To Örebro University

Short-term (24 h) violence risk assessment and management can reduce violence in institutional settings, yet they remain understudied in adolescent populations. This systematic review aimed to identify instruments used for short-term violence risk assessment and strategies for managing violence risk among adolescents in institutional settings, as well as to evaluate related outcomes. PRISMA was used as an evidence-based minimum set of items for reporting systematic reviews. The literature search (March 2024 and March 2025) was conducted in PubMed, PsycINFO, Web of Science, CINAHL, The Cochrane Library and Scopus, and references from selected studies were reviewed. Data extraction and analysis were performed in Covidence. Nine studies met inclusion criteria describing six assessment instruments: DASA, DASA-YV, V-RISK-Y, Kennedy Axis V, Pedi-BEWS and BVC. No studies regarding strategies for short-term violence risk management were identified. DASA-YV, BVC and V-RISK-Y predicted violence among adolescents within 24 h (AUC = 0.70-0.95); DASA predicted violence moderately (AUC = 0.50-0.69). Pedi-BEWS (ICC = 0.83) and Kennedy Axis V (ICC = 0.79) demonstrated similar inter-rater reliability. Due to the lack of studies, firm conclusions on the best instrument for clinical practice in institutional settings remained elusive. Further research is necessary to ascertain if youth-specific instruments (e.g., DASA-YV, V-RISK-Y) predict violence more effectively than non-age-specific instruments (e.g., DASA). The lack of youth engagement in violence risk assessment stands out clearly. Scoring was done by the staff, mostly by nurses. Future studies should involve adolescents in the scoring or evaluation of assessment and management. There is a need for evidence-based recommendations for youth engagement.

BACKGROUND: Restrictive practices, such as seclusion and restraint, in psychiatric inpatient settings carry significant risks of harm and raise critical ethical concerns, which has prompted efforts to minimize their use. Models like Safewards, with its ten interventions, have shown promise in reducing conflict and containment but require active engagement from all healthcare professionals. Despite their leadership roles, psychiatrists' engagement in implementing Safewards remains underexplored, even though their involvement is likely critical for the model's success. This study aimed to identify key facilitators and barriers to psychiatrists' engagement in implementing Safewards and other quality improvement work.

METHODS: In this qualitative exploratory study, semi-structured interviews and inductive content analysis were utilized. Ten psychiatrists from nine psychiatric clinics in Sweden, providing both voluntary and involuntary care and implementing Safewards to varying extents, were recruited via convenience sampling. Participants, equally distributed by gender, had an average of 12 years of experience in their roles. Interviews were conducted in person or digitally, lasting 30-90 min, and transcribed verbatim. Data were analyzed using qualitative content analysis, with coding and categorization conducted collaboratively to ensure consistency. Reflexive practice and the COREQ checklist were applied to enhance trustworthiness.

RESULTS: Psychiatrists' engagement in Safewards and quality improvement efforts was influenced by factors tied to their professional role and the clinical work environment. Positive influences included leadership aspects, professional training, and visible benefits for patient care, such as improved communication with patients and staff. Barriers included a narrow care perspective, feelings of detachment from holistic patient care, and the unpredictable nature of psychiatrists' work. Time allocation, prioritization, and support from local management also played crucial roles in shaping engagement.

CONCLUSIONS: This study identifies key facilitators and barriers to psychiatrists' engagement in implementing Safewards, offering guidance for enhancing their participation. Strengthening leadership, broadening perspectives, and ensuring protected time for quality improvement initiatives may optimize multidisciplinary collaboration. Future research should examine whether increased psychiatrist participation positively affects Safewards outcomes. TRIAL REGISTRATION: Clinical trial number: not applicable.

