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3. Observation and Engagement For staff that are responsible for the observation of patients. START FINISH

4. Course Objectives To understand what observation is and the various levels of observation. To have the knowledge and understanding in how to carry out patient observations effectively. To understand what engagement is and the importance of engaging with patients effectively. START FINISH

5. Observation Observation is described as the safe and supportive observation of patients at risk. It is a responsibility of all staff caring for all patients admitted to hospital. In practice, observation is usually the direct responsibility of in-patient nursing staff. The practice of continuous (level’s 3 and 4) observation is a highly skilled nursing task, designed to enhance the safety of those patients who are at high risk of serious harm to themselves or who are at risk of significant harm from others due to their vulnerability, or, who pose a significant risk to others as a result of their mental health problems. One of the drawbacks of level’s 3 and 4 observations is that it can be seen by the patient, being observed under level 3 or 4 as an intrusive intervention which can impinge on their privacy and dignity. It should therefore only be used in exceptional circumstances and when the assessed risk cannot be managed using less restrictive interventions. Nursing staff charged with observing patients under levels 3 and 4 must always treat the patient with sensitivity, mindful of their needs for privacy, balanced against the risk to their safety.

6. Observation The following SEPT Engagement and Formal Observation Appendices are used for recording the prescription and implementation of formal observation, including a competency checklist for those staff involved in providing formal observation: Appendix 1: Engagement and Formal Observation Care Plan for all inpatient’s Appendix 2: Engagement and formal Observation competency checklist for inpatient staff Appendix 3: Observation and Engagement Record Sheet for levels 2, 3 and 4 Appendix 4: Patient Whereabouts sheet (Observation record, for level 1 and Zoned Observations) START FINISH

7. Engagement The engagement process is a way of establishing a clinical relationship that should be supportive, explorative and reassuring towards patients who may feel alienated, isolated, threatened and fearful. Engaging with the patient, and establishing a rapport with them is the means by which the nurse can facilitate a more robust assessment of the patients mental state, thereby developing a more comprehensive understanding of the patients needs and any risks that the patient may present with. In turn this allows for the development of meaningful care plans and risk assessments carried out in collaboration with the patient and taking into account the views of the patient. START FINISH

8. Question Continuous observation of a patient is designed to enhance the safety of those patients. TRUE FALSE Continue START FINISH

9. Engagement Level 1 – General Observation Level 1 is a minimum acceptable level of observation for all inpatients. The location of all patients must be known to staff but not all need to be kept within sight. All information is to be clearly documented in the patients’ notes. All inpatients on level 1 and Zoned observations must be subject to hourly checks throughout the 24 hour period and recorded using Appendix 4 - Patient Whereabouts sheet. Those patients on level 2,3, and 4 are recorded on Appendix 3. Any patients unaccounted for must be reported immediately to the nurse in charge. START FINISH

10. Observation Level 1 – General Observation Both qualified and unqualified staff can be assigned to observe patients under any level of observation however before accepting the observation role all staff must have completed Appendix 2, Competency Check List, and this must be reviewed annually. Mental Health Nurses in inpatient settings have 24 hour responsibility, therefore after each nursing verbal handover outgoing and incoming nurses must account for the well being and whereabouts of each patient including reflection upon mental state and condition. The designated staff member must never leave the patient in the care of anyone else unless a handover is completed. Arrangements for relief and in cases of emergencies should be established before observation begins. The Nurse in Charge has ultimate responsibility for ensuring this is undertaken. Refer to Trust Handover Policy and Procedure CLPG 20. START FINISH

11. Engagement Level 2 – Intermittent Observation For Intermittent observation a patient must be periodically checked ensuring throughout that a positive therapeutic relationship is developed. Records are to be kept within patient’s records using Appendix 3 - Observation and Engagement Record sheet. Staff must ensure the times of observation are varied and spaced so that patients do not predict their movements, this must be at least five times per hour with no identifiable pattern. • Intermittent Observation is appropriate for the following: • When patients are potentially, but considered not immediately, at risk of • disturbed/violent behaviour. • Patients with no immediate plans to harm themselves or others • Patients who have previously been at risk of harm to self or others, but who • are in a process of recovery. • Patients on this level may only be allowed to leave the ward with an escort • and if considered clinically necessary and appropriate by the clinical team This must be documented in an agreed MDT management plan. START FINISH

