Clinical Supportive Observation, Intervention and Engagement of Service Users Policy Document Control Summary Status: Version: Author/Title: Owner/Title: Approved by: Ratified: Related Trust Strategy and/or Strategic Aims Implementation Date: Review Date: Key Words: Associated Policy or Standard Operating Procedures Replacement. Supersedes: Policy for the Observation and Engagement of Service Users C- YEL-ip-01 Version 2.0 v 1.0 Date: 24/07/2015 Tim Devanney - Lead for Safe Staffing Alison Bussey - Chief Operating Officer/Director of Nursing Policy & Procedures Committee Date: 13 th August 2015 Trust Board Date: 24 th September 2015 Trust Strategic plan to: Provide high quality recovery focused services and Respect inspire and develop our workforce September 2015 September 2018 Observation, Supportive, Engagement, Enhanced, Specialising, Levels. Supportive Observation, Intervention and Engagement of Service Users SOP Contents This Policy at a Glance... 2 1. Introduction... 3 2. Purpose... 3 3. Scope... 4 4. Evidence Base Underpinning the Practice of Observation... 6 5. European Convention of Human Rights, Mental Capacity Act (2005) / Deprivation of Liberty (DOLS.)... 6 6. Training... 6 7. Bank and Agency Staff... 6 8. Student Nurses... 7 9. Process for Monitoring Compliance and Effectiveness... 7 10. References... 8
Change Control Amendment History Version Dates Amendments V 1.0 24/07/2015 Supersedes: Policy for the Observation and Engagement of Service Users C-YEL-ip-01 Version 2.0 This Policy at a Glance South Staffordshire and Shropshire Healthcare NHS Foundation Trust is committed to delivering high quality, safe services and this policy describes the practice decisions and standards which our staff will provide when deploying the use of observation and engagement with service users in managing risk on our in-patient wards. This observation and engagement policy covers all Trust staff on our in-patient wards across all directorates and divisions. Observation is a specific skill used by a member of care staff as part of their day to-day duty in the care and assessment of service users under their care. The four levels of observation used by the Trust are: General Observation Intermittent Observation Within Eyesight Constant Observation Within Arms-length Constant Observation Enhanced observation and engagement is an intervention used for the highest risk and often acutely ill patients; members of care staff are required to employ a range of skills to develop therapeutic relationships with patients on enhanced observations. Given this, enhanced observation should not be carried out exclusively by unqualified staff as this is likely to undermine its potential effectiveness All enhanced observations must be carefully planned alongside the activities that shall be engaged in during each period of care. Page 2 of 8
1. Introduction 1.1. Observation is a specific skill used by a nurse/clinician as part of their day today duty in the assessment and treatment of service users under their care. The four levels of observation used by the Trust are are: 1.1.1.1. General Observation 1.1.1.2. Intermittent Observation 1.1.1.3. Within Eyesight Constant Observation 1.1.1.4. Within Arms-length Constant Observation 1.2. Observation should not be considered as a stand-alone or passive intervention; rather it must be part of an overall management plan addressing the identified clinical risks. Any planned observation must also be accompanied with a clear description of the activities or interventions and the type of engagement that are planned to take place between the service user and the member of staff allocated to undertake the observation. 1.3. In this way observation should be a supportive intervention that engages the service user. 1.4. It should be based on a risk assessment that considers both the target risks and those associated with the process and act of observation. 1.5. The level of observation should be selected based on the needs of the individual service user, including a historical knowledge of the effectiveness of enhanced observation and a consideration of service user preference to suit the individuals need along with associated interventions and activities designed to reduce the risks. 1.6. Clear explanations and expectations of the duration, activities and responsibilities that will be undertaken during the observation period will be discussed with the service user whenever practically possible and always with the person undertaking the observations. 1.7. The level of supportive observation and interventions will continue under review and will need to be adjusted to suit the individuals risk, clinical presentation and environment. 2. Purpose 2.1. To provide a safe environment for service users, clinical and support staff together with members of the public and visitors. 2.2. This policy has been written with regard to NICE guidance CG25 incorporating the observation and engagement element of the guidance. 2.3. Observation as an exercise in itself has a limited therapeutic value to service users. Being under such surveillance may be interpreted as reassuring, intrusive, threatening or number or other ways. It is therefore essential that any Page 3 of 8
