Policy No: MH03 Version: 5.0 Name of Policy: Patient Observation Policy Effective From: 25/08/2015 Date Ratified 24/07/2015 Ratified by Mental Health Act Committee Review Date 01/07/2017 Sponsor Associate Director Medical Unit Expiry Date 23/07/2018 Withdrawn Date Unless this copy has been taken directly from the Trust intranet site (Pandora) there is no assurance that this is the most up to date version This policy supersedes all previous issues Patient Observation Policy v5
Version Control Version Release Author/Reviewer Ratified by/authorised by 1.0 Date Changes (Please identify page no.) 2.0 3.0 01/11/2009 Judith Gibson Director of Nursing & Midwifery 23/09/2009 4.0 08/10/2012 Sandra Dickson Mental Health Act Committee 27/07/2012 New Policy Format Page 11 added Appendix 1 Patient Observation recording Sheet 5.0 25/08/2015 Judith Gibson Angela Chambers Mental Health Act Committee 24/07/2015 Patient Observation Policy v5 2
Contents Section Page 1 Introduction... 4 2 Policy Scope... 4 3 Aim of Policy... 4 4 Duties (Roles and Responsibilities)... 4 5 Definitions... 5 6 Observation Levels 6.1 General Observation... 5 6.2 Intermittent Observation... 6 6.3 Constant Observation... 6 6.4 Close Proximity Observation... 7 7 Training... 8 8 Equality and Diversity... 8 9 Monitoring compliance with the policy... 9 10 Consultation and review... 9 11 Implementation of policy (including raising awareness)... 9 12 References... 9 13 Associated documentation (policies)... 9 APPENDICES Appendix 1 24 HOUR OBSERVATION CAREPLAN AND CHART Level two... 10-11 Appendix 2 24 HOUR OBSERVATION CAREPLAN AND CHART Level three... 12-13 Appendix 3 24 HOUR OBSERVATION CAREPLAN AND CHART Level Four... 14-15 Patient Observation Policy v5 3
Patient Observation Policy 1 Introduction Observation is an important skill for all nurses. It is recognised that patients may need varying degrees of observation, depending upon the patient s identified need, behavior or current clinical risk assessment. In the acute phases of their illnesses some patients become a risk to themselves or to others. Observation of patients is an important part of the day to day nursing activity, which enables the multi-disciplinary team to assess patients and their progress throughout their stay. It should not be seen simply as a custodial activity. It is also an opportunity for the nurse to interact in a therapeutic manner with the patient on a one to one basis. Care should be taken to ensure that patients are not subjected to inhumane or degrading treatment in line with Article 3 (Prohibition of Torture) Human Rights Act 1998. A multi-disciplinary team approach is the best method of enabling patients to overcome their problems and return them to better health and lifestyles in the community. The member of staff undertaking the therapeutic activity will assume the responsibility for the level of observation during the activity. Skilled observation calls for empathy and engagement combined with readiness to act. Whereas most nursing interventions are designed 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, effort should be taken to monitor and minimize this potential side effect. Article 2 (Right to Life) Human Rights Act 1998, places a positive obligation upon the Trust to take appropriate steps to safeguard the lives of those within its jurisdiction. Provided the staff act in good faith working within the procedure identified and apply the training they have received, they will receive the support of their respective organization. 2 Policy scope Gateshead Health NHS Foundation Trust is committed to the development of comprehensive services for people with mental health problems. The responsibilities of promoting equality and opportunity and upholding human rights unless there is a real and serious danger to public safety are recognized. This policy defines four levels of observation used within the mental health inpatient areas as determined by the multi-disciplinary team. 3 Aim of policy The policy aims to provide a framework for outlining the use of, and skill of, observation, in order to prevent potentially suicidal, violent or vulnerable patients from harming themselves or others. 4 Duties (Roles and responsibilities) The Trust Board The Trust Board is responsible for implementing a robust system of corporate governance within the organisation. This includes having a systematic process for the development, management and authorisation of policies. The Chief Executive The Chief Executive is ultimately responsible for ensuring effective corporate governance within the organisation and therefore supports the Trust-wide implementation of this Policy. Patient Observation Policy v5 4