12. Engagement Level 2 – Intermittent Observation The patient can only be escorted by a member of staff or an agreed known relative/carer who have independently agreed to escort and are aware of major risk factors. If at any point the Nurse in Charge considers there may be substantial risk then no leave from the ward must be allowed. This must be documented and all staff made aware. Patients on this level if assessed as appropriate by the MDT could be encouraged to take the lead and report to staff on the agreed frequency stated. Records are to be kept within patients records using Appendix 3 - Observation and Engagement Record sheet. START FINISH

13. Engagement Level 3 – Within Eyesight Observation Within Eyesight Observation means that the allocated nurse can see the patient at all times, 24 hours a day and that access is clear dependant upon prescription. Records are to be kept within patient’s records using Appendix 3 - Observation and Engagement Record sheet. Within eyesight observation should be considered where there is clinical judgement of the care team that the patient could, at any time, make an attempt to harm themselves or others. All information should be clearly documented in the patient’s notes. Patients on this level may be confined to the ward and should only be allowed to leave the ward if this is considered necessary by the clinical team. In such instances, a patient must be accompanied at all times by a person nominated/authorised by the MDT. A management plan must be recorded in the patients notes and previously agreed by the MDT. START FINISH

14. Engagement Level 4 – Within Arms Length Observation Patients at the highest levels of risk of harming themselves or others may need to be nursed in close proximity at all times. Records are to be kept within patients’ records using Appendix 3 - Observation and Engagement Record sheet. Patients who require this level of observation are considered to be at extremely high risk, either to themselves or to others. The designated member of staff is expected to remain in close proximity (within arms length) to the patient at all times. More than one staff member may be necessary to ensure safety of staff and patients. All information should be clearly documented in the patient’s notes. • Gender issues of the member of staff especially where the patient wishes to • bathe and use the toilet must be considered. • A patient on this level of observation will not leave the safety of the ward • environment, unless clinically required and at such times escorts must • reflect risk and be documented in an agreed management plan. • The allocated staff member will ensure that intervention considering risk, • current presentation and future management takes place as per • prescription. START FINISH

15. Question How many levels of engagement are there? 5 3 6 4 Continue START FINISH

16. Zoned Observation • Zoned Observations encourages a flexible approach. The aim is to reduce dependency of patients on staff without the increase of risk of deliberate self harm • The ward/unit can be divided into set zones, risk assessed and agreed by the MDT. Allocated staff will be responsible for a designated zone. • This can include a bedroom area or any such small room. Zoned observations in these areas will be achieved by staff completing regular checks previously agreed by the MDT, this includes open doors to aide clear observation and access. • A set number of staff will be agreed according to clinical need and agreed zoned areas. At handover this will be reviewed and assessed as remaining safe by nurse in charge at the beginning of each shift based on current clinical needs of the ward. • Gender of staff must be continually considered in order to maintain privacy and dignity. • All information should be clearly documented in the patients’ notes. START FINISH

17. Zoned Observation • Times must be agreed and can be flexible for example at night General Observations may be used once someone has retired to bed increasing to Zoned or any other increased level during the day • Activity programmes will be encouraged promoting active engagement. • Prior to prescription a risk assessment must be completed followed by an Individual management plan which must be agreed and reviewed at a minimum of weekly by the MDT. • Communication must be maintained using verbal and non verbal communication between staff. Staff must inform observers in adjacent zones when a patient leaves one zone and passes into another to ensure continuous observations. • Ensure that all information is clearly documented in the patient’s notes. START FINISH

18. Zoned Observation • In any out of the way areas Radios must be used at all times to aide communication. • Patients will be required to inform the observing staff when they want to move between zones. • In order to minimise risk personal property may be restricted in bedroom areas in line with individual management plan. • Records are to be kept within patients’ records. START FINISH

19. Procedure The Nurse in Charge will ensure an identified member of staff as per Named Nurse Policy CLP 10 at the start of each shift Staff members must positively engage with all patients at all times Engagement must include an assessment of mental state, behaviour, mood and risk Appendix 1 - Observation Care Plan form must be fully completed Records for levels 2 and above must be kept using Appendix 3 - Observation and Engagement Record sheet with any risk identified verbally communicated Privacy and Dignity must be considered at all times especially gender issues Staff must have an awareness and show consideration of potentially intruding into the patient’s own space START FINISH

20. Procedure Any Searching of persons and belongings will be conducted if possible with consent as well as sensitively with due regard to legal rights as per Trust Policy Searching Patients Property MHA 28 and Forensic Searching Policy FSP 22S If consent is not given staff must consult the Consultant/Senior Nurse Manager/Site. Ensure that everything is documented in patients’ notes. Officer/Unit Co-ordinator as per Trust policy MHA 28 The least intrusive level of observation that is appropriate to the situation must always be used At all levels of observation following each observation period there must be a handover to staff which includes, as far as possible the patient. START FINISH

