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 acute psychiatric wards

Researchers at the City University, London, funded by the National Institute for Health Research service delivery and organisation programme, undertook a study to assess the relationship between special observation and self-harm rates.

They found that conducting regular checks on patients at short intervals, known as intermittent observation, was more effective at reducing self-harm than constantly observing patients. Patients 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.

More than 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 interviews with staff and patients. More than 50,000 responses were collected.

A high volume of admissions to a ward also seems to have a negative impact, and was linked with increased rates of self-harm. This might be because newly admitted distressed patients are more likely to 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.

Key measures

Professor Len Bowers of the St Bartholomew School of Nursing and 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 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 this form of containment is an option for staff.

  • Clinicians on wards where this is used at less than median levels (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

  • 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 (eight) 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.

Staffing levels

  • The link between a richer staff mix and lower rates of self-harm points to the importance of nurse staffing levels and grade mix on acute psychiatric wards. 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, The City 128 Study of Observation and Outcomes on Acute Psychiatric Awards.

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