tool chosen for this critical appraisal was CASP systematic review checklist.
CASP approaches research in three steps: (is the study valid); what are the results; and (iii) are
the results useful. Is the study valid? The 1st step is to decide whether the study was not biased
via the evaluation of its methodological quality. Various criteria for article’s validity are utilized
for various kinds of questions. Based on the validity of the article, the appraiser can categorize it
within a scale of evidence levels besides degrees of recommendations. What are the results?
Where it is decided that the article is valid, we can then proceed to look at results. At this stage, a
consideration is made whether the results of the study are important. A consideration of how
much uncertainty exist regarding the results, as expressed in terms of p-values, sensitivity
9

Nomthandazo Masuku
analysis and confidence intervals. Are the results useful? After a decision is made that the
evidence is valid and significant, the appraiser need to think about how it apples to the study
question. The critical appraisal skills avails a basis within which to consider such issues in the
explicit and transparent manner. CASP tools ranges from CASP systematic review checklist,
CASP randomized controlled trial checklist, CASP diagnostic checklist, CASP economic
evaluation checklist, CASP qualitative checklist, CASP case control checklist, CASP cohort
study checklist and CASP clinical prediction rule checklist.
However, for this critical review of literature, CASP systematic review checklist was
chosen. It was chosen since my project was based on a literature review and hence I
was convinced it would enable me critically appraise the articles in a systematic
manner. The questions asked in the systematic review were also appropriate in helping
me arrive at the best articles. The systematic review is also important because unlike
the traditional unsystematic and subjective methods of collecting data, analyzing and
interpreting results that are marred with issues of bias, and overestimation of value of
the study, systematic critical appraisal has a defined method of collecting and analyzing
study results to reduce bias. It is a higher level of review which is very important tool for
my research. It enabled me effectively evaluate the evidence using clearly formulated
topics which utilizes both organized and explicit methods for identifying, selecting as
well as critically appraising relevant study. It was also important in helping me to solve
the controversies between the conflicting findings and provided a reliable foundation for
making a decision on what articles to use.
10

Nomthandazo Masuku
Summary of Outcomes
From the critical appraisal, summary of the outcome was established. It was
established that of the thirty articles that were retrieved, seven of the articles met the
criteria set for the appraisal. These criteria included; relevance, current (published
between 2010 and 2017), and peer-reviewed. In terms of relevance, the article would
only be included if it directly contributed to the understanding of the problem being
studied. For relevance, I was looking for the themes coming from these studies in
relation to success, implementation of Seaward Model and the challenges with
implementation of the of the Seawards Model. For the peer-reviewed, I chose this
criteria because the information would be more credible, valid, and viable and verified
because they have been tested and the evidence proven. This will, therefore, help me
to have information that can be generalizable to inform the use of this Model.
For the timeline or date of publication (2010 to 2017), I chose this because of the
need to be current. I was convinced that this timeline captures updated states and these
could have corrected errors and omission that could have been made in the ancient
studies published before year 2010. These seven articles were, therefore, selected on
the basis of this inclusion and exclusion criteria as advanced in the “search retrieval and
selection section” above and reviewed using the critical review method to inform the
completion and the final compilation of the current study. The summary of the outcome
was given in terms of three common themes: Safewards Model has immensely
decreased the conflicts; Safewards have immensely eliminated the use of restrain and
rapid tranquilization; and Model is more inclusive.
11

Nomthandazo Masuku
12