Methods to reduce coercive measures within inpatient mental healthcare: Safewards and Six core strategies

Situations with conflict and violence are common within inpatient mental healthcare, situations that sometimes have to be resolved by coercive measures. Coercive measures can place patients and staff at risk of harm, both physical and psychological, and should always be used as a last resort. Several methods have been developed to reduce the use of coercive measures in mental health care and two of these are Safewards and Six core strategies.

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SBU Enquiry Service

Consists of structured literature searches to highlight studies that can address questions received by the SBU Enquiry Service from Swedish healthcare or social service providers. We assess the risk of bias in systematic reviews and when needed also quality and transferability of results in health economic studies. Relevant references are compiled by an SBU staff member, in consultation with an external expert when needed.

Question

What systematic reviews or scientific studies are there on the use of Safewards and Six core strategies to reduce coercive measures in inpatient mental healthcare?

Identified literature

Two relevant systematic reviews with moderate risk of bias [1, 2] and five primary studies were identified [3-7]. The primary studies were not assessed for risk of bias.

Table 1. Systematic reviews with low/medium risk of bias
Included studies Population/Intervention Outcome and Results
Finch et al. 2022 [1]
A Systematic Review of the Effectiveness of Safewards: Has Enthusiasm Exceeded Evidence?
13 studies included in SWiM
  • 9 studies with quantitative measures of containment
 Population: any mental health inpatient setting

Intervention: Safewards		 Containment (n = 9)
Significant reduction after implementation (n = 6):
3 high quality studies and 3 moderate quality studies

Non-significant reduction after implementation (n = 2):
1 high quality study and 1 low quality study

No change after implementation (n = 1):
1 moderate quality study
Authors' conclusion:
“Whilst there is evidence to suggest that Safewards is effective for reducing conflict and containment in general mental health services, there is insufficient high-quality empirical evidence to support its effectiveness in settings beyond this. Further research using robust methodological designs with larger, more representative samples is required in order for the effectiveness of Safewards to be established across the range of contexts in which it is currently being applied.”
Mullen et al. 2022 [2]
Safewards: An integrative review of the literature within inpatient and forensic mental health units
19 included articles
2 studies with consumer perspective qualitative data		 Population: adult patients within inpatient mental health or forensic mental health units

Intervention: Safewards		 Qualitative results (n = 2):
Consumers felt safer and more connected with staff, and more positive about the experience of being in an inpatient environment.
Recovery-based philosophical approaches were more apparent.

Improved overall feeling of safety and sense of community within the inpatient unit.

Consumers raised concerns around the language within some of the interventions in the model. Some interventions were seen as condescending or patronizing, flagging that staff may still execute the interventions in a way they were not intended or were not consistent with the model.
Authors' conclusion:
“The findings demonstrate evidence for the ability of the model to reduce the incidence of conflict and containment events and to improve the consumer experience. Despite this, there remains uncertainty as to how well the model reflects the consumer experience of safety and supports recovery-oriented practice.”

 

Tabell 2. Relevant primary studies not included in summarised systematic reviews
Reference Population/setting Participants Study design Comment
Six core strategies
Duxbury et al. 2019 [3] Acute mental health care wards Intervention: 7 wards, total n = 144 beds
Control: 7 wards, total n = 147 beds		 Controlled study  
Putkonen et al. 2013 [4] Secured mental health care for men with schizophrenia Intervention: 2 wards, total n = 50 beds
Control: 2 wards, total n = 38 beds		 Randomised controlled trial Included in Goulet et al. 2016 [8]
Riahi et al. 2016 [5] Tertiary level specialized mental health care facility n = 326 beds No control group  
Wieman et al. 2014 [7] Psychiatric inpatient facilities 43 facilities No control group Included in Goulet et al. 2016 [8]
Wale et al. 2011 [6] Psychiatric Emergency and Adult Inpatient Services n = 1 117 beds No control group Included in Goulet et al. 2016 [8]

