OBSERVATION OF PEOPLE WITH ACUTE MENTAL HEALTH PROBLEMS
REMIT OF WORKING GROUP
The Group was established in July 2000 with the following remit:
To develop a framework of practice for clinical teams in acute inpatient units to set and implement patient observation levels in ways that
WORKING GROUP MEMBERSHIP
Mr David Bertin (Chairman)
Clinical Nurse Manager - Lomond and Argyll Primary Care Trust
Mrs Susan Bishop
Chief Pharmacist - Forth Valley Primary Care Trust
Ms Joan Blackwood
Practice Development Facilitator/Research Associate - Mackinnon Unit, Stobhill Hospital
Dr Keith Brown
Consultant Psychiatrist - Forth Valley Primary Care Trust
Ms Moira Cossar
Clinical Nurse Manager - Crichton Royal Hospital
Dr Tim Dalkin
Consultant Psychiatrist - Royal Edinburgh Hospital
Mr Bob Gillies
Intensive Psychiatric Care Unit - Gartnavel Royal Hospital
Mr Michael Hughes
Ward Manager - State Hospital
Ms Elaine Hunter
Trust Advisor in Occupational Therapy - Royal Edinburgh Hospital
Ms Ruth Lockwood
CRAG Secretariat - Scottish Executive Health Department
Dr John Loudon
Principal Medical Officer - Scottish Executive Health Department
Mr Jamie Malcolm
Nursing Officer - Mental Welfare Commission for Scotland
Ms Jackie Meikle
Ward Manager - Royal Edinburgh Hospital
Mrs Alison Meiklejohn
Head Occupational Therapist - Royal Edinburgh Hospital
Ms Corinna Penrose
Senior Advocacy Worker - Advocacy Matters
Dr Linda Pollock
Nursing Director - Lothian Primary Care NHS Trust
Mr Colin Poolman
Royal College of Nursing Professional Officer - RCN Scottish Board
Mr Robert Samuel
Nursing Adviser - Scottish Executive Health Department
Mr Mark Simpson
Clinical Nurse Manager - Royal Dundee Liff Hospital
Mrs Frances Smith
Director of Nursing and Quality - Clinical Standards Board for Scotland
Ms Lesley Wilkes
Adviser, Mental Health, Scottish Health Advisory Service
To ensure that the work of the group was based upon the experience of the Service three consultation exercises were undertaken:
1 REVIEW OF TRUST PROTOCOLS
In October 2000 Chief Executives of Primary Care Trusts were invited to submit their current protocols to enable the group to develop an understanding of the impact on observation of the 1995 "CRAG Nursing Observation of Acutely Ill Psychiatric Patients in Hospital" report. Comments were invited on the original publication and implementation issues.
The vast majority of protocols refer to three levels of observation and were broadly in line with the suggestions in the original document although different terminology had developed; some policies referred to "close" observation as opposed to "constant" and some referred to "intensive" observation as opposed to "special". Three documents made specific recommendation to a fourth level of observation that sat between "general" and "constant" observation. One reply indicated that this level of observation had been left in due to a resistance from staff to alter this practice.
Recurring themes requiring greater clarity were: guidance on the observation role of other professionals and relatives, training, recording, post-incidence reviews and supervision, risk assessment, patient rights, and the therapeutic nature of observation.
2 OBSERVATION OF ACUTELY ILL PSYCHIATRIC PATIENTS IN HOSPITAL QUESTIONNAIRE
In December 2000, a questionnaire was sent out to Chief Executives of every Primary Care Trust seeking responses from senior nurses in acute wards and IPCUs. A total of 80 responses was received representing every Primary Care Trust. The purpose of the questionnaire was two-fold:
(a) to understand the impact and obstacles to implementing the 1995 nursing observation good practice statement
(b) to ensure that the views and experience of the Service were incorporated into the revised document.
In regard to the three levels of observation recommended, does your service policy broadly fall in line with these?
Virtually all respondents stated that their observation levels corresponded with the CRAG recommendations. 5/15 respondents commented that they used a fourth level of observation that tended to be "general with conditions".
What type of training, if any, has been carried out for staff regularly involved in observation of patients?
Training varies from Trust to Trust; 25% had received some training in observation as part of an induction package; 10% noted some awareness training and two noted
on-going training courses and regular team discussions. Only 6% were required to reach a competence level before being considered competent to carry out observation and 15% reported no training at all.
What particular problems have there been with implementing your observation policy and procedure?
Resource implications. Almost half of the respondents reported staffing problems, in particular low and decreasing numbers of trained staff and untrained bank staff unfamiliar with the ward. This leads to no cover during nurse breaks. Some concern was expressed that staffing restraints led to custodial rather than therapeutic care that compromises patients' privacy and dignity. Low staffing can have a negative impact upon other ward activities if there are high numbers of patients under observation. Others identified environmental issues as particular concerns. 16% reported problems with recalling medical staff to carry out medical reviews/reduce levels, particularly at weekends. Two respondents expressed concern that the observation policy is misused. Concerns were also expressed at the use of other professionals (mainly Occupational Therapists) to observe acutely-ill patients. 11% reported no problems.
