Assessment and Monitoring Toolkit
The American Psychiatric Nurses Association Council for Safe Environments has identified assessment and monitoring as factors that impact the safety of inpatient environments. APNA members were invited to submit brief, annotated summaries of references for inclusion in a ‘toolkit’ of assessment and monitoring resources. The CSE is happy to share these resources with psychiatric-mental health nurses.
Adverse consequence of continuous special observations.
Author/Source: Appleby, L. Kapur, N., Shaw, J. Windfuhr, K. Williams, A. Flynn, S., Tham, S. (2015). National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (NCISH). In-patient Suicide Under Observation. Manchester: University of Manchester
This article describes a 6-year study in the UK of inpatients being monitored on intermittent observations or continuous special observation (CSO). The study revealed the current observation levels are not working. Interventions based on engagement must be incorporated into the treatment of high-risk patients. The study describes the problems associated with CSO. They are intrusive and restrict the patient’s privacy. They increase agitation in the patients watched and place the staff watching them at risk. The study describes the problems with how CSO is implemented. Staff do not always observe the patient. Staff implementing the procedure are often the least trained and unfamiliar with the unit. Staff do not engage the patient, which eliminates the therapeutic value of CSO.
Continuous special observation (CSO) arouse strong patient feelings. Avoid the use of CSO with paranoid or agitated patients
Author/Source: Mason, T., Mason-Whitehead, E., and Thomas, M. (2009). Special observations in forensic psychiatric practice: gender issues of the watchers and the watched. Journal of Psychiatric & Mental Health Nursing, 16 (10), 910-918.
This article describes a research study employing a series of semi-structured interviews with clinical nursing staff. The data was analyzed using grounded theory. Findings revealed that the constant watching of patients can evoke intense feelings particularly during toileting and bathing. Observation during these private activities creates embarrassment for both the staff and the patient. Patient issues regarding the gender of the staff member maintaining the observation can create stress. Male patient can experience feelings of aggression, being threatened or sexual dominance. Female patients experience feelings of a power imbalance and sexual aggression.
Avoid implementing containment procedures (Continuous Special Observation) with patients who self injure.
Author/Source: Gallop, R. (2002) Failure of the Capacity for self-soothing in women who have a history of abuse and self-harm. Journal of the American Psychiatric Nurses Association, 8: 20-26.
This article reviews the purpose of self-harming behavior. It describes the development of the person’s sense of self and the effects that trauma can have on it. The author discusses the neurobiological impact of trauma. The abuse survivor experiences intense emotions as a result of the abuse and often exhibit panic, anxiety, dissociation, or somatization. The author describes how emotional pain is experienced as worse than physical pain and the abuse survivor’s only coping skill is to self-injure. The article describes the adverse consequences of using containment procedures (Continuous special Observation). If the focus of nursing care is to stop the self-injury then the self-injury “becomes the battleground.” The patient’s impulse to self injure may lead the nurse to use forced medication or restraints. This recapitulates the trauma. Finally, the author describes nurses role in helping the patient cope with the physiologic and emotional symptoms caused by the abuse.
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I spy with my little eye something beginning with O: looking at what the myth of ‘doing the observations’ means in mental health nursing culture.
Author/Source: Holyoake, D., Shaw, D. (2013). Journal of Psychiatric and Mental Health Nursing, 20: 840–850.
This paper explores the phenomenon of observation using ethnographic research conducted in psychiatric in-patient settings. The discussion offers a way to analyze and rethink about the meaning of observing in psychiatric nursing culture. Observation is viewed as not only a task to keep patients safe, but also part of a psychiatric culture comprised of caregivers and care recipients that is actually doing the observing.
Quote worth repeating: “[Observation] not only provides the meter and boundaries of time and space in a metaphorical sense but also symbolically defines the edge of psychiatric representation, an edge that is about policing behavior (Pg. 847).”
Nursing observation through engagement in psychiatric inpatient care.
Author/Source: Tracy Beaton. State of Victoria, Department of Health, (2013.) Mental Health, Drugs and Regions Division, Department of Health, State Government of Victoria, Melbourne, Australia.
This guideline highlights not only the opportunity for therapeutic engagement, but also the integral role that person-centered therapeutic engagement plays in enabling nurses to reach a comprehensive understanding of the most pressing issues of people receiving care.
Quote worth repeating: “Nursing observation informs assessment, while the choice to undertake different forms of observation is guided by assessment. The rationale and purpose of formal observation should be one of therapeutic engagement rather than one of surveillance and control, and this understanding is central to this guideline. Nurses’ active engagement with people receiving care and their carers means that people’s experience of inpatient settings is supportive of recovery, more positive and therapeutic, and will contribute to better outcomes for people and their families. (Preamble).”
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Two Nursing Protocols developed as alternatives to Continuous Special Observation
Author/Source: Ray, R., Perkins, E., Meijer, B. (2011) The Evolution of Practice Changes in the Use Special Observations. Archives of Psychiatric Nursing. 25(2): 90-100.
