OBJECTIVE A first study to compare suicides by missing persons with other suicide cases. DESIGN Retrospective cohort study for the period 1994-2007. GEOGRAPHICAL LOCATION: Queensland, Australia. POPULATION 194 suicides by missing persons and 7545 other suicides were identified through the Queensland Suicide Register and the National Coroners Information System. MAIN OUTCOME MEASURE χ(2) statistics and binary logistic regression were used to identify distinct characteristics of suicides by missing persons. RESULTS Compared with other suicide cases, missing persons significantly more often died by motor vehicle exhaust gas toxicity (23.7% vs 16.4%; χ(2)=7.32, p<0.01), jumping from height (6.7% vs 3.2%; χ(2)=7.08, p<0.01) or drowning (8.2% vs 1.8%; χ(2)=39.53, p<0.01), but less frequently by hanging (29.4% vs 39.9%; χ(2)=8.82, p<0.01). They were most frequently located in natural outdoors locations (58.2% vs 11.1%; χ(2)=388.25, p<0.01). Persons gone missing were less likely to have lived alone at time of death (OR 0.45, 95% CI 0.26 to 0.76), yet more likely to be institutionalised (OR 3.12, 95% CI 1.28 to 7.64). They were less likely to have been physically ill (OR 0.64, 95% CI 0.43 to 0.95) or have a history of problematic consumptions of alcohol (OR 0.52, 95% CI 0.31 to 0.87). In comparison to other suicide cases, missing persons more often communicated their suicidal intent prior to death (OR 1.58, 95% CI 1.13 to 2.22). CONCLUSIONS Suicides by missing persons show several distinct characteristics in comparisons to other suicides. The findings have implications for development of suicide prevention strategies focusing on early identification and interventions targeting this group. In particular, it may offer assistance to police in designing risk assessment procedures and subsequent investigations of missing persons.

Absconding is increasingly being recognized as a problem within mental health settings with significant risks for consumers. This study examines absconding behaviours across three acute care wards within an Australian psychiatric hospital campus over a 12-month period. A descriptive statistical analysis determined the rate of absconding from 49 consumers who absconded 64 times. The absconding rate was 13.33%(absconding events), with most absconding events arising from males diagnosed with schizophrenia (57.14%) aged between 20 and 29 years, and with 62.50% of absconding events occurring whilst consumers were on their first 21-day detention order. Nearly half of all absconding events were by consumers who had absconded previously, with the highest proportion of events occurring during nursing handover. A profile of people who abscond, time of day of absconding, legal status and repeated absconding behaviours are described. The emergent profile of consumers who absconded within this study bears some similarities to that described in overseas research, although in this study consumers were slightly older and 25% of absconders were female. Of particular interest are findings that identify the timings of absconding events in relation to a consumer's legal status. Implications for practice, including assessment of risk of absconding and management, are considered.

ABSTRACT: BACKGROUND: Suicide prevention by mental health services requires an awareness of the antecedents of suicide amongst high risk groups such as psychiatric in-patients. The goal of this study was to describe the social and clinical characteristics of people who had absconded from an in-patient psychiatric ward prior to suicide, including aspects of the clinical care they received. METHODS: We carried out a national clinical survey based on a 10-year (1997-2006) sample of people in England and Wales who had died by suicide. Detailed data were collected on those who had been in contact with mental health services in the year before death. RESULTS: There were 1,851 cases of suicide by current psychiatric in-patients, 14% of all patient suicides. 1,292 (70%) occurred off the ward. Four hundred and sixty-nine of these patients died after absconding from the ward, representing 25% of all in-patient suicides and 38% of those that occurred off the ward. Absconding suicides were characterised by being young, unemployed and homeless compared to those who were off the ward with staff agreement. Schizophrenia was the most common diagnosis, and rates of previous violence and substance misuse were high. Absconders were proportionally more likely than in-patients on agreed leave to have been legally detained for treatment, non-compliant with medication, and to have died in the first week of admission. Whilst absconding patients were significantly more likely to have been under a high level of observation, clinicians reported more problems in observation due to either the ward design or other patients on the ward. CONCLUSIONS: Measures that may prevent absconding and subsequent suicide amongst in-patients might include tighter control of ward exits, and more intensive observation of patients, particularly in the early days of admission. Improving the ward environment to provide a supportive and less intimidating experience may contribute to reduced risk.

