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
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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
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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.
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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).
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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).
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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?
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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
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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
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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
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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.
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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.
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Critical Summary Table
Source Research
question
presented
Use of right
type of
study
Design
minimize
bias
Analysis
accuracy
Conclusion
drawn from
data and
analysis
Contribution of study to problem
understanding
Bowers
(2013)
The research
question well-
presented and
explanation
given why
research was
needed
Intervention
s and hence
RCT used
well
The design
well-
chosen
and
minimized
bias
Analysis
was
accurate
The
conclusion is
strictly as per
data and
analysis
The study highly contributed the
Safewards Model understanding (Bowers,
(2013))
Bowers
(2014)
The research
question well-
presented. It
explained for
research
RCT was
effectively
applied
The biased
was
minimized
based on
good
choice of
design
The
accuracy
of analysis
was above
board
The analysis
and data well
informed the
conclusion
The source gave more details of Model
thereby boosting its understanding
Bowers
et al
(2014)
Research
question well
aligned to need
for study
The study
correctly
used the
RCT type of
study
The biased
was
extremely
minimized
by use of
right
design
Analysis of
finding was
so
accurate
The
conclusion
drawn from
the
investigations
relates to
analysis and
data
This study led to increased understanding
of Safewards Model implementation and
benefits
Kinner
(2016)
Presentation of
research
question was
performed and
acknowledged
the significance
Randomize
d Control
Trial was
used
effectively
No form of
biasednes
s recorded
due to right
design
The
analysis
was
precise
and
informed
The
deduction
drawn from
the review is
a clear
reflection of
More understanding of Safewards Model
was attributed to this study
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of study the
conclusion
effectively
data and
analysis
Mustafa
(2015)
Correct
research
question
presented and
recognized the
need for
Safewards
Model
The study
was about
therapy and
hence the
author
correctly
used RCT
There was
no
biasness in
the
investigatio
n due to
right
design
Truthful
and factual
analysis
was done
The
deduction
was on the
basis of data
and analysis
Much comprehension of Safewards
Model application including its potential
benefits to reduce conflicts were
presented correctly ()
Price et
al. (2016)
Precise
research
question
presented
RCT
correctly
applied
The
degree of
bias was
highly
minimized
Accuracy
of analysis
was
guarantee
d based on
facts and
reviewed
literature
Authors drew
correct
conclusion
from data and
analysis
The authors presented clear
understanding of Safewards Model as a
result of this study
Well et al.
(2015)
A clear and
explorative
question
presented
Being a
therapy,
Randomize
d Control
Trial was
applied
effectively
Authors
prevented
any form of
bias
Accuracy
was
ensured
during the
analysis
arising
from
factual
data
The
conclusion
was built from
data and
analysis of
the
information
gathered on
Safewards
Model
One can really get to understand the
Safewards Model from this study and
hence greatly contributed to the
understanding of the Model (Well et al.
(2015))
The table above presents the summary of the critical appraisal done for the seven articles included for this study. It
uses six criteria to appraise each articles. These included research question presentation, contribution (relevance), use
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of correct design (correct study type), whether the design eliminates/minimize bias, accurate analysis and whether the
conclusion arise from data and analysis. Each of the seven sources are listed in the first column with subsequent
columns highlighting each of the above criteria for each source.
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Summary Findings
Increased Uptake of Safewards Model
The review revealed an increasing success in the implementation of Safewards
Model as many facilities are embracing it and integrating it in their facilities. The
increasing Safewards Model is wholly organized by the mental health service staff and
this is a typical evidence of value put on Safewards by staff engaged with its
implementation (Kinner et al. 2016). Across the seven studies, this theme was evident
as many mental health facilities embrace Safewards for effective engagement between
nurses and patients. Safewards Enhance Mental Health culture and Atmosphere
There was a consensus throughout these seven articles regarding the above
theme. The evaluation of the use of Safewards suggests that the model can contribute
immensely in enhancing the culture as well as atmosphere in the mental health service
(Kinner et al. 2016). Unlike before where mental health services witnessed high levels
of conflict events including violence, aggression as well as absconding. These cases
are no longer experienced with full implementation of Safewards (Mustafa 2015).