21. Procedure to be followed when making a decision regarding observation Risk Assessment Risk Assessments must include consideration of High Risk periods including for newly detained inpatients and those within the first seven days of admission evening and at night, Safety First” (DOH, 2001). On admission, every patient must have a risk assessment as per CPA Policy CLP30 and CLP 28 Procedures for the Assessment and Management of Clinical Risk with a management plan developed taking into account possible periods of increased risk for example evenings and night, reduced staffing, difficulties in observing patients due to environmental difficulties, apparent improvement in patients mood and actions to be taken in account of these increased risks. The assessment must be fully completed within 72 hours of admission. Measures must be taken to address blind spots within environments including consideration of the use of CCTV and parabolic mirrors, and any issues identified from environmental audits. START FINISH

22. Risk Assessment The patient who is considered to be at imminent risk of suicide, or has committed an act of self harm, is considered at risk of harm to others or deemed vulnerable must be kept on a specific observation status considered necessary by the team for the first 72 hours or longer. If the patient insists on leaving the ward, a mental health assessment for possible detention under the Mental Health Act must be made if appropriate. In-patient teams caring for those who have been identified with suicide as a risk should have the authority to remove all potential ligatures from the identified patient at risk. This includes belts, ties, shoelaces and bandages (DOH Safety First, 2001). Searching of patient’s possessions is in direct breach of the First Protocol, Article 1 of the Human Rights Act 1998. However, in clinical risk management terms it may be deemed necessary to protect the safety of the patient and /or the safety of the general public or staff. This must be proportionate to the patient’s situation and the risk they pose to themselves and /or others. START FINISH

23. Risk Assessment It may be necessary to remove any tools or instruments that could be used for self harm or harm to others. It may be necessary to search the patient and their belongings, while having due regard for the patients legal rights and conducting the search in a sensitive way. This may include any religious clothing. Risk assessment includes an interview with the patient and carers, careful study of the patient history, use of ratified risk assessment tools and must take into account the assessments of other professionals as well as the patient, e.g. Social Workers, Psychiatrists, Community Psychiatric Nurses (CPNs), G.P’s, Community Mental Health Team (CMHT) or Family. The patient thoughts, feelings and wishes with regard to suicide, self-harm and harm to others must be approached using direct and respectful questions. START FINISH

24. Risk Assessment The patient notes are a vital source of information about past behaviour, as are relatives, friends and carers. Attention to the following factors are considered important: planned intent, severity of planned intent, access to means, preparation, avoidance planning, post-death provisions, recent loss, marked changes in behaviour or medication, paranoid ideas where the patient believes that others pose a threat, withdrawal/disengagement, sudden calmness and denial of recently expressed thoughts/intent. In some instances advance directives may be available. A previous history of suicidal attempts or of attacks on others suggests that the patient must be observed until a full assessment can be carried out but this must not automatically mean someone is placed upon increased observation. Any prescribed medications and their effects must be taken into account together with any recent changes START FINISH

25. Making decisions for Observation Decisions about observation must be made jointly by the Medical and Nursing Staff and where possible the MDT. A Medical Officer, or the Senior Nurse can initiate any level of observation, following a documented risk assessment. The reasons for increasing or decreasing a level of observation and any restrictions must be explained to the patient and his/her carers. Any decisions concerning raising an observation level above the general level must be conveyed to the patients consultant as soon as possible. Unplanned leave with no agreed management plan must not be arranged at the weekend and never with a patient still under level 3 or 4. All information MUST be documented in the patients’ notes. START FINISH

26. Question Only certain information regarding observation needs to be documented in the patients notes. TRUE FALSE Continue START FINISH

27. Review of patients observation status All observation levels must be reviewed by a joint medical and nursing team at least once a day within working hours and within the working week. This should normally be done by the ward doctor and only in exceptional circumstances by the duty doctor with reference made to the agreed MDT plan. Documentation should include an entry in nursing notes on each shift and entry in medical notes following each MDT review which should occur at least each week. If there is significant clinical disagreement, particularly concerning a reduction of the level of observation, this must be left unchanged and reviewed by the MDT or Consultant. A consensus of agreement must be reached explaining reasons and the outcome of the discussion must be documented in all patient records. START FINISH