Absconding by psychiatric patients from acute psychiatric wards has been a significant problem for some time. This study was conducted to identify the incidence rate of absconding in a psychiatric hospital and some of the characteristics of patients who had escaped from hospital in year 2006. In this descriptive cross-sectional study, all of absconds in our centre have been registered in the period of 9 months. We assessed patients' age, gender, marital status, hospital stay, substance abuse, psychiatric diagnosis and site of absconding. A total of 43 cases of absconding have been registered in this period, attempted by 35 patients, with the incidence rate of 3% in our centre. The mean age of absconders was 31.7 years; 95.3% of absconds were made by men; 67.4% were single; 37.4% absconded through the main door; 62.8% of our absconders had bipolar mood disorder or schizophrenia; mean in hospital stay before absconding was 18.4 days; and 53.5% of absconds were attempted by substance users. Absconders utilize a significant portion of hospital resources and have an adverse effect on ward milieu. It seems that the patients who are more prone to abscond are male, young, single, addict, with the diagnosis of bipolar mood disorder or schizophrenia and patients who are admitted not long ago.

Absconding is a significant problem with potential for harm to patients or the general public. The consequences of absconding include physical harm, prolonged treatment time, and substantial economic costs. The aim of this systematic literature review is to synthesize quality literature about absconding from psychiatric facilities, identify gaps in knowledge, and make recommendations for practice. An electronic search yielded 39 journal articles that met the review criteria. Findings demonstrate that a single definition of absconding remains elusive, making the prevalence of absconding difficult to establish. Absconding events are multifactorial, with environmental, psychosocial, and organic aspects. Negative consequences exist including violence, aggression, and self-neglect and harm to self and others. Papers are clustered around the following themes: harm and risk, absconder profiles, absconding rates, and perceptions of nurses and patients. Nursing interventions designed to decrease absconding have been implemented with success, but only in a few studies and in Australia, none have been reported in the literature to date. Further research is required to identify appropriate nursing-based interventions that may prove useful in reducing the risk of absconding.

Characteristics of patients absconding from an open psychiatry ward in a developing country may be different from both those in developed countries and a mental hospital setting. The aim of this paper is to study the incidence and characteristics of patients absconding from an open psychiatric ward in a general hospital-based psychiatric unit in India. We studied patients consecutively admitted to an open psychiatric ward over a 2-month period. We compared those who absconded with those who did not. Out of 231 patients admitted, 33 absconded. Among those who absconded, 15 had bipolar disorder, 11 had schizophrenia and five had substance-related disorders. Nine had indicated their intention to do so at admission. Ten patients had absconded by the second day. The treatment cost was the likely influencing factor for seven patients who absconded after deemed fit for discharge on clinical grounds. Only 10 patients were readmitted to the hospital within 2 weeks of absconding. The risk of absconding is highest in the early days following. Absconding patients did not differ significantly from others in many socio-demographic and clinical features. Treatment costs are an important consideration in India.

BACKGROUND Adverse incidents (violence, self-harm and absconding) can cause significant harm to patients and staff, are difficult to predict, and are driving an increase in security measures and defensive practice. AIMS To explore the relationship between adverse incidents on acute psychiatric wards, admissions and nursing workforce variables. METHODS A retrospective analysis of officially collected data covering a period of 30 months on 14 acute wards at three hospitals. This data included 69 serious untoward incidents. RESULTS Adverse incidents were more likely during and after weeks of high numbers of male admissions, during weeks when other incidents also occurred, and during weeks of high regular staff absence through leave and vacancy. CONCLUSIONS It may be possible to predict adverse incidents. Careful staff management and deployment may reduce the risks.

AIM This paper reports an examination of the relationship between adverse incident rates, the arrival of new junior staff on wards, and days of the week on acute psychiatric wards. BACKGROUND Incidents of violence, absconding and self-harm in acute inpatient services pose risks to patients and staff. Previous research suggests that the arrival of inexperienced new staff may trigger more adverse incidents. Findings on the relationship between incidents and the weekly routine are inconsistent. METHOD A retrospective analysis was conducted of formally reported incident rates, records of nursing student allocations and junior doctor rotation patterns, using Poisson Regression. Variance between days of the week was explored using contingency table analysis. The data covered 30 months on 17 psychiatric wards, and were collected in 2002-2004. FINDINGS The arrival of new and inexperienced staff on the wards was not associated with increases in adverse incident rates. Most types of incidents were less frequent at weekends and midweek. Incident rates were unchanged on ward-round days, but increased rates were found on the days before and after ward rounds. CONCLUSION Increased patient tension is associated with raised incident rates. It may be possible to reduce incident rates by moderating stimulation in the environment and by mobilizing support for patients during critical periods.

