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Acknowledgements
This literature review has been developed with the support and active participation of many people.
Advisory committeeMr Russell Bakey
Ms Jakqui Barnfield
Mr Anthony Baumgartner
Ms Isabell Collins
Mr Wayne Daly
Ms Christine Denton
Associate Professor Karen-leigh Edward
Ms Merinda Epstein
Dr Bridget Hamilton
Ms Allison Harrington
Ms Dianne Hawthorne
Ms Cayte Hoppner
Ms Sandra Keppich-Arnold
Mr Tim Lauder
Ms Daphne Lyle
Ms Cath MacLennon
Mr Rod Mann
Ms Maggie McIntosh
Ms Theresa Meiklem
Ms Janice Rouhan
Ms Dan Schiftan
Associate Professor Suresh Sundram
Ms Kate Thwaites
Dr Ruth Vine
Mr David White
Dr Rick Yeatman / Project lead
Adjunct Associate Professor Tracy Beaton
Project manager
Ms Amy Szczygielski
Researcher
Dr Cadeyrn Gaskin
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© Copyright, State of Victoria, Department of Health, 2013
This publication is copyright, no part may be reproducedby any process except in accordance with the provisions of the Copyright Act 1968.
Authorised and published by Victorian Government, 50 Lonsdale Street, Melbourne.
Published by the Mental Health, Drugs and Regions Division, Department of Health, State Government of Victoria, Melbourne.
September 2013
Contents
Acknowledgements
Introduction
Part 1 – Nursing observation in psychiatric inpatient settings
Background to the project
Project objectives
Method
Literature review
Findings
Literature review
Part 2 – The assessment and immediate management of suicide, self-harm, aggression and absconding risks in psychiatric inpatient settings
Background to the review
Review objectives
Method
Summary of main findings
Literature review
Risk of suicide in people receiving inpatient care
Risk of self-harm in people receiving inpatient care
Risk of aggression from people receiving inpatient care
Risk of absconding from inpatient care
Assessment of suicide risk in psychiatric inpatient units
Assessment of self-harm risk in psychiatric inpatient units
Assessment of aggression risk in psychiatric inpatient units
Assessment of absconding risk in psychiatric inpatient units
Actions taken following assessment of suicide risk in psychiatric inpatient units
Actions taken following assessment of self-harm risk in psychiatric inpatient units
Actions taken following assessment of aggression risk in psychiatric inpatient units
Actions taken following assessment of absconding risk in psychiatric inpatient units
Summary
References: Part 1
References: Part 2
Introduction
This literature review was completed to inform the development of the Department of Health guideline, Nursing observation through engagement in psychiatric inpatient care. The literature review and subsequent development of the guideline was instigated in response to the outcomes of theChief Psychiatrist’s investigation of inpatient deaths 2008–2010, as well as to the Coroners Court of Victoria 2011–2012 annual report, in which practices around nursing observation were questioned. In particular, Recommendation 7from the Chief Psychiatrist’s investigation outlined the need for the department and health services to ensure that clear and consistent processes and documentation for nursing observation are in place.
This literature review has been undertaken in two parts, each with its own summary.The first part focuses on nursing observation, the second on the assessment and management of risk, each within the inpatient context of mental health services. Completed as separate projects, the literature reviews for nursing observation and for the assessment and immediate management of risk are presented here together because of the interrelationship between the subject matter.
Nursing observation and the assessmentand management of risk are intertwined, where nursing observation informs assessment,and decisions to undertake different forms of observation are an outcome of assessment processes. Nurses can contribute to the identification of risk by engaging with people receiving care during the completion of evidence-based assessments, and by making clinical judgements about people’s psychosocial functioning, physical health and safety. In this way, a cycle of various forms of assessment and observation should be a continuous feature of the care of people in psychiatric inpatient units.
