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City - 128


The City-128 study was designed to test the City Model [link] which predicted factors to help create a calmer ward. These wards would be those where the staff positively appreciated patients, could contain their natural emotional responses to difficult patient behaviour, and provided an effective structure of rules and routines for those in their care. The study has become one of the largest cross sectional studies of acute psychiatric inpatient services yet undertaken. Data was collected for a six month period on 136 wards which represented 25% of the estimated total of 551 wards in England. The resulting dataset consisted of 46,000 end of shift reports on conflict and containment frequencies, 8,000 staff questionnaires, 1,000 patient questionnaires, plus data on multidisciplinary staffing complements and deployment, ward physical environments, and service contexts within which they operated.

Due to its size and uniqueness, the City-128 dataset has also been used to explore number of related issues. The majority of these analyses have been cross-sectional and have utilised multi-level modelling with Poisson regression. This is a technique that provides accurate estimates of associations with hierarchically structured data (shifts, within wards, within NHS Trusts).

Total conflict and containment

Conflict such as aggression, substance use, absconding etc threatens the safety of patients and staff. The containment to deal with this conflict such as coerced medication, special observation, manual restraint etc arouses both strong feelings for both patients and staff and is considered controversial.

Our previous work suggested three staff factors impact on rates of these events. These are the positive appreciation of patients by staff, the staff management of their own emotional reactions to patient behaviour, and the provision of an effective structure. The aim of this analysis was to test this theory. Multiple regression was therefore conducted to ascertain those factors most strongly associated with total conflict and containment rates.

The feature that staff most strongly and consistently associated with lower conflict and containment rates was structure. Other elements of the theory were less well supported by the data although there were patient and ward factors significantly associated with differences in conflict and containment rates between wards. In particular the proportion of patients formally detained under mental health legislation, the quality of the physical environment, and staff/patient ethnicity were exampled.

We concluded that conflict and containment are reliable and meaningful concepts. Staff factors are relevant in the determination of conflict and containment rates on wards. Most importantly wards require an effective, well organised structure of rules and daily routines.


Special observation (the allocation of nurses to watch over nominated patients) is one means by which psychiatric services endeavour to keep in-patients safe from harm. The practice is both contentious and of unknown efficacy. The aim of this analysis was to assess the relationship between special observation and self-harm rates, ward by ward, whilst controlling for potential confounding variables.

Constant special observation was not associated with self-harm rates, but intermittent observation was associated with reduced self-harm, as were levels of qualified nursing staff and more intense programmes of patient activities. We concluded that certain features of nursing deployment and activity may serve to protect patients. The efficacy of constant special observation remains open to question.


Morale on acute psychiatric wards has been considered to be problematic, and is reported to contribute to lower quality patient care. The aim of this analysis was to assess the relationship of staff morale to patient, service environment, physical environment, patient routines, conflict, containment, staff demographics, and staff group variables.

Morale was higher than published comparison samples. For staff the length of time in post was correlated with low morale, and qualified nurses had higher emotional exhaustion but also higher personal accomplishment. The level of verbal abuse on a ward was associated with low morale, as was a higher level of social deprivation among patients. Higher levels of order and organisation correlated with better morale.

We concluded that clear policies relating to the management of verbal abuse by patients, high levels of order and organisation, and staff rotation and education, may all support high morale. Acute inpatient psychiatry is generally a happy and rewarding work environment, and identified problems are likely to be due to other factors.

Nurses and patients on acute wards

A significant proportion of the UK population (7.6%) belong to an ethnic minority, and there are concerns that they are subject to excessive force and coercion within acute wards. The aim of this analysis was to describe the ethnic and demographic composition of staff and patients on acute psychiatric wards in England.

Ethnic minority patients were more likely to be younger, admitted with a diagnosis of schizophrenia, at risk of harm to others and to be legally detained. The association between ethnic minority status and detention remains, even when risk, age, gender and diagnosis are taken into account. Ethnic minority patients come from areas of greater social deprivation and fragmentation. Ethnic concordance between staff and patients varies, but the greatest difference is found in London where the proportion of minority staff is greater than the proportion of minority patients.

There continues to be evidence that ethnic minority patients are subject to an excessive amount of legal coercion in English mental health services. However the proportion of staff belonging to an ethnic minority is greater than the proportion of patients. Changes to recruitment strategies are required if ethnic concordance is to be achieved.