Acute psychiatric wards experience high levels of conflict behaviours (violence, absconding, self-harm, rule breaking and medication refusal) by patients. These events cause stress and injury to staff and patients. Their management through containment methods (e.g. sedation, restraint, seclusion) is contentious, and nurses are ambivalent about their use. The aim of this study was to reduce conflict and containment on two acute psychiatric wards through changes in nurses' beliefs, attitudes and practices. Two 'City Nurses' were employed to work with two acute wards for 1 year, assisting with the implementation of changes according to a working model of conflict and containment generation, itself based on previous research. Evaluation was via before-and-after measures. Statistically and clinically significant decreases in conflict occurred, with falls in aggression, absconding and self-harm. Ward atmosphere improved and nurse-patient interaction rates increased. There was no significant change in containment method use. Significant reductions in aggression, absconding and self-harm can be achieved on acute psychiatric wards. However, it does not appear that containment can be reduced, even through large reductions in conflict.

Absconding by acute psychiatric inpatients is associated with risk of harm to self and others, and creates considerable emotional as well as tangible burdens for staff. Previous research has led to the development of an effective nursing intervention to reduce absconding. In this project, that intervention was encapsulated in a self-training package, and offered freely to wards across the UK who agreed to implement it and audit the results. Fifteen wards completed this distributed audit, and achieved overall a 25.5% decrease in their absconding rates, as measured by official reports. The results support the efficacy of the intervention, and indicate that significant reductions can be made in absconding rates from unlocked or partially locked acute psychiatric wards.

Absconding from acute psychiatric wards is common. This paper reports the views of 25 staff nurses working on acute mental health wards in East London about absconding. Interviews explored how staff feel when a patient absconds, the complexities of risk assessment and observation policies, who is blamed when patients abscond and what might reduce absconding. The assessment of the level of risk which a patient posed varied considerably, with some wards using standard risk assessment tools and others talking about their own methods. There was some evidence of conflict with medical staff about what measures should be put in place to manage the risk (observation level, leave). The interviewees were aware of serious consequences of absconding, and this made them worry when patients absconded. Following an abscond most nurses look for an explanation, and this can lead to blame of other members of the team. A sizeable minority spoke of feeling unsupported by their managers, and that their jobs could be at risk following an abscond. The nurses felt that absconding could be reduced through a number of measures, principally raising staffing levels and reducing the reliance on agency nurses.

Absconding by patients from acute psychiatric wards is known to be linked to self harm and harm to others. Previous research has focused only on officially reported absconds, thus missing out many patients who although they abscond and pose a risk, are never officially processed. This paper reports the findings of a large prospective study of absconding in the East End of London using an objective definition of absconding not linked to official bureaucratic processes. Absconders are considered by staff to be high risk patients, and many have histories of violence and/or suicide attempts. Nevertheless nurses only request the aid of the police in returning patients on 47% of occasions. The actions of the police are very variable, and range from two policemen calling at the patient's house, to an entire team in riot gear appearing at the patient's door in the early hours of the morning. Most absconds result in no harm to anyone, and most absconders return by themselves. Relatives and carers also play a significant role in persuading the patient to return or bringing them back. Nurses should develop more sophisticated ways of working with the police and with relatives to maintain absconding patients' safety.

Information about how and when patients abscond from acute psychiatric wards may provide important clues to effective prevention strategies. This paper reports relevant findings from a large scale study of absconding conducted in the East End of London. In contrast to the findings in previous studies, the vast majority of absconders left from the ward directly, mostly via the front door. Some were known to be at risk of absconding, and although more than half had declared their intention to leave, they still succeeded in getting away. On some occasions they circumvented locked or guarded doors, or special nursing observation. Shift handovers were a peak time for absconds, possibly due to decreased nursing surveillance of the ward. Most absconds occur during the first few weeks of admission, and most absconders simply went home and engaged in normal, everyday activities. The findings indicate that physical security measures alone are not a sufficient answer to the problem of absconding, and nurses need to work harder to develop supportive alliances with patients.

