Implementing Safewards on Children and Young People’s Wards: A Process and Outcomes Evaluation

Figures & data

Table 1. The 10 Safewards interventions (from www.safewards.net).

Intervention	Description
Clear mutual expectations	A set of mutual expectations identified by ward staff in partnership with the patient community, for staff, patients and ward visitors, based around values, respect and mutual support, which are displayed on posters around the ward and revised when necessary.
Soft words	Short statements outlining potential strategies to use when handling flashpoints (e.g. responding to requests, setting limits, etc.), printed on postcards and/or posters hung in the nursing office which is changed every few days.
Talk down	A poster summarising basic to advanced de-escalation techniques placed in the nursing office. One member of staff who is a ward expert in de-escalation spends about 10-15 min with members of staff explaining the poster and what it means.
Positive words	When giving handover staff say something positive about what each patient has been doing during the shift, or draw attention to some positive quality they have, or something positive about the way in which staff supported them.
Bad news mitigation	Staff maintain an awareness of occasions and events that might cause people to feel upset or angry (e.g. phone calls or family, unwelcome news from the treatment team). The staff work with the team to express the bad news sympathetically or support the person after it has happened.
Knowing each other	Staff and patients produce a profile of who they are as a person (e.g. hobbies, interests, likes and dislikes, etc.) which is made available to everyone via either a notice board or a folder on the ward
Mutual help meeting	A voluntary meeting of all patients and staff on duty, to be held preferably in the morning, about how everyone can help everyone else during the rest of the day. The meeting follows a structured agenda (rounds of thanks, news, suggestions, requests and offers) stressing mutual support agreements. The meeting does not have to be chaired by a staff member.
Calm down methods	A box of distraction, sensory modulation, and relaxation tools to offer to people when they appear to be upset, tense or agitated (e.g. stress toys, mp3 players with soothing music, light displays, textured blankets, etc.).
Reassurance	Explanations and reassurance offered to all patients following potentially frightening incidents.
Discharge messages	A display of positive messages about the ward from people who have been discharged, covering what they liked about the wards and a helpful piece of advice for new patients.

Table 2. Wards selected for the Safewards implementation project.

Ward identifier	Trust identifier	Ward type	Region/cluster	Gender	Age-range in years	Bed numbers
WN1	T1	General Acute Admission Unit	North	Mixed	13–18	10 beds
WN2	T2	General Acute CAMHS	North	Mixed	13–17	10 beds
WN3	T3	CAMHS PICU	North	Mixed	12–18	12 beds
WN4	T4	Forensic – Medium Secure	North	Male	11–18	10 beds
WN5	T5	Children aged 5–13^1	North	Mixed	5–13	9 beds, increasing to 12
WC1	T6	Acute CAHMS	Central	Mixed	12–18	15 beds
WC2	T7	Acute CAMHS	Central	Mixed	13–18	10 beds
WC3	T8	Eating Disorder Unit	Central	Mixed	12–18	12 beds
WC4	T9	Acute CAMHS	Central	Mixed	13–18	15 beds
WC5	T10	Forensic Low Secure	Central	Mixed	13–18	10 beds
WSE1	T11	Eating Disorder Unit	South-East	Mixed	13–18	12 beds
WSE2	T12	Adolescent Intensive Care Unit	South-East	Mixed	13–18	10 beds
WSE3	T13	Eating Disorder Unit	South-East	Mixed	8–18	12 beds
WSE4	T14	Acute CAMHS	South-East	Mixed	12–18	12 beds
WSE5	T14	Acute CAMHS	South-East	Mixed	12–18	11 beds
WS1	T8	Acute Adolescent Unit	South	Mixed	12–18	10 beds
WS2	T8	CAMHS PICU	South	Mixed	12–18	Commissioned for 11 but capped at 5 due to building works 4/2/22
WS3	T15	Acute Adolescent Unit	South	Mixed	12–18	Commissioned for 16 beds but 12 due to staff shortages
WS4	T15	Forensic Low Secure	South	Mixed	12–18	Commissioned at 10 due to acuity but working towards 14
WS5	T16	Acute Adolescent Unit	South	Mixed	13–17  (referred to adult services when 18)	12 beds and 4-day places, however restricted to 10 due to building work

Figure 1. Final Safewards fidelity rates at 18 months.

