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New Research Identifies Ways to Reduce Self-Harm in Acute Psychiatric Wards.

LONDON, May 14 /PRNewswire/ --

Regularly checking on patients, raising the proportion of qualified nurses and organising more patient activity sessions can reduce self-harm and suicide attempts in psychiatric hospitals, according to one of the UK's largest research studies into self-harm on Britain's acute psychiatric wards, published today.

Regular checks on patients at short intervals, known as intermittent observation, was found to be more effective than constantly observing patients. Patents reported that they liked nurses checking on them regularly and appreciated staff efforts to keep them safe. The cost per patient of intermittent observation was also found to be lower compared to other measures.

Researchers at The City University, London, funded by the National Institute for Health Research (NIHR) Service Delivery and Organisation Programme, undertook the study to assess the relationship between special observation and self-harm rates.

Over 136 of the 500 acute admission psychiatric awards in England took part in the survey and used a mix of questionnaires and face to face to face interviews with staff and patients. Over 50,000 responses were collected.

The volume of admissions to a ward, or its throughput, also seems to have a negative impact, and was linked with increased rates of self-harm. This might be because newly admitted distressed patients self-harm, or they might disturb the atmosphere on the ward for existing patients, heightening their anxiety and increasing the likelihood of self-harming behaviour.

Professor Len Bowers from the St Bartholomew School of Nursing & Midwifery at The City University, London, led the research: "In summary, wards and trusts can take three measures that should lead to lower rates of self-harm: increase the use of regular checks on patients; ensure that wards run comprehensive programmes of patient activity sessions; and increase the numbers of qualified nursing staff."

"The current policy of having fewer psychiatric beds and greater patient throughput seems likely to lead to greater levels of self-harm on wards, and may need to be reconsidered," he warns.

The researchers also looked at the impact of a range of other factors including the physical environment and staff attitudes, but these did not appear to affect self-harm rates.

The researchers make the following recommendations relating to special observation, patient activity and staffing levels:

Intermittent special observation

- Trusts should review their special observation policies to ensure that this form of containment is an available option for staff.

- Clinicians on wards where this is used at less than median levels (i.e. less than five patient-shifts per day) should re-evaluate their practice.

- More research should be commissioned on the potential mechanisms that may link intermittent special observation with outcomes.

Patient activities

- Those services without a programme of patient activities should take urgent steps to provide one.

- Those with less than the mean number of patient activity sessions per week (8) should increase the numbers of such sessions.

- Staff, equipment, and space may all need to be provided to make sure any planned programme can be put into effect.


The link between a richer staff mix and lower rates of self-harm is a pointer to the importance of nurse staffing levels and grade mix on acute psychiatric ward. A systematic review of general acute care has shown lower patient mortality with a richer grade mix.

- A similar review of existing evidence on psychiatric nurse staffing levels and outcomes should be conducted.

- Standards for acute inpatient care must include nurse staffing levels and grade mix.

The research findings form part of an in-depth study, entitled The City 128 Study of Observation and Outcomes on Acute Psychiatric Awards, presented to the NHS SDO. The report is available on request to the contacts below.

Note to Editors:

Sample size

The sample size was 136 acute NHS psychiatric wards, their patients and staff, geographically situated proximate to three centres (London, Central England, Northern England). Acute psychiatric wards were defined as those that primarily serve acutely mentally disordered adults, taking admissions in the main directly from the community, and not offering long-term care or accommodation.