Absconding by patients from acute psychiatric care poses a significant problem to professional staff, and can involve significant risks for patients and others. This paper describes the methodology of a major prospective study of absconding recently completed in the East End of London, and reports the findings on why patients abscond from hospital. Interviews with 52 patients who returned to their wards showed that they abscond because they are bored, frightened of other patients, feel trapped and confined, have household responsibilities they feel they must fulfil, feel cut off from relatives and friends, or are worried about the security of their home and property. Psychiatric symptoms also contribute to the decision to leave, but in nearly every case patients can give additional and rational reasons for their abscond. Some patients leave impulsively and in anger following unwelcome news about delayed permission for leave or discharge. Others leave specifically in order to carry out some activity outside the hospital. In order to reduce absconding and rejection of care, nurses may need to carefully consider the meaning admission has for patients, and the impact it can have upon their everyday lives.

Incidents of absconding from inpatient care are high-risk events which have been linked to serious harm to self and others. This paper brings together for the first time findings from a disparate body of research literature spanning many years. Varied definitions of absconding and methods of calculating the rates of absconding make comparisons between studies difficult. Nevertheless, it is clear that absconders are more often young, male, from disadvantaged groups, and suffering from schizophrenia, compared to admissions generally. Roughly half of the abscondings take place while the patient is temporarily off the ward with permission, the remainder of absconding patients use an assortment of means to make their escape. A large variety of reasons for absconding have been elicited from patients or advanced as possibilities by researchers. Only six evaluative studies of interventions impacting upon absconding have been reported in the literature, but no firm conclusions can be drawn from them.

Community psychiatric nurses (CPNs) have long been involved in the operations of the English Mental Health Acts. Research has shown that compulsory detention is not used uniformly or consistently. Rates of involuntary hospitalization are reported to vary widely across Europe, but there is some consensus on patient profiles. The ethnicity, social status and gender of the patient, the involvement of the police, the availability of care, problems caused to relatives, and the country and particular legislative system where these judgements take place, all influence who is compulsorily detained. This article reviews recent evidence from Europe and argues that involuntary psychiatric care can no longer be seen as entirely dependent on the symptoms and behaviour of the patient and that CPNs should be aware of and reflect upon these factors before invoking the detention process.

ACCESSIBLE SUMMARY: • An extensive review of empirical literature (n = 39) on patient and staff perceptions of seclusion in psychiatric inpatient settings was undertaken. • Patients perceived seclusion negatively while staff perceived it to be therapeutic and vital for the running of inpatient units. • Better communication, more contact with patients and staff engaging with patients before during and after a seclusion episode were suggestions for improvements to care processes. ABSTRACT: This review explores patient and staff perceptions and improvement suggestions regarding seclusion in psychiatric inpatient settings. After an extensive literature search, 39 empirical papers were included in the review. According to the literature, patients perceived seclusion to be a distinct negative incident. Staff thought seclusion had a therapeutic effect and believed that units could not operate effectively without seclusion, but regretted that the situation was not resolved differently. Staff and patients had suggestions to improve the seclusion experience. Common themes in relation to the implications for practice are the need for better communication and more contact between patients and staff before, during and after the seclusion event.

Aims.Prisoners with mental illness on release from prison often face complex challenges with little support, leading to poor clinical and social outcomes. This feasibility study aimed to see whether a Critical Time Intervention (CTI) in the first weeks post-release effectively connects mentally ill prisoners with social, clinical, housing, and welfare services on leaving prison. The study took place in 2007 and involved local prisons in London and Manchester.Methods.A pilot randomised controlled trial in which CTI was compared to Treatment as Usual (TAU).Results.Sixty prisoners were randomised in the trial, with outcome measures completed on 23. A higher proportion of prisoners in CTI group were in contact with services at follow-up than those receiving TAU. CTI prisoners were significantly more likely to be receiving medication, and be registered with a General Practitioner (GP) than those in the TAU group.Conclusions.Continuity of care for prisoners with severe mental illness can be improved by working with them to identify their needs prior to release, and by assisting them to engage effectively to the necessary agencies in the community.

