Available online at www.sciencedirect.com

General Hospital Psychiatr

y 31 (2009) 523–530

Constant special observation and self-harm on acute psychiatric wards:a longitudinal analysis

Duncan Stewart, Ph.D.⁎, Len Bowers, Ph.D., Fiona Warburton, M.Sc.City University, E1 2EA London, UK

Received 24 February 2009; accepted 12 May 2009

Abstract

Objective: Special observation (the allocation of nurses to watch over nominated patients) is a method of preventing patients harmingthemselves. This study assessed the relationship between constant special observation (keeping a patient within eyesight or reach) and ratesof self-harm on acute psychiatric wards.Method: A longitudinal analysis of officially collected data covering a period of 2 1/2 years from 16 acute wards at three Hospitalsin London.Results: There was no statistically significant association between constant special observation and self-harm outcomes. Use of observationvaried markedly between hospitals and wards, but overall, there was a significant decline over time. Self-harm incidents were rare (recordedin only 7% of ward weeks) and did not decline over time, but were correlated over consecutive weeks.Conclusion: The lack of association with self-harm suggests that the use of constant special observation could be reduced withoutcompromising patient safety.© 2009 Elsevier Inc. All rights reserved.

Keywords: Self-harm; Acute psychiatric wards; Observation

1. Introduction

Special observation is a widely used method of prevent-ing acutely ill psychiatric inpatients from harming them-selves [1,2], but is also used to manage aggressive behavior,refusal of medication and to prevent absconding [1,3–6].One study reported that observation was used as analternative to seclusion [7]. The procedure involves assign-ing an identified person to the care of the “at-risk” patient fora certain period of time, above the minimum general level ofobservation required for all inpatients. UK practice guide-lines [8] suggest three levels of special observation:intermittent, where the patient's location must be checkedat specified intervals; within eyesight, where the patientshould be kept within sight at all times and within arms

⁎ Corresponding author. School of Community and Health Sciences,City University, E1 2EA London, UK.

E-mail address: duncan.stewart.1@city.ac.uk (D. Stewart).

0163-8343/$ – see front matter © 2009 Elsevier Inc. All rights reserved.doi:10.1016/j.genhosppsych.2009.05.008

length, where patients must be observed in close proximity atall times.

Up to a fifth of psychiatric inpatient admissions receivesome form of special observation during their stay [9], butinconsistencies in its application are widespread. A nationalsurvey of observation policies among psychiatric inpatientservice providers found variable terminology and standardsof record keeping, while one in 10 did not have a writtenpolicy at all [1]. Special observation is usually initiated bymedical staff [3,5,6,10], but some studies have reported thatnurses are able to make decisions without consulting medicalcolleagues [4,11,12]. The range of staff involved in specialobservation also varies, with some hospitals requiring anursing degree while others allow staff to volunteer toundertake the task [1,13,14]. Nursing assistants may beassigned to observation on night shifts [10]. When nursingstaff are not available, bank and agency staff are commonlyemployed for special observation [1].

There is little empirical evidence to support theeffectiveness of special observation in preventing patients

524 D. Stewart et al. / General Hospital Psychiatry 31 (2009) 523–530

from harming themselves or others [9]. Despite theimperative to prevent self-harm and suicide on acutepsychiatric wards, suicides do unfortunately occur whilepatients are under enhanced levels of observation. A nationalclinical survey in England and Wales found that a fifth of in-patient suicides were among patients under intermittentobservation and 3% were under constant observation [15].The present study uses longitudinal data to examine therelationship between self-harm and constant special observa-tion (CSO), defined as keeping a patient within eyesight orreach. Using official reports of self-harm and CSO hoursover a period of 140 consecutive weeks, the study aims to (a)describe patterns of self-harm and CSO over time, (b)identify factors associated with the use of CSO and (c) assessthe effect of CSO on rates of self-harm.

