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09. Engagement is the thing

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Time well spent

Introduction

More and more wards are moving away from the traditional, very passive (and generally disliked by patients!) practice of ‘observing’ patients as a primary way of trying to keep the ward safe. They feel that using the term and perfecting the practice of ‘engaging’ with patients is much more constructive, and engagement itself includes an element of observing.

Being observant is clearly a central skill, task and requirement for ward staff and indeed for therapists. Observing means being attentive to whatever or whoever you are watching. But it’s a very limited concept, the term not even embracing insightful opinions about the implications of what one is observing. Observing covers issues of what, where, when and perhaps how but rarely the crucial question of why. Arguably it is the most passive, detached and time-inefficient framing of a central feature of supporting acutely ill patients.

Ward observations are sometimes more about risk than reassurance. Patients don’t always fully understand the reasons (or need) for being observed. Mere observation makes it difficult to ascertain how the patient is feeling or what they are experiencing. Whereas engaging is dynamic and relational, it’s not just a one-way process and doesn’t just rely on cold objectivity. Whereas observation can increase feelings of paranoia, anxiety and agitation, engagement is warm, reassuring and comforting.

There are times when the patient is asleep and knocking on their door can be disruptive, scary and obtrusive, (especially when shining a torch in their face). But with a level of engagement and explanation it can also be important interactive intervention. Observation forms sometimes have very limited space to write about the patients mental and psychological state or record topics of conversation.

Support. That is, paradoxically, the missing ingredient in the exercise. Many wards are no longer using either the term or the concept of observation, usually replacing it with engagement. We strongly endorse this. Even where the task is to go round the ward and just check (and record) that patients are OK, this should be an opportunity for engaging with and being supportive to patients. The patients may decline to be engaged – at first. But most will appreciate the spirit of engagement and it reinforces staff accessibility and supportiveness. (In contrast, being observed tends to make patients feel depersonalised, and being simply ticked off on a clipboard every 15 minutes can feel like being part of a continuous stock-taking process!)

Even to ask ‘How are you doing?’ or ‘I’m here if you need me’ provides a way-in for the patient, and helps them feel less isolated.

Clarity about the purpose of observation engagement, and the effects it has on patients is, as always, the starting point. The City 128 Study of Observation and Outcomes on Acute Psychiatric Wards has many compelling accounts by patients of how humiliating and frustrating they found being observed, and in particular, being under ‘special observation’. Wards need to decide if the practice is basically about ‘keeping an eye’ on patients or whether it has more ambitious therapeutic goals. It would be a strange ward that felt that it was better to have a process which achieved less with the same amount of time and staff expertise.

Which leads us to the matter of language. If your ward has a philosophy and culture of dynamically pro-active engagement with patients, is it still using a term which implies and, we would strongly argue, reinforces the very opposite?

 There are two really helpful resources, looking at what works best with engagement and observation. City 128’s research is described below. Despite the term ‘observation’, Safe and supportive observation of patients at risk is a very useful, patient-friendly, practical guide. It was written in 1999 and perhaps over time the enriched practice of ‘observation’ they describe has morphed into something more distant and less interactive? Here’s how they describe observation:

What is observation?

Nursing observation  can be defined as “regarding the patient attentively” while minimising the extent  to  which  they  feel  that  they  are  under  surveillance. Observation is not simply a custodial activity.  It is also an opportunity for the nurse to interact in a therapeutic way with the patient on a one-to-one  basis.

What challenges are associated with nursing observation?

Observing a patient who is deeply distressed and potentially suicidal is one of the most difficult and  demanding   tasks  that  a  nurse  can  undertake.   Observation   calls  for  empathy  and engagement, combined with readiness to act.  Whereas most nursing interventions are intended to help patients achieve their own goals, observation  is deliberately  designed to frustrate the patients’ aims.  Consequently, patients who are being observed may be very angry with staff, or may experience the process as custodial and dehumanising.

