Adaptation of the safewards model to the New Zealand context: A mixed-methods evaluative study
Background: Mental health inpatient units can provide a sanctuary for people to recover from mental illness. However, research has shown these units to be sites of conflict, in an environment that service users do not experience as therapeutic. To support a therapeutic environment, the safety and wellbeing of service users and staff need protection through reduced conflict and containment rates. Conflict can be physical or verbal aggression, self-harm, suicide attempt, absconding, substance misuse and medication refusal. Containment involves methods used to control conflict, including administration of sedative medication, coerced intramuscular medication, increased level of observation, restraint and seclusion. The Safewards model, originating in the United Kingdom in 2015, proposes 10 interventions to address conflict and containment. These interventions are centred on: therapeutic relationships; person-centeredness; teamwork; and least restrictive care. This research pursued active transformation through codesign of an adapted Safewards model to fit the socio-cultural context of New Zealand. Objective: This thesis with publication describes the adaptation of the Safewards model to the New Zealand context. Cultural adaptation was critical due to significant health outcome disparities between Māori and non-Māori populations and the disproportionate representation of Māori within mental health services. The research sought to discover what a New Zealand model required, what the perspectives of inpatient tangata whai ora and staff were of the developed model and what changes it made to rates of conflict, containment and the ward atmosphere. Participants: Tangata whai ora and staff from the study setting were recruited to participate in focus groups before and after the implementation of the New Zealand Safewards model. Phase one focus groups included 15 staff and three tangata whai ora. Phase three focus groups included 13 staff and four tangata whai ora. Methods: This is a mixed-methods evaluative study structured into three distinct phases, using methods of participatory action research. The adapted Safewards model was implemented for 12 months, with a staggered introduction of 11 interventions. Qualitative data were derived from the thematic analysis of focus groups. Quantitative data were from the Patient-Staff Conflict Checklist, Essen Climate Evaluation Schema, Fidelity Checklist and Te Whatu Ora Waikato service data. Findings: A New Zealand Safewards model must: reflect a Te Ao Māori worldview; align with current practices; adapt Safewards interventions; and gain acceptance. Change management is one process that can reduce barriers to change. The adapted Safewards model reduced conflict, increased patient cohesion and improved the sense of safety perceived from staff and tangata whai ora in the study setting. The outcomes of this study hold the potential to contribute to the formulation and implementation of a New Zealand Safewards model, while also bearing relevance for the international adaptation of Safewards to culturally diverse countries and healthcare systems.
inpatient, nursing care, psychiatric nursing, risk management, safety
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