2. Methods

2.1. Sample

Data were drawn from official reporting systems of oneNational Health Service (NHS) Trust in London, England.The Trust (a self-governing organizational unit within theNHS) included 13 acute psychiatric wards and threepsychiatric intensive care units (PICUs) on three hospitalsites. All but one ward were of mixed gender. The numberof beds in the wards ranged between eight and 20, with atotal capacity across the Trust of 262 beds. Hospital andward names are presented as pseudonyms. Data onadmissions and incidents were available at two hospitalsfrom 2002, with the third commencing the incidentreporting system in 2003. Staffing data was recorded fromOctober 2003 and included hours of absence (sum ofvacancies, annual leave, sick leave, maternity leave andstudy leave) and hours of bank and agency staff usage.Therefore, complete information on admissions character-istics, incidents of conflict on the wards, staffing and use ofCSO was only available for all wards from October 2003until the end of the study in June 2006. Thus, the period forthis study comprised 140 weeks (2.7 years), including 2239ward weeks of data. None of the wards reported difficultiescollecting data during this period.

2.2. Procedures

The study combines data from three official datasources. (i) The Patient Administration System, the Trust'smain system for collating patient related statistics, was usedto provide data on admissions and patient characteristics byward, e.g., age, gender, ethnicity, diagnosis (ICD-10category). (ii) Data on adverse incidents are routinelycollected by nursing reports, which are entered on aproprietary computer system. We were provided with thedates and wards of all incidents falling into the followingcategories: verbal abuse, property damage, physical assault,self-harm and absconding. Some of these incidents were

severe, requiring special investigation and report, and werereferred to as “serious untoward incidents” (SUIs). An SUIwas any incident where medical treatment was required ordeath occurred, or where moderate to high financial loss, orloss of reputation, might occur. Managers, using guidelinesfrom the National Patient Safety Agency, decided whetheran incident was counted as an SUI. However, the preciseoutcome for self-harm and other incidents (such as injuriesor deaths) was not recorded on the official reportingsystems available to the study. (iii) Finally, weeklyworkforce information from ward managers was collatedcentrally, and covered staffing changes, vacancy rates, bankand agency nursing utilization, annual leave, study leave,sick leave and number of hours spent providing CSO.Permission to access and use these sources of data wasprovided by the NHS Trust managers and by the localethics committee.

2.3. Data analysis

In addition to raw frequencies per week, variables arepresented as means per 100 beds since bed numbers on thewards varied. Trends were analyzed by Spearman correla-tions with time (weeks) as the distribution of the variablesdescribed above was skewed. Differences between hospi-tals in self-harm incidents and the use of CSO weremeasured by Kruskal–Wallis tests. Analyses at thehospital and Trust level were conducted with aggregateddata (ward weeks averaged for each hospital or the sampleas a whole).

Mixed-effects regression modeling was conducted toidentify predictors of CSO (logistic regression) and self-harm incidents (Poisson regression, with beds as theexposure variable; results using logistic regression weresubstantively the same). Too few self-harm SUIs wererecorded to enable robust analysis of this variableseparately. Therefore, the analysis was conducted for allself-harm incidents. Independent variables included num-ber of incidents of verbal abuse, property damage,physical assault, self-harm and absconding; total hoursof staff absence; bank and agency staff hours; hours ofCSO; admissions classified by diagnosis, gender, age(under 35 years and 35 and over) and ethnic origin.Lagged variables of 1 week were created for eachindependent variable to examine any time dependenteffects. Hospital and ward were entered as random effectsto control for the hierarchical structure of the data (wardsnested within hospitals). Models were produced using abackwards stepwise procedure, with variables beingremoved one at a time until only significant variables(Pb.05) were left in the model. Initial models wereconstructed for admission demographics, admissionsdiagnosis, conflict, staffing and special observationvariables. Significant variables from these domain modelswere then used to construct a final model using the sameprocess of backward selection.