Divisional Managers and Matrons The Divisional Managers and Matrons are responsible for ensuring staff are aware of and adhere to this policy. Ward/Team Managers Are responsible for ensuring that all staff are aware of the levels of observation outlined in this policy, that all staff have a contact appraisal and that a personal development plan is completed. All Clinical Staff All identified staff, having contact with or involvement in the care of the service-user, are responsible for Ensuring that the principles outlined in this policy are adhered to and applied. Maintaining their individual competence in suicide prevention strategies, including Risk Assessment and Risk Management and attending training as required by their roles. Ensuring that a Mental Health Act Assessment (MHA) has been carried out. 5 Definitions Psychotic State - Psychosis refers to an abnormal condition of the mind Responsible Clinician (RC) Consultant Psychiatrist in charge of the patients care. Self Harm The various methods by which people deliberately harm themselves including cutting and self poisoning. Suicidal Ideation or Behaviour Thoughts or actions of engaging in suicide related behaviour. Suicide A deliberate act that intentionally end one s life. 6 Observation Levels 6.1 Level 1 (General Observation) This represents the minimum acceptable level of observation for all patients. Nursing staff will, as far as is practicable, have knowledge of the patient s whereabouts and the date and time of departure and return to the ward. At least once per shift a nurse should sit down and talk with each patient to assess mental state and this should be recorded in the nursing notes. Criteria for Care The minimum standards of care for patients on General observation will be attained by the criteria set out below: a) The nurse in charge will identify a named or associate nurse who will implement nursing care throughout normal ward activities. b) The nurse in charge, through the named or associate nurse who will as far as practicable know of and be alert to the patients whereabouts, even though the patient may be unaccompanied. c) The nurse in charge/named/ associate nurse will be responsible for ensuring that patient are made aware of the need to inform the nursing team when leaving and returning to the ward. Patient Observation Policy v5 5
6.2 Level 2 (Intermittent Observation) (Appendix 1) The patient s location must be checked at regular intervals (exact times to be stipulated in the notes). This category of observation is used for all patients who display an implied risk to themselves or others with specified regular contact by a health care professional at no less than 10 minute intervals. This level is appropriate when patients are potentially, but not imminently, at risk. Patients with depression, but no immediate plans to harm themselves or others, or patients who have previously been at risk of harm to self or others but who are in a process of recovery, require intermittent observation. This task can be undertaken with more than one patient during the normal activities on the ward or department. This level of care is reliant to a large extent upon the patient s co-operation; the patient should feel able to welcome the intensive support from staff rather than resent it. The patient should not be granted leave. As the patient s condition improves, Article 5 (Right to Liberty) Human Rights Act 1998, we would be required to demonstrate that there had been no undue delay in re-grading the patient to the lowest level of appropriate observation. Criteria for Care The minimum standards of care for patients on intermittent observation will be attained by the criteria set out below. a) The nurse in charge will be responsible for ensuring that a system is in place that clearly identifies nurses on duty to implement care for intermittent observation patients and for briefing other professionals who take on therapy with intermittent observation patients. b) Identified nurses/therapists or associate nurses will ensure regular visual contact of all patients designated as being on intermittent observation. c) The nurse in charge of the ward will be responsible for determining the level of nursing skills required for special observation and allocation of all nurses on an hourly rota to carry out intermittent observation. d) Cancellation of this category of observation must be recorded by the Responsible clinician (RC) (or nominated deputy) in the medical case notes and by the nursing staff in the nursing care plan and recorded on the Observation Charts depending on identified time. 6.3 Level 3 (Constant Observation) (Appendix 2) This category of observation is used for all patients who present an immediate risk to the health and safety of themselves or others and require a one-to-one nurse patient ration. The patient should not be granted leave. Article 5 (Right to Liberty) Human Rights Act 1998, a limited right exception, includes the detention of a person of unsound mind. European Case Law has established that there must be three minimum conditions for detention to be lawful under Article 5. A true mental disorder must be established before a competent authority on the bases of objective medical expertise. The mental disorder must be of a kind or degree warranting compulsory confinement. The validity of the continued confinement depends upon the persistence of the mental disorder. Patient Observation Policy v5 6
