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Using safety crosses for patient self-reflection

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Patients in a medium-secure mental health unit used Productive Ward safety crosses as a tool for self-reflection in order to promote recovery.


The Productive Mental Health Ward programme has been developed to improve efficiency and safety in the NHS. Patients in a medium-secure mental health unit used patient safety crosses as a tool for self-reflection as part of their recovery journey. This article describes how the project was set up as well as initial findings.

Citation: Silverton S (2012) Using safety crosses for patient self-reflection. Nursing Times [online]; 108: 22/23, 14-16.

Author: Sarah Silverton was an improvement facilitator (at the time of writing this article) for the Productive Mental Health Ward programme at the South London and Maudsley Foundation Trust. She is now patient and public experience lead at Dorset County Hospital Foundation Trust, Dorchester.

Lean techniques, used in the manufacturing industry, have been promoted in the NHS in recent years to improve efficiency and safety (Cooper and Mohabeersingh, 2008).

The NHS Institute for Innovation and Improvement developed the Productive Mental Health Ward (PMHW) initiative to help staff use lean techniques to redesign the way they work to release more time to care for patients (NHS III, undated).

PMHW uses a safety cross as a tool to display key information about the safety of the ward, which is completed daily (NHS III, undated). Each number on the cross represents the day and date for that month.

Staff, patients and carers work together to choose the safety measures relevant to the ward - such as slips, trips and falls - and display this on the PMHW safety-cross tool, making safety information available immediately and at a glance.

Spring Ward at the South London and Maudsley Foundation Trust (SLaM) is a medium-secure mental health unit for women. As part of the Knowing How We are Doing module in the PMHW initiative, during a ward community meeting the team discussed with patients the issue of monitoring violence, aggression and selfharm using the safety-cross tool. Patients responded by asking “What about us?”.

They explained they felt the team intended to use the tool to monitor violence and aggression towards staff only, and asked about monitoring the violence and aggression they may experience. They also felt it did not capture the times when they thought of self-harming but did not do so.

Using safety crosses

SLaM employs improvement facilitators to help implement the PMHW programme throughout the trust; I was the facilitator for Spring Ward. I attended the community meeting and suggested each patient be offered her own safety cross to complete.

Patients and staff then agreed an action plan - that it would be trialled for a month and offered as a tool for self-reflection that could be used in one-to-one time.

Patients could colour the chart in red if they were having a bad day, yellow a fair (soso) day and green a good day (Figs 1-3a), and wrote on the chart to explain their feelings behind the colours (Fig 3b). I suggested they write a sentence about how they felt on the back of the sheet, corresponding to the date. The results were extremely powerful.

For the purposes of this article all identifying information has been erased; each patient involved gave consent, including for anonymised materials to be published.


Patient 1 wrote sentences about her good days but not the so-so or bad days (Fig 1).

Her good days were related to attending ward rounds, hearing from her solicitor, it being the weekend and a party being held on the ward. This gave team members insight into her likes and dislikes, which may not otherwise have been disclosed.

They were able to explore whether she had difficulty sharing her feelings on the bad days and linked this to any self-harming behaviour she may have displayed.

Patient 2’s strength of feeling (Fig 2) was clear, as the red day struck in an otherwise good month. She was upset because she had been playing a board game with a nurse when the nurse was called away to do something “important” in the office. The person who suggested the nurse had something important to do had upset the patient unintentionally. She was able to apologise to the patient and reflect on the effect her words can have.

Patient 3 indicated that the afternoons and evenings were times when she could sometimes see her mood deteriorate (Fig 3a). In mental health we often try to determine diurnal mood variation in patients, but seeing such a visual record like this was extremely striking for the team. Again team members were able to explore what caused the patient’s mood to change as the day progressed. The patient also kept a brief record on the back of the paper (Fig 3b). On some days, her distress is clear and ended in self-harm. Staff were able to reflect on the safety cross with the patient and agreed some strategies for the red times.

Patient 4 (Fig 4) was unhappy about the food and about a toilet (which had previously been available to her in the day room) being designated a male staff toilet, especially as she felt there were not enough men working on the all-female unit to justify it. She had been using the toilet as her own was broken, so was given access to it again and her own repaired as a matter of urgency. This gave the team the opportunity to reflect on the importance of involving patients in the ward’s decisionmaking, no matter how inconsequential it may seem. Turning the day-room toilet into a male staff toilet had a huge impact on this patient’s activities of daily living.

