Observation of People with Mental Health Problems

A revision of the 1995 CRAG document Nursing Observation of Acutely Ill Psychiatric Patients in Hospital to bring it in line with current clinical practice and policy terminology.



"Engaging People" is a revision of the CRAG document "Nursing Observation of Acutely Ill Psychiatric Patients in Hospital" (1995) and is relevant to all who provide or receive acute psychiatric care. The general principles of the document can also be adapted to support care of other client groups requiring comparable care.

This report is a key document and should be made available to all staff who provide care in an acute psychiatric setting.

The report recommends three levels of observation:

  • General The staff on duty should have knowledge of the patients' general whereabouts at all times, whether in or out of the ward.

  • Constant The staff member should be constantly aware of the precise whereabouts of the patient through visual observation or hearing.

  • Special The patient should be in sight and within arm's reach of a member of staff at all times and in all circumstances.

After much discussion the group agreed that timed observations do not contribute to the safety of the observation process although being aware of a patient's whereabouts contributes to good general nursing practice.

It is clearly not good practice to simply "watch or guard" patients. Observation of patients is a therapeutic engagement; all staff involved in the process should be suitably trained in psychological intervention skills and risk assessment to maximise this process. The report lists the appropriate skills required to undertake observation. Excessive use of untrained temporary staff can impede the patient's progress and can increase the vulnerability of everyone involved in the observation process.

Whilst general observation is a multi-professional task, constant and special observation should be managed by named members of nursing staff who have
24-hour contact with the patient plus the clinical understanding of their condition. Relatives, carers and other professionals can be involved in observation at a general level and can often provide a helpful insight into the patient's condition. The report recommends some practical suggestions as to how to improve the observation process.

All local Trusts should develop local policies based upon the new national guidance; local observation systems should be flexible and patient-centred; the environment that observation is carried out in must be fit for purpose.

Patients undergoing observation should be kept informed at all times; written patient information should be made available for all patients and relatives involved. Local user groups should be encouraged to be involved in the drafting of such documents.

Following consultation with the Royal College of Psychiatrists about procedures for the reduction of observation level, it has been agreed that out-of-hours a named senior nurse can reduce the observation level in consultation with the junior on-call doctor, providing a written patient-specific plan is pre-agreed with the Senior Medical Officer.

Recording systems should provide a complete clinical picture and enable audit trails to monitor the effectiveness of the intervention and, if necessary, support Critical Incident Reviews (CIRs) and Fatal Accident Inquiries. The effectiveness of observation is also a key issue for Clinical Governance Committees.

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