The need to reduce restrictive practices in forensic mental health settings reflects a broader shift from traditional authoritarian and custodial approaches toward a more recovery-oriented ward environment. Safewards is an evidence-based model of care with ten interventions to reduce conflict and containment, focusing on social inclusion, communication skills, and patient support in stressful situations. This study aimed to describe the experiences of nursing staff with the implementation of Safewards in a Swedish forensic mental health clinic. Nine nurses participated in two focus group interviews. Using qualitative content analysis, three main themes were identified: Calling for leadership and resources, Striving for engagement, and Fostering awareness of nursing practice. Each main theme included two sub-themes. Participants described a general lack of leadership that left them feeling lost and uncertain during the implementation process. Descriptions related to preparation and training, hesitance to include patients in the implementation, and concerns about the fit of Safewards with existing clinical practices. Despite these challenges, the nurses were overall positive about Safewards, viewing the model as a step towards a recovery-oriented approach. The results support the implementation of Safewards Secure, a complement developed to the original Safewards model, tailored to the context of forensic mental health settings.

Inpatient mental healthcare settings should offer safe environments for patients to heal and recover and for staff to provide high-quality treatment and care. However, aggressive patient behaviour, unengaged staff approaches, and the use of restrictive practices are frequently reported. The Safewards model includes ten interventions that aim to prevent conflict and containment. The model has shown promising results but at the same time often presents challenges to successful implementation strategies. The aim of this study was to review qualitative knowledge on staff experiences of barriers and enablers to the implementation of Safewards, from the perspective of implementation science and the i-PARIHS framework. A search of the Web of Science, ASSIA, Cochrane Library, SCOPUS, Medline, Embase, PsycINFO, and CINAHL databases resulted in 10 articles. A deductive framework analysis approach was used to identify barriers and enablers and the alignment to the i-PARIHS. Data most represented by the i-PARIHS were related to the following: local-level formal and informal leadership support, innovation degree of fit with existing practice and values, and recipients' values and beliefs. This indicates that if a ward or organization wants to implement Safewards and direct limited resources to only a few implementation determinants, these three may be worth considering. Data representing levels of external health system and organizational contexts were rare. In contrast, data relating to local (ward)-level contexts was highly represented which may reflect Safewards's focus on quality improvement strategies on a local rather than organizational level.

Service users of psychiatry and their organisations have for decades been trying to convey users’ narratives on mental distress and its treatment. This work has made an impact; the trend is towards a humanistic psychiatric care and support; a journey from paternalism to social inclusion. Our aim in this chapter is to describe the user organisations’ narratives of psychiatric services. The method for analysis is from narrative art history focusing on 1) transformation, 2) desire for and 3) lack of.

The user’s organisations in Sweden started as a radical left-wing activist movement in the 1960s, supported by anti-psychiatry intellectuals. They managed to influence the public opinion and policy makers, which contributed to the deinstitutionalisation and humanisation of psychiatry. The following period was characterized by user organisations acting like trade unions moving towards a more dialogical work with the psychiatric services. Their major contribution was to influence the development of the new psychiatry based on outpatient care and community-based living. Today the user organisations are more integrated in the psychiatric services and an active partner in co-creation and co-production of psychiatric services.

The user organisations, together with other stakeholders, have managed to contribute to a transformation of psychiatry. The large mental hospitals have closed; there has been an increased access to healthcare and to the quality of life for many of the service users. Still, there are difficulties, like the lack of support for the users who are most severely affected by mental distress, and different kinds of coercion. These problems need to be addressed at the policy level, rather than in the psychiatric health care system. To be successful there is a lot to learn from history where user organisations have acted as activists and tough trade union representatives. More than ever, free user organisations are needed that can give a voice to those who are unable to argue for their rights themselves. Then, maybe, we could move towards social inclusion; a society where we are “Leaving No One Behind”.

BACKGROUND: The Safewards model aims to reduce conflict and use of containment on psychiatric wards. To evaluate the implementation of Safewards and understand why it is effective in some settings but not in others, it is important to assess the level of implementation fidelity. To do this, the Safewards Fidelity Checklist (SFC) is often used, which focuses on objective visual observations of interventions but does not include patient responsiveness. The latter is a key indicator of implementation fidelity and includes engagement, relevance, acceptability and usefulness. The aim of the present study was to investigate the fidelity of Safewards implementation on an acute psychiatric ward from the perspective of patient responsiveness.

METHOD: The study was conducted on a ward for patients with mainly affective disorders. To assess the general level of fidelity the SFC was used together with a detailed ward walkthrough. Ten patients were interviewed with a focus on patient responsiveness to each of the seven interventions implemented on the ward. Data were analysed using qualitative descriptive analysis.