Comparison of seclusion figures between wards in Dutch psychiatric hospitals showed substantial differences in number and duration of seclusions. In the opinion of nurses and ward managers, these differences may predominantly be explained by differences in patient characteristics, as these are expected to have a large impact on these seclusion rates. Nurses assume more admissions of severely ill patients are related to higher seclusion rates. In order to test this hypothesis, we investigated differences in patient and background characteristics of 718 secluded patients over 5,097 admissions on 29 different admission wards over seven Dutch psychiatric hospitals. We performed an extreme group analysis to explore the relationship between patient and ward characteristics and the wards' number of seclusion hours per 1,000 admission hours. In a multivariate and a multilevel analysis, various characteristics turned out to be related to the number of seclusion hours per 1,000 admission hours as well as to the likelihood of a patient being secluded, confirming the nurses assumptions. The extreme group analysis showed that seclusion rates depended on both patient and ward characteristics. A multivariate and multilevel analyses revealed that differences in seclusion hours between wards could partially be explained by ward size next to patient characteristics. However, the largest deal of the difference between wards in seclusion rates could not be explained by characteristics measured in this study. We concluded ward policy and adequate staffing may, in particular on smaller wards, be key issues in reduction of seclusion.

ACCESSIBLE SUMMARY: •  Verbal aggression is a common feature of life on a psychiatric ward. •  This study reports on how frequently patients were involved in incidents of verbal abuse, shouting, making threats, showing anger or making racist comments. •  Verbally aggressive patients tended to have a history of violence or drug misuse, but some patient characteristics were more strongly associated with particular types of verbal aggression. ABSTRACT: Verbally aggressive behaviour on psychiatric wards is more common than physical violence and can have distressing consequences for the staff and patients who are subjected to it. Previous research has tended to examine incidents of verbal aggression in little detail, instead combining different types of aggressive behaviour into a single measure. This study recruited 522 adult psychiatric inpatients from 84 acute wards. Data were collected from nursing and medical records for the first 2 weeks of admission. Incidents of verbal aggression were categorized and associations with patient characteristics examined. There were 1398 incidents of verbal aggression in total, reported for half the sample. Types of verbal aggression were, in order of prevalence: abusive language, shouting, threats, expressions of anger and racist comments. There were also a large number of entries in the notes which did not specify the form of verbal aggression. Staff members were the most frequent target of aggression. A history of violence and previous drug use were consistently associated with verbal aggression. However, there were also some notable differences in patient variables associated with specific types of verbal aggression. Future studies should consider using multidimensional measures of verbal aggression.

This study examined the antecedents to administration of pro re nata (PRN) psychotropic medication on acute psychiatric wards, with a particular focus on its use in response to patient aggression and other conflict behaviours. A sample of 522 adult in-patients was recruited from 84 acute psychiatric wards in England. Data were collected from nursing and medical records for the first 2 weeks of admission. Two-thirds of patients received PRN medication during this period, but only 30% of administrations were preceded by patient conflict (usually aggression). Instead, it was typically administered to prevent escalation of patient behaviour and to help patients sleep. Overall, no conflict behaviours or further staff intervention occurred after 61% of PRN administrations. However, a successful outcome was less likely when medication was administered in response to patient aggression. The study concludes that improved monitoring, review procedures, training for nursing staff, and guidelines for the administration of PRN medications are needed.

AIMS AND OBJECTIVES The study examined events before and after incidents of self-harm and attempted suicide and the characteristics of patients who engage in these behaviours. BACKGROUND Psychiatric inpatient populations have an elevated risk of self-harm and suicide, but relatively little is known about the circumstances of these events during an admission. DESIGN Retrospective case note analysis. METHOD Data were collected on conflict (aggression, rule breaking, etc.) and containment (coerced medication, restraint, etc.) during the first two weeks of admission for a sample of 522 acute psychiatric inpatients. RESULTS One in 10 patients self-harmed, and 4% attempted suicide. Aggression, attempting to leave the ward without permission and medication refusal were frequent precursors to incidents. Pro re nata medication and de-escalation were the most frequent interventions to follow an incident. Self-harm and attempted suicides during the current admission were significantly associated with younger age and a history of self-harm. CONCLUSIONS A minority of the sample were involved in these behaviours, but incidents occurred soon after admission and sometimes repeatedly during the course of a day. Assessment of risk should be completed as early as possible. RELEVANCE TO CLINICAL PRACTICE At-risk patients should be monitored for signs of withdrawal from ward activity, wanting to leave the ward without permission or non-compliance with medication to enable early intervention.

