Safewards in acute medical/surgical care wards: Capability, opportunity, motivation and behaviour model (COM-B) and theoretical domains framework analysis

Safewards is an evidence-based practice improvement model to minimise conflict in inpatient mental health units. There is limited published research on implementing Safewards in acute medical/surgical care wards. To identify, from nurses' perspectives, barriers, and facilitators to implement four Safewards interventions in acute medical/surgical care wards. This article reports qualitative findings from a funded mixed-method evaluation of the Safewards Acute Care Pilot Project. Six focus group interviews comprising 35 nursing staff from four hospitals in Victoria, Australia were completed between April and October 2022. The semi-structured interview guide included questions developed using the Capability, Opportunity, Motivation and Behaviour (COM-B) model. Data was thematically analysed and mapped to a matrix combining COM-B and the Theoretical Domains Framework (TDF) to elucidate barriers and facilitators to implementing four Safewards interventions in acute medical/surgical care wards. Three components in the COM-B model and three TDF domains were identified as barriers to the adoption of Safewards in acute medical/surgical care wards. Specific barriers included physical opportunity challenges related to the environmental context and resources domains. The key themes included time constraints and competing priorities; lack of physical space and infrastructure; and poor patient uptake due to lack of understanding. Gaps emerged as a psychological capability barrier within the TDF knowledge domain. Additionally, resistance to practice changes were associated with the motivation component of the COM-B model. Conversely, six TDF domains were relevant to facilitating the implementation of the Safewards interventions: memory, attention, and decision processes; physical skills; social influences; social/professional role and identity; goals; and beliefs about consequences. Key facilitators included the Safewards interventions serving as reminders to focus on compassionate nursing care; nursing staff possessing the skillset for interventions; peer pressure and mandated change; supportive and passionate leadership; presence of champions to drive momentum; belief in nursing staff ownership and expertise for leading implementation; personal commitment to improve work environments and care quality; and the belief that Safewards would improve ward culture. Addressing barriers and leveraging facilitators can inform strategies for enhancing staff capability to implement Safewards in acute care wards. Specifically, a tailored, multilayered approach focusing on leadership support, training, resources, patient input, and feedback can promote effective adoption of the Safewards model and adaptation of discrete interventions. Safewards adaptation: Addressing barriers like resources, space, and patient awareness; leveraging peer modelling and leadership strategies for success.