OBSERVATION OF PEOPLE WITH ACUTE MENTAL HEALTH PROBLEMS
1.1 This is a revision of the CRAG Good Practice Statement "Nursing Observation of Acutely Ill Psychiatric Patients in Hospital" (1995). It sets out guidance on the care of people with acute mental health problems who require observation and special care. The guidance will be relevant to NHSScotland Trusts (including the State Hospital) who provide acute psychiatric care, staff (of all disciplines), users and carers. Much of the content will be of use to other providers of mental health care.
1.2 The focus of this document is on the clinical practice within acute psychiatric settings. However, patients may become acutely ill in other types of wards or facilities, or in the community. If someone requires care and observation due to acute psychiatric illness then the suggestions and principles contained within this document apply. The review group did not specifically examine the issues of observation of people with learning disabilities or patients suffering from dementia, but believes much of this document would have relevance for these clinical conditions. The management of mental health patients in general hospitals and the management of patients in general hospitals awaiting referral to mental health services have not been addressed in this report.
1.3 Apart from guiding clinical practice this document will assist organisations to comply with the standards produced by the Clinical Standards Board for Scotland (CSBS) and the Quality Indicators from the Scottish Health Advisory Service (SHAS, 2001). It is relevant specifically to Standard 1 (Patient Focus) and Standard 2 (Safe and Effective Clinical Care) within the CSBS Generic Standards and Standard 5 (Transferring Care) within the CSBS Schizophrenia Standards, and to Quality Indicator 2 (the Delivery of Care) from SHAS.
1.4 The report focuses on the practice of observation of the patient but it must be recognised that observation policies and procedures are only one aspect of caring for people during periods of high distress. It is clearly not enough to simply observe people. The process must be both safe and therapeutic. People who need this level of help are going through a temporary period of increased need. Whatever the cause of this need they, at that moment, require safety, compassion, understanding and appropriate treatment. They must still be engaged in a positive and therapeutic relationship with staff after observation levels return to normal.
1.5 This document examines the issue of who should take the major role in observation. With the emphasis on multi-disciplinary and multi-agency working and with the increased role of users and carers in contributing to service delivery, it is timely to develop the observation role into a process in which many disciplines, carers and users have a role to play. However, it must be acknowledged that nurses, and particularly the nurses in charge of wards, remain the major professional players involved.
1.6 This document outlines both clinical and policy issues for consideration, debate and implementation at a local level. It is prescriptive only where clear, unambiguous guidance is seen to be appropriate.
2.1 In May 2000 the Mental Health & Well-Being Support Group invited CRAG to revise the CRAG Working Group on Mental Illness document entitled "Nursing Observation of Acutely Ill Psychiatric Patients in Hospital". The original document published in 1995 had been well received by the Service and the principles of good practice were largely adopted. However, some work was required to bring it in line with current clinical practice and policy developments.
2.2 A working group was established to carry out the review. The full remit of the group is given in Annex 1 and membership is listed in Annex 2. This group met on eight occasions and an editorial subgroup met twice. To ensure that the work of the group was based on the experience of the Service, three preparatory exercises were undertaken:
a review of Trust observation protocols
a survey on the impact and barriers to implementing the original good practice statement on observation
a brief survey of Service users' experiences of observation.
2.3 The information and views received through these consultations were added to the main group discussion and many are incorporated into the document. The details of these consultations are given in Annex 3.
2.4 The original report was prompted by several issues including a comment within the Annual Report from the Mental Welfare Commission for Scotland in 1992, which noted that considerable variation existed in the definition and application of observation levels throughout Scottish hospitals. The original CRAG document attempted to standardise these levels. A review, undertaken by the current working group, identified that the recommended three levels of observation are now in use in the vast majority of Trusts in NHSScotland. Furthermore, it is clear that the report is well known, generally well integrated into care and many of the changes suggested in the responses by clinicians and users around Scotland were, in fact, already largely referred to in the original text.
2.5 These findings supported the strong opinion within the group that the original report had strong validity within clinical practice, the good practice described within it was still largely relevant, and the report would be revised only if the amendments would add strength and depth to the document. The working group identified several key issues requiring attention:
to move from observation being seen as a purely nursing responsibility to a multi-disciplinary model
to clarify the role of relatives and other non-clinicians in observation
to make links to current service issues such as establishing and implementing standards, continuing quality assurance, and risk management within clinical governance processes
to review relevant literature and clinical practice to establish if a change was required to the three levels of observation
to review and suggest training needs
to highlight need and methods for observation to be therapeutic
to clarify the process for the increase/decrease of observation levels and how it is to be recorded.