OBJECTIVE The main objective of this study was to learn more about what increases or decreases the likelihood of patient conflict (such as verbal abuse, violence, and rule breaking) and containment (such as seclusion, manual restraint, and enforced medication) events in acute inpatient psychiatric wards. METHODS Line graphs that mapped the total conflict and containment scores over two years on 16 acute inpatient psychiatric wards in the United Kingdom (London) were matched with chronological events that were documented in 120 qualitative semistructured interviews with ward managers and consultant psychiatrists during the same two-year period. Conflict and containment scores were derived from the validated Patient-Staff Conflict Checklist-Shift Report, which was completed by nurses at the end of each shift to log the frequency of conflict behaviors of patients and the staff containment measures. RESULTS A total of 463 score transitions (upturns and downturns) were identified in the graphs. A total of 323 events were matched to these transitions. A thematic analysis of these events produced 40 themes, which were organized into four categories: patient centered, staff centered, practice or ward centered, or other themes. Thirteen themes were significantly associated with conflict and containment score transitions, 11 of which were staff centered. For example, negative staff morale and staffing change resulting in a negative impact significantly increased the likelihood that conflict and containment would occur, whereas report of positive staff practice significantly decreased the likelihood of such events occurring. CONCLUSIONS The results support the theory that ward staff play a crucial role in influencing the likelihood that conflict or containment events will occur in inpatient psychiatric settings.

AIMS   This is a report of a study of events before and after the use of constant special observation on acute psychiatric wards, and the characteristics of patients who received it. BACKGROUND   Constant special observation is a method of preventing acutely disturbed inpatients from harming themselves or others. It has been characterized as impersonal, intrusive and non-therapeutic. The circumstances of its use and place in broader intervention strategies are not well understood. METHODS   A sample of 522 patients were recruited from 84 acute psychiatric wards in 31 hospital locations in London and surrounding areas during 2009-2010. Data were collected for the first 2 weeks of admission from patients' case notes. RESULTS   Sixteen per cent of patients received constant special observation during the first 2 weeks in hospital (7% at the point of admission and 11% after admission), but with variation between hospitals. Absconding, violence and self-harm were the most common events to precede constant special observation during a shift. Other methods of containment, especially intermittent special observation, were frequently tried first. Episodes of constant special observation often involved de-escalation and extra medication. Aggression was more prominent during than before constant special observation. Attempted suicides were limited to postadmission episodes. CONCLUSION   Constant special observation is usually used in combination with other forms of containment, irrespective of when it is initiated. Placing patients considered at risk of suicide under constant special observation on admission may have a protective effect.

Locking the exit doors of psychiatric wards is believed to reduce the risk of patients absconding. The aims of the study were to investigate both the prevalence of door locking and other exit security measures on UK admission wards, as well as whether door locking appears to be effective in keeping inpatients in. A cross-sectional survey on 136 acute psychiatric wards in the UK was conducted, in which a range of data on patients, staff, and conflict and containment events, including door locking and absconding, were collected from shift to shift during a period of 6 months. About one-third of the participating wards (30%) operated with their ward exit door permanently locked, whereas another third (34%) never locked the ward door. Univariate analyses suggested little association between exit security measures and absconding. A more robust multilevel statistical analysis, however, did indicate a reduction of about 30% of absconding rates when the ward door was locked the entire shift. Although locking the ward door does seem to reduce absconding to a certain extent, it far from completely prevents it. As it may be unrealistic to strive for a 100% absconding-proof ward, alternative measures for door locking to prevent absconding are discussed.

