ENGAGING PEOPLE OBSERVATION OF PEOPLE WITH ACUTE MENTAL HEALTH PROBLEMS:
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This summary highlights key messages from the above Good Practice Statement published by CRAG. Copies of the full report are available from John Wilson (0131 244 2346) or online ( www.show.scot.nhs.uk/crag )
What is observation?
It 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 the normal monitoring of patients within a ward or care setting.
Why observe?
Formal observations should be introduced as a result of a risk assessment system that has identified increased concerns about the patient's mental state.
Who should observe?
Observation can be carried out by any appropriate person who has the right skills and training. This would normally be a member of the Mental Health Multi-Disciplinary Team but is not purely a responsibility of the nursing staff. Anyone carrying this responsibility must know exactly what they are being asked to do and have guidance and support in this process. The role of non-professionals is one for local discussion and consideration.
Communication
It is essential that all members of the Mental Health Team and all people caring for the patients are aware of the level of raised observations being used. The patient must be informed of this process starting and be given written information as well as the opportunity to discuss any concerns they would have or questions with an appropriate member of the multi-disciplinary team.
Engagement
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.
Levels of observation
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.
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.
Decisions regarding levels of observations
Decisions regarding the introduction of raised levels of observation must be based on a risk assessment of the patient's mental health at that time. Ideally such decisions should be made by the multi-disciplinary team with involvement of as many members of the team as possible. It is recognised that in some circumstances decisions have to be made quickly regarding this practice and that the nurse in charge of the ward and appropriate medical staff are key in this process.
The key standards which organisations are expected to follow from this report are detailed on the rear of this summary sheet.
KEY STANDARDS
Each local service should have a system of observation practice in place that is flexible and responsive to patient need and based upon Millan's ten principles.
Policies implementing each component of observation practice should be clear and unambiguous in terms of:
role
responsibility
reaction
reporting
to safeguard all those involved in the observation process.
The environment in which observation practice is carried out should be shown to be safe and suitable through a system of regular audit within the Trust's risk management and clinical governance processes.
Staff should be trained in the skills and competencies required to practise observation and be supervised in their practice of this therapeutic activity. An understanding of both risk assessment and psychological interventions is required by all staff, and the Trust should be able to demonstrate that this is regularly reviewed and attended to.
A system of recording must be in place that enables clear communication between staff members and ensures regular assessment and recording of risk. The system must allow immediate comprehension of the process as it applies at any moment to an individual and support an audit trail, which enables the review of clinical incidents.
Written patient information on the principles and practice of observation should be drawn up locally and provided to each patient.