Investment in acute inpatient care

The aim of this analysis was to describe the composition, variability and factors associated with nurse staffing costs in acute psychiatric inpatient care. Numbers of acute inpatient beds in England have fallen, creating an occupancy crisis. Numbers of acute inpatient nursing staff are linked to quality of care. Variance in staffing and beds has considerable resource implications, but little is known about how these costs are structured.

Our data comprised survey data from the City-128 study, matched with nationally available data on service levels, population and outcomes. The cost of providing acute inpatient care varied fivefold between different Trusts. This variation comprised of numbers of beds/population, numbers of nurses/beds, and the proportion of nurses qualified. These variations were not fully accounted for by differing levels of social deprivation. Although service provision levels in London were higher, wide variation in costs existed in every region. Associations between nursing cost per bed and performance indicators were found.

As investment in acute inpatient care varies widely, we need to know much more about the relationship of inputs to outputs, so that empirically based standard service levels can be defined.

Costs of conflict and containment

The economic cost of conflict and containment behaviour has not been available previously. This study sought to obtain and observe actual staff time managing conflict and containment. This was achieved by means of a new method of estimating costs arsing from the development of an interview schedule to use with key staff. The aim of this analysis was therefore to estimate the costs of different types of conflict and containment in the UK using events from 136 adult acute in-patient psychiatric wards in the UK and unit costs from a sample of 15 wards,.

An interview schedule was developed by health researchers and a health economist. This schedule asked staff to use their experience and knowledge to describe conflict and containment events and the resources typically used to manage these events. Interviewees were offered a range in terms of staff time utilised as well as what proportion of episodes fell into low or high range time consuming events. These estimated timed events and their arising resource use, were then multiplied against numbers of incidents and developed into cost data. This data was adjusted to provide annualized conflict and containment cost figures for each of the 136 wards as a well as an annualized average national cost figure for all the UK’s acute psychiatric wards.

The estimated mean annual cost for conflict is £145,177, and for containment £212,316. The total estimated annual costs in England for all conflict is £72.5 million and for containment is £106 million. The most expensive conflict behaviour to manage was verbal abuse with a mean cost per ward of £21.2k and a total of £10.5 million nationally. Self-harm had a mean cost of £8.2k per ward and costs £4 million in England. Intermittent and special observation cost £45 million and £35 million respectively. This study also suggests that approximately half of all nursing resources are expended in managing conflict and deploying containment.

Conflict and containment events have potential to give rise to wider financial and non-financial effects, which are difficult to assess and cost in detail. Further research could examine the potential costs saved when interventions are used to reduce conflict and containment in acute settings.

Attitudes towards coercive interventions by staff and patients

The aim of this analysis was to ascertain to which degree psychiatric inpatients and staff approved of various coercive measures commonly used in acute inpatient care.

Service users tended to be more homogenous in their views than staff in that there were fewer age or gender differences within this sub-sample. The staff responses varied according to both gender and age with females and older staff tending to disapprove more strongly of coercive measures. Exposure to ‘gentler’ measures (e.g. observation) enhanced approval and conversely, exposure to ‘harsher’ measures (e.g. IM medication) led to stronger rejection of the measure. Staff reported greater approval of those techniques they had used in their practice. There was evidence of strong disapproval amongst both staff and service users with regard to mechanical restraint. Attitudes toward other existing measures did not differ hugely between the two groups although service users tended to be more disapproving overall than staff.

There are clear gender differences in how coercive measures that are used in inpatient settings are viewed. Personal involvement in deploying coercive interventions was linked to greater acceptance, suggesting a link between experience and attitudinal changes.

Key factors associated with aggression

Aggressive behaviour is a critical issue for modern acute psychiatric services, not just because of the adverse impact it has on patients and staff, but also because it puts a financial strain on service providers. The aim of this analysis was to assess the relationship of patient violence to other variables: patient characteristics, features of the service and physical environment, patient routines, staff factors, the use of containment methods and other patient behaviours.

High levels of aggression were associated with several factors: a high proportion of patients formally detained under mental health legislation, high patient turnover, alcohol use by patients, ward doors being locked, and higher staffing numbers (especially qualified nurses). The findings suggest that the imposition of restrictions on patients exacerbates the problem of violence, and that alcohol management strategies may be a productive intervention. Insufficient evidence is available to draw conclusions about the nature of the link between staffing numbers and violence.

The relationship between staff group features

Conflict (aggression, substance use, absconding, etc.) and containment (coerced medication, manual restraint etc.) threaten the safety of patients and staff on psychiatric wards. Previous work has suggested that staff variables may be significant in explaining differences between wards in their rates of these behaviours, and that structure (ward organisation, rules and daily routines) might be the most critical of these. In this analysis we explored the City-128 data to assess the relationship between structure and other staff variables, using principal components analysis, structural equation modelling and cluster analysis.

