Project Summary
Uniting Communities in partnership with Flinders University has been awarded an ARIIA grant for their project ‘Implementation of Safewards to reduce the use of restrictive practices in residential aged care’.
This project seeks to address the problem of the overuse of restrictive practices in residential aged care settings by implementing a program of interventions to develop aged care staff capacity in the provision of day-to-day care of people with complex needs.
This project will adapt and implement the Safewards program, an evidence-based model and set of interventions developed to reduce restrictive practices in inpatient psychiatric settings. Co-design principles will be employed to implement and evaluate Safewards across two residential aged care settings. A stakeholder group of staff from participating sites and researchers will provide project oversight. Staff will be trained in the Safewards model and supported to adapt and implement Safewards interventions over a three-month period. Feedback from staff, residents and family members will be sought post-implementation to determine the feasibility, acceptability, staff confidence levels and suggested adaptations of Safewards for translation into residential aged care settings. During the pilot stage, restrictive practice use will be assessed to evaluate the effectiveness of Safewards. Project findings will provide an in-depth understanding of the successful implementation processes, the impact of Safewards in reducing restrictive practices, and recommendations for wider implementation of Safewards across residential aged care.
Project Outcomes
Background and Aims
Restrictive practices are any practice or intervention that has the effect of restricting a person’s freedom of movement or ability to make decisions. Restrictive practices include chemical, physical, environmental and/or mechanical restraint, and seclusion. Findings from the 2021 Australian Royal Commission into Aged Care Quality and Safety found the inappropriate use of restrictive practices were considered a form of abuse and a priority area to address.
Safewards is a model that was originally developed in the United Kingdom for use in mental health inpatient services. The model is based on training staff, and giving staff the resources, to implement 10 psycho-social interventions (follow this link to learn about all 10 interventions https://www.safewards.net/interventions) that support staff to reduce resident distress, agitation and anger. By doing so, the interventions reduce escalation of conflict between staff and residents, and in reducing conflict, there is a reduction in the use of restrictive practices, such as the use of physical restraint. The ARIIA funded project has been undertaken to explore whether the Safewards model is effective in the residential aged care setting.
Of the 10 Safewards interventions, the following 5 interventions were implemented in this project:
- Know Each Other intervention — staff, residents and families produce a profile (including a photo) of who they are as a person (e.g., hobbies, likes) which is made available to everyone via a noticeboard or folder.
- Meaningful Messages (replacing ‘Discharge Messages’) — a display of positive messages from families about what they like about the home and helpful advice for new families/residents.
- Positive Words — during handover, staff to say something positive about the resident, or the way in which staff supported them.
- Soft Words — short statements outlining potential strategies to use when handling trigger points (e.g., setting limits) printed on posters, postcards and changed every few days.
- Calm Down — a box of distraction, sensory modulation and relaxation tools to offer to people when they appear upset, tense or agitated.
The overarching project aim was to develop workforce capability to support people with complex needs living in residential settings and improve care through a reduction in use of restrictive practices.
What We Did
- An interdisciplinary Safewards Steering Committee met monthly to provide governancethroughout the project.
- 2-day intensive training on Safewards model and interventions provided to residential agedcare staff, including those identified as potential Safewards Champions.
- Adaptation of Safewards training and resources to the residential aged care setting.
- Provision of weekly on-site training sessions, available to all staff, on each of the Safewards interventions.
- Focus groups and interviews with aged care staff and leadership to understand, from theirperspective, the barriers and enablers to implementation.
- Co-design workshop to explore strategies to embed Safewards interventions (specifically, Know Each Other and Calm Down).
Outcomes
There was strong support from all Uniting Communities staff who participated in the project, for the intent of the Safewards model and the interventions that were implemented. This included a motivation to do things differently, to improve care for residents and to reduce the reliance on restraint.
The Safewards interventions that were simple, visible and tangible translated best to the aged care setting. The Know Each Other posters were considered to quickly and powerfully influence culture. The Calm Down boxes were well accepted and considered to benefit residents. These two interventions are described in detail.
The Know Each Other intervention involved staff completing a template (including a photo) of who they are as a person (e.g., hobbies, likes). Staff could share whatever information they chose. Most often staff included their country of birth, the places they had travelled, their favourite song, movie and meal. These personal profiles were printed in A3 size made available to everyone via a notice board or folder. There was enormous support for the intervention, which included recognition that by knowing each other better, people communicated with each other more often and that improved their experience at work. There was strong support to proceed with developing profiles for residents, with an understanding that knowing more about them as a person would enable staff to engage with and care for that person with dignity and safety.
The Calm Down intervention was implemented by having a box of sensory items, such as weighted soft toys, fiddle toys, colourful and textured items and colouring books, located in each home. Staff were encouraged to use the Calm Down box with residents when they appeared upset, tense or agitated.
There was support for the remaining three interventions that were implemented (Meaningful Messages, Positive Words and Soft Words) in addition to most of the interventions that were not implemented during this pilot project. However, it was acknowledged that further consideration about how to adapt those interventions not trialled in this pilot would be required prior to their use in the residential aged care setting.
The take-away message for aged care providers is to start small and start simple. The smallest of interventions, requiring only a small outlay of resources, that can be incorporated into day-to-day activities, is to get to know each other by developing and displaying staff and resident Know Each Other posters in prominent positions around the homes.
Once an organisation has the Know Each Other intervention embedded, consider the next intervention that meets urgent needs.
As interventions are adopted, adapted and embraced, they should be built into the organisation’s policies, procedures, practice and, most importantly, the culture, of the organisation.
Impact on Aged Care and Workforce
At both homes there has been an improvement in team building contributing to a positive change in culture. Empowering the staff by providing tools and strategies this would also assist with turnover and retention. Both homes have had a decrease in turnover in the last 12 months reducing by 10%, though this can not only be attributed to the project. Outcomes site 2 reported improved connection to the community with family participation and also a reduction in serious incidents reported.
Resources Developed
For all 10 Safewards interventions, there are power-point slides and videos of the 12-minute training session being delivered to aged care staff. The videos were developed to support ongoing training of staff and sustainability of the interventions. These resources are specific to Uniting Communities and therefore not publicly accessible. However, there are extensive resources that have been developed in the UK, Victoria and the Australian Capital Territory, where Safewards has been implemented.
Safewards Victoria | Training resources
Implementing Safewards in the ACT
Next Steps
Uniting Communities (UC) has incorporated further work on the Safewards model into their Strategic Business Plan for Residential Aged Care in 2025. The UC steering group members will convene early 2025 to determine next steps in the use of Safewards interventions and are committed to continuing its adoption at both sites. Researchers at Flinders University are developing a NHMRC Partnership Grant Proposal (for submission in 2025) that will build on the findings from this pilot study, which has demonstrated the feasibility of implementing Safewards into RAC. Older persons mental health teams provide in-reach into RAC across the state are ideally placed to facilitate broader implementation. A multi-centre stepped-wedge cluster randomised design will be used to evaluate Safewards implementation. Stage One will involve co-designing the implementation of Safewards into RAC. Stage Two will implement Safewards into 15 RAC homes. Stage Three will involve an implementation, effectiveness and cost evaluation.
Key contact for further information
Heather Fraser, Senior Manager, Uniting Communities