References

  1. Finch K, Lawrence D, Williams MO, Thompson AR, Hartwright C. A Systematic Review of the Effectiveness of Safewards: Has Enthusiasm Exceeded Evidence? Issues Ment Health Nurs. 2022;43(2):119-36. Available from: https://doi.org/10.1080/01612840.2021.1967533.
  2. Mullen A, Browne G, Hamilton B, Skinner S, Happell B. Safewards: An integrative review of the literature within inpatient and forensic mental health units. Int J Ment Health Nurs. 2022. Available from: https://doi.org/10.1111/inm.13001.
  3. Duxbury J, Baker J, Downe S, Jones F, Greenwood P, Thygesen H, et al. Minimising the use of physical restraint in acute mental health services: The outcome of a restraint reduction programme ('REsTRAIN YOURSELF'). Int J Nurs Stud. 2019;95:40-8. Available from: https://doi.org/10.1016/j.ijnurstu.2019.03.016.
  4. Putkonen A, Kuivalainen S, Louheranta O, Repo-Tiihonen E, Ryynanen OP, Kautiainen H, et al. Cluster-randomized controlled trial of reducing seclusion and restraint in secured care of men with schizophrenia. Psychiatr Serv. 2013;64(9):850-5. Available from: https://doi.org/10.1176/appi.ps.201200393.
  5. Riahi S, Dawe IC, Stuckey MI, Klassen PE. Implementation of the Six Core Strategies for Restraint Minimization in a Specialized Mental Health Organization. J Psychosoc Nurs Ment Health Serv. 2016;54(10):32-9. Available from: https://doi.org/10.3928/02793695-20160920-06.
  6. Wale JB, Belkin GS, Moon R. Reducing the use of seclusion and restraint in psychiatric emergency and adult inpatient services- improving patient-centered care. Perm J. 2011;15(2):57-62. Available from: https://doi.org/10.7812/TPP/10-159.
  7. Wieman DA, Camacho-Gonsalves T, Huckshorn KA, Leff S. Multisite study of an evidence-based practice to reduce seclusion and restraint in psychiatric inpatient facilities. Psychiatr Serv. 2014;65(3):345-51. Available from: https://doi.org/10.1176/appi.ps.201300210.
  8. Goulet M-H, Larue C, Dumais A. Evaluation of seclusion and restraint reduction programs in mental health: A systematic review. Aggression and Violent Behavior. 2017;34:139-46. Available from: https://doi.org/10.1016/j.avb.2017.01.019.
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Published: Report no: ut202220 Registration no: SBU 2022/532
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Literature search

Medline via OvidSP 29 August 2022

Title: Safewards and Six core strategies
/ = Term from the MeSH controlled vocabulary; .sh = Term from the MeSH controlled vocabulary; exp = Term from MeSH including terms found below this term in the MeSH hierarchy; .ti,ab = Title or abstract; .tw = Title or abstract; .kf = Keywords; .kw = Keywords, exact; .bt = Book title. NLM Bookshelf; .pt = Publication type; .ja = Journal abbreviation; .af = All fields; adjn = Adjacent. Proximity operator retrieving adjacent words, adj3 retrieves records with search terms within two terms from each other; * or $ = Truncation; “ “ = Citation Marks; searches for an exact phrase
Search terms Items found
Population:
1. Mentally Ill Persons/ 6404
2. Mental Health Services/ 37600
3. Hospitals, Psychiatric/ 25914
4. Psychiatric Department, Hospital/ 6982
5. Inpatients/ 27801
6. Forensic Psychiatry/ 9360
7. ((psych* or forensic* or mental*) adj6 (care or unit* or hospital* or ward* or team* or setting* or treat* or patient* or inpatient* or commit*)).ti,ab,kf,bt. 311019
8. or/1-7 [population] 375107
Intervention:
9. Involuntary Treatment, Psychiatric/ 80
10. "Commitment of Mentally Ill"/ 6958
11. Involuntary Commitment/ 68>/td>
12. Insanity Defense/ 1830
13. Behavior Control/ 1906
14. Coercion/ 4981
15. Violence/ 33872
16. ((conflict* or aggressi* or violen*) adj4 (containment or manage* or resolution or resolv* or reduc*)).ti,ab,kf,bt. 26343
17. ((physical* or mechanical* or chemical* or medica*) adj4 (restrain* or constrain*)).ab,bt,kf,ti. 8122
18. ((patient or inpatient*) adj6 (isolation or seclusion)).ab,bt,kf,ti. 2212
19. ((involuntary or non voluntary or forced or forcibl* or compuls* or coerc*) adj4 (treat* or intervention* or care or admission or admit* or commit* or hospitali* or patient* or medica* or reduc*)).ab,bt,kf,ti. 17620
20. or/9-19 [coercion] 96215
21. ("six core strateg*" or "6 core strateg*").ti,ab,kf,bt. 31
22. safeward*.ti,ab,kf,bt. 43
Study types: systematic reviews and meta-analysis
23. (Systematic Review/ or Meta-Analysis/ or Cochrane Database Syst Rev.ja. or ((systematic adj4 review) or "meta analys*" or metaanalys*).ti,bt,ab.) not (editorial/ or letter/ or case reports/) [SR] 395812
Combined sets:
24. 8 and 20 [psyc pop + coercion] 15680
25. 22 and 20 [systematic reviews] 352
26. or/21-22,25 416
Final result
27. 26 416