Table 3. Summary of Safewards CYP implementation mapped against the i-PARIHS framework.

Overview/Problem	Innovation	Facilitation	Recipients	Context (Inner and outer)
Evaluating whether the 10 Safewards interventions can be applied to Children and Young People wards (CYP).	The Safewards model consists of 10 interventions to reduce conflict and containment rates on inpatient wards. Previous research has demonstrated successful implementation on forensic, acute and older adult wards. Adaptations made during the project to respond to identified needs on CYP wards.	Content Ward staff received training on 10 Safewards interventions. Delivery One project worker was assigned for 5 wards to facilitate training of the 10-Safewards interventions. Clinical supervisor provided oversight for first 12 months and follow up support in final 6 months. Duration of training 2-days and ongoing support available over 12-month period Duration of implementation 18 months	Inpatient CYP multi-disciplinary mental health team comprising nurses, healthcare assistants, occupational therapists, and psychologists. Service users and parents/carers.	Inner Children and Young People wards. Outer NHS trusts and national policy

Table 4. Summary of facilitators and barriers to implementation mapped against four constructs within the i-PARIHS framework.

i-PARIHS Domains	Facilitators and barriers to implementation
Innovation	Facilitators Interventions were viewed as acceptable and adaptable by staff. Higher fidelity rates for visual interventions All participants believed model and interventions were suitable for CYP wards Majority of participants were optimistic they could sustain interventions on wards in the future.	Barriers Majority believed failure to implement an intervention was due to contextual issues. A few participants relayed struggling with theory-practice links of some interventions.
Facilitation	Facilitators All participants felt supported by project workers. All participants found training resourceful. Majority of participants found community of practice meetings beneficial to network and collaboratively overcame implementation delays.	Challenges Some participants struggled with training being remote due to COVID-19, as opposed to in-person.
Recipients	Facilitators Motivated staff increased fidelity of interventions. Parents/carers liked the “getting to know you board” as it familiarised them with staff caring for their children.	Challenges Due to COVID-19, parents/carers had limited access to wards hence less feedback provided on interventions. Some staff members held negative attitudes towards interventions due to belief that this undermined their current work. Limited feedback from CYP due to Covid-19 restricting ward access. There was some resistance to mutual help meetings from some CYP due to busy schedules.
Context	Facilitators Staff motivation supported uptake. Improved communication between staff during handover. Allocated time supported uptake.	Challenges High staff turnover delayed uptake. Staff shortages delayed implementation. Leadership changes delayed uptake. Impact of COVID-19. Lack of allocated time. High acuity on ward. Too early to relay whether it had impact on restrictive practices.

Table 5. Successful implementation and adaptation of Safewards interventions.

