APNA 3th Annual Conference Session 233: October 2. 216 The Effects of two Nursing Protocols on the Use of Continuous Special Observation Presented at: APNA 3 th annual Conference Presented on: October 2, 216 Presented by: Richard Ray, MS, RN, PMH-BC Purpose of CSO: Provide safety for all patients and staff while a particular patient is at risk of harming themselves and/or others (Clinical Resource and Audit Group, 22). Positive outcomes of CSO when staff engage the patient Provides increased opportunity for assessment, Provides time to establish therapeutic relationship Staff assist patient in developing coping skills. (Cleary et al. 1999) patients experience decreased hopelessness and suicidal thoughts and increased feelings of worth (Jones et al., 2b; Pitula & Cardell, 1996). Staff are able to intervene quickly and deescalate aggression and violence (Mackay et al., 2). Continuous Special Observation based on control The speaker has no conflict of interest to disclose. Staff exert control of patient to create safety Consequences of staff not implementing control Hamilton, B. & Manias, E. 28 Meechan et al (26) collected suicide data in England from 1996 2 There were 236 inpatient suicides 139 on intermittent observation 74 eloped on intermittent observation or Continuous Special Observation 17 died on 1:1 Objectives Discuss uses of Continuous Special Observations (CSO) Discuss Problems with CSO Discuss Nursing Protocols developed as an alternative to CSO Discuss research on how Nursing Protocols affect use of CSO Ray 1
APNA 3th Annual Conference Session 233: October 2. 216 Research Studies The City 128 Study by Bowers et al (26) Intermittent Observations (as opposed to Constant Observations) may act to reduce the rate of self harm Intermittent Observations are effective so long as patients frequently participate in staffed activity sessions and adequate numbers of nursing staff are available in the milieu Intermittent Observations may work because it places nurses out on the unit making them more accessible and visible to patients (Bowers, L.,& Simpson, A. 27) Nursing Protocols Psychiatric Nursing Availability (PNA) (21) designed for selfinjurious or suicidal patients Staff partners with patient in coping with violent impulses Relationship based: based on acceptance, tolerance and understanding Patient becomes active partner in maintaining own safety 7 1 Research Studies Dismantling Formal Observations and Refocusing Nursing Activity (Dodds and Bowles 21) Aim of study: Refocus nursing practice from control oriented interventions to care oriented interventionn Outcomes Nurses assumed control of Observations Patients felt more engaged in treatment Self Harm reduced by 67% Violence reduced by 33% Staff calling in sick reduced by 6% Cost savings of 47, pounds Nursing Protocols Psychiatric Monitoring and Interventions (PMI) (24) designed for violent intrusive, impulsive patients Based on removing elements of violence: Weapon, Target, Trigger, State of arousal Patient allowed privacy in their own room Staff partners with patient in coping with violent or impulsive behavior Staff interventions are focused on the entire unit Nurse develops individualized care plan when out of room 8 11 Engagement Engagement defined as being clinically involved with a patient while the patient moves towards their clinical treatment goals The process of engagement involves making a human human connection and conveying acceptance, understanding, and tolerance Engaging interventions are based on demonstrating care Nursing Model Primary Nursing Coordinator Assigned and empowered to manage a team of patients from admission to discharge 24/7 accountability Develops and drives the plan of care with the MD Paired with attending psychiatrist and interdisciplinary team 9 12 Ray 2
APNA 3th Annual Conference Session 233: October 2. 216 41 staff answered questionnaires on concern for safety monitoring patients on CSO and PMI using a 16 item Likert type scale 1 Minute Round documents 2 Concern for Personal Safety on CSO vs. PMI Number of Staff Responses Perception of Risk to Safety on CVO 21 2 Perception of Risk to Safety on PMI 1 12 11 11 11 1 3 3 3 2 Degree of Agreement "I Have Concern for My Personal Safety" : staff rated feeling safer on PMI than CSO (p<.). Problem Statement Have the two nursing protocols reduced the use of Continuous Special Observation? Identify Frequency and duration of CSO prior to nursing protocols Indentify how PNA impacted the Frequency and duration CSO Indentify how PMI impacted the Frequency and duration of CSO Analysis Descriptive analyses frequencies, percentage, mean, median and standard deviation Interrupted time series analysis Wilcoxon two sample test 14 17 Project Plan A12 year retrospective review of the 1 minute round document form from 9/1999 to 9/211 Has PNA reduced the use of CSO? Has PMI reduced the use of CSO? CSO and Nursing Protocols 7 6 4 3 PNA PMI CSO PNA Implemented 21 PMI developed 3/24 2 1 Initiation of study 9/1/1999 Move to new Unit 9/24/11 22 23 24 2 26 27 29 21 211* 1 Ray 3
