under the gaze of staff: special observation as surveillance

Under the Gaze of Staff: Special Observation as Surveillanceppc_299 2..9

Duncan Stewart, BA, PhD, and Len Bowers, RMN, BSc, MA, PhD

Duncan Stewart, BA, PhD, is a Research Fellow and Len Bowers, RMN, BSc, MA, PhD, is Professor of Psychiatric Nursing, Institute of Psychiatry, KingsCollege, London, UK.

Search terms:Acute, conflict, containment, observation,surveillance

Author contact:[email protected], with a copy to theEditor: [email protected]

First Received July 19, 2010; Final Revisionreceived October 3, 2010; Accepted forpublication October 13, 2010.

doi: 10.1111/j.1744-6163.2010.00299.x

PURPOSE: This study explores the relationship of special observation (SO) to arange of patient, staff, and ward variables.DESIGN AND METHODS: End-of-shift reports were completed by nurses on 136acute mental health wards in England during 2004 and 2005.FINDINGS: Intermittent SO (patient checked at specified intervals) was used fivetimes more frequently than constant SO (patient kept within sight or reach). Signifi-cant relationships were found between SO and measures of ward surveillance, doorlocking, and the ease of observing patients on the wards. Both types of SO were morecommon when higher numbers of staff without a nursing qualification were on duty.PRACTICE IMPLICATIONS: Improved ward design, less reliance on unqualifiedstaff, and greater use of surveillance measures may reduce the need for SO.

Special observation (SO) is a method of preventing acutelydisturbed psychiatric inpatients from harming themselves orothers. It involves assigning an identified person to the care ofthe “at-risk” patient for a certain period of time, above theminimum general level of observation required for all inpa-tients. SO may be intermittent, where the patient is checked atspecified intervals, or constant, where the patient is keptwithin sight or reach at all times (Department of Health,1999). In practice, however, a confusing range of terms areused to describe the various levels of observation practice(Bowers, Gournay, & Duffy, 2000). Reported rates of SO,expressed as a proportion of admissions to acute psychiatriccare, have tended to range between 3% and 20% (Bowers &Park, 2001), although one UK study found that 47% ofpatients had received intermittent SO during a 2-week period(Bowers, Simpson, & Alexander, 2003a). Once patients areplaced under SO, its reported duration ranges from a fewhours to several weeks (Cardell & Pitula, 1999). The most fre-quently cited reason for initiating SO is to prevent self-harm,but it can be used for many different purposes including themanagement of aggressive behavior, refusal of medication,and to prevent absconding (Bowers et al., 2000; Dennis, 1997;Langenbach et al., 1999; Neilson & Brennan, 2001). Most hos-pitals in England have policies for SO, but these are highlyvariable (Bowers et al., 2000), as are professional groups thathave authority to initiate or terminate the procedure andregulate the way in which it is carried out. Often initiated bydoctors, nurses have been found to make modifications to theprescribed level of SO (Kettles & Paterson, 2007).

The therapeutic value of SO has been questioned (Cutcliffe& Barker, 2002). Patients have reported positive aspects to SOsuch as feeling understood and secure, having reduced dys-phoria, and reduced suicidal thoughts; but also experiences offeeling isolated, degraded, or coerced (Cardell & Pitula, 1999;Jones, Lowe, & Ward, 2000). Allocating nurses to the care ofan individual patient means that less time is available forothers on the ward. Therefore, SO often requires extra bank oragency staff, which can be expensive. The cost to the healthservice in England has been estimated at £45 million a year forintermittent SO and £35 million a year for constant SO(Flood, Bowers, & Parkin, 2008).

Despite the imperative to prevent self-harm and suicideon acute psychiatric wards, suicides do unfortunatelyoccur while patients are under enhanced levels of observa-tion. Data for England and Wales suggest that moreinpatient suicides occur among those under intermittent SO(23%) than under constant SO (3%; Meehan et al., 2006). Incontrast, intermittent SO has been associated with fewerincidents of self-harm while constant SO has been found tohave no apparent benefit for patients (Bowers et al., 2008;Stewart, Bowers, & Warburton, 2009). Given such uncer-tainty about the necessity and effectiveness of SO, furtherwork is required to better understand the circumstances ofits use. The present article uses a large, national dataset toassess the relationship of SO to a range of factors includingpatient characteristics and behaviors, the use of other con-tainment methods, service environment, patient routines,and staffing variables.