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3. Results

3.1. Self-harm incidents

Self-harm incidents (n=179) were recorded in only 7%of the 2239 ward weeks of the study (Table 1); a minorityof these were reported as SUIs (n=41). There was nostatistically significant trend in self-harm incidents over thecourse of the study (r=0.008, P=.927). Nevertheless,patterns of self-harm incidents differed between hospitalsas well as wards within the same hospital. As Fig. 1shows, Refuge hospital had a higher number of self harmincidents during the study (total=107; 10% of ward weeks)than Haven (total=32; 4% of ward weeks) and Shelter(total=40; 5% of ward weeks) hospitals. This differencewas statistically significant (Kruskal–Wallis χ2

[2]=22.97,Pb.001). At Haven hospital, the number of self-harmincidents ranged from 3 to 10 across the wards; Empirewas the only ward in this hospital where more than oneself-harm incident in a single week was recorded. Therange of self-harm incidents was even greater amongwards in Refuge hospital: from nine in the PICU to 32 inThames ward. Shelter hospital had the only ward in thestudy to record just a single self-harm incident (ShelterPICU). The maximum number of incidents at Shelter was16 (Hoba ward).

Table 1Self-harm, other incidents and admissions characteristics

n % Ward week 100 bedsper week

Mean S.D. Mean S.D.

Self harmAll self-harm 179 7 0.08 0.32 0.49 2.03SUIs 41 2 0.02 0.13 0.12 0.88Non-SUIs 138 5 0.06 0.29 0.38 1.85

Other incidentsPhysical aggression 683 22 0.31 0.68 2.06 5.01Abscond 395 14 0.18 0.49 1.10 3.12Verbal aggression 233 9 0.10 0.37 0.69 2.62Property damage 125 5 0.06 0.27 0.36 1.90Substance use 67 3 0.03 0.19 0.18 1.22AdmissionsAll admissions 6328 2.82 2.05 16.71 11.96Male 3728 59 1.67 1.50 9.82 8.94Under 35 years 2988 47 1.34 1.27 7.95 7.60Ethnic minority 4241 67 1.89 1.58 11.27 9.42Caribbean 461 7 0.21 0.47 1.24 2.87Indian 206 3 0.09 0.32 0.57 1.99Bangladeshi 526 8 0.23 0.55 1.36 3.17Other black 552 9 0.25 0.51 1.50 3.12Other white 579 9 0.26 0.53 1.50 3.09Other ethnic group 1917 30 0.86 1.05 5.10 6.29Substance use 572 9 0.26 0.54 1.50 3.20Psychosis 3012 48 1.35 1.27 7.97 7.42Affective disorders 1934 31 0.86 1.03 5.09 6.08Neuroses 224 4 0.10 0.34 0.59 2.03Personality disorder 272 4 0.12 0.36 0.72 2.16

3.2. Constant special observation

A mean of 41.6 h (S.D.=87.60) of CSO per week wasrecorded across the 16 wards. There was a statisticallysignificant downward trend (r=−0.652, Pb.001) in CSOhours from a mean of 50.7 (S.D.=77.8) in the first week to7.8 (S.D.=31.1) hours in the final week of the study. Therewas no CSO for two thirds (67%) of ward weeks. Fig. 2shows mean CSO hours by hospital and ward. The use ofCSO differed significantly between the three hospitals(Kruskal–Wallis χ2

[2]=117.47, Pb.001). Substantiallymore CSO was recorded at Haven hospital (50% ofward weeks; mean hours=74.3, S.D.=115.1) comparedto Shelter (20% of ward weeks; mean hours=22.0,S.D.=60.5) and Refuge (27% of ward weeks; meanhours=32.4, S.D.=73.0) hospitals.

The extent to which CSO was used and the pattern ofits use over time varied considerably between wards in thesame hospital. For example, at Haven hospital, the PICUhad the highest CSO hours with a mean of 192.9 h perweek (S.D.=156.9) and CSO recorded for 80% of wardweeks. In the same hospital, CSO was used for 1 weekonly at Felstead ward. Although Refuge Hospital had thelowest observation hours overall, at one ward (Victoria)the use of CSO was recorded in 48% of ward weeks withan average of 69.8 h per week (S.D.=103.6). The highestlevel of CSO at Shelter Hospital was recorded forMetropolitan ward with a mean of 62.2 h per week(S.D.=89.0) and use for 57% of ward weeks, but twowards at this hospital (Hoba and Shelter PICU) werecharacterized by long periods without CSO (94% and 90%of ward weeks respectively).