such intervention with a significant element of observation should take into account the effect that being observed may have upon the service user. 2.4. Observation may be a significant part of a strategy to reduce risk and it must: 2.4.1. Be accompanied by a care plan which describes the planned supportive interventions agreed with the service user. 2.4.2. Give due regard to the interaction between the person being observed and the person undertaking that responsibility. 2.5. The purpose of this supportive observation policy is to: 2.6. Primarily to ensure the safety of service users with increased risks and to afford them additional intensive care and support until their risks reduce. 2.7. To provide structured supportive observation, intervention and engagement for service users who need enhanced intervention and or monitoring of their mental or physical health. 3. Scope 3.1. Directors Directors are responsible for: - Ensuring the policy is implemented in their Divisions - Bringing the policy to the attention of all clinical staff - Ensuring that all identified staff receive adequate training 3.2. Ward Managers Ward Managers are responsible for: - The implementation of this policy - Ensuring that practice on the ward conforms to this policy 3.3. Nurse in Charge The Nurse in charge is responsible for: - Ensuring there is multi-disciplinary risk assessment and that the level of observation/interventions employed for each patient matches the current level of care need. - Ensuring that effective communication takes place between those members of the MDT responsible for determining levels of observation, those undertaking the duty of observation and service users who are being observed. - Providing times, reviews and changes to the intervention / observation following multidisciplinary discussion. Page 4 of 8
- Recording the level of observation and any variation in the care plan. There should be a daily summary recording observation level(s) and progress in the service user s health record. - Nominating a suitably prepared person to undertake the planned interventions / observation, taking into account their experience, gender, knowledge and relationship with the service user. - Ensuring the intervention / observations for the subsequent periods are relevant to the current clinical need, explained to all, and those undertaking the intervention observation duties are clear about their role. - Informing all members of the ward team of the level of observations required and who the nominated persons responsible for in intervention observations are. 3.4. Member of Staff allocated to carry out observations and engagement The member of staff who is observing and engaging with the patient is responsible for: - Ensuring that they are familiar with the service user; their preferences and personal history and circumstances, paying utmost regard to their rights, privacy, dignity and self-respect. - Considering the location and any risk items in the environment taking reasonable steps to remove or mitigate risks. - Use planned interventions engaging the service user in appropriate / suitable activities. If this includes attending a group programme session, etc. the observing clinician should liaise with the group facilitator / therapist to agree how observations are best achieved. - Providing a full verbal report to the nurse/clinician taking over. Where appropriate, the service user should be involved in this process. - Making a record of their work on the service user s health records to document any occurrence and action taken during the observation period. - Being aware of the stresses associated with special observation levels on not only the service user but on the observing nurse/clinician and other service users. - Informing the service user of the rationale for the level of observation being implemented. Staff should be sensitive to service user s mental state when doing this. - Offer a copy of the Care Plan and communicate the intervention with the service user and relatives etc where appropriate. Page 5 of 8
4. Evidence Base Underpinning the Practice of Observation 4.1. There is a growing evidence base regarding the use of observation and engagement in mental health settings. Members of staff involved with undertaking and supervising the use of observation and engagement are encouraged to access the sources of evidence listed in the reference section of this policy. 4.2. Enhanced observation and engagement is an intervention used for the highest risk and often acutely ill patients and care staff are required to employ a range of skills to develop therapeutic relationships with patients on enhanced observations. Given this, enhanced observation should not be routinely carried out by unqualified staff as this is likely to undermine its potential effectiveness. (Stewart & Bowers, 2010) 5. European Convention of Human Rights, Mental Capacity Act (2005) / Deprivation of Liberty (DOLS.) 5.1. All those involved in observation and associated interventions must respect at all times the service user s human rights in particular Article 5 A Right to Freedom and Article 8 A Right to Respect for Family Life. The clinician should also have an understanding