Nursing - Research Publications

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    Outcomes of the Victorian Safewards trial in 13 wards: Impact on seclusion rates and fidelity measurement
    Fletcher, J ; Spittal, M ; Brophy, L ; Tibble, H ; Kinner, S ; Elsom, S ; Hamilton, B (WILEY, 2017-10-01)
    Restrictive practices are used in response to conflict and aggression in psychiatric inpatient settings. Reducing such practices is the focus internationally of policy and legislative change, many initiatives, and a growing body of research. Safewards is a model and a set of 10 interventions designed to reduce conflict and containment in inpatient services. In the current study, we aimed to assess the impact of implementing Safewards on seclusion in Victorian inpatient mental health services in Australia. The study used a before-and-after design, with a comparison group matched for service type. Thirteen wards opted into a 12-week trial to implement Safewards and 1-year follow up. The comparison group was all other wards (n = 31) with seclusion facilities in the jurisdiction, matched to service type. Mandatorily-reported seclusion event data for all 44 wards over a 15-month period were analysed using negative binomial regression. Adherence to Safewards was measured via fidelity checklists at four time points: twice during the trial, post-trial, and at 1-year follow up. Seclusion rates were reduced by 36% in Safewards trial wards by the 12-month follow-up period (incidence rate ratios (IRR) = 0.64,) but in the comparison wards seclusion rates did not differ from baseline to post-trial (IRR = 1.17) or to follow-up period (IRR = 1.35). Fidelity analysis revealed a trajectory of increased use of Safewards interventions after the trial phase to follow up. The findings suggest that Safewards is appropriate for practice change in Victorian inpatient mental health services more broadly than adult acute wards, and is effective in reducing the use of seclusion.
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    Consumer recommendations for enhancing the Safewards model and interventions
    Kennedy, H ; Roper, C ; Randall, R ; Pintado, D ; Buchanan-Hagen, S ; Fletcher, J ; Hamilton, B (WILEY, 2019-04-01)
    This paper critiques the Safewards model through the lens of lived experiences of psychiatric hospitalization, diagnosis of mental illness, and distress. Special focus is given to the model's tested 10 interventions and to five lesser known interventions, identifying the impact they can have on hospitalized consumers. We highlight the role and prevalence of trauma, as well as the need to prevent harm in hospital settings. We draw upon notions of hospital as a sanctuary for people and the importance of providing a safe ward. 'Sanctuary harm' and 'Sanctuary trauma' are thus defined, with emphasis placed on the Safewards interventions as means by which sanctuary can be achieved. Finally, the consumer-perspective authors propose expansions to the model, critiquing the defining literature and moving towards a consumer experience of safety that is beyond the model's original intention: to reduce seclusion and restraint practices. Throughout the paper, the term 'consumer' is used in this context to mean people who have experienced or are experiencing psychiatric inpatient care.
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    Working towards least restrictive environments in acute mental health wards in the context of locked door policy and practice
    Fletcher, J ; Hamilton, B ; Kinner, S ; Sutherland, G ; King, K ; Tellez, JJ ; Harvey, C ; Brophy, L (WILEY, 2019-04-01)
    There has been a shift towards provision of mental health care in community-based settings in Australia. However, hospitals continue to care for people in acute mental health wards. An increasing proportion of the people in wards are admitted involuntarily, subject to restrictions of movement to minimize risk of harm to self and others. In response to concerns about the safety of people absconding from care, Queensland Health introduced a policy requiring all acute mental health wards in the State to be locked. In response, the Queensland Mental Health Commission funded a project to understand the impact of this policy and develop evidence-based recommendations regarding provision of least restrictive, recovery-oriented practices in acute wards. Facilitated forums were conducted with 35 purposively selected participants who identified as consumers, carers, or staff of acute mental health hospital wards, to test the acceptability, feasibility, and face validity of a set of evidence-informed recommendations for providing least restrictive, recovery-oriented practices. Participant responses were recorded, and data were analysed through an inductive, thematic approach. A recovery-oriented approach was supported by all stakeholders. Reducing boredom and increasing availability of peer support workers were considered key to achieving this. Focusing less on risk aversion was reported as central to enabling true Recovery Orientation. This project enabled recognition of the perspectives of consumers, carers, and staff in the consideration of evidence-informed recommendations that could be implemented to provide least restrictive care in the context of locked doors.
