Mental Health Risk Assessment and Safety Planning During UK Covid-19 Pandemic Lockdown: Mixed Methods Survey and Interview Study.

Risk assessment and safety planning are central to mental health nursing practice but were seriously affected by the Covid-19 pandemic and associated lockdowns. In this study, we aimed to explore how the UK pandemic lockdowns affected risk assessment and safety planning from the perspective of mental health practitioners. A sequential, mixed methods study design was used. A link to an online survey questionnaire was distributed and semi-structured interviews with a subset of respondents were conducted. Survey data were analysed to describe perceived changes in the frequency and nature of risk assessment and safety planning during the pandemic lockdowns. This was supplemented by thematic analysis of qualitative interview data. In total, 106 practitioners were surveyed and 10 participated in semi-structured interviews. More respondents increased than decreased risk assessment frequency but there was no significant overall change. Remote contact was more common in community settings and largely involved telephone appointments. Participants did not wish to continue with remote working following the pandemic. Risk assessment practice changed in UK mental health services as a result of COVID-19 lockdowns.

A Systematic Review of Violence Risk Assessment Tools Currently Used in Emergency Care Settings.

INTRODUCTION: Violence risk assessment is commonplace in mental health settings and is gradually being used in emergency care. The aim of this review was to explore the efficacy of undertaking violence risk assessment in reducing patient violence and to identify which tool(s), if any, are best placed to do so. METHODS: CINAHL, Embase, Medline, and Web of Science database searches were supplemented with a search of Google Scholar. Risk of bias assessments were made for intervention studies, and the quality of tool development/testing studies was assessed against scale development criteria. Narrative synthesis was undertaken. RESULTS: Eight studies were included. Three existing violence risk assessment tools featured across the studies, all of which were developed for use with mental health patients. Three newly developed tools were developed for emergency care, and 1 additional tool was an adaptation of an extant tool. Where tested, the tools demonstrated that they were able to predict patient violence, but did not reduce restraint use. The quality issues of the studies are a significant limitation and highlight the need for additional research in this area. DISCUSSION: There is a paucity of high-quality evidence evaluating the psychometric properties of violence risk assessment tools currently used along the emergency care pathway. Multiple tools exist, and they could have a role in reducing violence in emergency care. However, the limited testing of their psychometric properties, acceptability, feasibility, and usability in emergency care means that it is not possible to favor one tool over another until further research is conducted.

The violence prevention climate of mental health wards: a cross-sectional study of staff and patient views.

PURPOSE: Ward climate can shape the behaviour of both staff and patients. A subset of the ward climate is the violence prevention climate, the unique characteristics that are perceived by the people within the environment as contributing towards the prevention of violence. The aim of this study was to explore differences between and within staff and patient groups in terms of their perceptions of the violence prevention climate. METHODS: A cross-sectional survey was conducted with staff (n = 326) and patients (n = 95) in mental health care pathways within one charitable trust. All participants completed the VPC-14 to measure perceptions of the violence prevention climate, a validated 14-item two-factor scale (staff actions and patient actions). Staff demographic information was collected on the VPC-14 front sheet; patient demographic, clinical and violence data were collected from electronic case records. Bivariate analyses were conducted to compare within- and between-group variables. Significant staff and patient variables were entered into multiple hierarchical regression analyses to assess their relationship with VPC-14 factors. RESULTS: Staff had a more positive view than patients of staff actions and patients had a more positive view of patient actions than did staff; staff- or patient-group membership was the best predictor of staff action scores. Individual staff characteristics accounted for a small amount of the variance in staff and patient action scores; individual patient characteristics explained more variance, but this was still below 20%. CONCLUSIONS: Staff perceive their violence prevention-related contributions more positively than patients and vice versa. This has implications for staff; they may need to better articulate their role in violence prevention to patients, as well as recognise the role that patients play. However, within staff and patient groups, individual variables only make up a small amount of variance of perceptions of the violence prevention climate. This suggests that the violence prevention climate is a valid construct, i.e. that despite differences in individual variables, individuals within the patient group have similar perceptions of the VPC, as do those within the staff group.

Examining the utility of the Violence Prevention Climate scale: In a metropolitan Australian general hospital.

