NHS FORTH VALLEY Mental Health Services PSYCHIATRIC OBSERVATIONS Date of First Issue 01/08/2009 Approved 14/09/2010 Current Issue Date 01/07/2013 Review Date 04/02/2016 Version 2.1 EQIA Yes 01/02/2010 Author / Contact Chris Beech Group Committee Clackmannanshire CHP Clinical Governance committee Final Approval This document can, on request, be made available in alternative formats Version 2.0 1stJuly 2011 Page 1 of 10 UNCONTROLLED WHEN PRINTED
Contributing Authors Consultation Process Charlie Scholes, Cathy Lund, Fiona Smith, Anne Cook, Caroline Gill, Stephen McDonald, Nabila Muzaffar, Chris Beech Consultation document sent to Division of psychiatry, service manager (adult mental health) Clinical Nurse Managers (Older Peoples Services) Change Record 15/4/09 Meeting to discuss updating current observation policy held. Amendments made 14/5/09 meeting held re amendments a few more to be made and then to go out for wider circulation 3/6/09 Addition to bibliography made 25/8/09 Consultation changes added to version 2 28/10/09 policy ready for clinical governance committees 1/7/11 Policy for review no amendments made Version 2.0 1st July 2011 Page 2 of 10
DEFINITION Observation is a process that ensures close monitoring of and engagement with someone who needs (for a period of time) intensive care and support. It is a formal structured process and therefore is fundamentally different from normal monitoring of patients within a ward or care setting. PURPOSE 1.1 The purpose of this document is to provide staff with a framework for observing patients in mental health in-patient settings. All patients within a clinical area will receive some degree of observation. However, levels of observation will vary according to the patients individual needs. 1.2 The timed check form of observation is seen as unsafe and should not be used as a means of meeting a need for increased level of observation (CRAG 2002) 1.4 There will be three levels of observation. (CRAG report 2002) General Observation: Staff on duty should have knowledge of the patients general whereabouts at all times, whether in or out of the ward Constant Observation: The staff member should be constantly aware of the precise whereabouts of the patient through visual observation or hearing Special Observation: The patient should be in sight and within arms reach of a member of staff at all times and in all circumstances. SCOPE This guidance relates to all patients receiving care from Forth Valley Primary Care NHS Trust Mental Health Services. The guidance in the policy will be implemented by all staff employed by NHS Forth Valley Adult and Older People Mental Health Services and Learning Disability Service. GENERAL PRINCIPLE 4.1 To comply with Clinical Governance/ Effectiveness, staff should make themselves familiar with the CRAG (2002) Engaging people: Observation of people with acute mental health problems: A good practice Statement. 4.2 The key purpose of increased level of observation is to provide a period of safety for people during temporary periods of severe distress, when there is a significant change in their mental state/ presentation that requires continuous assessment. 4.3 No patients care should be compromised due to increased observation levels. If placing a patient on a higher level of observation has an impact on the clinical needs of the ward, then nursing staff should contact the appropriate person in line with local procedures/protocols. Version 2.0 1st July 2011 Page 3 of 10
4.4 No patient should have their movements restricted to a particular area of the ward unless there is clear documented risk to the patient or others. 4.5 Observation must be both safe and therapeutic, consideration should be given to the use of activity, discussion and distraction processes but recognition should also be made of the need for silence and as much privacy as is safely achievable. 5. ASSESSMENT 5.1 Clinical teams should not hesitate to use increased levels of observation, if they believe it to be beneficial to the patient. Clinicians should understand the purpose and should be aware of the wider effects of such a decision. They should take into account that increased levels of observations can be perceived as intrusive and controlling and can have a detrimental effect on the patient s mental state. Observation should be set at the least restrictive level, for the least amount of time within the least restrictive setting. 5.2 It is important that all involved in the practice of observation comply with the principles of the European Convention of Human Rights, especially Article 5 which states that 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 (CRAG 2002) In such circumstances the team must consider the use of the Mental Health (Care and Treatment) (Scotland Act) 2003. 5.3 Open and in-depth dialogue between the clinical team and appropriate others is the key to sound risk assessment. Staff should apply information of the patient s previous presentations, information from third parties and come to a decision based on the patient s mental state at the time of the assessment. 5.4 Validated Risk assessment tools, e.g. FACE, should be used to aid the decision making process. Clinical judgement is paramount when assessing risk. 5.5 Patients should be assessed for risk at night on an individual basis. All patients on general observation will be observed at least two hourly during the night, however in some clinical areas patients will be observed more frequently. 6. COMMUNICATION Verbal 6.1 The nurse in charge will ensure that all staff on duty are informed that a patient has been placed on constant or special observations; or that the period of constant or special observation shave been terminated; they will be informed why the patient has been placed on a higher or lower level of observation and what the potential risks are. 6.2 Staff will give a verbal handover each time a member of the multidisciplinary team takes over a period of observation. The patient should be included in this discussion where practicable. Version 2.0 1st July 2011 Page 4 of 10
