Evidence in Practice Assessment: Safewards Model Efficiency Analysis

This report critically appraises the efficiency of the Safewards model in reducing violence and aggression against nurses within mental health hospitals. The study examines the model's impact by reviewing existing literature and research, including studies that employ diverse methodologies such as descriptive reviews, non-RCTs, pre-and post-test designs, and RCT designs. The appraisal focuses on the model's six domains and their effect on reducing conflict and containment rates. The report synthesizes findings from multiple sources, including CINAHL, PubMed, Cochrane Library, and Medline-EBSCO databases, using the PEO framework to formulate a clear clinical question. The analysis includes a PRISMA flow chart to identify relevant articles, alongside the application of exclusion and inclusion criteria. The report concludes that the Safewards model is effective in promoting the well-being of nurses and enhancing patient care within mental health settings. It emphasizes the importance of implementing the Safewards model across healthcare departments to ensure safety and quality of care.

Running Head: Critical Appraisal of the efficiency of safewards model 1
Critical Appraisal of the efficiency of safewards model
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Critical Appraisal of the efficiency of safewards model 2
Table of Contents
Title..................................................................................................................................................3
Summary of Clinical Scenario.........................................................................................................3
Clinical Question:............................................................................................................................4
Search History.................................................................................................................................4
Identification................................................................................................................................5
Eligibility.....................................................................................................................................5
Included.......................................................................................................................................5
Screening.....................................................................................................................................5
Citation............................................................................................................................................8
Critical appraisal of the study..........................................................................................................8
Clinical bottom line.........................................................................................................................9
References......................................................................................................................................11

Critical Appraisal of the efficiency of safewards model 3
Title
Critical Appraisal of the literature finding focusing on the efficacy of safewards model in
reducing the occurrences of violence and aggression against nurses in mental health hospitals.
Summary of Clinical Scenario
For quite a long time, workplace violence has been a global and worrisome problem
especially in the sector of healthcare (Nwobia & Aljohani, 2017). Although in most cases it is
endured and goes unreported where healthcare workers accept it as an occupational hazard, its
negative effects have been overwhelming (Hamdan, 2015). In fact, most studies on workplace
violence have revealed that nurses are the most affected population. It is reported in the study of
Shafran-Tikva et al. (2017) that nurses working in the psychiatric wards and mental health
department are at the risk of workplace violence. The author has validated that due to the
aggressive behavior of the mental ill patient, nurses can be exposed to physical injury or nursing
hazards (Acquadro Maran et al., 2018).
Different studies have proposed different approaches to curb workplace violence among
mental health nurses (Ramacciati et al., 2016). The rate of violence, absconding and self-harm
and other related issue that tends to threaten the safety of staffs and patient changes by the
hospital wards. The violent incidence leads to injuries, use of coercion in containment arouses
staffs ambivalence and poor staff and patient connection. Some of the wards have high rate while
other have low rate. The action of the staffs focusses on to prevent such incidents through
manual constraints or coerced medication (Coneo et al., 2019). The Safewards model provides
the comprehensive explanation for the difference in such rate. It includes six domains which

Critical Appraisal of the efficiency of safewards model 4
includes physical environment, staffs teams, patient community, regulatory framework, and
characteristic of patient and outside hospital (Baumgardt et al., 2019). The stated domain
provides risk to flashpoint, intervention of staffs reduce the conflict rate, prevent flashpoint,
ensure of not using containment and its causes towards conflict. Therefore, there is the need to
investigate the effectiveness of the Safeward model. This paper scrutinizes the efficiency of
safewards model in the reducing the incidence of violence and aggression in mental health care
sector.
Clinical Question:
Does safewards model reduce the incidence of violence and aggression in mental health
hospitals? In order to make the development of the research question easier and still come up
with a well-built clinical question that formulated the research strategy by identifying the key
concepts, PEO framework as shown below (Doody & Bailey, 2016).
P (Population): Violence and aggression on mental health nurses
E (Exposure): Use of Safewards model
O (Outcome): reduced incidences of violence and aggression against mental health nurses
Search History
In October 2019, five scientific database CINAHL, PubMed, Cochrane library and
Medline-EBSCO were searched by the use of various key terms related to the research question
(Eriksen & Frandsen, 2018). The PEO question provide specific key word to search relevant
articles that answers the clinical question. Use of search terms with MeSH and search criteria

Critical Appraisal of the efficiency of safewards model 5
helped to find justified articles. Use of Boolean operator to join the key terms has increased the
search methodology. The limit was sets for language and recent publication data. Search terms
such as “efficiency of safewards,” “safewards effectiveness,” “safewards AND mental health,”
“significance of safewards AND mental health settings” and “importance of safewards” were
used to come up with relevant articles. The search of literature has made use of snowball
technique to extend the manual search for the relevant reference and bibliography (Baird, 2016).
Exclusion criteria Inclusion criteria
1. Foreign language paper.
2. Half text articles.
3. Old articles more than five-year-old.
1. Systematic Reviews, Journal
Article.
2. Full text, published in last
5years.
3. English language.
Filters were used under the advanced search button to ensure that only latest articles were
considered. Following all these guidelines, a PRISMA flow chart was used to narrow down into
specific articles as shown below (Miller et al., 2015).