Perspectives in Psychiatric Care ISSN 0031-5990

2 Perspectives in Psychiatric Care 48 (2012) 2–9 © 2011 Wiley Periodicals, Inc.

Method

Sample

The sample comprised 136 acute psychiatric wards with theirpatients and staff in 67 hospitals in England during 2004–2005. Acute psychiatric wards were defined as those thatmainly served acutely mentally disordered adults, takingadmissions directly from the community, and not offeringlong-term care or accommodation. This national sample rep-resented 25% of the estimated total of 551 wards in England.

Instruments and Procedure

The study used the Patient–Staff Conflict Checklist (PCC-SR)to collect data on the frequency of conflict and containmentevents (Bowers et al., 2005a). The PCC-SR was completed bynurses at the end of each shift for a 6-month period on all par-ticipating wards. More than 45,000 PCC-SRs were collectedwith an average response rate of 67%. Conflict was defined asbehaviors likely to harm patients or others and included:verbal aggression, physical aggression against objects, physi-cal aggression against self or suicide attempt, physical aggres-sion against others, smoking in a no-smoking area, refusing toeat, refusing to drink, refusing to attend to personal hygiene,refusing to get up and out of bed, refusing to go to bed, refus-ing to see workers, alcohol use, other substance use, attemptto abscond, absconding, refusing regular medication, refusingpro re nata (PRN) medication, and demanding PRN medica-tion. Containment was defined as staff actions to protectpatients and others from harm and included: time out, showof force, manual restraint, enforced intramuscular medica-tion, PRN (psychotropic) medication, seclusion, sent to psy-chiatric intensive care unit (PICU) or intensive care area(ICA), intermittent SO, and constant SO. Staff were also askedto note whether constant SO included no or minimal interac-tion with the patient, for whatever reason (SO withoutengagement).

Data were also collected on patients’ age, gender, ethnic-ity, diagnosis, reason for admission, and postcode. A BongarLethality Scale (Bongar, 1991) was completed for all inci-dents of self-harm or attempted suicide. A researcher col-lected information on the physical environment andoperational policies of each ward. This was supplemented bya form completed by the ward manager. Ward observabilitywas assessed through calculating a single score representingthe complexity of the environment, with higher scores rep-resenting more complicated, difficult to observe wards.Observability included factors such as the number of roomsopen to patients during daytime shifts, number of indepen-dently observable zones, number of zones visible from themain nursing office, number of exits visible from the mainnursing office, and the number of floors comprising the

ward. Staff attitudes to difficult patients were assessed usingthe Attitude to Personality Disorder Questionnaire (APDQ;Bowers & Allan, 2006). Some staff and patients (10 perward) were asked to complete the Attitude to ContainmentMeasures Questionnaire (ACMQ; Bowers, Alexander,Simpson, Ryan, & Carr-Walker, 2004). Other instrumentsused included the Ward Atmosphere Scale (WAS; Moos,1974), Team Climate Inventory (TCI; Anderson & West,1999), Multifactor Leadership Questionnaire (MLQ; Bass &Avolio, 1995), and Maslach Burnout Inventory (MBI;Maslach & Jackson, 1991).

Data Analysis

Multilevel random-effects modeling was conducted usingStata (version 11, StataCorp, College Station, TX) to controlfor clustering by Trust (a self-governing organizational unitwithin the National Health Service), ward, and shift. Countsof intermittent and constant special observation were depen-dent variables, with number of beds on each ward used as theexposure variable. Models were produced through a processof backward selection, dropping the least significant variableat each stage and leaving only variables significant at p lessthan .05.