AIM AND OBJECTIVES: To evaluate and examine the utility of the Violence Prevention Climate scale by generalist healthcare professionals. BACKGROUND: Workplace violence in general hospital settings remains a challenge for healthcare organisations. High rates of violence are still being reported towards healthcare workers, despite organisational violence prevention strategies being implemented. There is a major challenge to healthcare organisation in the measurement of the effectiveness of these interventions, traditionally completed via the reporting and monitoring of workplace violent incidents. A novel approach to measuring workplace violence is by studying hospital atmosphere or climate. DESIGN: A cross-sectional survey using the STARD guidelines was used. METHODS: The Violence Prevention Climate scale was completed by 194 healthcare staff working in the emergency department, medical/surgical wards, respiratory/infectious disease, spinal care, renal unit, corrections health, and rehabilitation and community services of a major Australian tertiary referral hospital. The Violence Prevention Climate scale has previously been validated and used in mental health settings, but not general hospital settings. A content analysis of an open-ended question on violence prevention management strategies was also conducted. RESULTS: Comprising of 14 items with two factors (patients and staff), the study revealed a 9-item staff factor scale that can be used in the general hospital setting, the patient factor did not show adequate reliability. The content analysis revealed seven categories of staff identified violence prevention and management strategies. CONCLUSIONS: The use of the 9-item scale across an organisation annually, or added to existing organisational workforce surveys, could prove to be practical way of measuring the social climate of violence in a general hospital setting. RELEVANCE TO CLINICAL PRACTICE: The results of which could guide clinical practice, workplace safety, policy and educational initiatives for the prevention and management of workplace violence.

Longitudinal evaluation of a programme for safety culture change in a mental health service.

AIM: To evaluate whether a two-part culture improvement programme aimed at nurses in clinical and managerial positions in an inpatient mental health service was associated with culture change, and safety-related behaviour and knowledge improvements. BACKGROUND: Due to serious failings in the delivery of physiological care to mentally disordered inpatients, it was deemed important that interventions be applied to improve service culture. METHODS: A pre-test and post-test study was conducted to evaluate change associated with a mandated intervention aimed at culture change. Nurses in clinical and managerial positions at all levels attended relevant sessions. All were invited to participate in evaluation measures. RESULTS: N = 241 nurses participated in the evaluation (n = 137 and n = 104, pre-test and post-test, respectively). There was a small but significant change in organisational culture indicating greater adhocracy and less clan culture in the second survey period and a small decline in reported safety behaviour. Measures of safety culture, knowledge and emergency-related educational satisfaction were unchanged. CONCLUSION: Only a small change in measured culture was associated with the programme. IMPLICATIONS FOR NURSING MANAGEMENT: Attempts to evaluate culture change need to align anticipated outcomes with appropriate outcome measures. A mandated programme of culture change had little tangible effect on the outcomes measured.

Mental health services, care provision, and professional support for people diagnosed with borderline personality disorder: systematic review of service-user, family, and carer perspectives.

BACKGROUND: Mental health professionals' attitudes to people with Borderline Personality Disorder can be negative. No systematic review to date has examined how service-users and their families experience professional care. AIMS: To critically synthesise evidence of service-users' and families' subjective experience of mental health care for borderline personality disorder. METHODS: Multiple computerised databases were searched using comprehensive terms. All relevant, English language empirical studies were included. We read and critically assessed all papers independently. Study findings were subject to a meta-synthesis. RESULTS: A total of 38 studies were included. Analysis revealed four themes for service-users: assessment and diagnosis; approach of professionals; therapeutic interventions, and service provision; two broad themes for family/carers: support, burden, and information; and experience of professional and therapeutic approaches. Both groups expected to receive professional healthcare, and were clear they valued professionalism, respect, compassion and the therapeutic nature of positive relationships with professionals. Expectations were jeopardised where difficulties with knowledge, communication, information sharing, and support were perceived. CONCLUSIONS: Service-users and families/carers should expect to receive high quality, fair and equal care. In light of current evidence, a cultural shift towards more relational, person centred and recovery-focused care could improve experiences.

Clarity, confidence and complexity: Learning from mental health nurses' experiences of events involving physiological deterioration of consumers in acute inpatient mental health settings.