Nurses no longer need to use the restrictive practices as Safewards has improved the
safety for everyone including the mental health staff, visitors as well as consumers
(Bowers 2013). It appears from the review that the both staff and consumers of this
Model reported that it reduces conflict as well as enhanced communication. The model
also impacts on the decrease of the utilization of restrictive interventions (Hallett and
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Dickens 2015). The implementation of the Model has improved the local service
delivery.
Safewards Decrease Conflicts
It was a common theme from the seven articles this model has greatly reduced
conflicts between nurses and mentally ill patients. It is for this reason that the model is
being promoted through the social media as a new set of intervention to nurses that
have been proved to greatly decrease the conflict within the inpatient environment. The
new Safewards Model is anchored on the years of research by Len Bowers (Bowers
2015). The findings, presentations, training aids as well as guidance remain freely
available (Bowers et al. 2014). The Safewards Model is built on the backdrop of a
research that examined the potential harmful events including the aggression, rule
breaking substance utilization, medication refusal, absconding as well as self-harm
alongside the identified most effective means of containing such negative events
(Kinner et al. 2016). Whereas acknowledging that there is never a single response that
certain variables are outside any person’s control, the Safewards Model identifies 10
possible interventions that are the most efficient as well as effective means of
controlling such adverse events and have been proved to really make a difference
(Kinner et al. 2016).
Safewards have immensely eliminated the use of restrain and rapid
tranquilization
It was also a common them from the literature that such interventions as simple
as establishing precise mutual prospects, utilizing soft-words, bad-news mitigation, and
mutual assistance as well as growing the mutual-understanding, utilizing calm-down
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approaches as well as the provision of reassurance-strategies nurses utilize in their
routine activities (Kinner et al. 2016) were effective in improving client engagement.
Together with increasing the utilization of these techniques, it was found that using
Safewards Model interventions reduced many the most disliked intervention like
restraint, rapid tranquilization and hence the outcome is that conflict on wards declined
by over 14.60% and containment activities declined by 23.60%. Such findings remain
substantially significant and the nurses are increasingly becoming keen to encourage
the service providers including, ward managers as well as the broader team to adopt
the Safewards Model and apply it to their individual wards. All the evidence points
towards Safewards’ beneficial importance to both staff and also consumers (Kinner et
al. 2016).
Discussion:
Under this section, I will discuss the following main points: how Safewards Model
is more inclusive as it explicates conflicts behavior and containment mechanism; and
what is needed to be done for effective implementation of Safewards Model;
How Safewards Model is more inclusive as it explicates conflicts behavior
and containment mechanism;
The Model Seeks to explicate all the conflict behaviors as well as all containment
mechanisms together. Safewards model is hence more all-inclusive compared to
disjointed models for absconding and aggression among others and recognizes the
presently firmly empirically-proven correlation between them (Kinner et al. 2016).
Safewards depicts the bidirectional connection between containment and conflict and
hence indicates that the utilization of containment inspired by the urge to bar upcoming
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conflict is able, to certain incidence, cause such a conflict (Long, Afford, Harris and
Dolley 2016). The Model, hence, permits discrete interventions that decrease
containment without having to influence the rates of the conflicts like the several
seclusions as well as limit reduction initiatives in many economies globally. In deriving
the difference between the originating-domains as well as the flashpoints, Safewards
Model outlines the pressures generated by regular operations of the inpatient units
which are in fact the very intrinsic to it, as well as illustrating how such results are more
focused and time-located flashpoints (Long, Afford, Harris and Dolley 2016). The
standalone originating domains identification as well as flashpoints permits clearer ideas
regarding what can and cannot be altered by the clinical-staff working in such wards,
and hence facilitate the production of philosophies for rational alteration which have
potential for the reduction of containment and conflicts (Long, Afford, Harris and Dolley
2016).
The Safewards Model further results in important novel regards to the fore.
Patients-patient interactions, for first-time, are extremely regarded and added in the
explications fir containment alongside conflict rates (Bowers 2014). Whereas patient
physiognomies as well as symptoms have been broadly reported in the past as the
triggers of conflict besides containment, the Model recognizes treatment as the
operative and efficient safety-generating approach, and identifies that the manner staff
respond to their corresponding consumers’ features will substantially influence on the
capacity to result to actual conflict and containment incidences. The outside
structure/regulatory framework alongside its corresponding characteristics are identified,
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for the first-time, as the originating-domain for both conflict alongside containment in
such wards (Bowers 2014).
