Preventing and Reducing Coercive Measures-An Evaluation of the Implementation of the Safewards Model in Two Locked Wards in Germany.

Johanna Baumgardt,Karin Morgenstern,Nicole Stiehm,Edwin Emilio Velasquez Lecca,Dorothea Jäckel,Enrico Schöppe,Andreas Bechdolf,Ann-Kathrin Mc Cutcheon,Stefan Weinmann,Michael Schulz,Andre Voigt,Michael Löhr,Heike Helber-Böhlen

doi:10.3389/fpsyt.2019.00340

Abstract

IntroductionAggression and violence are highly complex problems in acute psychiatry that often lead to the coercive interventions. The Safewards Model is an evidence-informed conflict-reduction strategy to prevent and reduce such incidents. The aim of this study was to evaluate the implementation of this model with regard to coercive interventions in inpatient care.Materials and MethodsWe evaluated outcomes of the implementation of the Safewards Model in two locked psychiatric wards in Germany. Frequency and duration of coercive interventions applied during a period of 11 weeks before and 11 weeks after the implementation period were assessed through routine data. Fidelity to the Safewards Model was assessed by the Organization Fidelity Checklist.ResultsFidelity to the Safewards Model was high in both wards. The overall use of coercive measures differed significantly between wards [case-wise: χ2 (1, n = 250) = 35.34, p ≤ 0.001; patient-wise: χ2 (1, n = 103) = 21.45, p ≤ 0.001] and decreased post-implementation. In one ward, the number of patients exposed to coercive interventions in relation to the overall number of Patients decreased significantly [χ2 (1, 281) = 6.40, p = 0.01]. Furthermore, the mean duration of coercive interventions overall declined significantly [U(55,21) = −2.142, p = 0.032] with an effect size of Cohen’s d = −0.282 (95% CI: −0.787, 0.222) in that ward. Both aspects declined as well in the other ward, but not significantly.DiscussionResults indicate that the implementation of the Safewards interventions according to the model in acute psychiatric care can reduce coercive measures. They also show the role of enabling factors as well as of obstacles for the implementation process.

Highlights

Aggression and violence are highly complex problems in acute psychiatry that often lead to the coercive interventions
This is the first study that evaluated the implementation of the Safewards Model in locked acute psychiatric wards in the German health care context with regard to coercive measures
The characteristics of the patient population regarding age range and distribution are in line with numerous other surveys, e.g., a study by Adorjan et al that evaluated the use of coercive measures

Summary

Introduction

Aggression and violence are highly complex problems in acute psychiatry that often lead to the coercive interventions. The aim of this study was to evaluate the implementation of this model with regard to coercive interventions in inpatient care. Managing conflict and violent situations such as self-harm, drug abuse, physical aggression, verbal abuse, or aggressive behavior towards others is part of acute inpatient psychiatric care. It has become a major focus for staff interventions in such units [1, 2]. Rates of coercive interventions vary between individual units and across countries. A previous study suggests that coercive measures are used in between 21% and 59% of individuals admitted to psychiatric hospitals across various European countries [4]. Coercive measures are associated with longer duration of inpatient treatment and forced medication seems to have a significant impact on patient disapproval of treatment [10]

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