Intervention	Reflections	Adaptations
Clear mutual expectations	Participants shared positive experiences of implementing clear mutual expectations that were collaboratively developed between staff and patients. “Mutual Expectations, it had a lot of, a lot of ideas from the young people. So it’s painting on the wall like a beehive with like and the hexagonal blocks with each expectation in, and the expectations kind of came from all the young people as to what, what we want on the ward. So that was quite good. And now it’s quite a good visual representation of what we do expect, where people will see, I think they’ve probably been the most well implemented just because they are really visible, and they’re quite easy to see and to keep going, and so I think it’s meant that they do get updated, and they get looked at and thought about.” (SWN212)	Minor changes in language.
Soft words	Participants communicated that soft words had been successful both in practice and as a visual aid in the ward office as a prompt to remind staff. “We do have the Soft Words and Positive Words up in the office… […] Even if it’s been a crap day, there’s still something you can think of, like, yeah, this has happened, but you know what, she’s done well, she’s done okay… Soft Words, we’re trying to use anyways. I think that one will be more useful when we get new starters, because that’s something that we can introduce them to as well.” (SWN102)
Talk down	One participant said that “talk down” provided a reflective space to consider how best to communicate with CYP who are struggling to engage and how best to support them. “Interventions that worked on the ward is the, um, like, Talk Down de-escalation, you know, tips of words to use that young people find helpful. Yeah. Well, I just think that it was more beneficial to the environment that we work in because, we do use a lot of de-escalation in our day-to-day practice, so that’s what the staff and young people find more beneficial. (SWSE313)	Minor changes in language used.
Positive words	Three participants shared that “positive words” had positively influenced handovers and team meetings by encouraging staff to rephrase negative statements and seeking out positive parts of the day amidst the most difficult ones. “so positive words has always been one that’s worked really well on our ward… […] we’ve got, like, a positive word section on our handover. Whether we read out every day, we’ve got kind of posters and stuff, and there’s lots of different things we have on our notice boards. Like we’ve got a speech bubble that says instead of using and it might be a negative phrase that’s quite common at the moment. And then we think of a more positive phrase. People are quite good at looking at that.” (SWC211)
Bad news mitigation	One participant communicated that bad news mitigation had been successful when addressing the use of age-inappropriate apps. Others relayed that bad news mitigation became part of the ward’s other processes and procedures and could also be used with Positive Words. “bad news mitigation went into our safety huddle. So that’s used every day now and kind of join that with positive words. So we’ll say, Is there any bad news expected in the next 24 h? But then we’ll also say, Is there any been any good news to make sure it’s not just kind of negative as well as positive stuff in there.” (SWC211) “The other one that we use successfully is the Bad News Mitigation one. […] And that, sort of, was embedded into our daily handovers and MDT discussions that we’re thinking about what someone might struggle with on that day. What information might need to be shared, because I guess even, you know, even just the term Bad News Mitigation, it’s not always necessarily bad news. It’s sometimes just information sharing that might be difficult for a young person or their family that we’re thinking about how we’re going to support them with. So that’s one that we use well.” (SWN214)	One ward used the intervention for parents/carers as interactions were mainly with parents not CYP, but posters were put up for CYP.
Know each other	Most participants communicated that the “know each other” intervention was amongst the most successful. Some participants relayed that CYP were engaged and happy to complete their profiles. Several wards sought innovative ways to display their profiles e.g. through avatar characters and hot air balloons. Replica files were also made of staff profiles at waiting areas and reception for visitors to read. Participants relayed that this intervention is a great conversation starter and acts as an ice breaker for parents/carers and new CYP admissions. “Yeah, I think the one that’s been best so far has been those one-page profiles because everyone got so involved with those. We did it both for staff and young people. So the young people did theirs as a way of kind of introducing themselves to anyone new joining the wards that didn’t know them and didn’t want to overwhelm them, with