1. Some observations on observation practice Professor Len Bowers

2. Overview

3. City-128: observation and outcomes 136 wards participated (6 months), in 67 hospitals in 26 Trusts. PCC-SR: 47,000 end of shift reports were collected and scanned. 68 acute ward years of data Also information on: patients admitted, service environment, and physical environment Additional measures: –Attitude to Personality Disorder Questionnaire –Attitude to Containment Methods Questionnaire –Maslach Burnout Inventory –Multifactor Leadership Questionnaire –Team Climate Inventory –Ward Atmosphere Questionnaire (partial): order and organisation, program clarity, staff control

4. Self-harm model Positive correlations (more self-harm with more of these): –Rate of admissions and admissions during shift –Locked ward door –Ethnicity of staff/patients Negative correlations (less self-harm with more of these): –Intermittent observation –Numbers of qualified staff on duty

5. Null findings Constant special observation was not related to self-harm rates Staff attitudes, morale, teamwork, leadership and ward atmosphere were not associated with self-harm rates in this analysis Security practices were not associated with self- harm rates

6. Substitution Wards with cctv and better general observation features used less intermittent observation A general surveillance function that stays static and is implemented in different ways Intermittent and constant observation use were inversely correlated, i.e. more of one meant less of the other CSO use was associated with more Bank/Agency staff. But not intermittent.

7. Acceptability of containment

8. Conclusions on self- harm Premature to draw conclusions about the efficacy of special observation, but: –No indication that constant observation is effective –Startling and unexpected evidence on the possible efficacy of intermittent observation –Intermittent observation preferred by patients Use of intermittent observation should be facilitated and/or increased Means of effect? NPSA data shows. Enriching the nursing skill mix and increasing structured patient activities may also help to reduce self-harm Locking the ward door may have adverse consequences

9. The Tompkins Acute Ward Study Longitudinal study of 13 acute psychiatric wards and 3 PICUs over 5 years > 15k end of shift reports, all officially reported incidents, staffing deployment, PMVA training records, 191 patient interviews, 151 staff interviews, and over 500 staff questionnaires

10. Cross section versus time

11. Constant SO associations Affective disorder admissions Self harm Physical aggression to others Bank/agency staffing use

12. TAWS conclusions Not clear whether use of lots of constant special observation has a good outcome Constant observation used for self-harm and also for aggression

13. Conflict and containment sequence study The sequence or order of conflict and containment events (PCC-CN) First two weeks of admission Characteristics of patients Acute psychiatric wards and psychiatric intensive care units Random sample of adult (18-65 years old) patients Final sample: 522 patients on 84 wards in 31 hospital locations

14. Three types of CSO use 86 patients (16%) received CSO 1.36 patients (7% of sample) were placed under CSO at the point of admission 2.The most common event immediately prior to CSO was an end to intermittent SO (23%), prompted by self harm (8), absconding attempts (2) or physical violence (2) 3.Returning from absconding and aggression, particularly verbal aggression, and self- harm/suicide attempt were the next most frequent conflict behaviours to immediately precede initiation of CSO

15. Events during CSO use There was more aggression during CSO than before it Verbal aggression the most common event to occur during CSO Self-harm and suicide attempts also occurred Lots of PRN medication given during CSO. Sometimes show of force and manual restraint were used Patients with a previous history of self-harm were more likely to be placed on CSO, but not patients with a history of harm to others

16. Conclusions Three circumstances of use: on admission, when intermittent observation fails, and post crisis Three behaviours targeted: aggression, self- harm and absconding Constant SO irritating and may prompt aggression Unclear what impact it has on self-harm or suicide attempts, as these still occur

17. NPSA suicide attempts 602 reports of attempted suicide Between 01 st January 2009 and 31 st December 2009 In mental health inpatient units Included only attempts made on the ward, and attempts made off the ward where the actions of ward staff prevented the suicide. Aim: how were these prevented from becoming completed suicides

18. How patients were found by staff

19. CSO suicide attempts Ran into her bedroom, locking the door behind her, tying a ligature before access could be gained. Tying ligature underneath the bedclothes while in bed (n = 2) Allowed to go to the toilet unobserved while nurse waited outside the door, attempted suicide by suffocation while out of sight (n = 1), or by tying ligature (n = 2). Allowed to go to the toilet with door left open, but nurse stood to one side to give privacy. Ligature tied whilst out of sight.

20. Conclusions Intermittent observation is good CSO can be circumvented: be on your guard Be caringly vigilant and inquisitive

21. Literature review 1960-2009, 63 papers 4-16% of patients placed on CSO Mostly lasts 2 days or more Reasons for use: self-harm/suicide, absconding, aggression What outcome information there is relates to self-harm and suicide No outcomes or studies of CSO for aggression

22. Observations on observation for violence Two to one observation for violence: –No evidence on efficacy –Unusual practice –Justification on a PICU? Rationale? What goes on during such observation? Cost Review. How do you know when to stop?

23. Summary Intermittent observation for self-harm and suicide prevention is good. There is evidence it works, and patients prefer it CSO for self-harm and suicide is less clear in terms of evidence, but common sense says it works No evidence on efficacy for absconding prevention What little evidence there is for aggression suggests observation may increase it

24. Inpatient suicide prevention course Baseline MCQs and Attitude to Suicide Prevention Scale General risk assessment and inpatient risk assessment (videos, case studies, practice) Routines to prevent (videos, online discussion) Constant and intermittent observation (research review, evaluate 8 new ideas on obs practice, review local policy, share ideas) Being Caringly Vigilant and Inquisitive (review public news stories and clinical cctv footage) Understanding the suicidal mind (Schneidman’s 10 commonalities, build empathy) Spending time with suicidal people (interaction skills explained by expert nurse) Outcome MCQs and Attitude to Suicide Prevention Scale http://www.youtube.com/watch?v=hBrs53ZsPIY

25. len.bowers@kcl.ac.uk www.kcl.ac.uk/mentalhealthnursing www.safewards.net