Ward examples

  • The ward team focus on the reduction rather than progression of observation levels.
  • Patients are encouraged to work in collaboration with staff to review their observation level.
  • Bank staff attend TalkWell training prior to commencing observations.
  • The ward use a handover sheet, detailing important information and risks. All staff read this before observing patients.
  • Staff do not use the words “observation”, “obs”, “Level 1s” or “Level 2s” but use humanistic, relational language like: “one-to-one time”.
  • Staff engage in conservation with the patient rather than just sitting outside their bedroom.
  • During their hour with the patient staff explore reasons / need for observation with the patient.
  • Patients and staff work together to think about the pros and cons of the observation.
  • At the beginning of their hour with the patient staff ask the patient what they would like to get out of their time together.
  • Staff ask the patient if they have any preferences about the way they are observed.
  • Staff knock on the patients door before entering to do 15 minute checks.
  • Staff avoid shining a torch in the patient’s face at night.
  • Other engaging means of observation are continually considered and preferred.
  • Advanced levels of observation are used only as a last resort.
  • New admissions aren’t automatically put on advanced as a default course of action unless assessed as a necessity.
  • Staff don’t read magazines or newspapers or use their mobile phone when doing level 1 observation.
  • Continuity and consistency of staff members is considered.
  • As much focus and importance given to therapeutic activity as well as observation.  Each patient to be allocated therapeutic time  per shift whether it be a group or one to one time.
  • Even where the task is to go round the ward and just check (and record) that patients are OK, this should be an opportunity for engaging with and being supportive to patients. The patients may decline to be engaged – at first. But most will appreciate the spirit of engagement and it reinforces staff accessibility and supportiveness. (In contrast, being observed tends to make patients feel depersonalised, and being simply ticked off on a clipboard every 15 minutes can feel like being part of a continuous stock-taking process!). Simply asking ‘How are you doing?’ or ‘I’m here if you need me’ provides a way-in for the patient, and helps them feel less isolated.
  • We try out imaginative ways of trying to avoid intrusive, extensive 1:1 hours for patients. With one person, we thought it would make them feel much calmer if their family came to visit him.
  • “Staff need good training and support. We should be given instructions and advice beyond, “Please only write in black ink, not blue”!

The word from the ward

“Where a Wii or even a DVD night may be an expensive option, why not give a few minutes to set up a few tables and chairs and have a chat about the latest football results, the latest news about x-factor or strictly come dancing after all who doesn’t enjoy a chat over a coffee, tea or cup of juice?” (Health Care Support Worker)

 

Patient Examples

  • The ward had an amazing poster of all the activities going on that the patients had designed which helped me plan my time every day.
  • My favourite conversations with staff were when we didn’t talk about anything illness related but just chatted about everyday things. I think this balance is important.
  • I think having loads of distractions around is good. And also not feeling like you are being observed all the time.
  • I found that when I was committed to ward activities I became more committed to life in general.
  • I liked not feeling under pressure to join in activities but appreciated always being asked.
  • Every time I participated in something I felt a real sense of achievement.
  • Staff shouldn’t underestimate just how important their interactions are.
  • Make the most of your named nurse and get to know them. They are here to help you, mine made such a difference to my stay and of who I am today.
  • Every time I think ‘am I bothering them?’ I think ‘no, because they seem to want to listen and hear what I am thinking not just what I am saying’.
  • I always feel the staff engage rather than simply observe. It’s nice not to feel like an object and makes it easier to trust them.
  • I did self-harm on the ward but it’s been my way of coping for a while. Staff found me doing it a few times but they didn’t make a big thing about it. They just sat with me and I stopped after I felt their warmth and they told me other ways to cope that weren’t self-destructive.
  • You can’t expect everyone else to sort your life out for you. You have to meet the staff half way. You have to initiate that.
  • The staff let you talk to them when you feel scared. It makes you feel better.
  • Just doing a bit each day to attend to your responsibilities can really help. And there’s always support if you need it.
  • We used to encourage one another to join in with activities. In the end big groups of us used to go and we would know if someone in that group was struggling and how best to help them.
  • Each one of us would take responsibility for letting the others know what was going on and inviting them to join in a ward activity – it felt very inclusive and friendly.
  • I would tell myself – you only have to go for one minute – but I always stayed longer!

Special Observation

A little note from Marion Janner (founder of Star Wards)

I read this comment by a doctor: “Specialing usually means neglecting everything psychological and simply making sure that the patient’s body is intact.” It brought into focus for me how strange and, frankly, dysfunctional the current balance with specialing tends to be. For many patients it feels like the primary staff concern is with the physical – behaviour, protecting objects, preventing leaving the ward etc. The underlying feelings can feel, and be, neglected, although some patients do find it reassuring and companionable. The doctor’s comment made me review the positive functions of staff having intense contact with patients eg: connecting, understanding, supporting, protecting, mentalising….