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    Safewards Impact in Inpatient Mental Health Units in Victoria, Australia: Staff Perspectives
    Fletcher, J ; Hamilton, B ; Kinner, SA ; Brophy, L (FRONTIERS MEDIA SA, 2019-07-10)
    Introduction: Mental health professionals working in acute inpatient mental health wards are involved in a complex interplay between an espoused commitment by government and organizational policy to be recovery-oriented and a persistent culture of risk management and tolerance of restrictive practices. This tension is overlain on their own professional drive to deliver person-centered care and the challenging environment of inpatient wards. Safewards is designed to reduce conflict and containment through the implementation of 10 interventions that serve to improve the relationship between staff and consumers. The aim of the current study was to understand the impact of Safewards from the perspectives of the staff. Methods: One hundred and three staff from 14 inpatient mental health wards completed a survey 12 months after the implementation of Safewards. Staff represented four service settings: adolescent, adult, and aged acute and secure extended care units. Results: Quantitative results from the survey indicate that staff believed there to be a reduction in physical and verbal aggression since the introduction of Safewards. Staff were more positive about being part of the ward and felt safer and more connected with consumers. Qualitative data highlight four key themes regarding the model and interventions: structured and relevant; conflict prevention and reducing restrictive practices; ward culture change; and promotes recovery principles. Discussion: This study found that from the perspective of staff, Safewards contributes to a reduction in conflict events and is an acceptable practice change intervention. Staff perspectives concur with those of consumers regarding an equalizing of staff consumer relationships and the promotion of more recovery-oriented care in acute inpatient mental health services.
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    Consumer Perspectives of Safewards Impact in Acute Inpatient Mental Health Wards in Victoria, Australia
    Fletcher, J ; Buchanan-Hagen, S ; Brophy, L ; Kinner, SA ; Hamilton, B (FRONTIERS MEDIA SA, 2019-07-09)
    Background: Inpatient mental health wards are reported by many consumers to be custodial, unsafe, and lacking in therapeutic relationships. These consumer experiences are concerning, given international policy directives requiring recovery-oriented practice. Safewards is both a model and a suite of interventions designed to improve safety for consumers and staff. Positive results in reducing seclusion have been reported. However, the voice of consumers has been absent from the literature regarding Safewards in practice. Aim: To describe the impact of Safewards on consumer experiences of inpatient mental health services. Method: A postintervention survey was conducted with 72 consumers in 10 inpatient mental health wards 9-12 months after Safewards was implemented. Results: Quantitative data showed that participants felt more positive about their experience of an inpatient unit, safer, and more connected with nursing staff. Participants reported that the impact of verbal and physical aggression had reduced because of Safewards. Qualitatively, participants reported increased respect, hope, sense of community, and safety and reduced feelings of isolation. Some participants raised concerns about the language and intention of some interventions being condescending. Discussion: Consumers' responses to Safewards were positive, highlighting numerous improvements of importance to consumers since its implementation across a range of ward types. The findings suggest that Safewards offers a pathway to reducing restrictive interventions and enables a move toward recovery-oriented practice.
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    Prevention and Recovery Care Services in Australia: Describing the Role and Function of Sub-Acute Recovery-Based Residential Mental Health Services in Victoria
    Fletcher, J ; Brophy, L ; Killaspy, H ; Ennals, P ; Hamilton, B ; Collister, L ; Hall, T ; Harvey, C (FRONTIERS MEDIA SA, 2019-10-24)
    Background: Prevention and Recovery Care (PARC) services are relatively new sub-acute residential services that have supported people with mental ill-health in Victoria since 2003. Operated from a partnership model between non-governmental agencies and clinical mental health services, PARC services integrate intensive recovery-focused psychosocial input with clinical mental health care. Aim: To describe and contrast the 19 PARC services operating in Victoria at the time of the study, in terms of structures and function, resources, and content and quality of care. Method: Nineteen participants, one representing each PARC, completed two surveys: the first, a purpose-designed survey relating to the government guidelines for PARC services, and the second, the Quality Indicator for Rehabilitative Care. Results: Descriptive analyses highlighted that PARC services have operated in inner-city, urban, and regional areas of Victoria, from between 1 and 14 years. Participants reported that a recovery approach was at the core of service delivery, with a vast array of group and individual programs on offer. Across the state, there was variation in the quality of services according to the Quality Indicator for Rehabilitative Care domains. Conclusions: This study has identified that there is variation in the structure and function, resourcing, and content and quality of care offered across Victoria's PARC services even though, in the main, they are guided by government guidelines. Hence it appears that the services adapt to local needs and changes in service systems occurring over time. The findings indicate emerging evidence that PARCs are providing recovery-oriented services, which offer consumers autonomy and social inclusion, and therefore likely enable a positive consumer experience. The range of individual and group programs is in line with the Victorian guidelines, offering practical assistance, therapeutic activities, and socialization opportunities consistent with consumer preferences. Further research into implementation processes and their impacts on quality of care is warranted concerning this and similar service models.