6.3 With the patient s consent the patient s relatives/ carer will be informed of any increased observation at the earliest opportunity Written 6.4 Accurate records must be kept of all information relating to Psychiatric Observations. Records should be accurate, consistent and complete. 6.5 Constant and special observations will be recorded on the Psychiatric Observation Data Sheet (Appendix 2). Each person observing the patient will be responsible for ensuring that this is current and complete. Records 6.6 The patient record must state which members of the multi-disciplinary team were involved in making the decision to place a patient on a higher/lower level of observation. 6.7 The patient record will clearly indicate the reason for the patient being placed on higher or lower levels of observation. 6.8 The patient record will state The time a changed level of observation was commenced. Therapeutic engagement during periods of increased observation Ongoing risk assessment/risk management plan Evidence of a review date and time 6.9 The patient should be given the opportunity to be involved in the planning of their health needs. The nurse compiling and evaluating the care plan should discuss the reasons for considering an increase or decrease in observations levels with the patient. Allowing the patient to be involved in the decision making process ensures the patient has the opportunity to give consent to treatment as far as his/ her mental state allows. 6.10 Patients and carers will be given written information on the observation process and the patients rights while being observed (Written information will be developed once policy has been ratified). A simple patient information leaflet is demonstrated at appendix 1 and will be available in alternative formats on a needs led basis 7. CLINICAL MANAGEMENT PLAN 7.1 The decision to increase the level of observation will follow a process of assessment by the multi-disciplinary team (MDT). (The MDT will consist of a minimum of ST4-6, or staff grade, or associate specialist or consultant and a 1 st level Registered Mental Nurse (RMN) or Registered Nurse Learning Disability (RNLD)). In emergency situations the nurse in charge can make the decision to increase the observation level to ensure immediate patient safety. The appropriate medical team should review such a decision as soon as it is practicable. 7.2 The safety of the patient and others is paramount. The risk assessment to determine the level of increased observation must take into account the patient s rights in respect of dignity and privacy. If it is deemed necessary to compromise this e.g. toilet, shower, a Version 2.0 1st July 2011 Page 5 of 10
rationale must be documented and consideration should be given to special as opposed to constant observation. 7.3 There is an expectation that patients on constant or special levels of observation will not leave the ward unless there are extenuating circumstances. Time out will be granted with prior written agreement of an ST4-6, or staff grade, or associate specialist or consultant and the nurse in charge, detailing the circumstances for time out of the ward, the accompanying staff/ carer and any perceived risk to the patient and/or others. Please refer to Time out of ward policy Time Out of Ward 7.4 Where feasible it will be the responsibility of a 1 st level RMN/RNLD to undertake the first period of all observation. Each 1 st level RMN/RNLD that is included in the ward numbers, where practicable, must as a minimum spend at least one hour per shift with patients being observed on a higher level of observation. This will allow for continued assessment of the patients mental state and any perceived risk which the patient presents to themselves/others, verbal explanation of the observation process and patients rights. 7.5 Staff should observe for a period of no longer than an hour unless in extenuating circumstances. The duration of observation should take into account the needs of the patient, therapeutic activities being engaged in and the ward needs. Therefore the duration will be evaluated on an ongoing basis. 7.6 Core members of the multidisciplinary team other than nursing staff can be involved in the observation of patients on constant observation. This should be decided at local level following full multi-disciplinary discussion and clearly care planned for. The observer should be fully informed of their role and responsibilities while observing the patient. 7.7 Any decision to involve carers should be decided at local level following discussion with the multidisciplinary team the patient and their carer and clearly documented. The observer should be fully informed of their role, responsibilities and potential risks while observing the patient. 7.8 All Staff observing patients on increased levels of observations should have undergone de-escalation techniques and where practicable have undertaken the NHS Forth Valleys Therapeutic Responses to Management of Violence and Aggression course. 7.9 The care plan should be evaluated on an ongoing basis throughout the day. Each team of nursing staff coming on duty will have a written evaluation of the patients progress. The named nurse should discuss the evaluation with the patient. REDUCTION OF OBSERVATION 8.1 The reduction in the level of observation should ideally be a team decision. To ensure patients are not left on an increased level inappropriately, the MDT should plan ahead, particularly at weekends, clarifying the circumstances that would enable a reduction in observation level. 8.2 The decision to reduce the level of observation will follow a process of assessment by the multi-disciplinary team. There must be a specific plan for each patient, which outlines Version 2.0 1st July 2011 Page 6 of 10