A designated nurse keeps the patient under constant visual observation. A specific decision should be made, after discussion between medical and nursing staff, as to whether the patient should be ambulant or nursed in bed for a while and use a bedside commode as opposed to the normal ward toilet facilities. If the patient is able to use the ward toilets then he or she should not be able to lock or otherwise barricade themselves in and prevent staff access, as necessary, and the nurse should remain nearby. This may be seen as an infringement of Article 8 (Right to Respect for Family and Private Life) Human Rights Act 1998. However, it can be justified if, in accordance with the law, it is necessary in a democratic society to ensure public safety, for the prevention of disorder or crime, for the protection of health or morals or for the protection of rights and freedom of others. At all times the risk to staff, as a result of aggressive behaviour, should be taken into consideration. Criteria for Care The minimum standards of care for patients on Constant observation will be attained by the criteria set out below:- a) A minimum of one-to-one nurse to patient ratio. b) A nurse should remain with the patient at all times until arrangements are made for a relief nurse. c) The nurse in charge of the ward will be responsible for determining the level of nursing skills required for constant observation and allocation of all nurses on an hourly rota to carry out the constant observation. d) The reason for the application for constant observation should be clearly identified in the patients medical notes and in the nursing care plan, with a clear necessary plan of care to help meet the patient s needs as quickly and as effectively as possible and recorded on the observation chart. e) Constant observation should be reviewed at least every 24 hours by the Responsible clinician (or nominated deputy) and the nurse in charge. The objectives of constant observation should be jointly agreed for the next 24 hours. With regard to the constant observation being reviewed, the period of time outlined above is a minimum standard. The situation concerning constant observation can be reviewed and changed at any time providing that the Responsible Clinician (or nominated deputy) and the nurse in charge agree. f) Cancellation of this category of observation must be recorded by the Responsible Clinician (or nominated deputy) in the medical notes and by the nursing staff in the nursing care plan. As the patient s condition improves, under Article 5 (Human Rights Act 1998), we would be required to demonstrate that there had been no undue delay in re-grading the patient to the lowest level of appropriate observation. 6.4 Level 4 (Close Proximity Observation) (Appendix3) Patients at the highest levels of risk of harming themselves or others may need to be nursed within arms length and more than one nurse 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 in the care plan and recorded on observation chart. If the patient is impulsive and assessed as being a serious suicide risk, the designated nurse, or nurses should remain physically close to the patient. The patient may be confined to bed for short periods if the situation cannot otherwise be contained. The types of patients for whom close proximity observation is appropriate might include those expressing active suicidal intent, especially if no close relationship has been established with the patient, Patient Observation Policy v5 7
7 Training those in unpredictable psychotic states or where there have been recent episodes of selfharm with apparent serious suicidal intent. Special care should be taken if the patient is impulsive or aggressive. The patient should not be granted leave. Criteria for Care The minimum standards of care for patients on Close Proximity observation will be attained by the criteria set out below:- a) A minimum of one-to-one nurse patient ratio. b) The nurse should remain with the patient at all times until arrangements are made for a relief nurse. c) The nurse in charge of the ward will be responsible for determining the level of nursing skills required for close proximity observation and allocation of all nurses on an hourly rota to carry out close proximity observation. d) The reasons for the application of close proximity observation should be clearly identified in the patients notes and the nursing care plan with a clear plan of care necessary to help meet the patients needs as effectively as possible. e) In an emergency the nurse in charge of the ward may need to prescribe direct close proximity observation. The circumstances and reasons for