3.3. Other incidents

The most prevalent adverse incident on the wards wasphysical aggression (Table 1), reported in a fifth of wardweeks. There was an average of one absconsion per 100 beddays. Verbal aggression, property damage and substance usewere the less frequently recorded incidents (9%, 5% and 3%of ward weeks, respectively).

3.4. Staffing

An average of 407.3 h (S.D.=128.1) of staff absence wasreported per ward per week, ranging from 57 to 1006 h.Overall, a mean of 310.6 h (S.D.=111.6) of bank andagency staff time were recorded on the wards, ranging from0 to 877 h (bank and agency staff were used in 99% ofward weeks).

3.5. Admissions characteristics

A total of 6328 patients were admitted during the studyperiod at an average rate of nearly 17 per 100 beds per weekacross the Trust (Table 1). Admissions tended to be male andof non-white British ethnic origin. Approximately half ofadmissions were under 35 years old, and the majority were

Fig. 1. Self-harm incidents by hospital and ward.

526 D. Stewart et al. / General Hospital Psychiatry 31 (2009) 523–530

diagnosed with psychosis (48%) or affective disorders(31%). Nine percent of admissions were for a substanceuse disorder, and 4% were diagnosed with neuroses or apersonality disorder.

Fig. 2. Constant special observation

3.6 CSO and self-harm outcomes

To assess the relationship between CSO and self-harmoutcomes, ward weeks were grouped by the presence or

hours by hospital and ward.

Table 2Odds ratios for CSO models

Domain models Final model

OR 95% CI P OR 95% CI P

Admissions diagnosisAffective disorders 1.211 1.081–1.357 .001 1.183 1.042–1.343 .009ConflictSelf harm 1.690 1.238–2.308 .001 1.568 1.106–2.222 .012Physical aggression 1.310 1.119–1.534 .001 1.322 1.114–1.569 .001StaffingBank and agency 1.004 1.003–1.006 b.001 1.004 1.003–1.006 b.001Bank and agency (previous week) 1.002 1.000–1.003 .008ObservationCSO (previous week) 1.014 1.012–1.016 b.001 1.013 1.011–1.015 b.001Random effects variance (S.E.)Hospital 0.000Ward 1.551 (0.637)

OR, odds ratio.

527D. Stewart et al. / General Hospital Psychiatry 31 (2009) 523–530

absence of CSO and self-harm: (1) both CSO and self-harmrecorded (n=58); (2) no CSO but self-harm recorded (n=89);(3) CSO but no self-harm recorded (n=622); (4) no CSO orself-harm recorded (n=1375). Rates of self-harm in thefollowing week were then examined for each group. Forweeks with self-harm (Groups 1 and 2), rates of self-harm inthe following week were similar regardless of CSO (16% vs.17%). Outcomes for weeks with no self-harm (Groups 3 and4) were lower but also showed little difference by CSO status(7% vs. 6%). The results demonstrate an association betweenself-harm over consecutive weeks but no protective effect forCSO (χ2

[3]=23.45, Pb.001).

3.7 CSO and self-harm models

Given the variations in practice between wards describedabove and the possible influence of patient and staff factors,predictive analyses of CSO and self-harm were conducted

Table 3Incident rate ratios for self–harm models

Domain models

IRR 95% CI

Admissions demographicsUnder 35 (previous week) 1.249 1.118–1.396Admissions diagnosisSubstance use (previous week) 1.580 1.255–1.987Neuroses 1.572 1.064–2.324Personality disorder (previous week) 1.685 0.204–2.359ConflictSelf-harm (previous week) 1.638 1.241–2.163Physical aggression 1.231 1.031–1.468Property damage 1.499 1.201–1.871StaffingBank and agency 1.002 1.000–1.004Random effects variance (S.E.)HospitalWard

IRR, incident rate ratio.

using mixed-effects regression modeling techniques (logisticand Poisson, respectively). Domain models were constructedfor admission demographics, admissions diagnosis, conflict,staffing and special observation variables. Statisticallysignificant (Pb.05) variables were then used to construct afinal model.