RESULTS: The findings indicate high implementation fidelity, which was reflected in the SFC assessment, walkthrough and patient responsiveness. Patients gave examples of improvements that had happened over time or of the ward being better than other wards. They felt respected, less alone, hopeful and safe. They also described supporting fellow patients and taking responsibility for the ward climate. However, some patients were unfamiliar with a ward where so much communication was expected. Several suggestions were made about improving Safewards.

CONCLUSIONS: This study confirms previous research that patient responsiveness is an important factor for achieving fidelity in a prevention programme. The patients' descriptions of the acceptability, relevance and usefulness of the specific interventions reflected to a high degree the objective visual observations made by means of the SFC and ward walkthrough. Patient engagement was demonstrated by several suggestions about how to adapt the interventions. There is potential to obtain valuable input from patients when adapting Safewards in practice. This study also presents many examples of practical work with these interventions and the effects it can have on patients' experiences of care.

Background: The presence of violence within psychiatric and residential settings remains a challenge. Research on this problem has often focused on describing violence prevention strategies from either staffs' or service users' perspectives, and the views of ward managers has been largely overlooked. The aim of the present study was therefore to identify ward managers' strategies to prevent violence in institutional care, focusing on safety and values.

Methods: Data were collected using semi-structured interviews with 12 ward managers who headed four different types of psychiatric wards and two special residential homes for adolescents. Qualitative content analysis was applied, first using a deductive approach, in which quotes were selected within a frame of primary, secondary, and tertiary prevention, then by coding using an inductive approach to create themes and subthemes.

Results: Ward managers' strategies were divided into the four following themes: (1) Balancing being an active manager with relying on staff's abilities to carry out their work properly while staying mostly in the background; (2) Promoting value awareness and non-coercive practices in encounters with service users by promoting key values and adopting de-escalation techniques, as well as focusing on staff-service user relationships; (3) Acknowledging and strengthening staff's abilities and competence by viewing and treating staff as a critical resource for good care; and (4) Providing information and support to staff by exchanging information and debriefing them after violent incidents.

Conclusions: Ward managers described ethical challenges surrounding violence and coercive measures. These were often described as practical problems, so there seems to be a need for a development of higher ethical awareness based on a common understanding regarding central ethical values to be respected in coercive care. The ward managers seem to have a high awareness of de-escalation and the work with secondary prevention, however, there is a need to develop the work with primary and tertiary prevention. The service user group or user organizations were not considered as resources in violence prevention, so there is a need to ensure that all stakeholders are active in the process of creating violence prevention strategies.

BACKGROUND: Many psychiatric services include social inclusion as a policy with the aim to offer users the opportunity to participate in care and to form reciprocal relationships. The aim of this study was to explore opportunities and problems with regard to participation, reciprocity and social justice that different stakeholders experience when it comes to social inclusion for service users and minimizing violence in psychiatric inpatient care.

METHODS: Qualitative interviews were performed with 12 service users, 15 staff members, and six ward managers in three different kinds of psychiatric wards in Sweden. The data were analyzed using the framework method and qualitative content analysis, which was based on the three following social inclusion values: participation, reciprocity, and social justice.

RESULTS: Themes and subthemes were inductively constructed within the three social inclusion values. For participation, staff and ward managers reported difficulties in involving service users in their care, while service users did not feel that they participated and worried about what would happen after discharge. Staff gave more positive descriptions of their relationships with service users and the possibility for reciprocity. Service users described a lack of social justice, such as disruptive care, a lack of support from services, not having access to care, or negative experiences of coercive measures. Despite this, service users often saw the ward as being safer than outside the hospital. Staff and managers reported worries about staffing, staff competence, minimizing coercion and violence, and a lack of support from the management.

CONCLUSIONS: By applying the tentative model on empirical data we identified factors that can support or disrupt the process to create a safe ward where service users can feel socially included. Our results indicate that that staff and service users may have different views on the reciprocity of their relationships, and that users may experience a lack of social justice. The users may, due to harsh living conditions, be more concerned about the risk of violence in the community than as inpatients. Staff and ward managers need support from the management to foster a sense of community in the ward and to implement evidence-based prevention programs.