3 ELEMENTS OF GOOD PRACTICE
3.1 Purpose of Observation
3.1.1 The key purpose of observation is to provide a period of safety for people during temporary periods of distress when they are at risk of harm to themselves and/or others. It is essential to ensure this period is therapeutic and, although it may be perceived as not needed at the time, that it will generally be seen as a positive experience by the patient in time. It can also be used to provide an intensive period of assessment of a person's mental state. Acute admission facilities and intensive psychiatric care settings are the areas most involved in the practice of raised observation.
3.1.2 It has been reported in recent years that acute environments have seen a significant change in the profile of patients within their care. This would seem to indicate that most acute admission facilities are dealing with a patient population that is generally staying for a shorter duration than in the past but is more acutely ill or distressed. The implications of this are that more patients at any point in time may need raised levels of observation and therefore the need for clear guidance and policies on this issue may be even more essential than previously.
3.1.3 Formal observation systems should not be seen as inflexible and rigid and it is important that policy and clinical practice developments are not restricted. It is essential that clinical services feel able to develop new methods of engaging with high-risk patient behaviour. However, it is essential that such developments are carefully designed and researched to assist in developing the evidence base for dealing with this complex issue. The Chief Scientist Office, Nursing and Midwifery Practice Development Unit and CRAG may be able to support such projects.
3.1.4 It must be remembered that the process of observation can be distressing for patients and can be considered an imposition on their freedom and dignity. It has an impact on the use of the available staff resource, and thus on the care of other patients. Clinical teams should not hesitate to use increased levels of observation when their judgement indicates it is needed. However they should be clear about its purpose and aware of the wider effects of this decision.
A general principle is that observation should be set at the least restrictive level, for the least amount of time within the least restrictive setting.
3.1.5 In its review of the Mental Health (Scotland) Act (2001), the Millan Committee offered ten principles that have equal relevance and importance to this document. The ten principles are set out in full in Annex 6. The principles of participation and respect would lead us to involve patients in decisions regarding levels of observation and give clear, comprehensive answers to questions and requests. The principle of reciprocity should ensure that if we restrict patient freedom (because of observation requirements) then we are obliged to give high quality care and engagement with the patient. At the time of preparation of this report the exact content of the forthcoming mental health bill, based on the Millan Report, is not known.
3.1.6 It is important that all involved in the practice of observation comply with the principles of the European Convention on Human Rights, especially Article 5, which states that
"5.1 Everyone has the right to liberty and security of person. No-one shall be deprived of his liberty save in the following cases, and in accordance with a procedure prescribed by law . . .
(e) The lawful detention of . . . persons of unsound mind
5.4 Everyone who is deprived of his liberty by arrest or detention shall be entitled to take proceedings by which the lawfulness of his detention shall be decided speedily by a Court and his release ordered if the detention is not lawful".
In practice, the issue is that observation must take place on the basis of engagement and dialogue with the patient consenting, as long as that individual is capable. If the basis for such agreement no longer holds, then informal coercion on the basis of what staff members see as the immediate risks may contravene Article 5. Recourse to the provisions of the Mental Health (Scotland) Act 1984 will have to be considered if the relevant criteria can be met.
3.1.7 Spending time with patients, whether engaged in activity, discussion or simply being with them may allow close assessment and monitoring of behaviour and mental state. It therefore may meet many of the needs of observation but is not adequate in itself. At times it is essential to have a clear, unambiguous instruction regarding a patient's need for close or special procedures. Formal, standardised observation systems ensure clarity of the process for both patient and staff.
3.1.8 The key issue is to devise systems and processes that balance patient safety and well being with their therapeutic needs. It must be seen as unacceptable if adequate, caring, patient contact is only achieved by the utilisation of a formal observation system.
3.2 General Principles of Observation
3.2.1 The process of observation must not be seen as a low-level or less-skilled "task". It requires considerable skill and effort and can be most demanding and tiring for both parties. Therefore it is essential that there is:
staff with competence in a broad range of clinical skills
a suitable environment
a broad range of available activities
a culture that values and respects the role of observation
a clinical supervision process for staff
a good planning of staff breaks
access to full written explanations of the process for patients/carers
access to advocacy for patients who may feel discontent with the level or process of observation
a clear system for Critical Incident Reviews in the event of mishap
an audit trail on the use of observation procedures.