This article discusses adverse effects of Continuous Special Observation (CSO) and two alternative nursing protocols designed to treat high risk patients. The first protocol, Psychiatric Nursing Availability (PNA) designed to treat patients having suicidal or self-injurious thoughts. This protocol emphasizes developing a relationship based on engagement and making staff available for the patient to discuss distressing thoughts or impulses. The second protocol, Psychiatric Monitoring and Intervention (PMI) designed to prevent violent and impulsive behavior. This protocol is also based on engagement. The patient is allowed privacy in their room. In the day room, staff support the patient with impulse control. Staff interventions are based on removing the elements of violence: a target, a trigger, a weapon, and a state of arousal (Bailey 1977).
Having staff out on the unit engaging patients and implementing caring interventions can increase unit safety
Author/Source: Ray, R., Perkins, E., Roberts, P., Fuller E. (2017) The Impact of Nursing Protocols on Continuous Special Observation. Journal of the American Psychiatric Nurses Association. 23(1):19-27.
Two nursing protocols were developed as alternatives to Continuous Special Observation (CSO). The first protocol, Psychiatric Nursing Availability (PNA) designed to treat patients having suicidal or self-injurious thoughts. The second protocol Psychiatric Monitoring and Intervention (PMI) designed to prevent violent and impulsive behavior. The authors conducted a nine-year descriptive retrospective analysis of CSO, PNA and PMI. Results demonstrated PMI had the greatest impact. Both protocols had a secondary effect of increasing staff availability on the unit which may have increased safety and reduced CSO use. PMI interventions are focused on the entire unit milieu and patients may view these interventions as caring. Caring interventions are associated with hope which might also increase unit safety. This study reinforces when nurses take an increased role in unit decision making, there is a reduction in CSO.
Therapeutic Engagement and Supportive Observation: Policy 01
Author/Source: West London Mental Health, National Health Service Trust, England, UK
Regional hospital system policy describing use of therapeutic engagement and supportive observation, appendices include record keeping, leaflets for patients and guidance for staff.
Quote worth repeating: “The primary aim of therapeutic engagement and supportive observation should be to engage positively with the service user to reduce risk. This involves a two-way relationship…which is meaningful, grounded in trust, and therapeutic in nature. Observation can be a restrictive intervention and therefore the least intrusive level of observation should always be adopted…Therapeutic observation and engagement provides an opportunity to assess, encourage and engage the service user (pg. 4).”
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A modified grounded theory study of how psychiatric nurses work with suicidal people.
Author/Source: Cutcliffe, J. R., Stevenson, C. Jackson S., Smith P., (2006). International Journal of Nursing Studies. (7)791-802.
This article describes a research study to examine the effects of nursing interventions on patients who have recently attempted suicide. The authors believe that nursing care in psychiatric units is often associated with the mechanical process of observations and wanted to determine what nursing interventions, if any, were helpful to patients who experienced suicidal thoughts. The authors conducted semi-structured interviews on twenty patients who had recently attempted suicide and analyzed the data using modified grounded theory. Results indicate that patients with suicidal thoughts have become “disconnected from humanity” and the nursing interventions addressing this issue, which is the core variable, “re-connects the patient back to humanity.” The authors describe that depressed patients have unresolved psychosocial issues which are perceived by the patient as overwhelming. These persons feel that no one could understand their problems and eventually come to believe that they are a burden on others. As a result, they withdraw from others and have the perception that their life has no value and no one cares about them.
The nurse helps the patient through establishment of a warm, supportive, nonjudgmental relationship based on acceptance. The most important aspect of the nursing interventions is demonstrating care and concern about the patient. One of the most important interventions to demonstrate care is just being with the patient. The nurse spending time with the patient demonstrates that, contrary to the patient’s distorted belief, the nurse cares about the patient and will not abandon him. This caring relationship inspires the development of hope. Through this relationship, the patient discovers that he can connect with another human. The nurse acts as an ambassador in reconnecting the patient with humanity. (A more detailed version of this study can be found in Cutcliffe, J. R., & Stevenson, C. (2007). Care of the suicidal person. Elsevier Health Sciences.)
Safety Check Survey Results.
Author/Source: APNA Institute for Safe Environments. (2010). https://www.apna.org/i4a/pages/index.cfm?pageid=4363
The Safety Checks survey was sent out to the APNA membership by the Institute for Safe Environments in September of 2010. Over 300 members filled out the survey.
Does Safety Have to Mean Control?
Author/Source: Allen, D. (2015). Journal of the American Psychiatric Nurses Association, vol. 21, 3: pp. 180.
Editorial about emphasis on safety in psychiatric nursing and how it relates to our caring purpose.
Quote worth repeating: “I wish that nurses would spend less time trying to find new ways to control and restrict patients. I hope that nurses will spend more time trying to create environments and treatment programs that allow patients with mental illness, and the staff who care for them, to feel safe so they can focus on building trust, finding hope, and working toward recovery (pg. 180).”
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Why Do Nurses Continue to Watch Patients to Maintain Safety?
