A sad looking woman lies awake on a hospital bed.

Self-harm risk of patients under continuous observation in hospital wards

9 May 2024

Our latest investigation has found ‘limited evidence’ that the current approach to continuous observation of adult patients at risk of self-harm when on hospitals wards is effective.

The report, published today, details an investigation which explores in depth the activity of continuous observation and its use in reducing the risk of patients self-harming while receiving care for physical healthcare needs in an acute hospital ward. For context, the term ‘continuous observation’ is a ‘widely used intervention’ for staff to monitor and assess the mental and physical health of a person who may harm themselves. Self-harm is one of the most common reasons that people go to hospital. The report cites data from the Office of Disparities showing that between April 2021 – April 2022, nearly 94,000 were admitted to hospital in England as an emergency due to self-harm.

The report reveals that there is variation in hospital settings as to why, when, how and by whom continuous observation was carried out. There was limited evidence of the effectiveness of the observation and no consistency in patients experience. In addition, the investigation found that growing financial pressures and staff shortages within healthcare have resulted in continuous observation being increasingly scrutinised at all levels of healthcare. We also emphasise that human factors principles often are not considered, and this is needed to understand the complexities of this intervention and the environments in which it may take place – for example if staff are carrying out a mentally challenging task in poor light whilst fatigued is unreliable.

Patient case

The safety issues that were explored in our wider investigation had been seen in the patient case set out in the report. Emily-May, 18, was being cared for in a mental health hospital where she was detained under the Mental Health Act. She was taken by air ambulance to an acute hospital after a ‘life threatening’ self-harm event, where she had surgery for her wounds. Following surgery, she was transferred to intensive care and then onto a High Dependency Unit (HDU), where she remained for her stay in the acute hospital and her mental health care continued to be provided by staff from the mental health hospital.

While in the acute hospital HDU, Emily-May self-harmed while two members of staff were continuously observing her – they found she had a wound to her neck which had to be repaired in an operating theatre. In analysing the details of her case, we found that there were challenges in collaborative working between the acute hospital and mental health hospital that limited opportunities to reduce the risk of self-harm during her stay. This included a potential lack of therapeutic engagement with Emily-May and staff experiencing exhaustion after long periods of observation.

Examples

The wider investigation looked at three areas: what is continuous observation, what competencies do staff need for continuous observation and what helps and hinders continuous observation.

Some key quotes and examples from those interviewed include:

  • Staff and subject matter advisors told the investigation that some healthcare providers gained false assurance from a patient being on continuous observation, believing that this intervention eliminated the risk of self-harm. Whereas, the staff and subject matter advisors said, at best it can only reduce this risk and allow staff to quickly call for help in the event of a patient self-harming. At worst it can increase a patient’s risk of self-harm.
  • Staff and subject matter advisors told the investigation there was not a robust evidence base to support the use of continuous observation to reduce the risk of patients harming themselves or others. In addition, they said many patients found the practice intrusive and for some increased the risk of harm.
  • A systemic review explored patients’ experience of being continuously observed. Patients were more likely to report positive experiences when the staff ‘interacted’ with them, for example if they ‘showed care and concern’. Patients also ‘commonly report feelings of distress, anxiety, isolation and rebelliousness’. The reasons given for these negative feelings included feeling ‘restricted’, having ‘little or no privacy’ and ‘very little interaction’ with the staff observing them.
  • Subject matter advisors agreed that continuous observation was a “skilled activity”, but that this was often not acknowledged in practice with the intervention often given to healthcare support workers, which meant that “the least qualified and knowledgeable staff are caring for the most vulnerable and distressed”.
  • Staff and subject matter advisors said that acute hospital wards are often busy, stimulating, noisy, brightly lit and have limited space for moving about. They said that this environment was unhelpful for those with mental health problems. In addition, a consultant liaison psychiatrist stated that daily routines are often important to somebody struggling with mental health problems and that these can “go out the window” in an acute hospital.
  • In relation to vigilance and fatigue, the investigation was told that on mental health wards the staff carrying out continuous observation would change every 1 to 2 hours. In addition, the wider team was available for support, especially if a patient was “distressed and unpredictable”. In contrast, for a patient in an acute hospital, one member of staff may be carrying out observation over a 12-hour shift.

The report concludes with two safety recommendations focused on further research into the efficacy and acceptability of continuous observation and on producing national guidance for staff. We have also included local learning prompts for healthcare providers.

Clare Crowley
Clare Crowley, Senior Safety Investigator at HSSIB.

Investigator’s view

Clare Crowley, Senior Safety Investigator at HSSIB, says: “Continuous observation is one part of a person’s overall mental health plan but if the approach is not appropriate or is not done safely or effectively, there is a real risk that patients could harm themselves during their hospital stay. This is distressing and traumatic for all involved.

“During our investigation, we saw that there is no clear system of support and guidance at a national level for healthcare providers and their staff when it comes to continuous observation. We have emphasised that there is limited evidence that the intervention is effective – with many experts, patients, staff and researchers questioning its use. The inconsistency and variation in understanding of the purpose of continuous observation and how best to do it means that often the therapeutic element of the interactions can be lost. As we were told, this, rather than the ‘custodial element’ of observation is crucial to keeping the patient safe and is more likely to reduce the risk of self-harm.

“Emily-May told us that she was keen to support a positive change with regard to continuous observation – she shared her experiences of feeling frustrated and distressed at points. The aim of our report, safety recommendations and prompts is to shine a light on the issues and improve safety and care across England for those who are most at risk of self-harm when staying in hospital.”

Findings in full

  • There is a lack of evidence about how to optimise the safety and quality of continuous observations of adults, or when it is most appropriate to use this intervention.
  • Decisions about when to use continuous observation are made at healthcare provider level. This is because there are limited national guidelines and standards on when and how continuous observation should be carried out, and a lack of clear guidance on the training needs and competencies of staff doing this.
  • Variation exists within and across healthcare settings in the terms used to describe continuous observation, its purpose, when it should be used, how it is done, and which staff carry out this intervention for patients at risk of self-harm.
  • In order to create the conditions in which staff can best carry out continuous observation, consideration of human factors principles is needed to understand the complexities of this intervention and the environments in which it may take place.
  • Formal processes are often not in place to anticipate and support effective collaborative working where mental health staff work alongside physical health staff in an acute hospital to provide care to a patient at risk of self-harm.
  • When staff caring for a patient at risk of self-harm have witnessed a significant self-harm event this can be traumatic and staff cannot always access the support that they need.

Read the report

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