all bombarding them at once. So that was really nice.” (SWC306) “And it’s quite nice because the staff have really bought into it and shared a lot of stuff that they probably wouldn’t necessarily get to share. And for a lot of the newcomers to the ward, it’s a great conversation starter, you know, we’ve got a young girl who just looks like the picture of an angel and she’s into thrash metal and just, you know, when you’re just like, seriously, did she just make it up to put it on there? And actually she’s not, she’s really knowledgeable, but nobody in a million years would ever have thought of that.” (SWC404)	Some reluctance from staff to share information so many wards worked collaboratively with CYP and staff to find questions that all were happy with.
Mutual help meeting	Half of participants found mutual help meetings to be successful with CYP. Participants relayed that it allowed for open and honest discussions as well as suggestions for improvement. Additionally, it allows the ward community to celebrate its successes collaboratively. “One of the ones that I think has been really successful is the mutual help meetings, in the way that one of our wards applied that is a really positive experience for the whole ward community to come together, and they’ve chosen to do that in a way that enables discussions of challenges, but also kind of appreciation of what’s going on too. So, I think it’s called thank you, suggestions and appreciation, or no, thank you, suggestions and something else, but the whole experience of that meeting is positive, it enables the community to talk about difficult things, but also celebrate success within the community.” (SWC510)	Some participants communicated that CYP found the mutual help meetings difficult due to overpacked schedules, so some wards incorporated it into their regular community meetings.
Calm down methods	Calm down methods was another successful intervention shared by several participants. Participants communicated that wards had calm kits and self-soothe boxes for CYP as well as displays of soothe-boxes in lounges on wards. Resources include age-appropriate content such as fidget toys, sensory resources, scented oils and mindfulness colouring books. “Yeah, definitely, like, mainly the essential oils, but they all love them. Yeah. And a lot of people are having their crisis plans about using the essential oils. And they’ll have particular, we’ve got those of different ones that smell different. And they’ll, yeah. And like the face masks are in there, so they might do a face mask before bed.” (SWN408) Some participants relayed that self-soothe boxes were already embedded as part of the culture, so this intervention was a development on existing practice by applying the language of Safewards.	Some spoke of having to be aware of potential risks with certain items and COVID-19 had meant sharing items was not possible. There were also changes in language used. “We don’t do the Calm Down Boxes, instead, we do Self Soothe Boxes. And I guess for me it’s about the play on words where, actually, if you have a Calm Down Box, you only use it when you’re not calm.” (SWS507) Some wards had asked families to help stock calm down items. “So we’d be talking about something in the DBT group, but we didn’t have any stock of that to be able to put into the boxes for them to use. So it was a reliance on parents or family members or whatever to be able to bring those in.” (SWC404)
Reassurance	Some participants relayed that staff already provided a lot of reassurance, so this specific intervention was required less. “Staff already do a lot of reassurance interventions before Safewards started so staff are more likely to do it naturally”. (SWN501)	Most wards were yet to implement this intervention.
Discharge messages	Three participants said that discharge messages had been a particular success on wards. Participants found it easy to get up and running and that their cohort of CYP were engaged with completing their messages. “Well, I think the Discharge Messages are always really successful because that, that projects hope. So hope is a really important part of anyone’s journey, irrespective of how difficult things are in that moment. Things will always change, comes from DPT. So that’s I think, that for young people, that’s a really important and poignant message that they can see that change does happen, even if it’s really difficult to envisage or mentalise. Other people haven’t gone through the same things as them, but they’ve had similar challenges. So that’s really important. I think that’s really successful for young people.” (SWS507)	Some wards had fewer discharges so added positive messages of hope and recovery instead. “…and they’re painting kind of positive messages on the tree, so although they’re not discharge messages, they’re messages from the young people to other young people within the service. So, it carries the same theme promoting kind of hope and recovery.” (SWC510)