As in previous analyses of the same dataset (Bowers et al.,2008, 2010), variables were initially grouped into sevendomains. These were: patient variables (background charac-teristics of admissions and mean responses to the patientACMQ); service environment variables; physical environ-ment; conflict (all conflict variables on the PCC-SR); contain-ment (all containment variables on the PCC-SR, plusintensity of security policies such as banning items, searchingpatients, restrictions on patient access to certain areas, drug/alcohol monitoring, and access to security guards); staff char-acteristics (including numbers of nurses and allied staff andtheir demographic characteristics); and staff group factors(mean scores from the staff ACMQ, APDQ, MBI, MLQ, TCI,and WAS). Variables within each domain were used to buildseparate models, from which the significant variables wereentered into a final comprehensive model using the sameprocess of backward selection. Coefficients are expressed asincidence rate ratios. There was little appreciable differencebetween models for constant SO with or without engage-ment. Because nearly all the recorded constant SO was withengagement, a statistical model for constant SO withoutengagement is not presented.

Results

Intermittent was the most common form of SO, with a meanof 1.70 (SD = 2.40) events per shift on a standardized 20-bedward. The mean for constant SO with engagement was .35

Under the Gaze of Staff: Special Observation as Surveillance

3Perspectives in Psychiatric Care 48 (2012) 2–9 © 2011 Wiley Periodicals, Inc.

(SD = .73) per shift. Very few shifts utilized constant SOwithout engagement (mean = .09; SD = .51), so this form ofSO was included only as an independent variable in furtheranalysis.

Multilevel models

The results of multilevel regression models are shown inTables 1 and 2. Only intermittent SO retained any patient

Table 1. Regression Models for Intermittent SO

Domain Models Final Model

IRR p Lower CI Upper CI IRR p Lower CI Upper CI

PatientsProportion under 35 11.654 .031 1.252 108.444 14.730 .007 2.083 104.167Proportion harm to others .023 .006 .002 .331 .051 .001 .009 .299Proportion Irish .000 .059 .000 1.332Patient ACMQ mean .905 .045 .821 .998 .894 .012 .818 .976

Service environmentAdmissions during shift 1.050 .000 1.036 1.064 1.040 .000 1.026 1.055

Physical environmentWard observability 1.084 .031 1.008 1.166 1.082 .019 1.013 1.157

Patient routinesNil significant

ConflictVerbal aggression 1.020 .000 1.015 1.025 1.016 .000 1.011 1.021Physical aggression against others .978 .002 .964 .992 .983 .019 .969 .997Smoking 1.036 .000 1.030 1.043 1.033 .000 1.026 1.039Refusing to eat 1.083 .000 1.067 1.099 1.072 .000 1.058 1.087Refusing to wash 1.024 .000 1.014 1.034 1.027 .000 1.017 1.037Alcohol use 1.029 .003 1.010 1.049 1.022 .029 1.002 1.042Substance use 1.056 .000 1.039 1.075 1.055 .000 1.036 1.074Attempting to abscond 1.009 .041 1.000 1.018Absconding (official report) 1.053 .001 1.022 1.085 1.054 .000 1.024 1.085Refused regular medication 1.048 .000 1.035 1.062 1.045 .000 1.032 1.059Refused PRN medication 1.038 .000 1.018 1.059 1.044 .000 1.023 1.066Demanding PRN medication 1.021 .000 1.013 1.030 1.013 .005 1.004 1.022Self-harm .970 .000 .961 .979 .969 .000 .960 .979

ContainmentSearching .836 .010 .730 .958 .875 .027 .778 .985Door security 1.370 .004 1.103 1.702 1.297 .013 1.056 1.592Alarms 1.229 .022 1.031 1.467 1.194 .029 1.018 1.400CCTV unit .553 .030 .324 .944 .585 .027 .363 .942Locked doorsLess than one hour 1.083 .005 1.024 1.146 1.073 .014 1.014 1.134One to three hours 1.103 .000 1.053 1.155 1.099 .000 1.049 1.152More than three hours 1.162 .000 1.103 1.225 1.144 .000 1.086 1.206Whole shift 1.106 .000 1.069 1.144 1.101 .000 1.064 1.140PRN medication 1.054 .000 1.047 1.061 1.047 .000 1.039 1.054Coerced IM medication 1.048 .005 1.015 1.083Constant SO with engagement .943 .000 .935 .952 .939 .000 .930 .948Constant SO without engagement .898 .000 .886 .910 .878 .000 .865 .892Show of force 1.047 .000 1.032 1.061 1.018 .016 1.003 1.033Manual restraint 1.022 .036 1.001 1.044Time out .959 .000 .947 .972 .947 .000 .933 .960