AIMS AND OBJECTIVE: To capture the experiences of nurses in relation to the acutely physiologically deteriorating consumer. BACKGROUND: Improving the physical health care of consumers with mental illness has been widely adopted as a priority for mental health nursing. Much of the effort thus far has focused on routine screening, prevention and treatment of common comorbidities including cardiovascular disease, diabetes mellitus and cancer. There has been less focus on the acutely physiologically deteriorating consumer in the mental health setting. Further study is warranted since this issue poses a set of highly complex challenges for nurses within the inpatient setting. METHOD: An exploratory, descriptive study was employed using focus groups to gather narrative data, which was then subject to qualitative analysis. Eleven mental health inpatient wards within a local health district in Sydney, Australia, were studied, comprising ward-based nurses (n = 64) and nurse unit managers (n = 8). This paper follows the COREQ guidelines for reporting qualitative health research. RESULTS: Qualitative data analysis revealed three themes central to the nurses' experience: (a) lack of clarity (subthemes: procedures and leadership accountability); (b) confidence in the workforce (subthemes: knowledge and skills, training needs, relevant experience, collaboration with emergency and medical teams, stigmatising attitudes); and (c) complexity (subthemes: complexity as the new norm and suitability of the mental health environment). CONCLUSION: The themes found in this study can be used to guide and inform healthcare policy, protocols, education and processes around building a more confident nurse workforce for the acutely physiologically deteriorating consumer. RELEVANCE TO CLINICAL PRACTICE: Findings provide a rich data set for the generation of measurement tools and protocols to guide physical health care and evaluate performance.

Nurses' Attitudes and Perceptions towards Hand Hygiene in Mental Health and Medical Inpatient Settings: Comparative, Cross-Sectional Study.

Poor hand hygiene is a major contributor to hospital acquired infection. In this study, a comparison of the related attitudes of psychiatric and non-psychiatric nurses was made using a cross-sectional survey design. N = 79 nurses who work in psychiatric or non-psychiatric hospital wards completed questionnaires regarding intended compliance with hand-washing protocols and potential cognitive predictors of compliance. Perceived ease of compliance and behavioural norms, and working in a non-psychiatric ward, predicted superlative intended compliance. Working in psychiatry did not in itself predict outgroup membership suggesting that psychiatric ward-related factors, rather than psychiatric nurse-related factors are most relevant in determining between-group differences. Consideration of factors unique to psychiatry wards during service design could improve compliance.

Mixed-methods evaluation of an educational intervention to change mental health nurses' attitudes to people diagnosed with borderline personality disorder.

AIMS AND OBJECTIVES: To evaluate and explore mental health nurses' responses to and experience of an educational intervention to improve attitudes towards people with a diagnosis of borderline personality disorder (BPD). Report findings are concordant with relevant EQUATOR guidelines (STROBE and COREQ). BACKGROUND: Attitudes towards people with a diagnosis of BPD are poorer than for people with other diagnoses. There is limited evidence about what might improve this situation. One intervention with reportedly good effect uses an underlying biosocial model of BPD. No previous intervention has been co-produced with an expert by experience. We developed and delivered a 1-day intervention comprising these elements. DESIGN: A mixed-methods design was used comprising prospective within-subjects cohort intervention and qualitative elements. Participants were mental health nursing staff working in inpatient and community settings in one NHS Board in Scotland, UK. METHODS: Measurement of cognitive and emotional attitudes to people with a diagnosis of BPD at pre- and postintervention (N = 28) and at 4-month follow-up. Focus groups were used to explore participants' experiences of the intervention (N = 11). RESULTS: Quantitative evaluation revealed some sustained changes consistent with expected attitudinal gains in relation to the perceived treatment characteristics of this group, the perception of their suicidal tendencies and negative attitudes in general. Qualitative findings revealed some hostility towards the underpinning biosocial model and positive appreciation for the involvement of an expert by experience. CONCLUSIONS: Sustained benefits of an educational intervention for people working with people diagnosed with BPD in some but not all areas. Participants provided contrasting messages about what they think will be useful. RELEVANCE TO CLINICAL PRACTICE: The study provides further evidence for incorporation of a biosocial model into staff training as well as the benefits of expert by experience co-production. Mental health nurses, however, believe that more well-resourced services are the key to improving care.

Mental health nurses' attitudes, experience, and knowledge regarding routine physical healthcare: systematic, integrative review of studies involving 7,549 nurses working in mental health settings.