Principal components analysis resulted in the identification of each questionnaire as a separate factor, indicating that the selected instruments assessed a number of non-overlapping items relevant for ward functioning. Structural equation modelling suggested a linear model in which leadership influenced teamwork, teamwork structure; structure burnout; and burnout feelings about difficult patients. Finally cluster analysis identified two significantly distinct groups of wards, the larger of which had particularly good leadership, teamwork, structure, attitudes towards patients and low burnout, and the second smaller proportion which was poor on all variables and high on burnout. The better functioning cluster of wards had significantly lower rates of containment events.

We concluded that the overall performance of staff teams is associated with differing rates of containment on wards. Interventions to reduce rates of containment on wards may need to address staff issues at every level, from leadership through to staff attitudes.

Ward features associated with medication refusal

This analysis explored the relationship of medication related conflict (refusal of regular medication, refusal of pro re nata (p.r.n.) medication, demanding p.r.n. medication) to other conflict behaviours, the use of containment methods, service environment, physical environment, patient routines, staff demographics, and staff group variables.

The mean daily rate (at ward level, standardised to 20 beds) of incidents of regular medication refusal was 0.89 (sd 0.52), p.r.n. medication refusal 0.30 (sd 0.19) and demanding p.r.n. medication 1.09 (sd 0.63). The frequency of these events was found to be associated with passive resistant patient behaviours, higher levels of containment (specifically locking the main ward door, the use of special observation, and time out) and unstable staffing profiles.

We concluded that it may be possible to achieve greater medication concordance amongst patients in acute mental health wards through a more consensual approach to care. Paradoxically, fewer restrictions may promote better treatment acceptance and safer outcomes. Consistent nurse staffing and therefore better staff-patient relationships, are also likely to improve cooperation and outcomes.

Wards as places of safety

In recent years the purpose and quality of provision delivered in acute inpatient psychiatric settings have been increasingly questioned. Studies from a service user perspective have reported that whilst some psychiatric inpatients feel safe and cared for, others see their time there as neither safe nor therapeutic. As part of the City-128 study, sixty semi-structured interviews were conducted with psychiatric inpatients randomly selected from sixty psychiatric wards in England. The interviews were analysed thematically, to explore the experiences of service users on acute inpatient psychiatric wards in England regarding their feelings of safety and security whilst in hospital.

A third of the respondents felt safe in hospital and felt supported by staff and other patients in times of need. Other patients sense of security was eroded by: fighting between patients, intimidation, bullying, theft, racism, and illegal substances such as alcohol or cannabis being smuggled onto the ward. Psychiatric wards are still perceived by many as volatile environments, where service users feel forced to devise personal security strategies in order to protect themselves and their property.

It would appear that there remains much to do before research findings and policies are implemented in ways that facilitate all service users to derive the maximum benefit from their in-patient experience.

The practice of seclusion and time out

Seclusion is widely used internationally to manage disturbed behaviour by psychiatric patients, although many countries are seeking to reduce or eliminate this practice. Time out has been little described and almost completely unstudied. The aim of this analysis was to assess the relationship of seclusion and time out to conflict behaviours, the use of containment methods, service environment, physical environment, patient routines, staff characteristics, and staff group variables.

Seclusion is used infrequently on English acute psychiatric wards (0.05 incidents per day), whereas time out use was more frequent (0.31 incidents per day). Usage of seclusions was strongly associated with the availability of a seclusion room. Seclusion was associated with aggression, alcohol use, absconding and medication refusal, whereas time out was associated with these and other more minor conflict behaviours. Both were associated with the giving of ‘as required’ medication, coerced intramuscular medication and manual restraint. Relationships with exit security for the ward were also found.

We concluded that, given its low usage rate, the scope for seclusion reduction in English acute psychiatry may be small. Seclusion reduction initiatives need to take a wider range of factors into account. Some substitution of seclusion with time out may be possible, but a rigorous trial is required to establish this. The safety of intoxicated patients in seclusion requires more attention.

Manual restraint and shows of force

Manual restraint is used to manage disturbed behaviour by patients. This analysis 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.

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 variation 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.

Special observation as surveillance

Special observation (SO) is a method of preventing psychiatric inpatients harming themselves or others. This analysis explored the relationship of SO to patient conflict behaviours, the use of containment methods by staff, the physical environment of wards, patient routines and staffing variables.