What is needed to be done for effective implementation of Safewards
Model?
There are things that the staff can do when undertaking the implementation of
such structures which have the significant potential to decrease the risk of conflict as
well as containment. Nevertheless, Safewards Model further illustrates some actions
capable of being taken at the uppermost policy degrees that can culminate in wars
which are increasingly safer for consumers and staff (Cox, Campbell, and Dalton 2016).
Furthermore, the Model integrates impacts on the behavior of the patients from the
external environment thereby offering novel understandings hence new means of
intervention (Bowers 2014). Whereas the significance of physical-environment has
effectively been examined by the other researchers, the Model goes beyond the
unsophisticated recommendations of development in quality to clearly describe physical
characteristics of wards and the corresponding impacts on patient and staff safety.
Implication:
Under the implication, I will discusses the implication of Safewards to three
different areas; healthcare practice, education and future research. The following
subheading provides a detailed discussions on each of the three areas.
(i) Healthcare Practice
The Model has clear and precise implication for conflict alongside containment
reduction to staff. The unhidden implication to staff is that any intervention which may
result in alterations to the psychological understanding, emotional regulation, increased
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commitment, teamwork skills, technical mastery, building positive appreciation as well
as effective structure of wards is probably to account for the reduction of the conflict as
well as containment rates (Bowers 2014).
The option strategy is to stress on acknowledged flashpoints, obtaining better
means to manage them effectively (Bowers 2014). The flashpoints remain the social-
locations in wards which are highly probably to cause conflict, the interactions between
staff and consumers whereby the ward-structure is created, reaffirmed, established as
well as instantiated (Bowers 2014). Taking a modest illustration, rather than waiting for
the patients to bump at office door, nurses can pre-empty requests by walking around
the ward and subsequently enquiring patients what they require/ want prior.
(ii) Education
The implication to education calls for finding the best ways and competencies to
understand the patient physiognomies. The dependable connections to younger age as
well as male gender demonstrate that much conflict and resultant containment is around
insurrection, power, and independence (Bowers 2014). All these remain greatly
noticeable matters for men and/or the fledgling individuals. This points that education
should be focused on finding proper ways to improve choices, freedom as well as
avoiding control of consumers over their diagnosis will help in the reduction of both
conflict alongside battles with staff hence better engagement (Bowers 2014). Attempts
in education should focus on how to engage patients and nurses to accomplish a
reciprocally respectful partnership between the duos as this will do much to prevent
conflict arising from such matters (Bowers 2014).
(iii) Future Research
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The future research should also be adjusted towards the appreciation of the link
between conflict and containment to diseases and symptoms that further carries serious
lessons. . The future research should inform the choices when responding to patients
to make sure that only better responses are given to help in the enhancement of
patients’ coping strategy to prevent adverse responses that will only increase the
patient’s stress thereby eliciting yet more symptoms (Paton et al. 2016) which can be a
barrier in the recovery process.
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Long, C.G., Afford, M., Harris, R. and Dolley, O., 2016. Training in de-escalation: an
effective alternative to restrictive interventions in a secure service for women. Journal of
Psychiatric Intensive Care, 12(1), pp.11-18.
Mustafa, F.A., 2015. The Safewards study lacks rigour despite its randomised design.
International journal of nursing studies, 52(12), pp.1906-1907.
Parish, C., 2013. Mental health model cuts conflict in acute settings: Professor explains
how staff can implement interventions to make wards ‘happier places’.
Parish, C., 2016. Len Bowers: the man behind the Safewards model: The professor of
nursing, whose approach to care has found worldwide popularity, talks to Colin Parish
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Practice, 19(5), pp.37-40.
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Paton, F., Wright, K., Ayre, N., Dare, C., Johnson, S., Lloyd-Evans, B., Simpson, A.,
Webber, M. and Meader, N., 2016. Improving outcomes for people in mental health
crisis: a rapid synthesis of the evidence for available models of care. Health
Technologyl Assessment, 20(3).