BACKGROUND The link between positive outcomes and qualified nurse staffing levels is well established for general hospitals. Evidence on staffing levels and outcomes for mental health nursing is more sparse, contradictory and complicated by the day to day allocation of staff resources to wards with more seriously ill patients. OBJECTIVE To assess whether rises in staffing numbers precede or follow levels of adverse incidents on the wards of psychiatric hospitals. DESIGN Time series analysis of the relationship between shift to shift changes over a six month period in total conflict incidents (aggression, self-harm, absconding, drug/alcohol use, medication refusal), total containment incidents (pro re nata medication, special observation, manual restraint, show of force, time out, seclusion, coerced intramuscular medication) and nurse staffing levels. SETTINGS 32 acute psychiatric wards in England. METHODS At the end of every shift, nurses on the participating wards completed a checklist reporting the numbers of conflict and containment incidents, and the numbers of nursing staff on duty. RESULTS Regular qualified nurse staffing levels in the preceding shifts were positively associated with raised conflict and containment levels. Conflict and containment levels in preceding shifts were not associated with nurse staffing levels. CONCLUSIONS Results support the interpretation that raised qualified nurse staffing levels lead to small increases in risks of adverse incidents, whereas adverse incidents do not lead to consequent increases in staff. These results may be explicable in terms of the power held and exerted by psychiatric nurses in relation to patients.

There is disagreement among psychiatric professionals about whether the doors of acute psychiatric wards should be kept locked to prevent patients from leaving and harming themselves or others. This study explored patient, staff, and visitor perceptions about the acceptability of locking the ward door on acute psychiatric inpatient wards. Interviews were conducted with 14 registered nurses, 15 patients, and six visitors from three different acute wards. Findings revealed commonalities across all groups, with general agreement that locking the door reduced absconding. Staff expressed feelings of guilt, embarrassment, and fear of being blamed when a patient absconded. Staff also reported that open wards created anxious vigilance to prevent an abscond and increased workload in allocating staff to watch the door, whereas staff on partially-locked doors also perceived an increased workload in letting people in and out of the ward. Patients had mixed feelings about the status of the door, expressing depression, a sense of stigma, and low self-esteem when the door was locked. The issue of balancing safety and security on acute psychiatric wards against the autonomy of patients is not easily resolved, and requires focused research to develop innovative nursing practices.

Manual restraint is used to manage disturbed behaviour by patients. This study aimed to assess the relationship of manual restraint and show of force to conflict behaviours, the use of containment methods, service environment, physical environment, patient routines, staff characteristics, and staff group variables. Data from a multivariate, cross-sectional study of 136 acute psychiatric wards in England were used to conduct this analysis. Manual restraint was used less frequently on English acute psychiatric wards (0.20 incidents per day) than show of force (0.28 incidents per day). Both were strongly associated with the proportion of patients subject to legal detention, aggressive behaviours, and the enforcement of treatment and detention. Medical, nursing, and security guard staff provision were associated in different ways with variations in the use of these coercive interventions. An effective ward structure of rules and routines was associated with less dependence on these control methods. Training for manual restraint should incorporate the scenarios of attempted absconding and enforcement of treatment, as well as violent behaviour. Attempts to lessen usage of these interventions could usefully focus on increasing the availability of medical staff to patients, reducing reliance on security guards and establishing a good ward structure.

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ABSTRACT: BACKGROUND: Suicide prevention by mental health services requires an awareness of the antecedents of suicide amongst high risk groups such as psychiatric in-patients. The goal of this study was to describe the social and clinical characteristics of people who had absconded from an in-patient psychiatric ward prior to suicide, including aspects of the clinical care they received. METHODS: We carried out a national clinical survey based on a 10-year (1997-2006) sample of people in England and Wales who had died by suicide. Detailed data were collected on those who had been in contact with mental health services in the year before death. RESULTS: There were 1,851 cases of suicide by current psychiatric in-patients, 14% of all patient suicides. 1,292 (70%) occurred off the ward. Four hundred and sixty-nine of these patients died after absconding from the ward, representing 25% of all in-patient suicides and 38% of those that occurred off the ward. Absconding suicides were characterised by being young, unemployed and homeless compared to those who were off the ward with staff agreement. Schizophrenia was the most common diagnosis, and rates of previous violence and substance misuse were high. Absconders were proportionally more likely than in-patients on agreed leave to have been legally detained for treatment, non-compliant with medication, and to have died in the first week of admission. Whilst absconding patients were significantly more likely to have been under a high level of observation, clinicians reported more problems in observation due to either the ward design or other patients on the ward. CONCLUSIONS: Measures that may prevent absconding and subsequent suicide amongst in-patients might include tighter control of ward exits, and more intensive observation of patients, particularly in the early days of admission. Improving the ward environment to provide a supportive and less intimidating experience may contribute to reduced risk.