3.2.2 Observation should be seen as a partnership between the multi-disciplinary team and the patient and carers. It must not be punitive or custodial. To assist in achieving this partnership both the reasons for, and the process of, observation should be transparent to all parties and discussed openly.
3.2.3 A mechanistic approach to the observation process, which may be seen as "watching the doors" or "guarding the patient" is totally inadequate. Observation of patients who are acutely ill must be seen as a skilled task involving assessment of the patient's mental state and the development of a rapport and therapeutic relationship with the person being observed. The process should be open, transparent and well communicated. All staff who undertake observation should be specifically trained to do so, understand the importance of the duty they are carrying out and have the skills to deliver brief psychological and practical interventions to benefit the patient. Excessive use of temporary and casual staff can impede the development of good rapport between staff and their patients and the quality of treatment afforded.
3.2.4 Research into the use of untrained nursing staff in the process of observation has demonstrated that, as staff changed on an hourly basis, patients were repeatedly asked the same questions (Duffy 1994). Lessons can be learned from this that can improve the quality of care, e.g. handover reports should be carried out before and after every period of observation. This will avoid unnecessary duplication and improve continuity of care. The observational task can be delegated to unqualified members of staff, but the qualified nurse delegating this duty must ensure that the unqualified colleague knows why they are observing the patient and what the purpose of the observation is. The nurse in charge of a particular shift is responsible for ensuring that individuals requiring extra observation are allocated a member of staff skilled to undertake this duty.
3.2.5 For staff, one specific and skilled element of observation, in relation to protecting oneself and others, is the detection of signs of impending aggression. The close proximity inherent in observation and the risk of patients feeling aggrieved or anxious during prolonged periods of observation may increase the probability of violence. It is therefore essential that all staff should receive training in techniques for the detection, de-escalation and management of aggression prior to being involved in raised levels of observation. (This requirement is detailed within the CRAG Good Practice Statement on "The Prevention and Management of Aggression", 1996.)
3.3 Making Observation Work
3.3.1 To ensure the distress and discomfort that may be felt during raised levels of observation is minimised, a careful balance of activity, silence or privacy must be obtained. This balance will differ for each person and will vary across time. The availability of music, creative activities, magazines/newspapers, board games, jigsaws, etc., as well as somewhere appropriate for using them is helpful. Activities can also offer an effective method of observing an individual's level of functioning, as is the chance to assess someone's mental state from the general conversation that often occurs around such activities. Being left alone in as private a setting as possible is also appropriate. A careful selection of the available activities is essential and should involve patient choice where appropriate.
3.3.2 Some practical suggestions are as follows.
Activities of Daily Living _ assist individuals to maintain self-care, maintaining some responsibility and dignity. Assist with bed-making, tidying room and doing personal laundry. As appropriate write letters, make telephone calls.
Social Interaction _ respect a patient's right for silence. If a patient wishes to talk don't only talk about symptoms but introduce general conversation topics. Remember the habit of talking at the patient may be due to a staff member's personal difficulty with silence.
Clinical Interaction _ a spell of uninterrupted contact allows time for brief psychological interventions, focused on negative or intrusive thought patterns, reality-checking and problem solving, or self-harming thoughts. There is much therapeutic self-help written material available now, and it can be helpful for the patient to have some guidance in working through it (see paragraph 10.2).
Ask the patient what would be helpful to them at that moment in time. Is there anything in the patient's history which could be discussed further with benefit?
Respect a patient's wishes within safety boundaries, and the level of observation in force. Open the door or sit outside the room if the patient's mental state is deteriorating as a consequence of the close proximity and constant observation that is in force.
On-ward occupational therapy to assist patients in engaging in activities during the time of an acute onset.
Nurse management systems should be aimed at increasing direct patient contact by ensuring staff are available to patients as much as possible. Appointment systems for named nurse sessions can ensure planned contact and give patients a chance to discuss concerns and frustrations.
Spending time with patients, whether engaged in activity, discussion, or simply being with them, allows close assessment and monitoring of behaviour and mental state. It is the basis of all good clinical practice and can meet many of the needs of observation, but may not be adequate in itself to reduce risk. At times it is essential to have a clear, unambiguous instruction regarding a patient's need for close or special procedures. Formal, standardised observation systems ensure clarity of the process for both patient and staff.
