A dynamic evidence-based practice model that aims to reduce seclusion and restraints in mental health wards is putting the emphasis back on the care at the centre of mental health nursing.

UK mental health nurse Professor Len Bowers, a Professor of Psychiatric Nursing at London’s Institute of Psychiatry, developed the Safewards model and 10 point intervention to improve safety for patients and staff in acute mental health wards through the establishment of calmer and more positive environments.

Safewards is now being trialled at 18 inpatient wards at Monash Health and NorthWestern Mental Health, Alfred Hospital and Werribee Mercy in Melbourne, and in regional Victoria at Wangaratta, Bendigo and in the Latrobe Valley. The Centre for Psychiatric Nursing (CPN), based at the University of Melbourne, is overseeing the trial, which has been funded by the state’s Department of Health.

Trial lead Dr Bridget Hamilton, a mental health nurse and senior lecturer at the School of Health Sciences at the University of Melbourne, says Safewards is a change in practice that champions good mental health nursing.

“Everyone knows there is such a thing as de-escalation - using words to assist people who are charged up to calm down but it takes time and we don’t always notice but some nurses are better at it than others - they’ve got a much better repertoire of skills,” she says.

“In an inpatient unit, all of a sudden, instead of being an associate charge nurse or someone who is highly regarded because you’re efficient and you make sure everything runs efficiently on the day you’re in charge, you’re being recognised for being the go-to person if a patient’s upset - you’re going to be the most skilful person for talking them down.

“It’s really nice the way that Safewards shifts the emphasis from maybe being a good organisational citizen to being a good interpersonal practitioner.

“That doesn’t always happen for nurses. If a nurse is caring and takes a bit longer…they can be quite criticised for that.

“There’s something about Safewards that helps to redress that and pay attention to the fact that people who have good skills in managing other people who are upset, those are things that should be highly valued in their own right.”

The Safewards trial is the first of its kind in Australia and the largest one in the world outside the original cluster randomised controlled trial that was used to prove the value of Safewards in the UK.

Safewards enables mental health nurses to address ‘flashpoints’ - moments of opportunity to prevent conflict - with specific interventions, while some of the interventions directly target patients.

The 10 interventions being implemented in the Victoria trial are labelled - clear mutual expectations, soft words, talk down, positive words, bad news mitigation, know each other, mutual help meeting, calm down methods, reassurance and discharge messages. In many Victorian sites, the allied health staff and peer workers are playing an important part in interventions, such as the mutual help meeting, calm down toolboxes and the discharge messages.

Dr Hamilton, a researcher who also works as a clinical nurse consultant at St Vincent’s Mental Health, says Safewards is not about communicating differently all the time - it’s about seeing a potential for conflict and addressing that situation before it escalates.

It’s a model and practice that centres on mental health nurses using time efficient micro-interventions as part of their ordinary practice.

“For example, soft words encourages people to use consumer centred language and it has these posters around the ward to remind staff for example to say - yes, if you can, don’t say no,” she explains.

“That’s a kind of classic behavioural communication change. You could say that’s good customer service but it’s much harder to do in situations of potential conflict.

“So if you’ve got a situation where the patient wants to leave the ward because they desperately want to go next door and buy a coffee or something and as far as the nurse knows there’s concerns about their safety on leaving the ward, then working out a way to say yes to them, even though you might need to delay or modify what can be done.

“You might say - I’m going to do everything in my power to assist you to go next door but it will probably mean that I have to get special permission and come with you.”

Another intervention is the use of positive words.

“That’s about deliberately at handover saying something positive about every patient,” Dr Hamilton says.

“That’s important because quite often a lot of problem-focused things get said at handover and to some extent that can set up a sort of low expectation or an expectation of difficulty with a particular patient.

“So encouraging people to say positive things about the patients again is geared towards this idea of helping nurses not to be over sensitised in advance to be expecting conflict but to see what’s going well for that person…and so nurses will go out of handover feeling more positive about the people that they are going to interact with.”

Another intervention, discharge messages, harnesses the power of patients to have a beneficial impact on other patients.

Mental health wards participating in the trial will have a message board, often in the form of a tree on the wall, that enables the patient being discharged to write an encouraging message, such as on a leaf, for the person who comes into their ward or their room.

“When people are feeling a bit hopeless that leads to them feeling more inclined to act badly or to come into conflict with staff,” Dr Hamilton says.

“To have the support of other consumers and to have the encouragement from other people who’ve been there really helps.”

After the Safewards implementation phase, the trial will be evaluated with feedback sought from both nurses and patients.

Dr Hamilton says one of the key indicators of the success of the model will be whether the use of seclusion and restraints has been reduced.

“That’s a goal that everybody is committed to these days and appreciates that wherever possible we don’t want to do these coercive, heavy-handed things,” she says.

“We’re really hoping that we will see a statistically significant difference in those services after the Safewards implementations.”

With its focus on reducing conflict events, such as absconding, self-harm, verbal or physical aggression, Safewards is designed to create a safer working environment for nurses.

Dr Hamilton says there’s ample evidence that shows if nurses do their job well and patients feel less agitated, mental health wards can be safer for everyone.

“Sometimes there’s been concerns that if you don’t lock people up in seclusion that that makes it less safe for nurses but there’s not really a lot of evidence to support that,” she says.

“Generally if people do good preventative things and if they are in some ways encouraged by their organisation to invest time in setting up good alliances with patients and taking care of patients at this point of conflict, then overall it goes better for everyone.”

Dr Hamilton says the Victorian Safewards trial has the potential to revolutionise mental health care for both patients and nurses in Australia.

“Nurses often have these other things that they’re supposed to be doing - arranging various rosters or organising - there’s a lot of instrumental things that nurses are doing to try and maintain a routine in a ward,” she says.

“Part of why Safewards has been so warmly received by nurses in the trial is that nurses do recognise that it’s about nursing and this is quite an easy fit for them.

“Safewards has so many concrete things that can add up to an experience for consumers that they are being treated more as an individual, and their individual needs are more respected,” she says.

“I’m keen on Safewards - this is a model that really operationalises good practice and that’s really helpful for everyone.”