APNA 3th Annual Conference Session 233: October 2. 216 6 Monthly Median Total CSO Duration Per Patient Mean number of hours on CSO 4 3392 3 2 3 3 1 Episodes of CSO Increasing trend by. per month prior to Nov 2 (P=.83) Decreasing trend by.7 per month after Nov 2 (P=.111) Median Episode Duration (hours) for CSO Before Nov 2: 66 (range 9.7 484.7) After Nov 2: 33 (range 8.2 226.7), p=.4 2 2 1 1 196 129 69 22 2 26 211 21 211 211* 19 Number of PMIs 3 2 2 1 1 Quarterly number of PMIs Episodes of CSO Increasing trend by. per month prior to Nov 2 (P=.83) Decreasing trend by.7 per month after Nov 2 (P=.111) Median Episode Duration (hours) for CSO Before Nov 2: 66 (range 9.7 484.7) After Nov 2: 33 (range 8.2 226.7), p=.4 Discussion Differences between CSO and Nursing Protocols Constant Special Observation (CSO) Ordered by Physician based on Physician interview Intervention based on control to decrease risk Intrusive often resulting in adverse outcomes Costly to implement and poor use of nursing resources Nursing Protocols Ordered by Nursing based on 24 hour ongoing assessment Intervention based on Engagement Designed to treat individual patient needs Patient is able to develop alternative coping skills increases staff presence on unit 23 Nursing Protocols and use of Locked Seclusion 7 6 4 3 Number of PNAs PMIs and Seclusion Incidents Discussion Secondary Outcomes Employee satisfaction increased Employee satisfaction 4.4 in 2 to 4.6 in 29 Is there appropriate staffing to deliver safe care? 3.4 in 2 to 3.88 in 29 2 1 22 23 24 2 26 27 29 21 211* PNA PMI subjects in seclusion Ray 4
APNA 3th Annual Conference Session 233: October 2. 216 Discussion Why did PMI make more impact on CSO? PMI implemented much more frequently than PNA Protocol influences number of staff out of the nurses station and in milieu City 128 study findings indicate close supervision decreases the CSO by placing more staff in the milieu with patients PMI Interventions directed towards the patient and the entire milieu PMI interventions designed to provide patient safety to in the milieu which can be viewed by patients as caring intervention Caring interventions influences hope Questions? 2 Limitations Design was not a randomized controlled study Small sample size Research conducted on one 17 bed unit The primary researcher worked on unit throughout study Conducted research in 27 on staff s perception of safety employing PMI compared to CSO Paper published in 211 The Evolution of Practice Changes in the Use of Special Observations. Archives of Psychiatric Nursing 2 (2), 9 1 References Bowers, L., Whittington, R., Nolan, P., & D Parkin S., (26) The City 128 Study OF Observation and Outcomes on Acute Psychiatric Wards. Report to the NHS Service Delivery and Organization Program. City University, London. Bultima, J., Getzfrid, M., Slade, M., (1996) Defining Professional Practice: The Evolution of the RANA Model. Journal of the American Psychiatric Nurses Association 2 117 126 Cutcliffe, J. R., & Stevenson, C. (28) Feeling our way in the dark: The psychiatric nursing care of suicidal people: A literature review. International Journal of Nursing Studies 4 (6) 942 93. Dodds, P., Bowels, N., (21) Dismantling formal observation and refocusing nursing activity in acute inpatient psychiatry: a case study. Journal of Psychiatric & Mental Health Nursing, 8 (2), 183 188. Mechan, J., Kapur N., Hunt, IM., et.al (26). Suicide in mental health in patients and within 3 months of discharge. National clinical survey. British Journal of Psychiatry, 188, 129 134. Polacek, M., Allen, D., Damin Moss, R., Schwartz, A.,Sharp, D.,Shattell, M., Souther, J., Delaney, K. (21) Engagement as an Element of Safe Inpatient Psychiatric Environments Journal of the American Psychiatric Nurses Association 21181 19. 29 Conclusion Safety can be achieved by: having staff out on the unit With Patients using intermittent observations and engagement Constant Special Observation emphasizes control Protocols emphasize care and engagement to treat patients Reduction in Constant Special Observation supports mission of NMH Improves best patient experience Improves best employee experience Improves financial performance References (Continued) Ray R., Perkins E., Meijer B., (211) The Evolution of Practice Changes in the Use of Special Observations. Archives of Psychiatric Nursing 2 (2), 9 1. Savage, George (1884). Constant Watching of Suicidal Cases The British Journal of Psychiatry, Vol. 3, 17 19 Whitehead, E., & Mason, T. (26) Assessment of risk and special observations in mental health practice: A comparison of forensic and non forensic settings. International Journal of Mental Health Nursing 1 (4) 23 241. 27 3 Ray
APNA 3th Annual Conference Session 233: October 2. 216 Thank You Ray 6