Staff demographicsBank/agency unqualified staff 1.018 .000 1.009 1.028

Staff group factorsMBI Positive appreciation 1.107 .021 1.015 1.207

Note: IRR, Incidence rate ratio; CI, confidence interval; SO, special observation; ACMQ, Attitudes to Containment Measures Questionnaire; PRN, pro renata; CCTV, closed circuit television; IM, intra-muscular; MBI, Maslach Burnout Inventory.



variables in the final models and was associated with a greaterproportion of younger patients and fewer patients admittedfor causing harm to others. The number of admissions duringa shift was a significant predictor in both final models.

Aspects of the ward physical environment were related toSO. Intermittent SO was associated with more complex anddifficult-to-observe wards, while constant SO was associatedwith fewer windows in the doors of single rooms.

Table 2. Regression Models for Constant SO

Domain models Final model

IRR p Lower CI Upper CI IRR p Lower CI Upper CI

PatientsProportion legally detained 6.240 .036 1.130 34.462Proportion Caribbean .015 .010 .001 .366Patient ACMQ mean .943 .084 .882 1.008

Service environmentAdmissions during shift 1.077 .000 1.047 1.108 1.058 .000 1.027 1.090

Physical environmentWindows in 1.541 .002 1.167 2.034 1.425 .007 1.102 1.843

Patient routinesNil significant

ConflictVerbal aggression 1.030 .000 1.019 1.041 1.021 .000 1.010 1.032Physical aggression against objects 1.039 .002 1.014 1.064 1.033 .010 1.008 1.059Physical aggression against others 1.058 .000 1.033 1.084 1.031 .020 1.005 1.058Refusing to drink 1.058 .005 1.017 1.101 1.062 .001 1.024 1.101Refusing to attend to personal hygiene 1.039 .000 1.018 1.060 1.043 .000 1.023 1.064Attempting to abscond 1.065 .000 1.047 1.083 1.054 .000 1.035 1.073Absconding (missing without permission) 1.063 .005 1.018 1.109 1.059 .011 1.013 1.107Absconding (official report) 1.114 .000 1.054 1.177 1.084 .006 1.023 1.148Refused regular medication 1.087 .000 1.058 1.117 1.060 .000 1.031 1.090Refused PRN medication 1.088 .000 1.045 1.132 1.049 .031 1.004 1.095Demanding PRN medication 1.043 .000 1.024 1.062 1.023 .020 1.004 1.043

ContainmentBanned items score 1.059 .007 1.016 1.103 1.041 .020 1.006 1.078Searching score .907 .037 .828 .994Locked doors (compared to open)Less than an hour .966 .592 .851 1.097 .967 .604 .852 1.098One to three hours 1.164 .003 1.053 1.288 1.139 .011 1.030 1.260More than three hours 1.377 .000 1.231 1.540 1.331 .000 1.189 1.489Whole shift 1.172 .000 1.094 1.255 1.153 .000 1.076 1.235PRN medication 1.065 .000 1.050 1.080 1.043 .000 1.026 1.060Coerced IM medication 1.206 .000 1.137 1.279 1.166 .000 1.097 1.239Sent to PICU or ICA 1.385 .000 1.266 1.516 1.360 .000 1.233 1.500Seclusion 1.065 .036 1.004 1.130 1.075 .029 1.007 1.147Intermittent SO .957 .000 .950 .965 .959 .000 .951 .966Show of force 1.086 .000 1.055 1.118 1.034 .029 1.004 1.066Manually restrained 1.067 .001 1.028 1.107