Intermittent SO (patient checked at specified intervals) was used five times more frequently than constant SO (patient kept within sight or reach at all times).

Both were positively associated with verbal aggression, absconding, refusing regular medication, demanding PRN medication and refusing PRN medication, but intermittent and constant SO were negatively correlated. Intermittent SO was associated with fewer self-harm incidents. Significant relationships were found between SO and measures of ward surveillance, door locking and the ease of observing patients on the wards. Both types of SO were more common when higher numbers of unqualified staff were on duty.

We concluded that complex range of factors are associated with intermittent and constant forms of SO. Improved ward design, less reliance on unqualified staff and greater use of CCTV and other surveillance measures may reduce the need for SO in some cases.

Contributors to this research: Len Bowers, Alan Simpson, Teresa Allan, Diane Hackney, David Parkin, Kam Bhui, Peter Nolan, Richard Whittington, Chloe Foster, Chris Flood, Lindsey Neil, Catherine Painter, Julia Jones, Marie Van Der Merwe, John Baker, John Owiti, Martin Crowder, Duncan Stewart, Charlotte Dack, Eric Noorthoorn, Bridget Hamilton & Eimear Muir-Cochrane.


CITY 128 Internet Paper 05 Bowers, L. (2007) CITY INTERNET 128 PAPER 05 – Is the relationship between total conflict and total containment linear or curvilinear?

CITY 128 Internet Paper 01 Bowers, L., Allan, T., Simpson, A. Jones, J. (2007) CITY 128 INTERNET PAPER 01 – Leadership on acute wards.

CITY 128 Internet Paper 02 Bowers, L., Allan, T., Simpson, A. Jones, J. (2007) CITY 128 INTERNET PAPER 02 – Team Climate on acute wards.

CITY 128 Internet Paper 03 Bowers, L., Allan, T., Simpson, A. Jones, J. (2007) CITY 128 INTERNET PAPER 03 – Attitude to Personality Disorder.

CITY 128 Internet Paper 04 Bowers, L., Allan, T., Simpson, A. Jones, J. (2007) CITY 128 INTERNET PAPER 04 – Atmosphere on acute wards.

Final City 128 report to NHS SDO this is the final report as accepted by the funders.


Baker, J. Bowers, L. and Owiti, J. (2009) Wards features associated with high rates of medication refusal by patients. General Hospital Psychiatry 31:80–89

Bowers, L. (2009) Association between staff factors and levels of conflict and containment on acute psychiatric wards in England. Psychiatric Services 60(2)231-239

Bowers, L. and Flood, C. (2008) Nurse staffing, bed numbers and the cost of acute psychiatric inpatient care in England. Journal of Psychiatric and Mental Health Nursing 15:630–637

Bowers, L. and Simpson, A. (2004) Major Study Launched to Shed Light on the Differences Between Acute Inpatient Wards. Mental Health Practice 7(5)6

Bowers, L., Allan, T., Simpson, A. Jones, J. Van Der Merwe, M., and Jeffery, D. (2009) Identifying key factors associated with aggression on acute in-patient psychiatric wards. Issues in Mental Health Nursing 30:260-271

Bowers, L., Allan, T., Simpson, A., Jones, J. and Whittington, R. (2009) Morale is high in acute inpatient psychiatry. Social Psychiatry and Psychiatric Epidemiology 44(1)39-46

Bowers, L., Jones, J. and Simpson, A. (2008) The demography of nurses and patients on acute psychiatric wards in England. Journal of Clinical Nursing 18:884-892

Bowers, L., Whittington, R., Nolan, P., Parkin, D., Curtis, S., Bhui, K., Hackney, D., Allan, T., Simpson, A. (2008) Relationship between service ecology, special observation and self-harm during acute in-patient care: City-128 study. British Journal of Psychiatry 193(5)395-401

Flood, C., Bowers, L. and Parkin, D. (2008) Estimating the Costs of Conflict and Containment on Adult Acute Inpatient Psychiatric Wards. Nursing Economics 26(5)325-30

Whittington, R. Bowers, L. Nolan, P. Simpson A., and Neil, L. (2009) Approval ratings of inpatient coercive interventions in a national sample of mental health service users and staff in England. Psychiatric Services 60(6)792-798

Bowers, L.; Van der Merwe, M.; Nijman, H.; Hamilton, B.; Noorthoorn, E.; Stewart, D.; Muir-Cochrane, E.. (2010) The Practice of Seclusion and Time-out on English Acute Psychiatric Wards: The City-128 Study. Archives of Psychiatric Nursing, 24(4)275–286

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