Price, O., Burbery, P., Leonard, S.J. and Doyle, M., 2016. Evaluation of Safewards in
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Well, E., First, F., Dignity, P., it Out, W. and Training, C.B., 2015. Evaluation of
safewards in forensic mental health. Mental Health Practice, 19(8).
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Appendix
Figure 1: Simple Safewards Model
The above figure describes the most basic form of Safewards Model that gives a
summary of factors that influence conflicts and containment rates, and explicates why
certain wards have much more containment and conflicts than others. The terms in the
Model assumes the following meanings:
Originating domains are categories of aspects of psychiatric wards as social and
physical locations, separate from patients normal residences for the provision of 24/7
mental health care on a basis of mixed voluntary and legal coercion, which to the
degree they are present or absent can influence the frequency of conflict and/or
containment.
Staff modifiers are features of the staff as individuals or teams, or ways in which the
staff act in managing the patients or their environment, initiating or responding to
interactions with patients that have the capacity to influence the frequency of conflict
and/or containment.
Patient modifiers are ways in which patients respond and behave towards each other
that have the capacity to influence the frequency of conflict and/or containment, and
which are susceptible to staff influence.
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Flashpoints Conflict Containment
Staff
modifiers
Originating
domains
Patient
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Flashpoints are social and psychological situations arising out of features of the
originating domains, signaling and preceding imminent conflict behaviors.
Conflict collectively names all those patient behaviors that threaten their safety or the
safety of others (violence, suicide, self-harm, absconding etc.).
Containment collectively names all the things staff do to prevent conflict events from
occurring or seek to minimize the harmful outcomes (e.g. prn medication, special
observation, seclusion, etc.).
Figure 2: Full Safewards Model
The above figure 2 shows full form of the Safewards Model Six domains identify
the key influences over conflict and containment rates: the patient community, patient
characteristics, the regulatory framework, the staff team, the physical environment and
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outside hospital. The outermost ring summarizes the key features within those domains
that can give rise to conflict and containment events. The next ring indicates the patient
modifiers, what patients can do together that influences the way in which the features of
the six domains give or do not give rise to conflict and containment events.
The next ring indicates the staff modifiers in a similar fashion. Where arrows exist
between this ring and the outmost one, they indicate that staff also have the power to
directly modify or alter the features of the domains so as to reduce the risk of conflict or
containment events. The innermost ring identifies the flashpoints most closely related to
the domains within which they sit, flashpoints being those events or social
circumstances that are most likely to trigger a conflict or containment event in the very
short term. Conflict and containment are in the centre of the model, linked by a bi-
directional arrow representing the fact that while conflict can trigger containment,
containment use can itself trigger conflict.
Figure 3: Additional Information on Implication of Safewards Model on Education,
Future Research and Healthcare Practice:
(i) Healthcare Practice
The Model has clear and precise implication for conflict alongside containment
reduction to staff. The unhidden implication to staff team is that any intervention which
results to alterations to the psychological understanding, emotional regulation,
increased commitment, teamwork skills, technical mastery, building positive
appreciation as well as effective structure of wards is probably to account for the
reduction of the conflict as well as containment rates (Bowers 2014). Two-fold precise
paths to bringing about these changes are the training/education as well as clinical-
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supervision of the forefront workers. Nevertheless, there are additional possibilities. The
ward-managers as well as qualified-nurses are able to project such values, model such
skills, casually give instructions to colleagues, challenge one another, as well as review
the patient care on the basis of such principles (Bowers 2014). Further, it could as well
be feasible to nudge the ward in the proper direction by devising various tasks as well
as protocols for undertaking things, or implementing trivial procedures which propel the
individual toward the required alteration.
The option strategy is to stress on acknowledged flashpoints, obtaining better
means to manage effectively (Bowers 2014). The flashpoints remain the social-locations
in wards which are highly probably to cause conflict, the interactions between staff and
patient whereby the ward-structure is created, reaffirmed, established as well as
instantiated (Bowers 2014). It is never such challenging to obtain means which nurses
can elucidate structure with patient cohort, maybe decrease the quantity of rules and be
increasingly unswerving in corresponding applications (Bowers 2014). The means
nurses use to interrelate with their patients over such matters can as be altered (Bowers
2014). Taking a modest illustration, rather than waiting for the patients to bump at office
door, nurses can pre-empt requests by walking around the ward and subsequently
enquiring patients what they require/ want prior. Identical small alterations to routine as
well as usual practices will have the capability to make unimaginable huge impacts on
the rates of conflict and hence containment (Bowers 2014).
