The Effects of two Nursing Protocols on the Use of Continuous Special Observation Presented by: Richard Ray, MS, RN, PMH-BC The speaker has no conflict of interest to disclose. 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 Richard E. Ray, MS, RN, PMH BC 1
Purpose of CSO: Provide safety for all patients and staff while a particular patient is at risk of harming themselves and/or others Positive outcomes from CSO Staff are able to intervene quickly and deescalate aggression and violence. Provides increased opportunity for assessment. Provides time to establish therapeutic relationship. Staff assist patient in developing coping skills. Patients experience decreased hopelessness and suicidal thoughts and increased feelings of worth. Continuous Special Observation based on control Staff exert control of patient to create safety Consequences of staff not implementing control 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 5 Research Studies The City 128 Study by Bowers et al (26) Intermittent Observations (as opposed to CSO) 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. 6 Richard E. Ray, MS, RN, PMH BC 2
Research Studies Dismantling Formal Observations and Refocusing Nursing Activity 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 7 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 Nurse demonstrates they care about the patient Caring interventions increase patient s feelings of self worth and hope Hope reduces suicidal thoughts The outcome of nursing engagement is the patient reconnects with humanity (Cutcliffe & Stevenson 27). 8 Nursing Protocols Psychiatric Nursing Availability (PNA) (21) designed for selfinjurious or suicidal patients Staff assigned to be available in the milieu Nurse helps patient fill out safety agreement Staff partners with patient in coping with self injurious impulses Patient becomes active partner in maintaining own safety Staff s availability to patient fosters the patients to reconnect with humanity 9 Richard E. Ray, MS, RN, PMH BC 3
Nursing Protocols Psychiatric Monitoring and Interventions (PMI) (24) designed for violent intrusive, impulsive patients Elements of violence: Weapon, Target, Trigger, State of arousal (Bailey R.H.,1977). Staff assigned to be available in the milieu 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 1 Nursing Model Primary Nursing Coordinator PNCs and Physicians are viewed as equals 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 11 41 staff answered questionnaires on concern for safety monitoring patients on CSO and PMI using a 16 item Likert type scale Concern for Personal Safety on CSO vs. PMI Number of Staff Responses 25 2 15 1 5 Perception of Risk to Safety on CVO Perception of Risk to Safety on PMI 3 3 3 5 2 21 12 11 11 11 Degree of Agreement "I Have Concern for My Personal Safety" Findings: staff rated feeling safer on PMI than CSO (p<.5). Richard E. Ray, MS, RN, PMH BC 4
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 13 Project Plan A12 year retrospective review of the 15 minute round document form from 9/1999 to 9/211 Has PNA reduced the use of CSO? Has PMI reduced the use of CSO? PNA Implemented 21 PMI developed 3/24 Initiation of study 9/1/1999 Move to new Unit 9/24/11 14 Analysis Descriptive analyses frequencies, percentage, mean, median and standard deviation Interrupted time series analysis Wilcoxon two sample test 15 Richard E. Ray, MS, RN, PMH BC 5
Findings CSO and Nursing Protocols 7 6 5 Hours 4 3 PNA PMI CSO 2 1 22 23 24 25 26 27 29 21 211* Findings 6 Monthly Median Total CSO Duration Per Patient 5 4 Hours 3 2 1 221 224 227 221 231 234 237 231 241 244 247 241 251 254 257 251 261 264 267 261 271 274 277 271 291 294 297 291 211 214 217 211 2111 2114 2117 Episodes of CSO Increasing trend by.5 per month prior to Nov 25 (P=.83) Decreasing trend by.7 per month after Nov 25 (P=.111) Median Episode Duration (hours) for CSO Before Nov 25: 66 (range 9.75 484.75) After Nov 25: 33 (range 8.25 226.7), p=.4 17 Findings 3 25 Quarterly number of PMIs Number of PMIs 2 15 1 5 Episodes of CSO Increasing trend by.5 per month prior to Nov 25 (P=.83) Decreasing trend by.7 per month after Nov 25 (P=.111) Median Episode Duration (hours) for CSO Before Nov 25: 66 (range 9.75 484.75) After Nov 25: 33 (range 8.25 226.7), p=.4 Richard E. Ray, MS, RN, PMH BC 6
Findings 35 3 3392 Mean number of hours on CSO Hours 25 2 15 196 129 1 569 5 22 25 26 211 21 211 211* Discussion Differences between CSO and Nursing Protocols Continuous 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 2 Discussion Secondary Outcomes Employee satisfaction increased Employee satisfaction 4.4 in 25 to 4.65 in 29 Is there appropriate staffing to deliver safe care? 3.54 in 25 to 3.88 in 29 Richard E. Ray, MS, RN, PMH BC 7
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 PMI interventions directed towards the patient and the entire milieu PMI interventions can be viewed by other patients in the milieu as caring intervention Caring interventions influences hope 22 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 the 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 25 (2), 9 1 Conclusion Continuous Special Observation emphasizes control Nursing Protocols emphasize care and engagement to treat patients Safety can be achieved by: having staff out on the unit With Patients using intermittent observations with engagement Nurses need to develop evidence based interventions which embrace engagement to treat high risk patients 24 Richard E. Ray, MS, RN, PMH BC 8
References Bailey R.H. (1977). Violence and Aggression. New York, NY: Time life books. 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 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 45 (6) 942 953. Cutcliffe, J. R., & Stevenson, C. (27). Care of the suicidal person. Elsevier Health Sciences. 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. 25 References (Continued) Polacek, M., Allen, D., Damin Moss, R., Schwartz, A.,Sharp, D.,Shattell, M., Souther, J., Delaney, K. (215) Engagement as an Element of Safe Inpatient Psychiatric Environments Journal of the 21181 19. Ray R., Perkins E., Meijer B., (211) The Evolution of Practice Changes in the Use of Special Observations. Archives of Psychiatric Nursing 25 (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 15 (4) 235 241. 26 Richard E. Ray, MS, RN, PMH BC 9