this decision should be recorded in the nursing care plan at the first opportunity. The Responsible clinician (or nominated deputy) should be informed of the event. f) Close Proximity observation should be reviewed 3 times during the day by the Responsible Clinician (or nominated deputy) and the nurse in charge of the ward. Twice during the course of the day and once again before handing over care of the patient to the night shift. The objectives of close proximity observation should be jointly agreed for the periods between the reviews. The situation concerning close proximity observation can be reviewed and changed at any time providing that the Responsible clinician (or nominated deputy) and nurse in charge agree. g) Implementation and cancellation of this category of observation must be recorded by the Responsible Clinician (or nominated deputy) in the medical notes and by the nurse in charge in the nursing care plan. Basic Training (Level 1) All staff will have access to Level 1 training in Mental Capacity, Risk Assessment and Suicide prevention through the Mental Health Act Training Day. This training should be undertaken every two years. Ward/Team managers and Educational Leads should ensure staff are aware of their responsibilities regarding patient observation and should review competencies during contact appraisals. 8 Equality and diversity The Trust is committed to ensuring that, as far as is reasonably practicable, the way we treat members of staff and patients reflects their individual needs and does not discriminate against individuals or groups on the grounds of any protected characteristic (Equality Act 2010). An equality analysis has been undertaken for this policy. Patient Observation Policy v5 8
9 Monitoring compliance with the policy Standard/process/issue Suicide Prevention Audit Monitoring and audit Method By Committee Frequency National Suicide Mental Yearly Toolkit. Prevention Health Act Ward- Leads - Committee Managers Checklist 10 Consultation and review The policy was developed using best practice guidelines, in consultation with members of the Mental Health Act Committee and Mental Health Practitioners. 11 Implementation of policy (including raising awareness) This policy will be implemented in accordance with policy OP27 Policy for the development, management and authorisation of policies and procedures and policy training will be included in the programme of training as detailed in section 7 of this policy. 12 References Department of Health Standing Nursing and Midwifery Advisory committee (1999) Practice Guidance Safe and Supportive Observation of Patients at Risk. Human Rights Act (1998) Mental Capacity Act (2005 Mental Health Act 1983 Reid, W (1993) the role of the nurse providing care for the suicidal patient. Journal of Advanced Nursing 18 1369-1376. Morgan, GH, Coleman, J et al (1992) Suicide Prevention: The challenge confronted. A manual of guidance for the purchasers and providers of mental health care. The Health of the Nation. (NHS Advisory Service) 13 Associated documentation This policy should be read in conjunction with: RM01: Risk Management Policy RM10: Violence at Work MH29: Clinical Risk Management & Suicide Prevention Policy MH27: Care Programme Approach (CPA) & Management Patient Observation Policy v5 9
Appendix 1 24 HOUR OBSERVATION CAREPLAN AND CHART Level two 10 minute observations Name Consultant M Number Named Nurse Date Reason for Obs Care Need Evaluation date Objective Nursing Actions 1).. will be allocated to a qualified nurse for the shift. 2) The allocated nurse will engage in a period of therapeutic discussion with.., assessing the risk in relation to activities leading to observation level. Including their thoughts on why they are being observed, how they currently feel regarding this, what are their thoughts for the future? 3) The named nurse will complete the mental health risk assessment weekly based on the information gained from the daily intervention. 4) The observing nurse to assess the patient s behaviour and patterns in a non-obtrusive way being mindful of the observation policy and human rights act in providing observations in a non-custodial manner and engaging in therapeutic discussion. 5) The observations will be reviewed each 24 hour period by the nurse in charge and RMO as per policy. 6) Information to be fedback to allocated nurse and recorded in mental health care plan. Time Name Sig Time Name Sig Time Name Sig 0730 1030 1330 0740 1040 1340 0750 1050 1350 0800 1100 1400 0810 1110 1410 0820 1120 1420 0830 1130 1430 0840 1140 1440 0850 1150 1450 0900 1200 1500 0910 1210 1510 0920 1220 1520 0930 1230 1530 Patient Observation Policy v5 10