Critical Appraisal of the efficiency of safewards model 6
Records identified through
CINAHL, PubMed, Cochrane
library
Sc
re
en
in
In
cl
ud
ed
Eli
gib
ilit
y
Id
en
ti
fic Additional records identified
through Medline-EBSCO
(n=12)
Records identified through database
(n = 44)
Records after duplicate
removed
(n =20)
Records excluded for
title and abstract
(n = 10)
Full-text articles
assessed for eligibility
(n =10)
Full-text articles
excluded, with reasons
(n = 6)
 Other
intervention n=1
Studies included in
qualitative synthesis
(n = 4)
Studies included in
quantitative synthesis
(meta -analysis)

Critical Appraisal of the efficiency of safewards model 7
The six articles which made it to the final stage as shown in the PRISMA diagram above
were summarized as shown in the table below. Among the major elements considered in each of
the articles were:
Article
Ref.
Authors &
Year
Study
Design
Aim of study Source of
evidence
Level of
evidence
Findings/outcome
1 Bowers et
al., 2014
Descriptive Review and
evaluate the
effectiveness of
safewards
CINAHL Level V Safewards are effective in
conflict and containment
2 Price et
al., 2016
Non-RCT To evaluate the
effects of
safewards
PubMed Level III Safewards model
promotes staff adherence
3 Hamilton
et al.,
2016
Pre-and
Post- test
design
Investigate the
effectiveness of
safewards
PubMed Level III Safewards are contribute
to wellbeing of nurse and
patient in health care
sector.
4 Fletcher et
al., 2019
Cross-
sectional
post
interventio
n survey
design
Describe the
impacts of
safewards on
consumer
experiences
CINAHL Level IV Safewards were effective
in reducing violence in
mental health care setting
5 Bowers et RCT To test the Medline- Level 1 Safewards were efficient

Critical Appraisal of the efficiency of safewards model 8
al., 2015 design efficiency of
safewards
EBSCO in reducing violence
against nurse.
6 Baumgard
t et al.,
2019
Pre-and
Post- test
design
To test the
efficiency of
safewards
Cochrane
library
Level III Safewards were effective
in reducing aggressive
behavior of mental ill
patient in mental health
settings
Citation
Fletcher, J., Buchanan-Hagen, S., Brophy, L. M., Kinner, S., & Hamilton, B. (2019).
Consumer perspectives of safewards impact in acute inpatient mental health wards in Victoria,
Australia. Frontiers in psychiatry, 10, 461. The study is based on the cross-sectional survey
design which utilize the experience of the consumer using safeward model, thus it provides
unbiased outcome and reliable result (Omair, 2015). It is evident that live survey of pre and post
intervention provides primary data which provide accurate information for the interpretation of
result (Beauchamp et al., 2015). Thus, it is applicable to answer the clinical question.
Critical appraisal of the study
The study has clearly stated the aim of the study which address the research question on
impact of the safeward on the experience of consumer of inpatient mental health issue. The
mixed methodology used in the study is appropriate according to the research question which
involves experience and interpretation of data collected through survey (McCusker & Gunaydin,
2015). The selected design is cross sectional study which used the data from the target

Critical Appraisal of the efficiency of safewards model 9
population and analyses by considering various variables (McCusker & Gunaydin, 2015). Thus,
the study design justifies the aim of the research which involves the impact of safeward model on
the mental health population. The recruitment of the sample was explained by the author and
included 72 mental health consumer from 10 inpatient mental health ward. The chosen
population justify the aim of the research which focus on the mental health patient. The data was
collected by the mean of post intervention survey and as it is evident survey is the effective mean
of data collection to evaluate the perspective and experience of some service (Bryman, 2017).
Hence, the chosen data collection method is appropriate. The high sample size and interpretation
of the data through statistical analysis helps to get unbiased and reliable result (Morse, 2015).
The research finds that all the mental health consumer were having positive response and
interpret that it is the effective means of reducing the restrictive intervention and conflict.
The finding supports and answers the clinical question of the research related to
effectiveness of the safewards model in reducing the incidence of the violence and aggression in
the mental health hospital. Thus, the result of the evaluate paper can be applicable to the general
population and clinical practice setting as it has given importance to the consumer voice, their
view after safewards. The participant of the study has been presented for minimum of 1 week in
safeward experience hence the result extracted is reliable and generalized.
Clinical bottom line
Lastly, from the above discussion it can be concluded that safeward model is the most
effective mean of lowering violence against nurse in mental hospital thus promoting their
wellbeing. The main purpose of this research study, as it applies in the problem mentioned above
was to prove whether safewards model was an effective approach to curb workplace violence