Aggression meditates the correlation between structure and containment.
Limiting setting or patients request which are repudiated don’t, on standalone basis,
culminate in containment (Bowers 2014). However, if a frustrated, disordered, as well as
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disparaged patient reacts with annoyance which is met by the merger of anxiety with
irritation by staff, the utilization of containment could also be the ultimate outcome.
Cutting such cycle as well as others like it might pay a severe dividend (Bowers 2014).
(ii) Education
The implication to education calls for finding the best ways and competencies to
understand the patient physiognomies. The dependable connections to younger age as
well as male gender demonstrate that much conflict and resultant containment is around
insurrection, power and independence (Bowers 2014). All these remain greatly
noticeable matters for men and/or the fledgling individuals. This points that education
should be focused on finding proper ways to improve choices, freedom as well as
control of patients over their conditions will help in the reduction of both conflict
alongside battles with staff hence better engagement (Bowers 2014). Attempts in
education should focus on how to engage patients and nurses to accomplish a
reciprocally respectful partnership between the duos as this will do much to prevent
conflict ascending from such matters (Bowers 2014). These hints towards prospective
value of the adjusted therapeutic community in such wards and further demonstrate that
any authoritarianism hint on the part of the staff will become highly counter-productive
as well as incendiary (Well et al. 2015). The current nursing education should
appreciate the fact that a significance share of conflict and containment events are
contributed by the smaller share of patients thereby indicating the feasible efficacy of (a)
staff altering their reactions/responses to patients following the first incidence to evade
consequent ones, and (b) targeted therapeutic interventions focused towards the most
challenging patients (Well et al. 2015).
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Nurses further require great endowment with skills and knowledge to understand
the link between symptoms and conflict and containment. This means that education of
all nurses should focus on equipping them with the expert knowledge to enable them
recognize the psychotic symptoms (Bowers, James, Quirk, Simpson, Stewart and
Hodsoll 2015). This needs to go beyond a mere delusions as well as hallucination,
integrating detailed comprehension of an array of thought disorders as well as their
corresponding implications for care alongside in-depth knowledge as well as
understanding of cognitive challenges experienced by the psychotic patients (Bowers
2014). Moreover, nurses must be educated to understand that the latest psychotic are
due to generic inheritance coupled with childhood adversity, abuse as well as
deprivation hence making nurses to appreciate that strategies like trauma informed care
worthy regards in this context (Well et al. 2015).
(iii) Future Research
The future research should also be adjusted towards the appreciation of the link
between conflict and containment to diseases and symptoms that further carries serious
lessons. Firstly, the effective as well as speedy treatment of the patient shall reduce
symptoms and conflict and containment (Well et al. 2015). Nevertheless, treatment for
psychoses doesn’t have to imply drugs alone. It might further include aspects of
cognitive behavioral therapy, social skills training, and functional analysis alongside
additional psychotherapeutic treatments (Well et al. 2015). Yet, it must be admitted that
only few of such have been embraced for acutely ill inpatient, or have already been
tested for efficacy among the acute ward patients. Additional research is inevitable here.
This being the case, the origins on conflict in psychiatric symptoms still never means
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that there is nothing which nurses can do (Parish 2016). The symptoms are never
expressed or experienced in the vacuum, but in social setting of the ward. The research
needs to be undertaken to inform the choices when responding to patients to make sure
that only better responses are given to help in the enhancement of patients’ coping
strategy so as to prevent adverse responses that will only increases the patient’s stress
thereby eliciting yet more symptoms (Paton et al. 2016). The research is further
required to ensure that nurses only positively influencing how patients respond to one
another’s symptomatic behavior, respect, modelling efficacy, dignity-providing as well as
de-escalatory strategies, or even directly reaching as well as advising other patients on
positive things to do for smooth recovery process (Well et al. 2015).
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