The domain and final models for CSO are shown inTable 2. Use of CSO was associated with the number ofpatients admitted with an affective disorder diagnosis andhigher levels of self-harm and physical aggression on thewards. There was also a positive association between CSOand bank and agency staffing hours during the week as wellas from the week prior, although the latter variable was notretained in the final model. Finally, CSO was predicted byCSO hours in the previous week.

The models for self-harm are shown in Table 3. Theseanalyses confirmed that there was no statistically significantassociation between CSO and self-harm incidents, even

Final model

P IRR 95% CI P

b.000 1.175 1.042–1.324 .008

b.001 1.488 1.172–1.889 .001.023 1.604 1.085–2.369 .018.002 1.562 1.112–2.197 .010

b.001 1.699 1.288–2.242 b.001.021

b.001

.010 1.002 1.000–1.003 .011

0.143 (0.160)0.175 (0.115)

528 D. Stewart et al. / General Hospital Psychiatry 31 (2009) 523–530

when other factors were controlled for. The risk of self-harm was significantly increased if there had been self-harm on the ward in the previous week. Physicalaggression and property damage were associated withincreased risk of self harm in the domain model but werenot retained in the final model. Admissions with neuroticdisorders increased the risk of self-harm, as did substanceuse and personality disorder admissions during the previousweek. Admissions under the age of 35 during the previousweek and bank and agency staff hours were also associatedwith increased self-harm incidents.

4. Discussion

The results of this study show no significant relationshipbetween CSO and self-harm outcomes. The use of CSO wasnot associated with a lower incidence of self-harm in thefollowing week, nor was the number of self-harm incidentspredicted by CSO after controlling for the influence of othervariables. There was also a reduction in the use of CSOduring the study with no corresponding increase in self-harm. These findings are consistent with a national study of136 acute admission psychiatric wards which found nocross-sectional correlation between CSO and rates of self-harm but intermittent observation to be associated with lowerlevels of self-harm [16]. Previous research has highlighteddeficiencies in ward design which hinder observation [15]and found increased length of patient stay and pooreroutcomes to be associated with prolonged CSO use [3]. Thelack of relationship may also reflect poor implementation ofobservation practices, such as miscommunication betweenobservers and other staff members or unclear decisionmaking as to when to commence or stop various levels ofobservation [17]. The present findings cast further doubt onthe effectiveness of CSO as a psychiatric nursing procedureto prevent self-harm.

4.1. Factors associated with self-harm

Self-harm on the wards was rare, with incidents recordedfor only 7% of the 2239 ward weeks of the study, but over aquarter of self-harm incidents were classified as serious.Risk of suicide is high for psychiatric inpatients, althoughsuicide rates for this population in England have declined inrecent years [18]. Less research is available on levels ofattempted suicide or other forms of self-harm, but our datasuggest that around one in eight of all reported incidentsconcerned self-harm. This is consistent with the onlyavailable data on self-harm incidents in England [19]. Self-harm and suicide among psychiatric inpatients are linked[20,21] and patients with a history of suicide attempts aremore likely to report engaging in other types of self-harming behavior, indicating that suicidal and self-harmbehaviors are likely to coexist in many patients [22,23].

There was evidence of clustering of self-harm incidents,with self-harm during the previous week representing the

strongest predictive factor for self-harm in the regressionmodels. However, it is not possible to determine from thedata whether or not this was due to the same patient beinginvolved in more than one self-harm incident in the courseof a week (or over consecutive weeks) or that the self-harming behavior of by some patients was copied byothers as has been observed in the case of inpatientsuicides [24,25].