28. Review of observation during weekends Medical reviews at weekends will only be undertaken for individual service users who have been placed on observation levels 3 and 4 the previous day or during the weekend with reference made to the agreed multi disciplinary management plan. Patient’s assessed risk factors should be reviewed: a) By all staff during each shift change, and b) By the multi-disciplinary team (MDT) at each MDT meeting. The outcomes of any reviews (even if it meant no change to observation levels) must be recorded in the medical and nursing notes. START FINISH

29. Documentation/Record Keeping when decisions are made Arrangements for observation while the patient is using the toilet or bathroom must be recorded under "Special Instructions" on the Observation Care Plan form. For example, the member of staff observing the patient may stand outside a shut toilet/bathroom door and may make visual checks and verbal prompts where cases of concern that something untoward may be happening or may have to remain with the patient at all times. Staff must be able to access the room immediately if it is felt necessary The outcome of risk assessments and the decision to place a patient on any level of observation must be clearly recorded in the patient’s notes (medical and nursing). The "Observation Care Plan" form - Appendix 1 must also be completed and signed. This must state clearly on the "Observation Care Plan" form any additional instructions to be followed by the designated staff member. START FINISH

30. Amending levels of observation Where there is a need to amend or change the level of observation, Appendix 1 - the Care plan form must be revised and the reasons for amendment documented on the form and in the nursing and medical notes. In addition to medical officers, the nurse in charge can INCREASE a patient’s observation status at any time if a patient appears to present a greater risk than originally identified. This decision by the nurse in charge must be communicated to all staff immediately and recorded in the patient’s notes. The ward doctor and the patient's consultant or the doctor covering, must be informed of any such decision as soon as practically possible. A patient’s observation status can be DECREASED by a senior nurse (see policy 3.4.1 for definition) who has knowledge of the patient in line with a previously agreed management plan, which is clearly documented and agreed by the patient’s Consultant and MDT. A new risk assessment must be undertaken and documented with clear plans in place. At the time of any decrease the medical team must be notified which would include notifying the Duty Doctor if appropriate medical team not available START FINISH

31. Discontinuation of observation Patients must never be removed from any of the observation levels without discussion and agreement between medical and nursing staff. Any reduction in observation level must be a graduated decreasing process taking into account all aspects of risk. The decision to discontinue observation levels 2, 3, & 4 must be discussed with the patient’s consultant or designated deputy and MDT in advance and process documented in the agreed management plan. The decision must be communicated to all members of the clinical team which includes the patient. Once an agreement is reached, the decision must be recorded and signed in the medical and nursing notes, as soon as possible by the ward doctor and the nurse in charge, and on the discontinuation of formal observation section of the "Observation Care Plan" form - Appendix 1. Actions to be taken by the nurse in charge (please see also "Responsibilities of the nurse in charge, Section 3.4 of the policy). START FINISH

32. Discontinuation of observation The period of observation carried out by each individual should not exceed one hour at any one time. At the end of each observation period, the staff member should have a break from observation. An individual staff member should not carry out observation above the general level for more than 2 hours( NICE, February 2005 Clinical Guideline 25). On occasions more than one staff member may be necessary. Issues of privacy, dignity and consideration of the gender in allocating staff and the environmental dangers need to be discussed and incorporated into the care plan. Specific observation tasks must be undertaken by registered nurses who may delegate to other competent persons. Both qualified and non-qualified staff can be assigned to observe patients under any level of observation. For all staff, the "Observation Competency Check List" (Appendix 2) must be implemented and signed by a nurse in charge and by the staff member who is to carry out the observations and reviewed annually. START FINISH

33. Discontinuation of observation The designated staff member must never leave the patient in the care of anyone else unless a handover is completed. Arrangements for relief and in cases of emergencies should be established before observation begins. Nurses in charge must make Service Managers or Assistant/Deputy Directors aware of the need for extra staff so that they can authorise adequate numbers and grades of staff for future shifts. Staffing levels may change due to the levels of observation within the clinical area. This must be taken into account by the nurse in charge who should arrange extra staff to cover. START FINISH

34. Seclusion If seclusion is used an observation schedule must be specified, see trust Policy CLP 41 & CLPG 41 Policy for the Use of Seclusion and Seclusion Procedure Appendix 1. If the patient is secluded the potential complications of rapid tranquillisation must be taken particularly seriously. The patient must be monitored by “within eyesight” observation by an appropriately trained individual. Once rapid tranquillisation has taken effect, seclusion must be terminated as per CLPG 41. START FINISH