Staff demographicsRegular qualified staff 1.177 .000 1.152 1.203 .911 .000 .894 .929Regular unqualified staff 1.207 .000 1.187 1.227 1.051 .000 1.034 1.069Bank/agency qualified staff 1.135 .000 1.109 1.162 .842 .000 .823 .862Bank/agency unqualified staff 1.419 .000 1.397 1.442 1.240 .000 1.219 1.260Proportion of staff Asian .105 .045 .012 .953

Staff group factorsTCI (team climate) .582 .017 .372 .908 .616 .013 .420 .902Staff ACMQ mean 1.118 .012 1.025 1.219

Note: IRR, incidence rate ratio; CI, confidence interval; SO, special observation; ACMQ, Attitudes to Containment Measures Questionnaire; PRN, pro renata; PICU, psychiatric intensive care unit; ICA, intensive care area; TCI, Team Climate Inventory.



Similarities were found in the types of patient behaviorsassociated with intermittent and constant SO. Both werepositively associated with verbal aggression, absconding,refusing regular medication, demanding PRN medication,and refusing PRN medication. Intermittent and constant SOwere also associated with rule-breaking behaviors, althoughthe type of infringements varied. Incidents of physical aggres-sion against persons and objects were positively associatedwith constant SO, but the former was negatively associatedwith intermittent SO. There was a negative correlationbetween intermittent SO and incidents of self-harm.

The models show a negative association between intermit-tent and constant SO (with or without engagement). In termsof other containment methods, coerced and PRN medicationwere both associated with SO, although coerced medicationwas not retained in the final intermittent SO model. Bothforms of SO were linked with show of force, but seclusion waspredictive of constant SO only. Being sent to PICU or ICA wascorrelated with constant but not intermittent SO.

Relationships between SO and measures of ward surveil-lance and security were notable. Intermittent SO was associ-ated with less searching and use of closed-circuit television(CCTV) monitoring, but more door security, door locking,and use of alarms. Door locking was also positively correlatedwith constant SO, as was the banning of items. Staffing vari-ables were more closely associated with constant than inter-mittent SO, but both types showed an association with highernumbers of unqualified staff (i.e., those without a nursingqualification) on duty.

Discussion

This large and representative study of acute wards in Englandfound that intermittent SO was reported around five timesmore frequently than constant SO with engagement, whileSO without engagement was little used. These findingssuggest that the benefits of engaging with patients duringobservation have been recognized. There are few studies ofintermittent SO with which to compare the results, but con-sistent with our findings, a Scottish study reported 15-minobservations to be more frequently used than both generaland constant observations (Kettles, Moir, Woods, Porter, &Sutherland, 2004), prompting the authors to questionwhether staff were being overcautious with some patients.

The preference for intermittent SO may have been influ-enced by resource constraints. Higher staffing levels weremore strongly associated with constant rather than intermit-tent SO; probably because the former is much more resourceintensive. The unit cost of constant SO has been estimated tobe around three times higher than intermittent SO (Floodet al., 2008). One study calculated that constant SO repre-sented up to 20% of the total nursing budget (Moore,Berman, Knight, & Devine, 1995).

The results indicate that SO is frequently conducted byless qualified staff. Greater numbers of unqualified staffwere correlated with more SO. It did not make a differencewhether qualified nurses were regular or bank staff, as bothof these variables were negatively correlated with constantSO. Previous research has found SO to be regarded as anunpleasant and low status activity that can be delegated tojunior or untrained staff (Reynolds, O’Shaughnessy, Walker,& Pereiram, 2005), sometimes against official hospital policy(Gournay & Bowers, 2000). SO use is only likely for patientsposing the highest risk to themselves or others, yet thispractice contrasts sharply with the delegation of intensivepsychiatric nursing care to those least well trained to conductit. This could have an adverse impact on team functioning,as greater team cohesion was associated with less constant SO.It may be that where multidisciplinary teams made decisionsabout observation SO was used less frequently (Kettles &Paterson, 2007).