Scopus via scopus.com 30 August 2022

Title: Safewards and Six core strategies
TITLE-ABS-KEY = Title, abstract or keywords (including indexed keywords and author keywords); ALL = All fields; W/n = Within. Proximity operator retrieving terms within n words from each other; PRE/n = Precedes by. Proximity operator, the first term in the search must precede the second by n words; LIMIT-TO (X) = Includes only results of specified type, e.g., publication type or time range; DOCTYPE = Publication type; “re” = review; “le” = letter; “ed” = editorial; “ch” = book chapter; “cp” = conference proceedings; * = Truncation; “ “ = Citation Marks; searches for an exact phrase
Search terms Items found
Population:
1. ( TITLE-ABS-KEY ( ( psych* OR forensic* OR mental ) W/5 ( care OR unit* OR hospital* OR wards OR team* OR setting* OR treat* OR patient* OR inpatient* OR commit* ) ) ) 480 438
Intervention:
2. ( TITLE-ABS-KEY ( ( conflict* OR aggressi* OR violen* ) W/3 ( containment OR manage* OR resolution OR resolv* OR reduc* ) ) ) 82 190
3. TITLE-ABS-KEY ( ( physical* OR mechanical* OR chemical OR medica* ) W/3 ( restrain* OR constrain* ) ) 40 807
4. ( TITLE-ABS-KEY ( ( patient* OR inpatient* ) W/5 ( isolation OR seclusion OR restrain* ) ) ) 16 914
5. ( TITLE-ABS-KEY ( ( involuntary OR "non voluntary" OR forced OR forcibl* OR compuls* OR coerc* ) W/3 ( treat* OR intervention* OR care OR admission OR admit* OR commit* OR hospitali* OR patient* OR medica* OR reduc* ) ) ) 29 291
6. ( TITLE-ABS-KEY ( de-escalat* OR deescalat* OR "behavio* control" ) ) 21 780
7. 2 OR 3 OR 4 OR 5 OR 6 187 573
8. TITLE-ABS-KEY ( "six core strategies" OR "6 core strategies" OR safeward* ) 72
Study types: systematic reviews and meta-analysis
9. TITLE-ABS-KEY ( ( systematic W/2 review ) OR "meta analy*" OR metaanaly* ) AND ( EXCLUDE ( DOCTYPE , "le" ) OR EXCLUDE ( DOCTYPE , "ed" ) OR EXCLUDE ( DOCTYPE , "ch" ) OR EXCLUDE ( DOCTYPE , "cp" ) )  
Combined sets:
10. 1 AND 7 12 630
11. 9 AND 10 435
12. 11 OR 8 497
Final result
13. 12 497

INAHTA via inahta.org 19 August 2022

Title: Safewards and Six core strategies
/ = Term from the MeSH controlled vocabulary; .sh = Term from the MeSH controlled vocabulary; exp = Term from MeSH including terms found below this term in the MeSH hierarchy; .ti,ab = Title or abstract; .tw = Title or abstract; .kf = Keywords; .kw = Keywords, exact; .bt = Book title. NLM Bookshelf; .pt = Publication type; .ja = Journal abbreviation; .af = All fields; adjn = Adjacent. Proximity operator retrieving adjacent words, adj3 retrieves records with search terms within two terms from each other; * or $ = Truncation; “ “ = Citation Marks; searches for an exact phrase
Search terms Items found
Intervention:
1. (((seclusion OR restraint))[Title] OR ((seclusion OR restraint))[abs]) OR ("six core strateg*")[Title] OR ("six core strateg*")[abs] OR ("safeward*")[Title] OR ("safeward*")[abs] 11
Final result
2. 1 11
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