BACKGROUND: There has been a recent growth in research addressing mental health nurses' routine physical healthcare knowledge and attitudes. We aimed to systematically review the empirical evidence about i) mental health nurses' knowledge, attitudes, and experiences of physical healthcare for mental health patients, and ii) the effectiveness of any interventions to improve these aspects of their work. METHODS: Systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Multiple electronic databases were searched using comprehensive terms. Inclusion criteria: English language papers recounting empirical studies about: i) mental health nurses' routine physical healthcare-related knowledge, skills, experience, attitudes, or training needs; and ii) the effectiveness of interventions to improve any outcome related to mental health nurses' delivery of routine physical health care for mental health patients. Effect sizes from intervention studies were extracted or calculated where there was sufficient information. An integrative, narrative synthesis of study findings was conducted. RESULTS: Fifty-one papers covering studies from 41 unique samples including 7549 mental health nurses in 14 countries met inclusion criteria. Forty-two (82.4%) papers were published since 2010. Eleven were intervention studies; 40 were cross-sectional. Observational and qualitative studies were generally of good quality and establish a baseline picture of the issue. Intervention studies were prone to bias due to lack of randomisation and control groups but produced some large effect sizes for targeted education innovations. Comparisons of international data from studies using the Physical Health Attitudes Scale for Mental Health Nursing revealed differences across the world which may have implications for different models of student nurse preparation. CONCLUSIONS: Mental health nurses' ability and increasing enthusiasm for routine physical healthcare has been highlighted in recent years. Contemporary literature provides a base for future research which must now concentrate on determining the effectiveness of nurse preparation for providing physical health care for people with mental disorder, determining the appropriate content for such preparation, and evaluating the effectiveness both in terms of nurse and patient- related outcomes. At the same time, developments are needed which are congruent with the needs and wants of patients.

Systematic review of therapeutic leave in inpatient mental health services.

AIM: To identify, critically evaluate, and synthesise the empirical evidence about therapeutic leave from mental health inpatient settings. BACKGROUND: "Leave" occurs when a mental health inpatient exits the hospital ward with the appropriate authorisation alone, or accompanied by staff, family, or friends. Limited research has previously addressed therapeutic as opposed to unauthorised leave, and the evidence-base has not been systematically evaluated. DESIGN: Systematic review methodology following relevant Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement guidance. DATA SOURCES: Multiple electronic databases (CINAHL; Criminal Justice database; PsycARTICLES; Scopus; OpenGrey; Cochrane; GoogleScholar) for papers published from January 1967 to July 2017. REVIEW METHODS: Information was extracted under the following headings: study, purpose/aims, sample, country, setting, design and data collection method(s), data collection instrument, and results. Papers were assessed, as per the hierarchy of scientific evidence, and where there was sufficient data, we calculated a range of standardised rates of leave incidence. RESULTS: Standardised leave rates in forensic settings reflect security level. There was little meaningful information on which to base calculation of rates for civil settings. The strongest evidence supports leave used for supervised discharge; other forms of leave lack an evidence base and decisions appear to be made on the basis of heuristic rules and unsupported assumptions. Clinical decision making about therapeutic leave cannot claim to be evidence-based. CONCLUSION: Research is urgently needed to provide information about how leave is managed, the best ways to support leave, and what happens on leave.

Structured risk assessment for reduction of multiple risk outcomes in a secure mental health setting: Use of the START.

BACKGROUND: Structured risk assessment is commonly used in secure settings to aid prediction and prevention of risky behaviours; the expected benefits have rarely been investigated. AIMS: The aim of the study is to determine whether adverse outcomes (physical and verbal aggression, self-harm, victimisation, self-neglect, unauthorised leave and substance abuse) reduced after patients were assessed with the Short-term Assessment of Risk and Treatability (START). METHODS: In a naturalistic study, anonymised demographic and clinical information was collected from 50 male patients. Data included START assessment and frequency of target behaviour for 3 months before and after first assessment. Chi-square and linear mixed models analyses were used to determine whether there was any change in the behaviours of interest. RESULTS: There were no significant changes in physical or verbal aggression over time, although a tendency towards fewer incidents was apparent. Other adverse behaviours were very infrequent at baseline, precluding adequate analysis. CONCLUSIONS: In this small sample, START did not achieve its primary purpose of significant reduction in adverse behaviours. Although our sample size was informed by a power calculation, we may have over-estimated the size of anticipated change. Further, the 3-month comparison periods before and after the assessment follow-up period were rather short. Accordingly, we recommend more research on the value of this tool in practice rather than discontinuing its use. Copyright © 2017 John Wiley & Sons, Ltd.

