Norbury House PICU Reduces Conflict and Containment Using SafeWards

Rationale / Objectives

SafeWards is a thoroughly studied and refined model of care targeted at nursing staff of acute psychiatric wards aiming to reduce violent conflicts and containments in the hospital environment. In 2014, Norbury House PICU (Psychiatric Intensive Care Unit) developed a programme to launch the SafeWards model to reduce restrictive interventions, increase positive engagement and improve patient experience. 

Project/Program Description & Major Achievements

The Safewards model is based on identifying where conflict and containment are generated, and where staff and patients can intervene to reduce and de-escalate challenging situations. SafeWards has been implemented and found to be successful in wards all over the world including in countries like Germany, Holland, Iceland, Finland, Canada, New Zealand and Australia.1 Six months after implementation, Norbury House observed success in decreasing physical restrictions. The rate of physical interventions decreased by 23% with an even bigger decrease of 42%1 in prone restraint (restraining a patient belly-down). Furthermore, positive evaluations from Norbury House's patient satisfaction surveys increased and they also received positive feedback from patients, carers and others involved at the facility.


Lessons Learned

Improving staff relationships with inpatients effectively reduces the frequency of conflict and containment.2 The successful cases of SafeWards implementation solidify the unique conclusion of the model which claims conflict and containment are partially but certainly linked to each other.3 This means wards with high incidents of one type of conflict (abscond, for example) would also have a high rate of another (self-harm, drug use, etc.). Furthermore, wards with a high rate of conflict have been found to have a high rate of containment. 

Further Description

The SafeWards model was developed based on extensive research into evidence-based practice and observing its impact on hundreds of wards. City-128 studyTompkins Acute Ward Study, City Nurses study, CONSEQ study, and HICON study4 are all examples of the extensive research reviewed when developing SafeWards. The defining study conducted was the Safewards Cluster Randomised Controlled Trial where 31 wards at 15 different hospitals participated in the testing of the efficacy of SafeWards. 16 wards were given the 10 interventions to implement while the other 15 served as control groups.  After the 24-week trial period, though the 10 modifiers were applied fully for a short 8 weeks, the study revealed a 15% decrease in the rate of conflict and 26.4% drop in the rate of containment events.2

The SafeWards model presents ten basic interventions to be implemented into the care practice:

1.      Clear Mutual Expectations: agreed and publicised standards of behaviour by and for patients and staff;

2.      Soft Words: short advisory statements on handling flashpoints, hung in the nursing office and changed every few days;

3.      Talk Down: de-escalation model used by the best de-escalator on the staff to expand the skills of the remaining ward staff; 

4.      Positive Words: a requirement to say something good about each patient at nursing shift handover)

5.      Bad News Mitigation: scanning for the potential bad news a patient might receive from friends, relatives, or staff, and intervening promptly to talk it through

6.      Know Each Other: structured, shared, innocuous, personal information between staff and patients (e.g. music preferences, favourite films and sports, etc.) via a ‘know each other’ folder kept in the patients’ day room

7.      Mutual Help Meeting: a regular patient meeting to bolster, formalise and intensify inter-patient support

8.      Calm Down Methods: a crate of distraction and sensory modulation tools to use with agitated patients (stress toys, mp3 players with soothing music, light displays, textured blankets, etc.)

9.      Discharge Message: a display of positive messages about the ward from discharged patients

10.    Reassurance: reassuring explanations to all patients following potentially frightening incidents1 2

In the context of SafeWards, the term 'conflicts' refers to behaviours posing a risk to patients or those around them such as violence; suicide and acts of self-harm; alcohol or drug use, absconding (leaving the ward without permission and missing care)2 5. Containments are the actions of staff to manage conflicts such as extra medication (one-off doses that are only used to sedate or control patients); increased monitoring or observation of patients; restriction placed on patients by moving to a more secure ward or restricting movement on the ward.2 5 "Flashpoints" are times or situations that can potentially lead to conflicts.5 Norbury House is a 13 bed mixed sex PICU and implemented the model in an effort to respond to increasing patient acuity and conflict on the unit.

Major Achievements

At Norbury House, they observed the following positive changes:
  • Staff have a positive attitude going into a shift after hearing the strengths and positives of a challenging patient (Positive Words) from their colleague during handover. 
  • Highly distressed and agitated patients respond to the distraction/sensory modules from the calm box, in place of being encouraged to take calming medication or quiet time in their room
  • After an anxiety-provoking incident, staff members provide immediate support to patients who have witnessed it, rather than focussing on the incident itself, reducing the risk of triggering self-harm or AWOL. 
  • A level of connection is established between staff and patients through the ‘know each other’ folder where they share some generalised personal information.
  • A patient previously known not to engage well with staff when feeling distressed and to frequently and seriously hurt himself began responding to talk down methods. Talk down methods consisted of calm, nonconfrontational method of offering support, understanding, etc.
  • Though many staffs initially thought that soft words felt patronising or too obvious, now staff acknowledge having used soft words to calm and divert a potential conflict and the possible use of restrictive measures. Staff recognize soft words as a guidance to their approach and a reinforcement of their values.1


    Metric Result Detail
    Rate of physical interventions reduced by 23% one-year post implementation
    Rate of prone restraint use decreased by 42%