3.3 Bowers Safewards Model

Len Bowers’ Safewards Model (2014) is a thorough depiction of sources of aggression and de-escalation strategies that can be used to prevent and defuse violent acts. , The model is founded on the principle that conflict, i.e. acts of aggression by patients, and containment, i.e., the methods healthcare staff use to control aggression by patients, exist in symbiosis. Aggressive patients who are contained (through seclusion, restraints, special observation, etc.) are likely to escalate violence in response to their

3.3.1 Safewards Domains

The Safewards model, unlike other de-escalation frameworks that begin with the first signal of patient aggression, requires understanding potential sources of patient discomfort throughout the de-escalation process. In this way, the Safewards model has an aerial view: its components comprise the entire healthcare ecosystem at all times. This is once again in contrast to other models that narrow their scope to the patient-staff member interaction. The model includes:

  1. Originating Domains – elements of the ward that can lead to flashpoints. These elements are unalterable elements of hospital life and can be further broken down into six general categories: patient community (patient-patient interaction), patient characteristics (symptoms and demography), regulatory framework (legal framework and hospital policy), staff team (how staff manage feelings and interact with each other), physical environment (hospital layout and comfort), and outside hospital environment (what the patient’s family and community is like outside the hospital).
  2. Flashpoints – situations in which aggression could arise as a result of one of the originating domains.
  3. Patient Modifiers – the ways in which patients respond toward originating domains and toward each other.
  4. Staff Modifiers – the way that staff manage patients or the environment to reduce conflict and containment.
  5. Conflict – any patient behavior that threatens their safety or the safety of others.
  6. Containment – ways in which staff manage conflict, e.g. medication, seclusion, restraint, etc.
3.3.2 In Practice

The Safewards Model’s de-escalation framework suggests that staff modifiers can affect all other domains to limit conflict and the resulting need for containment. It emphasizes consistent review and modification of all elements of a patient’s experience. Through this holistic de-escalation process, Bowers (2014) implies that flashpoints can be mitigated, and the cycle of conflict and containment avoided.

An updated version of the model specifies 10 specific interventions for implementation in acute psychiatric wards: (1) staff and patients mutually agree upon, then publish, standards of behavior; (2) management hangs statements on using “soft words” during flashpoints in the nursing office; (3) the ward elects the best de-escalator; that person develops a de-escalation model to improve the skills of other staff; (4) management creates a requirement to say something good about each patient during nursing handover; (5) staff must scan for bad news a patient may receive from family or other staff, and speak with patient immediately; (6) staff creates a “know each other” folder that contains personal but non-private information about both patients and staff, such as music preferences or favorite sports teams; (7) staff members host a regular patient meeting to formalize support; (8) patient’s room is equipped with a crate of distraction and sensory modulation toys; (9) staff provide reassuring explanations to all patients after potentially frightening incidents; and (10) hallways contain a board of positive messages from discharged patients. These interventions are tailored for psychiatric wards. However, an evaluation of potential transferability to other departments is recommended.

3.3.3 Safewards Efficacy

In 2011, a collaboration between the Institute of Psychiatry, King’s College London, Maudsley NHS Foundation Trust, and the National Institute for Health Research (NIHR) generated 298 de-escalation training intervention ideas based off the Safewards Model. Expert nurses and ward managers evaluated the interventions and selected 15 interventions for implementation in four wards in East London. Following implementation of the 15 interventions, the 10 most successful ideas were selected for a full trial in 2013.

The 10 interventions were implemented in generic acute wards and psychiatric intensive care units in 15 randomly chosen hospitals in South England. It is reported that, following the eight-week intervention, conflict decreased by 15%, and containment decreased by 24%.

3.4 Utilizing Security Personnel

The previously described de-escalation frameworks describe de-escalation and violence control in a one-on-one context, generally. While it is important to teach skills that medical practitioners can use as individuals, it is also imperative that security personnel be trained in violence management and that hospital staff learn protocols for contacting security personnel. IAHSS details the expectations that should be established by healthcare facilities, in this regard.