To Örebro University

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.