When anyone is unsafe, everyone is unsafe by Kate Gorman
24 June 2019
HCCA welcomes the news that a pilot program, known as SafeWards, will be implemented in the ACT’s secure mental health facility Dhulwa. Safewards is a program originally developed by Professor Len Bowers and colleagues in the UK, which has been shown to be effective in reducing the rates of conflict and containment in psychiatric wards and facilities. The ACT has historically had very low levels of seclusion and restraint, (what is called ‘containment’ in the Safewards literature), however consumer organisations in the ACT have been concerned for some time at the increasing levels of seclusion and restraint of consumers in ACT mental health facilities over the last few years and hope that this initiative will go some way towards reducing this.
‘Restraint’ refers to the use of physical or chemical methods to restrain a person, and ‘seclusion’ means the involuntary isolation of a person in a secure place. Restraint and seclusion are interventions of last resort used when other options have failed to maintain safety for the person experiencing distress, staff or others. Restraint and seclusion are not therapeutic interventions. (SA Health).
Since its creation in the UK, the Safewards program has been rolled out in many places across the world, including Victoria Australia, which hosts the most substantial and systematic implementation of this program in the world to date. In 2016, following a successfully evaluated trial, the Victorian government supported the extension of Safewards to all public mental health services. They have also committed to an expansion to other areas of health, most significantly the Emergency Department and acute medical and surgery units.
Safewards is based on a series of 10 interventions which aim to make wards safer by creating a culture of mutual respect, support and ‘being known’ between staff and patients.
The interventions are:
- Clear mutual expectations –expectations of consumers and whilst on the inpatient unit are discussed when a patient is admitted.
- Know each other – each staff member provides non-confidential information about themselves that they are happy to share with consumers. Consumers are also encouraged to share similar information about themselves.
- Mutual help meetings –each day is started in a partnership meeting facilitated by staff. Consumers and staff are encouraged to identify ways of helping and supporting each other during the day.
- Soft words – staff are coached with statements of 1-2 sentences to help them speak to consumers at any of the three primary escalation flashpoints:
- saying no
- asking to stop behaviour
- and asking consumers to do something they don’t want to do.
- Talk down (de-escalation) – training staff in a range of de-escalation techniques, which are also displayed on posters in staff areas.
- Bad news mitigation – raising staff awareness during handovers and ward rounds, of potential ‘bad news’ events that consumers may experience. Training staff in ways to convey bad news sympathetically to the patient and offering support.
- Calm down methods – creating a calming environment and the opportunity for low stimulus and time out for consumers. A box of items that consumers can use to help them feel calmer is offered before considering medication.
- Reassurance – following an anxiety- provoking incident on the inpatient unit, consumers are followed up either in small groups or alone, to reassure them and help them understand what happened. Staff maintain a higher visibility post-incident so consumers feel safer and more secure.
- Positive words – during each handover, staff make an effort to identify patient strengths and say something positive about each patient and/or identify contributing factors to difficult behaviours.
- Discharge messages – prior to discharge, consumers are encouraged to write a positive and helpful message that is then placed on a message board/discharge tree. These messages can be viewed by visitors for reassurance and to increase feelings of hope for inpatients.
On June 18, the Mental Health Community Coalition ACT hosted a forum about Safewards to give ACT consumers, carers, and agencies the opportunity to hear from Victorian Safewards Practice Leaders who shared their learnings from the successful implementation across their State.
The Victorian speakers were:
- Associate Professor Bridget Hamilton, the Director of the Centre for Psychiatric Nursing who is currently leading the evaluation of Safewards in Victoria.
- Hamilton Kennedy, consumer researcher and advocate, and
- Indigo Daya, consumer academic and advocate
Hamilton and Indigo are consumer members of the team involved in the adaptation of the UK Safewards model for Victoria, and its rollout, including staff training and evaluation. They gave impressive presentations touching on a number of aspects of Safewards.
What stood out for me, at a time when Canberra Health Services is considering its response to increasing rates of violence and aggression towards staff, was their emphasis on the correlation between controlling workplace cultures (expressed in part through the use of seclusion and restraint) and workplace violence.
Indigo talked about the biological ‘fight’ response to fear (such as the fear of being restrained, coerced or medicated against one’s will) that humans can experience. And how, with the knowledge that these things can be, or have been done to us, consumers feel afraid and unsafe. Hamilton noted that seclusion and restraint is traumatic for everyone involved, including staff, and that causing additional trauma to patients in using these methods is counterproductive in a place of healing and respite. He emphasised the need for emotional and physical safety for consumers and staff in any therapeutic environment, saying “when anyone is unsafe, everyone is unsafe”.
- For more information on the incidence of seclusion in Australian States and Territories, click here
- For more information about Safewards Victoria click here:
- For videos about each of the Safewards interventions, click here
- For more on Indigo Daya and her work as a mental health consumer advocate, click here.
- For more on Hamilton Kennedy and his work as a mental health consumer advocate click here