She had not expressed her upset to the team and the safety cross gave her an opportunity to show this. The catering services were invited to the patient community meeting to resolve the catering issue she raised.

Patient 5 (Fig 5) had two days when she was unable to do activities in which others were taking part because of her leave status; she attended Healing Gardens, a therapeutic area in the unit, and went on a day trip to Hastings for staff and patients. When the team saw the impact of this, they were able to arrange something for her to do on the ward to compensate.


The PMHW initiative promotes visual management to display key information at a glance. Using the safety cross in this way displays the most vital information - a patient’s thoughts and feelings - to any mental health nurse.

Having thoughts and feelings displayed in such a visual way is an extremely effective way of communicating.

The red, yellow and green colours are a global language so even patients with very limited English language skills were able to make their feelings known.

Having a severe mental health problem can mean it is sometimes difficult to communicate or remember events clearly. Using safety crosses meant patients were empowered to use a different medium for communication other than talking, enabling them to take control of their recovery.

The trust supports a recovery-oriented approach to mental health services and promotes working in partnership with patients to facilitate their recovery journeys. A position statement by psychiatrists from SLaM and the South West London and St George’s Mental Health Trust (2010) challenged clinicians to “look beyond clinical recovery and to measure effectiveness of treatments and interventions in terms of the impact on goals and outcomes to the individual service user and their family”. Safety crosses provide patients and clinicians with the opportunity to do just that and to see beyond a set of symptoms. They also give clinicians the chance to access the undercurrent of thoughts and feelings that occur, despite patients appearing (to use a hackneyed word) “settled”.

Representing feelings visually is a safe way of showing emotion. We do not know how many incidents of self-harm or violence and aggression may have been prevented because patients used safety crosses to display their thoughts instead of demonstrating them physically. However, the ward is measuring this separately as part of the Knowing How We are Doing module; incidents in both areas have reduced.

During one month there were no incidents at all, which is why staff and patients were treated to a day out to Hastings. Again this is another way of promoting recovery.

The feedback provided in the safety crosses has meant concerns can be addressed immediately, leading to a safer environment and improvements in care.

This also means problems do not fester in a long-stay ward.


Beginning to use patient safety crosses on the ward was not without its challenges.

One of the initial difficulties was getting the whole team on board. Despite my support and encouragement, the team saw it as a project in which only one or two members of staff were involved. Although the trust endorses mental health professionals to consider ways in which practice can be oriented to actively support recovery ideas across services (SLaM and SWLSTG, 2010), this message takes time to filter through to frontline staff.

It was also difficult to achieve multidisciplinary ownership, so it was not just seen as something nurses did. Furthermore, competing demands on team time meant the project was difficult to sustain. This could be overcome by buy-in from the multidisciplinary team, which we achieved when the consultant used the safety crosses as part of ward rounds and in patients’ recovery folders.


Together with the staff nurse lead, I continued to encourage such use of safety crosses on the ward. As patients returned them, the team started to see the benefits of using them in one-to one sessions; staff and patients found it useful to have the structure. This was enhanced when the consultant used them as part of ward rounds and in the recovery folder.

The government’s strategy for health promotes “no decision about me without me” as a central principle (Department of Health, 2010). Patient safety crosses mean patients have a personal record to use in the decision-making process.

The crosses were a useful tool for communication, especially for patients in distress and for those whose first language was not English.

They promote much of the philosophy of the SLaM recovery model and help to maintain hope when, over time, there are more green days than red ones. Opting to use safety crosses to express thoughts and feelings also enables patients to take responsibility and control of their situation.


Patient safety crosses are a valuable tool to help patients express emotions in a safe way. They can be used to promote recovery and may reduce levels of violence and aggression as well as self-harm. Now that use of safety crosses is more embedded in the team, Spring Ward aims to see whether these incidents reduce over time as service users opt to represent their feelings in a safe, visual way. The team is also collecting feedback from staff and service users about their experiences of using the crosses.

Key points

  • The Productive Mental Health Ward initiative uses safety crosses as a tool to display key information
  • Patients can be given their own safety cross to complete as a tool for self-reflection
  • Empower patients to use a different medium for communication other than talking
  • This tool may reduce levels of violence and aggression as well as self-harm
  • Patient safety crosses are a valuable tool to help patients express emotions in a safe way 
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