The literature shows various clinical factors to beassociated with suicide and self-harm among psychiatricinpatients, including affective disorders [21], schizophrenia[26], a history of self harm or suicidal ideation [21,22,26,27],and substance use [27], while one study found no associationbetween psychiatric diagnosis and self-harm behaviors [28].These contrasting findings are likely to reflect diverse studysamples, substantial comorbidity among psychiatric inpati-ents, and the difficulty of predicting self-harm with precision[22]. In the present study, the risk of self-harm was increasedby admissions of younger patients and those with apersonality disorder, neuroses, or substance use diagnosis.As the majority of self-harm incidents were classified asnonserious, this limits comparability with other researchwhich has predominantly focused on factors associated withsuicide. However, the findings are consistent with a previousnational study which found younger age and nonschizo-phrenia diagnoses to be associated with self-harm rates [16].

It is notable that patients with a personality disorder,neuroses or substance use diagnosis were a minority,comprising only 17% of total admissions during the study.Although it is possible that these admissions arrived on theward in a disturbed and acutely ill condition and subse-quently self-harmed within the same week, it cannot beinferred that it was these patients who self-harmed. Highernumbers of patients with these diagnoses could haveimpacted on the ward environment, thereby affecting thebehavior of other patients and triggering others to self-harm.This may explain the lagged effects for substance use andpersonality disorder diagnoses, as well as the associationbetween self-harm and other conflict behaviors. The findingsmight also reflect anxiety among patients at the prospect ofdischarge, a period of particular risk for suicidal behavior[29], since substance use and personality disorder patientshad the shortest length of stay (a median of 1 and 2 weeks,respectively). Such brief periods of hospitalization may notbe the most effective means of reducing the risk of self-harmand suicidal behaviors for these patients. For example, anextended program of partial hospitalization (involving apackage of psychotherapy interventions) for borderlinepersonality disorder patients has shown favorable self-harmoutcomes compared to standard care [30].

4.2. Factors associated with CSO

Overall, CSO was recorded in a third of ward weeks, butthe profiles across the study period showed large variationsbetween hospitals, wards and on the same wards over time.

529D. Stewart et al. / General Hospital Psychiatry 31 (2009) 523–530

This strongly suggests idiosyncratic practice driven byclinicians with different views on observation policy andprocedures. Similar variations have been reported by wardand by consultant [10,31]. Levels of observation tend to bedetermined by the clinical judgment of medical staff ratherthan systematic assessment procedures [6,12], while nursessometimes modify official observation procedures accordingto their perceptions of the patient's best interest [11,12].

The finding that CSO was predicted by CSO in theprevious week probably reflects the polarity in its use acrossthe wards: the practice was barely used at all in some wardsbut was very common in others. We found no lagged patientor conflict variables which predicted CSO, suggesting thatdecisions to place patients under CSO were based uponcontemporary events within the same ward week. Forexample, CSO was correlated with self-harm and physicalaggression in the same week. Unfortunately, the nature of thedata does not allow more detailed examination of whetherpatient conflict preceded or followed the use of CSO withineach week. Thus, CSO may have been initiated in responseto self-harm or aggressive incidents, but these types ofincidents could also have occurred while patients were underspecial observation. Similarly, the relationship between CSOand greater numbers of affective disorder admissions mayreflect the precautionary use of CSO for patients perceived asof particular risk of self-harm. Alternatively, these patientscould have been responsible for incidents which resulted inthe use of CSO, although our analysis indicates that this wasunlikely to be the case for self-harm incidents. A longitudinalstudy of patient level data would probably be required todetermine the direction of these relationships.

Despite variations in practice, there was a statisticallysignificant downward trend in CSO use during the studyperiod. This is not explained by the characteristics ofpatients since affective disorder admissions was the onlypatient variable predictive of CSO. A new observationpolicy was implemented during the study (from February2005) which reintroduced the use of intermittent observa-tion having removed it from practice a year earlier.Although the policy did not seek to reduce CSO, it is likelythat intermittent observation was used instead of CSO formany patients, perhaps becoming the preferred option onsome wards. Reduced use of CSO may also reflect pressureson resources at the hospitals. Observation is labor intensive,and this may explain the association between the use ofCSO and bank and agency staff which was found overconsecutive weeks. As a consequence, CSO is expensive infinancial terms and can represent a significant proportion ofnursing budgets [32]. The cost unit cost of CSO has beenestimated to be approximately three times that of inter-mittent observation [33].