Mental health nurses' attitudes, behaviour, experience and knowledge regarding adults with a diagnosis of borderline personality disorder: systematic, integrative literature review.

AIMS AND OBJECTIVES: To establish whether mental health nurses responses to people with borderline personality disorder are problematic and, if so, to inform solutions to support change. BACKGROUND: There is some evidence that people diagnosed with borderline personality disorder are unpopular among mental health nurses who respond to them in ways which could be counter-therapeutic. Interventions to improve nurses' attitudes have had limited success. DESIGN: Systematic, integrative literature review. METHODS: Computerised databases were searched from inception to April 2015 for papers describing primary research focused on mental health nurses' attitudes, behaviour, experience, and knowledge regarding adults diagnosed with borderline personality disorder. Analysis of qualitative studies employed metasynthesis; analysis of quantitative studies was informed by the theory of planned behaviour. RESULTS: Forty studies were included. Only one used direct observation of clinical practice. Nurses' knowledge and experiences vary widely. They find the group very challenging to work with, report having many training needs, and, objectively, their attitudes are poorer than other professionals' and poorer than towards other diagnostic groups. Nurses say they need a coherent therapeutic framework to guide their practice, and their experience of caregiving seems improved where this exists. CONCLUSIONS: Mental health nurses' responses to people with borderline personality disorder are sometimes counter-therapeutic. As interventions to change them have had limited success there is a need for fresh thinking. Observational research to better understand the link between attitudes and clinical practice is required. Evidence-based education about borderline personality disorder is necessary, but developing nurses to lead in the design, implementation and teaching of coherent therapeutic frameworks may have greater benefits. RELEVANCE TO CLINICAL PRACTICE: There should be greater focus on development and implementation of a team-wide approach, with nurses as equal partners, when working with patients with borderline personality disorder.

Predictive validity of the HCR-20 for violent and non-violent sexual behaviour in a secure mental health service.

BACKGROUND: Violent and non-violent sexual behaviour is a fairly common problem among secure mental health service patients, but specialist sexual violence risk assessment is time-consuming and so performed infrequently. AIMS: We aimed to establish whether a commonly used violence risk assessment tool, the Health Clinical Risk management 20(HCR-20), has predictive validity specifically for inappropriate sexual behaviour. METHODS: A pseudo-prospective cohort design was used for a study in the adult wards of a large provider of specialist secure mental health services. Routine clinical team HCR-20 assessments were extracted from records, and incidents involving inappropriate sexual behaviour were recorded for the 3 months following assessment. RESULTS: Of 613 patients, 104 (17%) had engaged in at least one inappropriate sexual behaviour; in 65 (10.6%), the sexual act was violent. HCR-20 total score, clinical and risk management subscales, predicted violent and non-violent sexual behaviour. The negative predictive value of the HCR-20 for inappropriate sexual behaviour was over 90%. CONCLUSIONS: Prediction of violent sexual behaviour may be regarded as well within the scope of the HCR-20 as a structured professional judgement tool to aid violence risk prediction, but we found that it also predicts behaviours that may be of concern but fall below the violence threshold. High negative predictive values suggest that HCR-20 scores may have some utility for screening out patients who do not require more specialist assessment for inappropriate sexual behaviour. Copyright © 2015 John Wiley & Sons, Ltd.

The HCR-20 as a measure of reliable and clinically significant change in violence risk among secure psychiatric inpatients.

OBJECTIVE: Periodic structured violence risk assessment is the principle method underlying treatment planning for mentally disordered offenders but little is known about how risk changes over time. We aimed to determine whether hospitalised patients underwent reliable clinical change in assessed risk. METHOD: We used a pseudo-prospective longitudinal study design. Demographic, clinical and risk assessment data of adult inpatients (N=480) who had been routinely assessed with the HCR-20 on two to four occasions over a mean period of 17 months (SD=2) were collated. Linear mixed models regression was conducted to determine change over time on total, subscale, and individual item scores, and relative change between clinical and demographic groups. The Reliable Change Index was calculated to examine whether change was greater than that expected by measurement error; clinically significant change was defined as the extent to which HCR-20 scores reduced below previously reported scores for patients not requiring hospitalisation. RESULTS: HCR-20 total score (Estimate -0.42, 95% CI=-0.84, -0.01, p<.05; d=.20) and clinical score (Estimate=-0.42, 95% CI=-0.64, -0.20, p<.001; d=.36) reduced over assessments. Significant differences in change were evident between clinically and demographically defined groups. A maximum of 3% of individuals showed clinically significant reliable reductions in HCR-20 total scores. The scores of patients whose overall level of risk was judged to have decreased did not reduce between assessments. CONCLUSION: Violence risk changes very little over the course of treatment although there is some variation between groups. Most change cannot be demonstrated to be reliable or clinically significant. Important clinical management decisions should not depend solely on evidence from changes in HCR-20 risk assessment.