Clearly, providing 1:1 (or even more intensive) support happens in the context of all the other therapeutic safety considerations including patient activities, strong staff-patient relationships, and security measures such as searching patients on admission, locking the ward door, time out, medication etc. Particularly now that hospitals are suffering from financial cuts, intensive support is generally used as sparingly as possible. In 2003 the fab City University team found a reported rate of the use of special observation, expressed as a proportion of admissions to acute psychiatric care, of 47%. This seems incredibly high and, 8 years later perhaps the figures would be very different, as would another extraordinary figure City cited, albeit from over 20 years ago:

Once initiated, the duration of SO can vary considerably, with reported durations ranging from two hours to 89 days” (Shugar and Rehaluk, 1990). 89 days!!

Here’s what City said about the controversial nature of ‘special observation’:

“The use of SO is itself a matter of controversy amongst UK psychiatric nurses. Some characterise this debate as a polarisation between observation and engagement (Cutcliffe and Barker, 2002). Use of SO has been portrayed as impersonal guard duty, infantilising, disliked by patients, directed primarily at protection of the organisation from scandal. Instead it is argued that psychiatric nurses should concentrate on developing personal relationships with patients and engaging with them in the resolution of their personal and psychological difficulties. Others have argued that observation and engagement are not incompatible, and that the proper practice of SO includes the processes of engagement and interaction with the patient (Bowers, Gournay and Duffy, 2000). There is little robust empirical evidence that helps to resolve this debate.”

As to its effectiveness, given that one of the primary uses of ‘special observation’ (OK, let’s call it intensive support for now) is to protect suicidal patients, the Confidential Inquiry into Homicides and Suicides (DoH, 1999b) reported that 21% of the inpatients who killed themselves were on ‘special or close observation’. Fascinatingly and importantly, City’s meticulous research found that:

“the use of intermittent [rather than special] observation may act to reduce rates of self-harm, and demonstrate the cost per patient is low and that the practice is highly acceptable to patients.”

They commented:

“The absence of a positive correlation between self-harm and constant special observation is surprising, as self-harm or suicide risk is the most commonly cited reason for the use of constant special observation.” (Bowers, Gournay and Duffy, 2000).

Their conclusions were that:

“Wards and Trusts can take three measures that may lead to lower rates of self-harm: increase the use of intermittent special observation; ensure that wards run comprehensive programmes of patient activity sessions; and increase the numbers of qualified nursing staff.”

We strongly endorse these findings and would like to fling in a few of our own:

  • Skilled, friendly, warm staff who, wherever possible, have a good relationship with the patient. Bank/agency, new nursing assistants may indeed have most of these qualifications but providing intensive support for patients shouldn’t almost automatically be delegated to staff who may feel and/or be the least equipped to perform this highly demanding role.
  • Support for the staff – a few minutes of preparation, discussing concerns, strategies etc, focusing on what is known about the patient’s preferences, current mental state….
  • Taking turns! Constant observation should always be a team responsibility and no one nurse be required to sit in the one to one situation for prolonged periods of time. Skill comes in being able to recognise when a nurse wants a break, and changing places naturally (without saying things like “I have come to relieve you”) Sometimes the swap-overs may need to be every 10 minutes and sometimes the task can be companionable and comfortable for a prolonged period, but body language readily communicates to the client when the nurse has ‘had enough’ and is very counter-productive for both containment and therapy.
  • Encouraging staff to make use of all the time, even when not directly engaging with the patient but being companionably alongside them. Depending on the patient’s state, it can be a time to ponder things like:
    • Ways in which you’ve helped particular patients in the last day, week, year
    • How ex-patients are getting on now that they’re back home
    • Compliments people have given you
    • Compliments you’d like to give other people
    • And then… this can be an opportunity to congratulate yourself for the quality of your work and what this means to each patient. (Fling in all the adjectives you can think of – good-humoured, patient, knowledgeable, friendly, accessible….)
  • Staff comfort – drinks, breaks, toilets and support – must always also be considered.
  • Most policies stipulate that staff shouldn’t spend more than 1 hour on this kind of observation – please refer to your local policy and know when you need a break.
  • Use mentalising, imaging, or visualisation to put yourself in the patients shoes. This will help create a sense of empathy and connection.
  • Patients feeling the person with them is behaving in a therapeutic way rather than being custodial or on ‘auto-pilot’
  • Patients being able to ask for 1:1 support. It may not be possible, or appropriate, to provide it but this can be discussed and perhaps an alternative found which similarly meets the patient’s need for feeling secure, noticed, listened to, empathised with etc.
  • Even patients who go missing due to their mental state usually have good, sensible reasons for wanting to get away from the ward. They may have worries about family, friends, boredom, fear of other patients, their home and responsibilities. These concerns aren’t always known and therefore not able to be addressed by staff.

 

 

Categories: Imagination, Wardipedia
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