Critical Appraisal of the efficiency of safewards model 10
which has been affecting nurses, particularly nurses working under mental health departments
where patients tend to be aggressive and violent (Fletcher et al., 2019). Literature reviews done
before on conflict and containment mainly focused on single items like violence and absconding,
has showed the positive impact of safeward model (Kennedy et al., 2019). Thus, it can be said
that in order to promote safety of nurse and promoting quality of care, safewards model must be
implemented in every health care department.

Critical Appraisal of the efficiency of safewards model 11
References
Acquadro Maran, D., Varetto, A., Zedda, M., & Magnavita, N. (2018). Workplace violence
toward hospital staff and volunteers: a survey of an Italian sample. Journal of
Aggression, Maltreatment & Trauma, 27(1), 76-95. Retrieved from
https://doi.org/10.1080/10926771.2017.1405314
Baird, R. (2018, October). Systematic reviews and meta-analytic techniques. In Seminars in
pediatric surgery. WB Saunders. Retrieved from
https://doi.org/10.1053/j.sempedsurg.2018.10.009
Baumgardt, J., Jäckel, D., Helber-Böhlen, H., Stiehm, N., Morgenstern, K., Voigt, A., ... &
Schulz, M. P. (2019). Preventing and reducing coercive measures–An evaluation of the
implementation of the Safewards Model in two locked wards in Germany. Frontiers in
psychiatry, 10, 340. Retrieved from https://doi.org/10.3389/fpsyt.2019.00340
Baumgardt, J., Jäckel, D., Helber-Böhlen, H., Stiehm, N., Morgenstern, K., Voigt, A., ... &
Schulz, M. P. (2019). Preventing and reducing coercive measures–An evaluation of the
implementation of the Safewards Model in two locked wards in Germany. Frontiers in
psychiatry, 10, 340. Retrieved from https://doi.org/10.3389/fpsyt.2019.00340
Beauchamp, A., Buchbinder, R., Dodson, S., Batterham, R. W., Elsworth, G. R., McPhee, C., ...
& Osborne, R. H. (2015). Distribution of health literacy strengths and weaknesses across
socio-demographic groups: a cross-sectional survey using the Health Literacy
Questionnaire (HLQ). BMC public health, 15(1), 678. Retrieved from
https://doi.org/10.1186/s12889-015-2056-z

Critical Appraisal of the efficiency of safewards model 12
Bowers, L., Alexander, J., Bilgin, H., Botha, M., Dack, C., James, K., ... & Papadopoulos, C.
(2014). Safewards: the empirical basis of the model and a critical appraisal. Journal of
Psychiatric and Mental Health Nursing, 21(4), 354-364. Retrieved from
https://doi.org/10.1111/jpm.12085
Bowers, L., James, K., Quirk, A., Simpson, A., Stewart, D., & Hodsoll, J. (2015). Reducing
conflict and containment rates on acute psychiatric wards: The Safewards cluster
randomised controlled trial. International journal of nursing studies, 52(9), 1412-1422.
Retrieved from https://doi.org/10.1016/j.ijnurstu.2015.05.001
Bryman, A. (2017). Quantitative and qualitative research: further reflections on their integration.
In Mixing methods: Qualitative and quantitative research (pp. 57-78). Routledge.
Retrieved from
https://www.taylorfrancis.com/books/e/9781315248813/chapters/10.4324/978131524881
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Coneo, A. M., Thompson, A. R., Parker, K., & Harrison, G. (2019). The outcome of a training
programme (RESPECT) on staff’s attitudes towards causes and management of
aggression in a Regional Referral Hospital of northern Uganda. Journal of psychiatric
and mental health nursing. Retrieved from https://doi.org/10.1111/jpm.12549
Doody, O., & Bailey, M. E. (2016). Setting a research question, aim and objective. Nurse
researcher, 23(4). Retrieved from doi: 10.7748/nr.23.4.19.s5
Eriksen, M. B., & Frandsen, T. F. (2018). The impact of patient, intervention,
comparison, outcome (PICO) as a search strategy tool on literature search quality: a