the agreed changes in behaviour that would facilitate a reduction in observation level and the exact procedure for this decision to be actioned 8.3 A 1 st level RMN/RNLD who has been named in advance by the MDT, can reduce a patient s level of observation, following discussion with the junior doctor. This will be following a process of prior support and agreement from the Ward Management Team. The appropriate medical team should review such a decision at the first opportunity. 8.4 Once the decision has been made to reduce the level of observation it will be recorded detailing the date and time the decision was made. The record should also demonstrate who was involved in the decision-making process and include the rationale behind the decision and ongoing management plan. 8.5 All staff on duty and the patient will be informed of the decision for reducing the observation. PHYSICAL ENVIRONMENT The Charge Nurse/ control book holder should ensure that risk assessments of the physical environment are performed and adhere to Safety Action Notices. AUDIT AND EVALUATION Adherence to the policy will be carried out locally and co-ordinated by the charge nurse, at agreed timescales in conjunction with an agreed audit tool. CLINICAL SUPERVISION Staff involved in observing patients on constant or special observation should have access to clinical supervision. Version 2.0 1st July 2011 Page 7 of 10
11. Bibliography ADAMS, B., (2000) Locked doors or sentinel nurses? Psychiatric Bulletin. 24, pp. 327-332. BARKER P. and CUTCLIIFFE, J. (1999). Clinical risk: a need for engagement not observation. Mental Health Practice. 02 (08) 08-12. Bowers L, Whittington R, Nolan P, Parkin D, Curtis S, Bhui K, Hackney D, Allan T and Simpson A (2008) Relationship between service ecology, special observation and self harm during acute in-patient care: City-128 study. British Journal of Psychiatry 193 395-401 BOWLES N. ET AL. (2002). Formal observations and engagement: a discussion paper. Journal of Psychiatric & Mental Health Nursing. 9 255-260 CARDELL R. AND PITULA C R. (1999). Suicidal Inpatients Perceptions of Therapeutic and Non therapeutic Aspects of Constant Observation. Psychiatric Services. 50 (08) 1066-1070. CLINICAL RESEARCH AND AUDIT GROUP. (2002). Engaging People Observation Of People With Acute Mental Health A Good Practice Statement. Scottish Executive Health Department: Edinburgh. CONVENTION OF HUMAN RIGHTS. Human Rights. Coe int. Http:// www.conventions. Coe.int/ treaty/en/treaties/html/005.htm. (14 th February 2001). CUTCLIFFE, JR, & BARKER. (2002). Considering The Care Of The Suicidal Client and The Case For Engagement and Inspiring Hope Or Observations. Journal of Psychiatric & Mental Health Nursing. 09, 05.pp611-622 DENNIS, S., (1997). Close observation: how to improve assessments. Nursing Times. 93 (24) 54-56. DODDS, P. & BOWLES, N., (2001). Dismantling Formal Observation and Refocusing Nursing Activity in Acute Inpatient Psychiatry: A Case Study. Journal of Psychiatric and Mental Health Nursing. 8 (02)...pp183-188. DUFFY, D., (1995). Out Of The Shadows: A Study Of The Special Observation Of Suicidal Psychiatric Inpatients. Journal Of Advanced Nursing. 21, pp944-950. FENTON, M. ET AL., (2003). Containment strategies for those with serious mental illness (protocol for a Cochrane Review). In: The Cochrane Library. Issue 1, 2003. Oxford: Update Software. JONES, Julia, et al., (2000). Psychiatric Inpatients Experience of Nursing Observation. Journal of Psychosocial Nursing. 38(12).pp.10-20. Langenbach M, Junaid O, Hodgson-Nwaefulu CM, Kennedy J, Moorland SR, Ruiz P (1999) Observation levels in acute psychiatric admissions. European Archives of Psychiatric Clinical Neuroscience 249-33 Version 2.0 1st July 2011 Page 8 of 10
Scottish Executive (2003) Mental Health (Care and Treatment) (Scotland Act) 2003. The Stationary office. Edinburgh NEILSON, P. & BRENNAN, W., (2001). The use of special observations: an audit within a psychiatric unit. Journal of Psychiatric and Mental Health Nursing. 08, (02).pp 147-155. ROYAL COLLEGE OF PSYCHIATRISTS. (1996) Royal College of Psychiatrists Council Report CR53. In: CLINICAL RESEARCH ANDAUDIT GROUP., (2002). Engaging People Observation of People With Acute Mental Health A Good Practice Statement. Scottish Executive Health Department: Edinburgh. SCOTTISH EXECUTIVE. (2001). Caring for Scotland. The Strategy for Nursing and Midwifery in Scotland. Edinburgh: HMSO. STANDING NURSING and MIDWIFERY ADVISORY COMMITTEE. (1999). Practice Guidance Safe and Supportive Observation Of Patients At Risk Mental Health Nursing Addressing Acute Concerns. TURNMORE, R. & THOMAS, B. (1999). Nursing Care Plans in Acute Mental Health Nursing Mental Health Practice. 04, (03).pp32-37. WILSON J, (1999). Clinical Risk Modification in Practice. In: WILSON J, & TINGLE, J. eds. (1999). Clinical Risk Modification. A route to clinical governance. Oxford: Butterworth- Heinmann. Version 2.0 1st July 2011 Page 9 of 10
Publications in Alternative Formats NHS Forth Valley is happy to consider requests for publications in other language or formats such as large print. To request another language for a patient, please contact 01786 434784. For other formats contact 01324 590886, text 07990 690605, fax 01324 590867 or e-mail - fv-uhb.nhsfv-alternativeformats@nhs.net Version 2.0 1stJuly 2011 Page 10 of 10 UNCONTROLLED WHEN PRINTED