Reducing Containment in Open-Door Acute Mental Health Care: A Retrospective Before-and-After Analysis of Safewards Implementation

Background: Safewards is an evidence-based model designed to reduce conflict and restrictive practices in mental health inpatient settings. Although Safewards has been evaluated in multiple international contexts, evidence from routine implementation in open-door settings remains limited, particularly within Southern European healthcare systems. This study examined changes in the frequency and nature of conflict events and the use of containment measures following Safewards implementation in an open-door acute mental health inpatient unit. Methods: A retrospective before-and-after analysis was conducted using prospectively recorded routine clinical data from a 14-bed acute mental health unit in a public hospital in Spain. Conflict and containment events were recorded at the end of nursing shifts using the Patient–Staff Conflict Checklist–Shift Report (PCC-SR). The primary comparison included 242 baseline shifts (29 July–27 October 2019) and 162 post-implementation shifts (1 November 2021–30 January 2022). Safewards was implemented progressively, with the COVID-19 interruption excluded from the primary comparison. Shift-level event rates were compared using negative-binomial regression with calendar-date cluster-robust standard errors. For outcomes with no post-implementation events, Fisher’s exact test and exact Clopper–Pearson confidence intervals were used. Results: During the post-implementation period, verbal aggression decreased from 0.40 to 0.01 events/shift (IRR = 0.031, 95% CI 0.007–0.131, p < 0.0001), and verbal containment decreased from 1.93 to 0.09 events/shift (IRR = 0.048, 95% CI 0.022–0.104, p < 0.0001). Physical aggression towards objects decreased from 0.14 to 0.00 events/shift, while forced medication and environmental seclusion fell to zero recorded events. Overall containment interventions decreased from 2.21 to 0.10 events/shift (IRR = 0.048, 95% CI 0.023–0.098, p < 0.0001), and coercive containment from 0.27 to 0.01 events/shift (IRR = 0.045, 95% CI 0.011–0.194, p < 0.0001). Mechanical restraint remained infrequent and did not differ between periods (0.01 events/shift in both; IRR = 1.49, 95% CI 0.14–16.30, p = 0.74). A total of 404 shift reports were completed, representing 74% of expected shifts. Conclusions: The period following Safewards implementation was associated with reductions in several conflict behaviours and containment interventions in this open-door acute mental health unit, while overall recorded conflict remained broadly stable. Mechanical restraint did not decrease in the primary comparison, and differential PCC-SR recording completeness between study periods warrants cautious interpretation. Controlled, multicentre studies with longer follow-up are needed to determine the effectiveness and sustainability of Safewards in open-door mental health settings.