Table

	Fully	Partially	Not started yet
Clear Mutual Expectations	○	○	○
Soft Words	○	○	○
Talk Down	○	○	○
Positive Words	○	○	○
Bad NewsMitigation	○	○	○
Know Each Other	○	○	○
Mutual HelpMeeting	○	○	○
Calm DownMethods	○	○	○
Reassurance	○	○	○
Discharge Messages	○	○	○

Table

	All thetime	Sometimes	HardlyEver	Never	N/A
Clear Mutual Expectations	○	○	○	○	○
Soft Words	○	○	○	○	○
Talk Down	○	○	○	○	○
Positive Words	○	○	○	○	○
Bad NewsMitigation	○	○	○	○	○
Know Each Other	○	○	○	○	○
Mutual HelpMeeting	○	○	○	○	○
Calm DownMethods	○	○	○	○	○
Reassurance	○	○	○	○	○
Discharge Messages	○	○	○	○	○

Table

	Yes, we’ve adapted thisintervention	No, we haven’t adaptedthis intervention
Clear Mutual Expectations	○	○
Soft Words	○	○
Talk Down	○	○
Positive Words	○	○
Bad NewsMitigation	○	○
Know Each Other	○	○
Mutual HelpMeeting	○	○
Calm DownMethods	○	○
Reassurance	○	○
Discharge Messages	○	○

Table

Excellent	Good	Average	Poor	Terrible
○	○	○	○	○

Table

No impact	A minor impact	A moderate impact	A significant impact
○	○	○	○

Table

Extremely likely	Somewhat likely	Neither likely nor unlikely	Somewhat unlikely	Extremely unlikely
○	○	○	○	○

Table

Safewards CYP Staff Interview Schedule
Introduction: Thanks for taking time to speak with me today. As you know, Safewards is a model that involves 10 interventions designed to reduce conflict and containment on inpatient mental health units for working age adults. The reason we wanted to talk to you today was to find out your experiences of adapting, implementing, and using Safewards in Children’s and Young People’s units.
1. So, to start off, can you tell me a bit about your role in implementing Safewards on your ward?
2. If I was a new member of staff coming on to your ward, how would I know Safewards was happening? 2.1 What does Safewards look like on your ward?
3. What do you think has changed, if anything, since Safewards started on your ward? 3.1 Do you feel implementing Safewards has required changes to the way your ward and organisation works? What were these changes? 3.2 Do you feel using Safewards has required you and/or your staff to change your approach to your work? In what ways?
4. Have there been any Safewards intervention(s) that you feel have been particularly successful on your ward? 4.1 Which ones and why? 4.2 Did you make any adaptions to the interventions to make them more suitable to your ward or do you think any adaptions are needed? (E.g.to make them more suitable to the service user group (forensic, PICU etc.) or the age of your young people/children?)
5. Are there any other factors which you feel helped to make these intervention(s) particularly successful on your ward? For example…: Financial support Support/enthusiasm from managers, ward staff, service users/carers? Support from project workers? Training from project workers? Training and practical resources?
6. Did you encounter any difficulties or barriers to implementing these interventions? For example…: Financial support? Lack of support from managers, ward staff, service users/carers? Lack of support from project workers? Training and practical resources? Lack of staff time? High staff turnover? Was duplicating things we were already doing? Competing projects/priorities?
7. Do you feel Covid-19 had a particular impact on your ability to implement any of the Safewards interventions?
8. You’ve told me a bit about the interventions you feel were successful on your ward, were there any interventions that you feel weren’t successful or that you weren’t able to implement on your ward? 8.1 What barriers did you encountered to implementing these? 8.2 Why weren’t these interventions suitable for your ward? 8.3 If you could change these interventions to make them more suitable for your ward, what would you change?
9. What do you think the young people on your ward have noticed/liked about Safewards? 9.1 How has it benefitted the young people on your ward? 9.2 Has there been any negative feedback from young people? 9.3 How has benefitted the young people’s carers and has there been any negative feedback from families/carers?
10. What do you think families and carers who have come on to the ward have noticed/liked about Safewards? 10.1 How has it benefitted families and carers? 10.2 Has there been any negative feedback from families/carers?
11. What do you think your staff/colleagues have noticed/liked about Safewards? 11.1 How has it benefitted staff on the ward? 11.2 Has there been any negative feedback from staff/colleagues/managers?
12. Overall, do you think that Safewards has had any effect on the atmosphere of your ward/unit? 12.1 Why/why not and in what ways? 12.2 Has it reduced the number of conflict incidents on your ward (e.g. number of incidents of physical or verbal aggression, absconding or property damage?) 12.3 Has it reduced the use of containment/restrictive practices on your ward? (e.g. use of seclusion, restraint, IM medication, PRN medication)
13. Out of all the Safewards interventions, which do you think your ward will most likely still be using in 12 months’ time? Why?
14. Are there any interventions that you think your ward definitely won’t be using in 12 months’ time? Why?
15. What advice you give to a colleague/ward manager on another ward who was just starting out with Safewards?

Data availability statement

Data is not available for this project.