35. Further Reading Barker 1998, 2000, Barker and Buchanan-Barker (2004) Bridging:talking meaningfully about the care of people at risk. Mental Health Practice. 8, 3, 12-15 Barker Buchanan-Barker (2005) The Tidal Model:A Guide for Mental Health Professionals. Brunner-Routledge, 2005 Barker P, Cutcliffe J (1999) Clinical Risk:a need for engagement not observation. Mental Health Practice. 2, 8, 8-12 Byers, V. B. Nursing Observation. Iowa:WMC Brown, 1977. Cardell R, Pitula CR (1999) Suicidal inpatient’s perceptions of therapeutic and non-therapeutic aspects of close observation. Psychiatric Services. 50, 1066-1070. Dennis, S. Formal Observation in acute in-patient setting:Mental Health Care vol.21, Sept.1998 Department of Health Safety First' February 2001 START FINISH

36. Further Reading Jones J et al (2000) Psychiatric inpatients experience of nursing observation:A United Kingdom perspective. Journal of Psychosocial Nursing. 38, 12, 10-20. Moore, P. et al Constant Observation:Implications for nursing practice. Journal of Psychosocial, Nursing 1995 National Institute for Clinical Excellence. Violence, the short –term management of disturbed /violent behaviour in psychiatric in-patient settings and emergency departments. Clinical Guideline 25 Issue date: February 2005 Ritter, S. Bethlem Royal and Maudsley Hospital Manual of Clinical Psychiatric Nursing Principles and Procedures. London:Harper and Row, 1989 Standing Nursing and Midwifery Advisory Committee (SNMAC) Practice Guidance:Safe and Supportive Observation of Patients at Risk, June 1999 START FINISH

37. References Barker 1998, 2000, Barker and Buchanan-Barker (2004) Bridging: talking meaningfully about the care of people at risk. Mental Health Practice. 8, 3, 12-15 Barker Buchanan-Barker (2005) The Tidal Model: A Guide for Mental Health Professionals. Brunner-Routledge, 2005 Barker P, Cutcliffe J (1999) Clinical Risk : a need for engagement not observation. Mental Health Practice. 2, 8, 8-12 Byers, V. B. Nursing Observation. Iowa: WMC Brown, 1977. Cardell R, Pitula CR (1999) Suicidal inpatient’s perceptions of therapeutic and non-therapeutic aspects of close observation. Psychiatric Services. 50, 1066-1070. Dennis, S. Formal Observation in acute in-patient setting: Mental Health Care vol.21, Sept.1998 Department of Health Safety First‘ February 2001 Jones J et al (2000) Psychiatric inpatients experience of nursing observation: A United Kingdom perspective. Journal of Psychosocial Nursing. 38, 12, 10-20. Moore, P. et al Constant Observation: Implications for nursing practice. Journal of Psychosocial, Nursing 1995 National Institute for Clinical Excellence Violence The short –term management of disturbed /violent behaviour in psychiatric in-patient settings and emergency departments. Clinical Guideline 25 Issue date: February 2005 Ritter, S. Bethlem Royal and Maudsley Hospital Manual of Clinical Psychiatric Nursing Principles and Procedures. London: Harper and Row, 1989 Southend Community Care Services NHS Trust Policy on Patient Observation, June 1997 Thameside Community Healthcare NHS Trust Observation of In-patients Policy, June 1999. Standing Nursing and Midwifery Advisory Committee (SNMAC) Practice Guidance: Safe and Supportive Observation of Patients at Risk, June 1999 The Scottish Office Home and Health Department clinical research advisory group (CRAG) CRAG/SCOTMEG. Nursing observation of acutely ill psychiatric patients in hospital.Edinburgh: HMSO, 1995 START FINISH

38. Remember, if you want to find more information / evidence about this subject or anything else which is relevant to your work or study, join your local healthcare library. For staff in Essex contact Basildon Healthcare Library. www.btuheks.nhs.uk library@btuh.nhs.uk 01268 524900 EX3594 It may be that you work in a different area, for example Luton. Details of all the Health Libraries in the East of England can be found at this site… You are welcome to join any of these. www.eel.nhs.uk START FINISH

39. Review of Objective(s) Before completing the test, please ensure you have acquired the relevant knowledge against the modules objective(s) below: “To understand what observation is and the various levels of observation. To have the knowledge and understanding in how to carry out patient observations effectively. To understand what engagement is and the importance of engaging with patients effectively.” If not, please take this opportunity to revisit the presentation content. CONTINUE START FINISH

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