Author/Source: Ray, R., Allen, D. (2015). Journal of the American Psychiatric Nurses Association, vol. 21, 6: pp. 381-383.
Editorial asking psychiatric nurses to rise to the challenge of finding new alternatives to constant special observation as a means to keep patients safe from harm.
Quote worth repeating: “Responsibility for patient safety falls squarely in the domain of the nurse, and this is an opportunity for nurses to demonstrate that nursing actions have meaning and value. We should not continue to use interventions that we have learned are not therapeutic or effective practices, simply because that is what we have always done and we do not know what else to do (pg. 383).”
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The Brøset Violence Checklist: clinical utility in a secure psychiatric intensive care setting.
Author/Source: Clarke D., Brown A., Griffith, P. (2010). Journal of Psychiatric & Mental Health Nursing. 17(7): 614-620.
This article describes a three-month trial of the Brøset Violence Checklist (BVC) on an 11-bed secured Psychiatric intensive care unit to assess nurses perception of its utility. After this initial trial, the BVC was implemented on the rest of the hospital’s 80 beds. The BVC assesses three patient characteristics (confusion, irritability and boisterousness) and three patient behaviors (verbal threats, physical threats and attacks on objects) as present or absent. The majority of the nurses (83%) of the nurses felt that the tool was easy to use and reflected the patients’ behavior somewhat to very accurately. Nurses however, denied their care was influenced by BVC scores rather continuing to make their decisions based on their own intuitive clinical assessments. Despite this, the nurses wanted to continue to use the BVC. Nurses found using the BVC scores helpful when talking to physicians about the need for patient medication changes. The BVC was also found useful in substantiating the acuity of the unit to assess staffing need. The BVC can also be helpful in validating the nurse’s intuitive assessment of an agitated patient.
Structured Assessment of Violence Risk in Schizophrenia and Other Psychiatric Disorders: A Systematic Review of the Validity, Reliability, and Item Content of 10 Available Instruments
Author/Source: Singh, J., Serper, M.,Reinharth, M., Fazel, S.( 2011). Schizophrenia Bulletin, vol. 37 no. 5 pp. 899–912, 2011 doi:10.1093/schbul/sbr093
Systematic review of structured risk assessment in predicting community violence in psychiatric populations found that researchers have not yet found a fool-proof way to accurately predict violence.
Safety in psychiatric inpatient care: The impact of risk management culture on mental health nursing practice.
Author/Source: Slemon, A., Jenkins, E., Bungay, V.(2017). Wiley’s Nursing Inquiry. March:1-10. DOI: 10.1111/nin.12199
Describes growing concerns that risk management and safety have overshadowed the primacy of caring in psychiatric care settings.
Quote worth repeating: “We suggest that to re-centre meaningful support and treatment of clients, nurses should provide individualized, flexible care that incorporates safety measures while also fundamentally re-evaluating the risk management culture that gives rise to and legitimizes harmful practices (Abstract).”
APNA Psychiatric-Mental Health Nurse Essential Competencies for Assessment and Management of Individuals At Risk for Suicide
Author/Source: APNA Suicide Prevention Task Force. (2015). (Adapted* from Suicide Prevention Resource Center (SPRC) & American Association of Suicidality (AAS) (2008). Assessing and Managing Suicide Risk: Core Competencies for Mental Health Professionals. https://www.apna.org/i4a/pages/index.cfm?pageID=5684
“The role of the nurse specific to suicide prevention includes both systems and patient level interventions. At the systems level the nurse assesses and maintains environmental safety, develops protocols, policies, and practices consistent with zero suicide, and participates in training for all milieu staff. At the patient level, the nurse
assesses risk for suicide, provides suicide-specific psychotherapeutic interventions, monitors and supervises at-risk patients, and assesses outcomes of all interventions. The expectation is that these essential competencies will serve to provide the foundation for training curricula and in measuring the knowledge, skills, and attitudes necessary for expert care. The role of the nurse specific to suicide prevention includes both systems and patient level interventions. At the systems level the nurse assesses and maintains environmental safety, develops protocols, policies, and practices consistent with zero suicide, and participates in training for all milieu staff. At the patient level, the nurse assesses risk for suicide, provides suicide-specific psychotherapeutic interventions, monitors and supervises at-risk patients, and assesses outcomes of all interventions. The expectation is that these essential competencies will serve to provide the foundation for training curricula and in measuring the knowledge, skills, and attitudes necessary for expert care.”
Other Assessment and Monitoring References
Bowers, L., Simpson, A. (2007). Observing and engaging. Mental Health Practice, 10(10): 12-14.
Harding, A. (2010). Observation Assistants: Sitter effectiveness and industry measures. Nursing Economics, 28:330-336.
Polacek, M., Allen, D., Damin-Moss, R., Schwartz, A., Sharp, D., Shattell, M., Delaney, K. (2015). Engagement as an element of safe impatient environments. Journal of the American Psychiatric Nurses Association. 21,181-190. http://journals.sagepub.com/doi/full/10.1177/1078390315593107