Four Steps to Safety: Violence reduction programme on inpatient psychiatric wards South London and Maudsley NHS Foundation Trust

Acute behavioural disturbance presenting as violent behaviour occurs frequently in psychiatric units. A national audit found that over a third of service users had been attacked and threatened, and almost half had witnessed this on the ward. Violence and aggression within psychiatric environments has a significant impact on patient treatment outcomes, patient and staff safety, and the therapeutic environment.

South London and Maudsley NHS Foundation Trust developed and piloted a toolkit that takes a systematic approach to team working, using evidence-based safety tools and predictive assessment. It was shown to reduce the number of violent and aggressive incidents at the trust.

This project involved spreading use of this toolkit (‘Four Steps to Safety’) across the trust, as well as to Devon Partnership NHS Trust. The project involved a variety of change methodologies including social networks, collaboratives, campaigns, change champions, demonstration sites, training, and measurement and feedback.

Evaluation showed that, overall, the implementation of Four Steps to Safety had no impact on rates of violence and aggression in either of the trusts. There was evidence of a reduction in violence and aggression on some individual wards, but there were also wards that saw an increased risk of violent and aggressive incidents. 

Implementation of the programme was more complex than anticipated, despite often sustained efforts by ward staff, and there were a number of barriers that hindered the successful adoption and implementation of the programme. 

The underlying problem of the pressure on mental health care make inpatient wards a very difficult context in which to implement programmes such as this. The co-production and service user involvement was promising, but faced difficulties that were beyond the control of the trusts.