3.4 Involvement and Engagement
3.4.1 "Building relationships" is a generally accepted premise upon which psychiatric care is based, and high-quality care is considered to be that which takes note of the individual needs of patients (Altschul 1972, Cormack 1976, Reynolds 1985, Beck et al 1988 and Peplau 1988). Caring for acutely-ill psychiatric patients is no different in this respect, and the research evidence shows that promoting a therapeutic environment and culture is crucial in the care of "at risk" and suicidal patients. As the Mental Welfare Commission stated, the challenge for the psychiatric nurse (and other professions) is "to create a balance between care and control" (Mental Welfare Commission, 1993).
3.4.2 Observation of a patient is clearly patient-centred, but should be seen as part of an overall "holistic approach" to care. Multi-disciplinary teams should take the lead in determining the style and content of staff-patient interaction, making every attempt to create an environment which is therapeutic and which treats patients with respect and dignity. While intensive levels of observation may be unavoidably restrictive, observation must never become a form of de facto detention for voluntary patients. As far as possible, the team should seek the consent and understanding of the patient being observed.
3.5 The Context and Setting of Observation
3.5.1 As previously stated, observation policy and practice is only one element of acute psychiatric care. Having policies and procedures that ensure safety alone is not sufficient. Acute psychiatric care is challenging and demanding both for staff and patients alike. To achieve a high-quality, comprehensive service, acute units need to address many issues including the following:
clarity of purpose
philosophies that are patient-focused
systems of supporting and developing clinical practice
management systems that provide clear leadership to the Service
robust communication between clinical team members
range of therapeutic evidence-based treatments available
practices which identify sources of risk and minimise them proactively
respect for, and involvement of, patients and their carers
consistent, skilled multi-disciplinary staff who feel valued and supported
appropriate physical environments with space and privacy.
The physical environment in which observation occurs can influence both the frequency and intensity of its usage. Poor ward design and layout can lead to problems of carrying out General Observation leading to increased levels of observation. Inadequate or inappropriate facilities may well be a clinical governance issue for services to consider. Even in older buildings, the ward manager should have the opportunity to work with the Estates Department (or similar) to reduce any obvious hazards. The environment must be made to be fit for purpose, therapeutic, and all environments must be specifically audited for availability of ligature points as detailed in recent Safety Notices (reference no. SAN(SC) 98/49 & SAN(SC) 01/21).
3.5.2 It is the case that on occasion patients in need of raised levels of observation may be cared for in an Intensive Psychiatric Care Unit (IPCU). These wards generally have increased staff:patient ratios and locked doors and can offer an extra level of safety and care. The fact that these ward doors are locked should not mean patients are denied appropriate engagement and one-to-one staff attention. The therapeutic component of observation must be in place whatever the setting.
3.5.3 The locking of any ward doors outwith an IPCU must only be done within clear local protocols and subject to frequent, regular review and audit. Locking of doors would only be required in exceptional circumstances. The Mental Welfare Commission (1999) recommends that a local protocol is developed which requires authority from senior clinical staff and hospital managers and ensures that clear information is made available to patients and their relatives. There are practice implications too, arising from the European Convention on Human Rights, for other patients whose freedom is restricted unnecessarily (see paragraph 3.1.5).
3.5.4 Observation is used for patients who require extra monitoring. Patients under observation are either very ill and/or distressed and are thought at that point in their care to pose a significant risk to themselves or others. It therefore follows that there will be a risk to a patient leaving a ward area even with staff in attendance. However, there are times when the patient may wish to simply get fresh air or attend a department outwith the ward. It must be acknowledged that the feeling of containment felt by some patients under observation may lead to deterioration in their behaviour if their needs are not addressed. However, like all risk assessment decisions this judgement must consider the risks and benefits of all options. It is unlikely that a rigid policy regarding patients leaving the ward would meet individual needs.
3.5.5 Outwith a hospital setting the need for formal observation is less relevant. However, it is essential to consider two key areas where increased vigilance is needed. The first is at the time of the organisation of an admission to hospital where the patient has been assessed and it is agreed that inpatient care is required. This decision often happens in a primary care, day care or domiciliary setting, where staff or carers may not be so prepared for constant observation practice. Mental health services must ensure there are clear protocols on managing these situations including, where needed, providing training and support to primary care or in other community settings in which people may wait pending admission arrangements being made. The other risk time is within the immediate period after discharge or leave of absence. The Safety First Report (2001) from the Confidential Inquiry into Suicide and Homicide by People with Mental Illness highlights the risk of self-harm in this period. It recommends follow-up for patients within seven days of discharge (where the patient suffers from severe mental illness or has a history of self-harm within the previous three months). Clear discharge plans that allow community services time to organise a response are essential in minimising this risk.