There was an inverse correlation between intermittent andconstant SO, indicative of one form of SO being purposefullychosen over another during a shift. Although the study didnot measure antecedents to SO directly, the findings indicatethat both forms of SO were usually associated with patientbehaviors rather than broader patient characteristics. More-over, many of the same conflict items were associated withintermittent and constant SO, specifically verbal aggression,absconding, refusing regular and PRN medication, demand-ing PRN medication, and breaking ward rules. The decisionto use intermittent or constant SO in response to these behav-iors would seem therefore to reflect other factors. Previousstudies have found large and unexplained differences in SOuse between wards and clinicians in the same hospital (Kettleset al., 2004, Stewart et al., 2009), exacerbated by the scarceempirical evidence to support the effectiveness of SO, but alsoreflecting varying clinical cultures between wards rather thansystematic and consistent assessment.

Physical aggression against others and objects was associ-ated with constant SO. Violent behavior is likely to requiremore intensive supervision of patients in order to keep themand others safe. More than half of violent incidents on wardshave been found to be followed by SO (Bowers, Nijman,Palmstierna, & Crowhurst, 2002), and SO has been used as asubstitute for seclusion in the management of violent patientsin a PICU (Lehane & Rees, 1996). Unfortunately, the studycannot determine whether constant SO is reserved for thesemost urgent patterns of behavior or that such incidents occurwhile patients are under constant SO. Alternatively, whilepatients are being observed, others on the ward may be morelikely to become aggressive. The association between constantSO and patients being sent to psychiatric intensive care sup-ports the conclusion that patients under constant SO have themost disturbed and problematic behavior, which may requiretransfer from the ward if SO and other strategies are not



proving successful. This explanation is less likely to apply toseclusion, which was also associated with constant SO,because hospital seclusion policies may recommend staffconstantly observe patients placed in seclusion.

An analysis of other containment measures showed aconsistent relationship between SO and coerced and PRNmedication. This could mean that patients receiving moremedication require greater observation during or after it isgiven: A previous study reported that SO is sometimes used incombination with rapid tranquilization (Lehane & Rees,1996). Another explanation, as the correlations between con-flict behaviors and SO suggest, could be that patients underSO are more likely to also refuse regular or PRN medication.This might well involve staff using a show of force to encour-age patients to accept their medication, before resorting tocoercion (under manual restraint).Alternatively, while nursesare busy undertaking SO, it becomes easier for other patientsto refuse medication in order to gain attention. This explana-tion may be less likely because both intermittent and constantSO were associated with medication refusal, but staff wouldbe expected to have more time available for other patientsduring the former.

The results point to the role of ward environment in influ-encing SO use. A more complex physical layout was related togreater intermittent SO, possibly because of difficulty con-ducting even routine observation of patients on some wards.On the other hand, a lack of windows in the doors of singlerooms may mean that maintaining a continuous nursingpresence is the only practical method of observation undersome circumstances. Ward design has been identified asimpeding observation in instances of patients committingsuicide while under SO (Appleby et al., 1999; Meehan et al.,2006). These studies report that patients were more likely tobe under intermittent than constant SO at the time of suicideand suggest that the former method of observing at-riskpatients may be unsafe. However, self-harm was negativelycorrelated with intermittent SO in the present study. Giventhe potentially serious implications for patient safety, ourresults suggest that interactions between ward design, obser-vation practice, and patient safety require further researchattention.

One solution to observing patients in poorly designedwards is to use CCTV cameras. These have been used to detectand verify assaults (Nolan & Volavka, 2006), but the implica-tions of CCTV use on regular psychiatric wards have not beenevaluated. One study describes the introduction of nighttimeCCTV on a low secure unit as complementing rather thanreplacing traditional methods of observation, which provideopportunities for interaction with patients and confer feel-ings of safety (Warr, Page, & Crossen-White, 2005). This doesnot appear to have been the case in the present study. Wefound less frequent SO when wards used CCTV and searchedpatients, indicating that these strategies were being used as

alternative methods of achieving a broader surveillance func-tion. The finding was most apparent for intermittent SO,perhaps because this was considered as primarily a means ofchecking the physical whereabouts of patients, and so mostakin to passive surveillance, which could also be conducted byCCTV. Alternatively, CCTV and patient searches could havebeen regarded as effective and efficient means of managingself-harm, violence, and absconding risk on some wards, tothe extent that SO was required less often.