4.3. Limitations

The lack of association between CSO and self-harmshould be interpreted with some caution. The design of the

study does not allow causal associations between CSO andself-harm to be tested. The analyses are based upon weeklycounts of official data which may be subject to a number ofdifferent influences (e.g., the concerns of managers and theimpact of national or local policy changes). In addition, theanalyses did not control for length of admission, which isknown to be associated with self-harm [29]. Self-harmincidents often occur when patients are not on the wards; themajority of in-patient suicides take place while patients areon agreed leave or have absconded [15,22]. The study doesnot include measures of other forms of containment whichmay have been used to manage difficult behavior on thewards, or initiatives specifically designed to reduce the riskof self-harm. Thus, the reduced levels of CSO on the wardsmay have been accompanied by increases in other interven-tions (e.g., medication). In practice, a systematic approach,involving a number of measures to minimize self-harm risk,is likely to have the greatest protective effect for patients.These might include banning sharp items from patients'possession and restrictions on access to certain areas of theward (e.g., kitchens and bathrooms) where observation ismade more difficult [29].

4.4. Conclusions

Special observation has become a controversial practice,characterized by debate over the compatibility of observa-tion and therapeutic engagement with the patient [1,34].Failure to follow observation policies can result in seriousharm to patients [35], but this debate has been hampered bythe scarcity of evaluative data. The present study is thesecond from this research group to find no statisticalassociation between CSO and self-harm. Furthermore,reduced use of CSO during the study was not accompaniedby an increase in the number of self-harm incidents.Changes to CSO policy would warrant a prospectiveevaluation with patient-level data, but the findings indicatethat this expensive practice could be reduced or bettertargeted without compromising patient safety.

Acknowledgments

The authors wish to thank the clinical and adminis-trative staff that helped the research team obtain the datareported in this study. The research was supported byfunding from the Tompkins Foundation and the Depart-ment of Health. However, the views expressed in thispublication are those of the authors and not necessarilythose of the funding bodies.

References

[1] Bowers L, Gournay K, Duffy D. Suicide and self-harm in inpatientpsychiatric units: a national survey of observation policies. J Adv Nurs2000;32:437–44.

530 D. Stewart et al. / General Hospital Psychiatry 31 (2009) 523–530

[2] Bowers L, Simpson A, Alexander J. Patient-staff conflict: results of asurvey on acute psychiatric wards. Soc Psychiatry Psychiatr Epidemiol2003;38:402–8.

[3] Shugar G, Rehaluk R. Continuous observation for psychiatricinpatients: a critical evaluation. Compr Psychiatry 1990;1:48–55.

[4] Dennis S. Close observation: how to improve assessments. Nurs Times1997;93:54–6.

[5] Langenbach M, Junaid O, Hodgson-Nwaefulu CM, et al. Observationlevels in acute psychiatric admissions. Eur Arch Psychiatry ClinNeurosci 1999;249:28–33.

[6] Neilson P, Brennan W. The use of special observations: an audit withina psychiatric unit. J Psychiatr Ment Health Nurs 2001;8:147–55.

[7] Lehane M, Rees C. Alternatives to seclusion in psychiatric care. Br JNurs 1996;5:974–9.

[8] Department of Health. Mental Health Nursing: Addressing AcuteConcerns. London: Standing Nursing and Midwifery AdvisoryCommittee, Department of Health; 1999.

[9] Bowers L, Park A. Special observation in the care of psychiatricinpatients: a literature review. Issues Ment Health Nurs 2001;22:769–86.

[10] Porter S, McCann I, McGregor A. Auditing suicide observationprocedures. Psychiatr Care 1989;5:17–21.

[11] Aidroos N. Nurses' responses to doctors' orders for close observation.Can J Psychiatry 1986;31:831–3.

[12] Duffy D. Out of the shadows: a study of the special observation ofsuicidal psychiatric in-patients. J Adv Nurs 1995;21:944–50.

[13] Goldberg RJ. Use of special observation with potentially suicidalpatients in general hospitals. Hosp Com Psychiatry 1987;3:303–5.