0940 1240 1540 0950 1250 1550 1000 1300 1600 1010 1310 1610 1020 1320 1620 1630 1740 1850 1640 1750 1900 1650 1800 1910 1700 1810 1920 1710 1820 1930 1720 1830 1940 1730 1840 1950 2000 0000 0350 2010 0010 0400 2020 0020 0410 2030 0030 0420 2040 0040 0430 2050 0050 0440 2100 0100 0450 2110 0110 0500 2120 0120 0510 2130 0130 0520 2140 0140 0530 2150 0150 0540 2200 0200 0550 2210 0210 0600 2220 0220 0610 2230 0230 0620 2240 0240 0630 2250 0250 0640 2300 0300 0650 2310 0310 0700 2320 0320 0710 2330 0330 0720 2340 0340 New care plan Accountability record Initial Signature / print Initial Signature / print Name Consultant M Number Named Nurse Patient Observation Policy v5 11
Appendix 2 24 HOUR OBSERVATION CAREPLAN AND CHART Level three 5 minute observations Name Consultant M Number Named Nurse Date Reason for Obs Care Need Evaluation date Objective Nursing Actions 1).. will be allocated to a qualified nurse for the shift. 2) The allocated nurse will engage in a period of therapeutic discussion with.., assessing the risk in relation to activities leading to observation level. Including their thoughts on why they are being observed, how they currently feel regarding this, what are their thoughts for the future? 3) The named nurse will complete the mental health risk assessment weekly based on the information gained from the daily intervention. 4) The observing nurse to assess the patient s behaviour and patterns in a non-obtrusive way being mindful of the observation policy and human rights act in providing observations in a non-custodial manner and engaging in therapeutic discussion. 5) The observations will be reviewed each 24 hour period by the nurse in charge and RMO as per policy. 6) Information to be fed back to allocated nurse and recorded in mental health care plan. Time init Time init Time Init Time Init Time Init Time init 0730 0835 0940 1045 1140 1245 0735 0840 0945 1050 1145 1250 0740 0845 0950 1055 1150 1255 0745 0850 0955 1100 1155 1300 0750 0855 1000 1105 1200 1305 0755 0900 1005 1110 1205 1310 0800 0905 1010 1115 1210 1315 0805 0910 1015 1120 1215 1320 0810 0915 1020 1125 1220 1325 0815 0920 1025 1130 1225 1330 0820 0925 1030 1125 1230 1335 0825 0930 1035 1130 1235 1340 0830 0935 1040 1135 1240 1345 Patient Observation Policy v5 12
1350 1655 2000 2305 0210 0515 1355 1700 2005 2310 0215 0520 1400 1705 2010 2315 0220 0525 1405 1710 2015 2320 0225 0530 1410 1715 2220 2325 0230 0535 1415 1720 2025 2330 0235 0540 1420 1725 2030 2335 0240 0545 1425 1730 2035 2340 0245 0550 1430 1735 2040 2345 0250 0555 1435 1740 2045 2350 0255 0600 1440 1745 2050 2355 0300 0605 1445 1750 2055 0000 0305 0610 1450 1755 2100 0005 0310 0615 1455 1800 2105 0010 0315 1620 1500 1805 2110 0015 0320 0625 1505 1810 2115 0020 0325 0630 1510 1815 2120 0025 0330 0635 1515 1820 2125 0030 0335 0640 1520 1825 2130 0035 0340 0645 1525 1830 2135 0040 0345 0650 1530 1835 2140 0045 0350 0655 1535 1840 2145 0050 0355 0700 1540 1845 2150 0055 0400 0705 1545 1850 2155 0100 0405 0710 1550 1855 2200 0105 0410 0715 1555 1900 2205 0110 0415 0720 1600 1905 2210 0115 0420 0725 1605 1910 2215 0120 0425 New care plan 1610 1915 2220 0125 0430 1615 1920 2225 0130 0435 1620 1925 2230 0135 0440 1625 1930 2235 0140 0445 1630 1935 2240 0145 0450 1635 1940 2245 0150 0455 1640 1945 2250 0155 0500 1645 1950 2255 0200 0505 1650 1955 2300 0205 0510 Accountability record Initial Signature / print Initial Signature / print Patient Observation Policy v5 13
Appendix 3 24 HOUR OBSERVATION CAREPLAN AND CHART Level Four..close proximity observations Name Consultant M Number Named Nurse Date Reason for Constant Obs Care Need Evaluation date Objective Nursing Actions 1).. will be allocated to a qualified nurse for the shift. 2) The allocated nurse will engage in a period of therapeutic discussion with.., assessing the risk in relation to activities leading to observation level. Including their thoughts on why they are being observed, how they currently feel regarding this, what are their thoughts for the future? 3) The named nurse will complete the mental health risk assessment weekly based on the information gained from the daily intervention. 4) The observing nurse to assess the patient s behaviour and patterns in a non-obtrusive way being mindful of the observation policy and human rights act in providing observations in a non-custodial manner and engaging in therapeutic discussion. 5) The observations will be reviewed each 24 hour period by the nurse in charge and RMO as per policy. 6) Information to be feedback to allocated nurse and recorded in mental health care plan. Time Name Sig Time Name Sig 0730 1630 NOTES FOR COMPLETION 0800 1700 0830 1730 Staff to work in thirty minute or 0900 1800 one hour spells dependent on 0930 1830 patient condition 1000 1900 1030 1930 Night shift hours overleaf 1100 1130 1200 1230 1300 1330 Please sign accountability overleaf 1400 Patient Observation Policy v5 14
1430 1500 1530 1600 Time Name Sig 2000 2030 2100 2130 2200 2230 2300 2330 0000 0030 0100 0130 0200 0230 0300 0330 0400 0430 0500 0530 0600 0630 Accountability record Initial Signature / print Initial Signature / print Name Consultant M Number Named Nurse Patient Observation Policy v5 15