of the service user s mental capacity and decisions regarding increasing or decreasing levels of observation; this decision needs to take into account a service user s capacity. The level of observation needs to balance therapeutic considerations with safety factors. In practice this may result in restricting the service user s autonomy, personal freedom, privacy and dignity in order to maintain their safety and the safety of others. The activity should be used for the minimum length of time appropriate to the service user. 6. Training 6.1. The ward manager is responsible for ensuring that all staff on the ward are familiar with the policy and aware of their responsibilities. Staff will have their competency assessed on the practice of observation and an exploration of the practicalities of the procedure (Appendix 5). 6.2. To aid this process there is attached at Appendices 3 & 4 a standard operating procedure and flowchart. Training guidance provided for staff should not be viewed in isolation but opportunities should be taken to support the activity of observation through clinical and managerial supervision. 6.3. The Trust s expectations with regard to observation training are detailed within the Trust s Training Needs Analysis which staff can locate on the Trust s website. 7. Bank and Agency Staff 7.1. On occasions when bank and agency staff are employed on the ward it would be good practice to use the regular staff in the first instance. If it is necessary, to utilise Bank and Agency staff to perform supportive observations; the nurse in charge of the shift will ensure that member of staff understands what is required of them, is familiar with this policy and is competent to carry out the required intervention on that individual service user for that particular duration of the shift. Page 6 of 8
8. Student Nurses 8.1. Student nurses are not employees of the organisation and cannot be counted amongst the numbers as member of the nursing or care staff. They are learning through practical experience within the clinical area. Second and Third year students may, once they are assessed as competent, undertake enhanced levels of observation as part of a learning activity. 8.2. Student nurses will not be assigned to carry out enhanced levels of observations with a patient who is at risk of violence and aggression due to the risk associated with this activity. 8.3. The student should be clear what the purpose of the observation is and understand the record keeping requirements. The student should know when to seek support from a qualified practitioner. Students should also be educated as to the roles, responsibilities and functions of the principles and practices on observation and engagement. 9. Process for Monitoring Compliance and Effectiveness 9.1. Auditing of this policy will be undertaken as part of the clinical audit programme to monitor the effectiveness of the policy and practice. It will take into consideration the rationale behind decisions made to commence observation levels incorporating the levels of engagement undertaken. Where compliance is deemed to be insufficient and the assurance provided is limited then remedial actions will be drawn together through an action plan. This progress against the action plan will be monitored at the specified committee / group. Aspect of compliance or effectiveness being monitored Monitoring method Individual or department responsible for the monitoring Frequency of the monitoring activity Group/Committe e/forum which will receive the findings/monitor ing report Committee/ individual responsible for ensuring that the actions are completed Duties Audit Clinical Audit via audit programme Annual QERC QERC Process for observation at differing levels Audit Clinical Audit via audit programme Annual QERC QERC Organisation s expectations in relation to staff training Monitoring Reports Learning and Development Department Monthly HR&ODE Committee HR&ODE Committee Record-keeping Audit Clinical Audit via audit programme Annual QERC QERC Page 7 of 8
10. References (Please read in conjunction with the Restrictive Practices Policy) Mental Health Act 1983 as amended by the Mental Health Act 2007 and Revised Code of Practice Great Britain. Mental Capacity Act 2005. London: The Stationary Office. Available at: http://www.opsi.gov.uk/acts/acts2005/ukpga_20050009_en_1 National Institute for Clinical Excellence (NICE) Clinical Guideline 25 Violence The Short-Term Management of Disturbed/Violent Behaviour in Psychiatric In-patient Settings and Emergency Departments (2005) Stewart, D. Bowers, L. (2010) Under the Gaze of Staff: Special Observation as Surveillance. Perspectives in Psychiatric Care 48 p 2-9. Stewart, D. Ross, J. Watson, C. James, K. Bowers, L. (2011) Patient characteristics and behaviours associated with self-harm and attempted suicide in acute psychiatric wards. Journal of Clinical Nursing, 21, p1004 1013, Stewart, D. Bowers, L. Ross, J. (2012) Managing risk and conflict behaviours in acute psychiatry: the dual role of constant special observation. Jan. p1340 1348 SSSFT (2014) Carer Engagement in Service users Care, SSSFT Online: http://www.sssft.nhs.uk/service-users-carers/information-for-carers#c7. Page 8 of 8