[14] Green S, Grindel C. Supervision of suicidal patients in adult inpatientpsychiatric units in general hospitals. Psychiatr Serv 1996;47:859–63.

[15] Meehan J, Kapur N, Hunt I, et al. Suicide in mental health in-patientsand within 3 months of discharge: national clinical survey. Br JPsychiatry 2006;188:129–34.

[16] Bowers L, Whittington R, Nolan P, et al. The relationship betweenservice ecology, special observation and self-harm during acute in-patient care: the City-128 study. Br J Psychiatry 2008;193:395–401.

[17] Janofsky JS. Reducing inpatient suicide risk: using human factorsanalysis to improve observation practices. J Am Acad Psychiatry Law2009;27:15–24.

[18] Kapur N, Hunt IM, Webb R, et al. Suicide in psychiatric in-patients inEngland, 1997–2003. Psychol Med 2006;36:1485–92.

[19] National Patient Safety Agency. With Safety in Mind: Mental HealthServices and Patient Safety. London: National Patient Safety Agency;2006.

[20] Appleby L, Dennehy J, Thomas C, Faragher E, Lewis G. Aftercare andclinical characteristics of people with mental illness who commitsuicide: a case-control study. Lancet 1999;353:1397–400.

[21] Hunt I, Kapur N, Webb R, et al. Suicide in current psychiatric in-patients: a case-control study. Psychol Med 2007;37:831–7.

[22] Powell J, Geddes J, Deeks J, Goldacre HK. Suicide in psychiatrichospital in-patients: risk factors and their predictive power. Br JPsychiatry 2000;176:266–72.

[23] Sansone RA, Songer DA, Sellbom M. The relationship betweensuicide attempts and low-lethal self-harm behavior among psychiatricinpatients. J Psychiatr Pract 2006;12:148–52.

[24] Rissmiller D, Rissmiller F. Inpatient suicide epidemics and suggestionsfor prevention. Hosp Com Psychiatry 1990;41:922–4.

[25] Taiminen T, Salmenpera T, Lehtinen K. A suicide epidemic in apsychiatric hospital. Suicide Life Threat Behav 1992;22:350–63.

[26] Shah A, Ganesvaran T. Inpatient suicides in an Australian mentalhospital. Aust N Z J Psychiatry 1997;31:291–8.

[27] Haw C, Hawton K, Casey D, Bale E, Shepherd A. Alcoholdependence, excessive drinking and deliberate self-harm: trends andpatterns in Oxford, 1989-2002. Soc Psychiatry Psychiatr Epidemiol2005;40:964–71.

[28] Sansone RA, Songer DA, Miller KA. A naturalistic study of therelationship between self-harm behaviors and Axis I diagnosticgroupings among inpatients. Int J Psychiatry Clin Pract 2007;11:73–5.

[29] Appleby L, Shaw J, Amos T, et al. Suicide within 12 months of contactwith mental health services: national clinical survey. BMJ 1999;318:1235–9.

[30] Bateman A, Fonagy P. Effectiveness of partial hospitalization in thetreatment of borderline personality disorder: a randomized controlledtrial. Am J Psychiatry 1999;156:1563–9.

[31] Kettles A, Moir E, Woods P, Porter S, Sutherland E. Is there arelationship between risk assessment and observation level? J PsychiatrMent Health Nurs 2004;11:156–64.

[32] Moore P, Berman K, Knight M, Devine J. Constant observation:implications for nursing practice. J Psychosoc Nurs 1995;33:46–50.

[33] Flood C, Bowers L, Parkin D. Estimating the Costs of Conflict andContainment on Adult Acute Inpatient Psychiatric Wards. Nurs Econ2008;26:325–30, 324.

[34] Cutcliffe J, Barker P. Considering the care of the suicidal client and thecase for ‘engagement and inspiring hope’ or ‘observations’. J PsychiatrMent Health Nurs 2002;9:611–21.

[35] Gournay K, Bowers L. Suicide and self-harm in in-patient psychiatricunits: a study of nursing issues in 31 cases. J Adv Nurs 2000;32:124–31.