Basic ward data was collected on two forms, one completed by the researcher visiting the ward in conjunction with the ward manager, the second completed by the ward manager alone. Staff attitude to difficult patients was assessed using the Attitude to Personality Disorder Questionnaire (APDQ, Bowers and Allan 2006). Ward structure was assessed using the Order and Organisation, Programme Clarity and Staff Control subscales of the Ward Atmosphere Scale (WAS, Moos 1974). The quality of ward leadership was assessed by taking the score for the Ward Manager, as rated by ward staff, using the Multifactor Leadership Questionnaire (MLQ, Bass & Avolio 1995). Multidisciplinary team cohesion was assessed using the Team Climate Inventory (TCI, Anderson & West, 1999). Burnout was assessed using the Maslach Burnout Inventory (MBI, Maslach & Jackson 1981). Some staff and patients were asked to complete the Attitude to Containment Measures Questionnaire (ACMQ, Bowers 2004). This scale provides relative measures of views on acceptability, efficacy, dignity, safety of patients and safety for staff of different forms of containment for disturbed behaviour.

The 136 wards of the sample were situated within 67 hospitals within 26 NHS Trusts. The mean number of beds per ward was 21, with a range of 11 to 30, with an average of 51% of these beds in single rooms. Most wards (48%) were built in the 1980s and 1990s, with 17% in 2000 or later, 19% in the 1960s and 1970s, and only 16% prior to this. The mean number of nursing staff in post per bed was 0.99 WTE (s.d. 0.22); the mean proportion of these staff who were qualified nurses was 0.61 (s.d. 0.12), and the mean vacancy rate was high, at 15%. Male only and female only wards were in the minority (13% and 14% respectively), with most (73%) being for both genders. A significant proportion of wards (41%) had no establishment Occupational Therapists allocated to them, and the vast majority (87%) had no dedicated Clinical Psychologist time at all. Over 45,000 PCC-SRs and 9,000 other questionnaires were collected for this study during 2004-05.

Research team

Len Bowers, PhD RMN, The City University, London; Richard Whittington, PhD CPsychol, AFBPsS, BA, PGCert., University of Liverpool; Peter Nolan, Staffordshire University; David Parkin, The City University, London; Sarah Curtis, Queen Mary Westfield College, University of London; Kam Bhui, Queen Mary Westfield College, University of London; Diane Hackney, Independent User Consultant; Teresa Allan, The City University, London, Alan Simpson, RMN BA(Hons) PhD, The City University, London.

LB, RW, PN, TA and AS designed the overall study; SC designed the geographical aspects, KB designed ethnicity related aspects, and DP designed health economics aspects of the study; TA conducted the statistical analysis in conjunction with LB; DH contributed the service user viewpoint; all contributed to the interpretation of findings and to the final manuscript.

Acute psychiatric care

Key objectives are:

1) Keep people safe

2) Assess the nature and extent of the person's problems

3) Provide treatment for their illness

4) Address the person's basic self-care deficits and needs

5) Provide physical healthcare and treatment

The City University, London

The City University was founded in 1894 as the Northampton Institute and was awarded full university status in 1966. Today the University is renowned for its international focus, the employability of its graduates (5th in The Sunday Times 2006 graduate employability table) and its links with business and professions.

The University is made up of eight schools based in and around the City of London: School of Arts, School of Informatics, School of Social Sciences, School of Engineering and Mathematical Sciences, Cass Business School, The City Law School, School of Allied Health Science and St Bartholomew School of Nursing and Midwifery.

During the 2006/07 academic year The City University attracted over 23,000 students from 157 countries, while teaching staff are drawn from 41 international locations, ensuring that the University has a truly international outlook.

The NIHR SDO Programme

The NIHR Service Delivery and Organisation Programme improves health outcomes for people by:

- commissioning research and producing research evidence that improves practice in relation to the organisation and delivery of health care, and

- building capacity to carry out research amongst those who manage, organise and deliver services and improve their understanding of research literature and how to use research evidence.

LONDON, May 14 /PRNewswire/ --

For further information or media interviews with the researchers, please contact: Helena Clay, Assistant Press Officer, The City University, London, T: +44-(0)20-7040-8788 or +44-(0)7970-271-260, E:; Louise Scodie, Press Officer, The City University, London, T: +44-(0)20-7040-8783 or +44-(0)7970-271-260, E:
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Date:May 13, 2007
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