Keeping patients in locked wards would seem to requiremore SO, possibly to deal with the negative consequences oflocking ward doors. Staff and patients can view locked doorsas a means of creating a safe environment and preventingpatients from harming themselves and others, but disadvan-tages include a more volatile ward environment and depres-sion associated with lack of patient freedom (Van Der Merwe,Bowers, Jones, Simpson, & Haglund, 2009). Although a fre-quently cited reason for the use of SO and for locking theward door is to prevent absconding by patients, both werepositively correlated with SO. The locking of the ward door issometimes justified by the argument that SO can thereby bereduced; however, our evidence shows that this benefit is notroutinely achieved. Other security measures such as banningitems and use of alarms were also positively correlated withSO, having controlled for the levels of conflict behaviors onthe ward. It is therefore possible that SO is being used morethan necessary by risk-averse and anxious staff.

The principle limitation of this study is its cross-sectionaldesign, which means that observed correlations do not allowfirm conclusions about the direction of causality. Diagnosticinformation about the patients only included the proportionof patients suffering from schizophrenia. There is a possibilitythat some variables were identified as significant by chancebecause of the large number of variables entered in the analy-ses. However, the large scale of the study, the inclusion ofpotential confounding variables, and the statistical allowancemade for the clustering of responses by organization andward increase the accuracy and the reliability of the findings.

Implications for Nursing Practice

The study found that in England’s acute psychiatric wards,most SO is intermittent in form, with some evidence that con-stant SO is used for the most severe incidents and behaviors.However, there were similarities in some of the behaviorsassociated with intermittent and constant SO, particularlywith regard to absconding and medication issues, which aredifficult to explain. In this sense, the study supports previousfindings that the functions of SO are confused (Bowers &Park, 2001). The decision to use intermittent or constant SOfor these behaviors may actually reflect variations in localclinical practices, philosophies, and resource availability.There would therefore seem to be scope for national and hos-



pital policies to clarify the circumstances under which inter-mittent or constant SO should be initiated. That said,improved knowledge of what works best, and for whom, isstill required for this intervention to be delivered with greaterconfidence and consistency, and for more efficient manage-ment of staffing and financial resources. For example, the useof both SO and locking ward doors to reduce the risk ofpatients absconding is unnecessary as there are alternativepackages of anti-absconding measures that have been imple-mented successfully (Bowers, Alexander, & Gaskell, 2003b;Bowers, Simpson, & Alexander, 2005b).

It is of concern that some of the most acutely ill patients arelooked after constantly by the least qualified staff. SO is not apassive intervention. Nurses employ a range of skills todevelop therapeutic relationships with patients under SO(Mackay, Paterson, & Cassells, 2005), but reliance on unquali-fied staff is likely to undermine its potential effectiveness. Infact, our findings are consistent with others (Langenbachet al., 1999) that the presence of more qualified and experi-enced nursing staff on wards may actually reduce the need forconstant SO.

The choice to use intermittent or constant SO does notrelate solely to patterns of patient behavior. The ease withwhich nurses can see patients on the wards seems to influencethe necessity for SO. As many wards are not ideally designedfor observing patients, CCTV, searching, and other methodsof increasing patient visibility could be regarded as alternativemeans of ensuring patient and staff safety. The case for theseforms of surveillance may be strengthened if SO is being rou-tinely undertaken by less qualified staff and being imple-mented under financial constraints. Freeing up nurses’ timefrom conducting observations could enable greater engage-ment with patients and delivery of more therapeutic activi-ties. Further research into the use of electronic surveillance isrequired, but future studies must consider the role of otherforms of containment if the benefits, or otherwise, are to beproperly established.

Acknowledgments

This article presents independent research commissioned bythe National Institute for Health Research (NIHR) under itsProgramme Grants for Applied Research scheme (RP-PG-0707-10081). The views expressed are those of the author(s)and not necessarily those of the NHS, the NIHR, or theDepartment of Health. The authors have no conflict of inter-est to declare, nor do they have any relevant financial interestin this manuscript.

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under the gaze of staff: special observation as surveillance

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