A Service Evaluation of a 1-Year Dialectical Behaviour Therapy Programme for Women with Borderline Personality Disorder in a Low Secure Unit.

BACKGROUND: Previous studies about the effectiveness of Dialectical Behaviour Therapy for the treatment of Borderline Personality Disorder have had promising results. However, no previous studies have examined its effectiveness when delivered in low secure inpatient services for women. AIMS: To evaluate clinical outcomes during and after a 1-year period of admission within a low secure unit for women offering a Dialectical Behaviour Therapy programme. METHOD: A naturalistic, within subjects study of clinical data collected as part of routine practice was conducted. Participants were 18 consecutively admitted women who met the diagnostic criteria for Borderline Personality Disorder and had completed at least 1 year of treatment. Measures covered: risk behaviours; self-reported symptoms of Borderline Personality Disorder, and current mood and symptom experience; staff reports of clinical problems, needs and social functioning. Scores were compared between admission and at 6 months and 1 year. RESULTS: There was a statistically significant improvement on all 13 measures over the year's treatment. Most improvement was demonstrated between admission and 6 months. CONCLUSIONS: Engagement in1-year's treatment was associated with significant reduction in risk behaviours and both staff-rated and self-rated outcome measures. Some significant questions remain about which elements of the programme are most effective but the results are encouraging.

Facial emotion processing in borderline personality disorder: a systematic review and meta-analysis.

A body of work has developed over the last 20 years that explores facial emotion perception in Borderline Personality Disorder (BPD). We identified 25 behavioural and functional imaging studies that tested facial emotion processing differences between patients with BPD and healthy controls through a database literature search. Despite methodological differences there is consistent evidence supporting a negative response bias to neutral and ambiguous facial expressions in patients. Findings for negative emotions are mixed with evidence from individual studies of an enhanced sensitivity to fearful expressions and impaired facial emotion recognition of disgust, while meta-analysis revealed no significant recognition impairments between BPD and healthy controls for any negative emotion. Mentalizing studies indicate that BPD patients are accurate at attributing mental states to complex social stimuli. Functional neuroimaging data suggest that the underlying neural substrate involves hyperactivation in the amygdala to affective facial stimuli, and altered activation in the anterior cingulate, inferior frontal gyrus and the superior temporal sulcus particularly during social emotion processing tasks. Future studies must address methodological inconsistencies, particularly variations in patients' key clinical characteristics and in the testing paradigms deployed.

Predictive validity of the HCR-20 for inpatient self-harm.

BACKGROUND: Few instruments have been developed to assess the risk of self-harm by psychiatric patients and the evidence for their predictive validity is limited. Given that individuals who self-harm may also engage in other-directed aggression, and that the behaviour can be a precursor to violence, we tested whether, and for which groups, the commonly used violence risk assessment HCR-20 demonstrated predictive validity for self-harm. PROCEDURES: A pseudo-prospective cohort study (N=504) was conducted in a UK secure/forensic mental health setting using routinely collected data. HCR-20 assessments were completed by the clinical team and incidents of self-harm during the 3months following assessment were coded from patient records. FINDINGS: The HCR-20 total score, H10 and R5 subscales, and SJ for violence significantly predicted self-harm; however, AUC values did not demonstrate large effect sizes (range .345 to .749). Personality disorder and impulsivity were the strongest predictors of self-harm, but the R5 scale contained the greatest proportion of relevant items. Predictive efficacy was superior for women compared with men and for those with schizophrenia or personality disorder compared with organic and developmental disorders. CONCLUSIONS: The HCR-20 appears to be a significant predictor of self-harm. It may be possible to supplement HCR-20 ratings with case specific knowledge and additional known risk factors for self-harm to make a valuable summary judgement about the behaviour and thus minimise the need for multiple assessment tools.