What are the current issues and concerns within your own area at the moment regarding observation of patients?
Major problems are resource implications and lack of qualified staff. 14% reported difficulties contacting medical staff to approve lowering of observation levels. Several respondents highlighted issues of risk and risk assessment _ lack of training and lack of confidence, anxieties that individual staff will be blamed/involved in legal actions if problem occurs. Staff fatigue working full time on observation. Seven respondents reported local environmental issues. Only four reported no problems or concerns.
If observation was to be moved from a purely nursing responsibility to one that could be shared among other professionals and potentially relatives, what would your views be on this and what concerns or issues would you like the group to address?
One-fifth reported that shared observation is already happening although not all wards extend this to relatives and carers. A third would welcome future involvement of other professionals, more than half of this group would also welcome some involvement with relatives but cautioned that training and guidelines would have to be provided to ensure observation retained its therapeutic role. Many were concerned about relinquishing responsibility and decision making on behalf of the patient. Only 10% would not welcome the involvement of other professions and relatives stressing that observation was a skilled nursing intervention based upon professional experience.
Any other concerns, questions or information that you feel would influence the group?
There was a great interest in more tailored training to support nursing staff _ topics identified were risk management, symptom identification, team working, record keeping and liability. There was a call for additional research/audit and a request for a sample audit tool to support new guidance. It was noted that returning responsibility to patient can be disruptive _ this should be dealt with sensitively.
3 SURVEY OF USERS' VIEWS
Question One: During either your current stay in hospital or on a previous occasion, have you been placed on a "Nursing Observation Level"?
Question Two: Were you given a clear and understandable verbal explanation of:
Question Three: Can you recall what type of observation level had been prescribed for you?
Question Four: Describe what happened during the observation?
Question Five: In your own words describe how you felt whilst on an observation level?
Question Six: What, if anything, could have made this experience better for you?
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THE ASSESSMENT OF RISK
(ROYAL COLLEGE OF PSYCHIATRISTS COUNCIL REPORT CR53 (1996))
The essentials of this report are as follows.
There are four general principles:
In the history taken from an individual being assessed, certain items must be sought:
It is important to identify potential victims, particularly those who figure in abnormalities in the patient's mental state (for example, the focus of delusions or the apparent source of hallucinations). In the patient's mental state the emotionality with which the patient presents (for example irritability, anger, hostility or suspicion) is important, as are specific threats made by the patient. Also, beliefs of threat, or persecution or control of mind or body by external forces are noteworthy.
In recording the assessment the following points have to be noted:
In managing risk, there are two basic principles:
Considerations for managing risk include:
If the patient is being managed in the community, other questions come to the fore:
Fundamental to the management of any situation is:
MILLAN'S TEN PRINCIPLES
(from "New Directions": Report on the Review of the Mental Health (Scotland) Act* 1984)
People with mental disorder should, whenever possible, retain the same rights and entitlements as those with other health needs.
All powers under the Act* should be exercised without any direct or indirect discrimination on the grounds of physical disability, age, gender, sexual orientation, race, colour, language, religion or national or ethnic or social origin.
3. Respect for Diversity
Service users should receive care, treatment and support in a manner that accords respect for their individual qualities, abilities and diverse backgrounds and properly takes into account their age, gender, sexual orientation, ethnic group and social, cultural and religious background.
Where society imposes an obligation on an individual to comply with a programme of treatment and care, it should impose a parallel obligation on the health and social care authorities to provide appropriate services, including ongoing care following discharge from compulsion.
5. Informal Care
Wherever possible care, treatment and support should be provided to people with mental disorder without recourse to compulsion.
Service users should be fully involved, to the extent permitted by their individual capacity, in all aspects of their assessment, care, treatment and support. Account should be taken of their past and present wishes, so far as they can be ascertained. Service users should be provided with all the information necessary to enable them to participate fully. All such information should be provided in a way which renders it most likely to be understood.
7. Respect for Carers
Those who provide care to service users on an informal basis should receive respect for their role and experience, receive appropriate information and advice, and have their views and needs taken into account.
8. Least Restrictive Alternative
Service users should be provided with any necessary care, treatment and support both in the least invasive manner and in the least restrictive manner and environment compatible with the delivery of safe and effective care, taking account where appropriate of the safety of others.
Any intervention under the Act* should be likely to produce for the service user a benefit which cannot reasonably be achieved other than by the intervention.
10. Child Welfare
The welfare of a child with mental disorder should be paramount in any interventions imposed on the child under the Act *.
* The Act refers to the new Act, which will arise from the report, not the existing 1984 Act