Part 1 – Nursing observation in psychiatric inpatient settings
Background to the project
Observing peoples’ behaviour in psychiatric inpatient units is an essential but (arguably) undervalued aspect of nursing care (Hamilton and Manias, 2007). Common situations in which formal forms of observation may be prescribed include when individuals have self-harmed or attempted suicide, shown potential for self-harm or suicide, acted aggressively or displayed potential for absconding (Bowers et al., 2000). Although nurses routinely undertake formal observation, they do so in the absence of a strong empirical base to support its use (Manna, 2010). Some opponents of formal observation use the dearth of quality studies as sufficient reason to abandon the practice (Dodds and Bowles, 2001), while others add that it is ineffective, contributes to poor care (Bowles et al., 2002), is stressful for clinicians, reinforces a custodial environment (Cox et al., 2010) and is a product of clinical pragmatism and tradition (Bowers and Park, 2001). What these writers seem to be against, however, is formal observation when the main purpose is maintaining control over those receiving care (principally for ensuring the safety of the person and others). Some researchers have adopted broader definitions of formal observation, however, suggesting that therapeutic actions can sit alongside safety objectives for those receiving care (Cleary et al., 1999, Fletcher, 1999, MacKay et al., 2005). Indeed, the alternatives to formal observation that its opponents propose (for example, engagement; Bowles et al., 2002) seem to fit within these broader definitions. Herein lies one of the main problems within the research literature, public policy and practice; there is a lack of consistency in the use of terminology, definitions and practice of formal observation. For research and practice in formal observation to advance, these issues need attention.
Terminology used in this review
With such inconsistency in usageand understanding of terms in the literature, it is important to state how such nomenclature will be used in this review. Where possible, the terms that authors have used in their papers have been used in this review, accompanied with brief definitions of what these terms mean. Elsewhere in this review (for example, this introduction, initial paragraphs of sections and the summary) the term formal observation has been preferred and is taken to mean the observation of a nominated person at a greater frequency and intensity than general observation. This definition is used to differentiate formal observation from the practice of general observation that nurses undertake on a routine basis. No position is taken on the purpose of formal observation (that is, whether its purpose is safety of the person, therapy or something else).
Project objectives
The main purpose of this project was to review the literature on nursing observation in psychiatric inpatient units in relation to safety and quality of care. Particular attention was paid to investigating the efficacy of this practice as a method of preventing people receiving care from harming themselves, and as a way to understand effective managementof aggressive behaviour and the times when a person refuses medication.
Method
Literature review
A broad search of the electronic databases Medline and CINAHL was conducted using the search terms nurs*, observ*, inpatient andpsychiatric or mental health. The search was limited to the last 20 years (1991 to July 2011) and identified 201 database entries. For each entry, the title and abstract were read to determine the relevance of the contents to this literature review. When the relevance was not clear from reading the title and abstract, full papers were obtained and read. Given the breadth of the search, many of the papers found were not relevant to the literature review (for example, studies in which observation was used as a form of data collection). Of the 201 entries retrieved, 18 were relevant to this literature review.
Using the same strategy, three additional searches were conducted to source additional papers on the effectiveness of formal observation in preventing self-harm and in the management of aggressive behaviour and refusal of medication. The search terms, number of entries retrieved and number of new articles (that is, those not found in the original search) are shown in Table 1.
Table 1: Results from secondary literature searches
Search terms / Entries retrieved / New articlesaggress*, observ*, nurs*, psychiatric or mental health / 115 / 0
self-harm, observ*, nurs*, psychiatric or mental health / 30 / 2
medication, observ*, nurs*, psychiatric or mental health / 117 / 2
The reference lists of the retrieved papers were visually scanned for additional articles that may have relevance for this review.
A search for grey literature was also undertaken, initially using the search terms observation and psychiatric in Google. Additional searches were undertaken on the websites of the following organisations: the American Psychiatric Association (APA) < the National Institute for Health and Clinical Excellence New South Wales Health The Joint Commission The Royal College of Psychiatrists The Royal Australian and New Zealand College of Psychiatrists the United States (US) Department of Health and Human Services andthe World Health Organization
Although these searches were successful in locating information about the use of formal observation to prevent behaviours such as suicide and self-harm, minimal information was found about the use of observation in medication administration. A supplementary search was undertaken of the electronic databases Medline and CINAHL using combinations of the search terms medication, swallow, observ*, inpatient andpsychiatric or mental health.
Findings
Literature review
Formal observation is a common practice in psychiatric inpatient units. Review evidence suggests that up to half of all people receiving care in some psychiatric wards experience periods of constant observation during their admissions (Stewart et al., 2010). Although medical staff are the usual prescribers of formal observation, nurses have a substantial influence on whether or not their requests are met and in what form (Gournay and Bowers, 2000). This literature review begins with an outline of the meaning and practice of formal observation before focusing on the effectiveness of formal observation, ways of enhancing formal observation, research on observation policies and people’s experiences of formal observation.
The meaning and practice of formal observation
Using shared definitions of key terms is one of the foundations both of good research and of good practice; having common meanings of important terms facilitates communication among colleagues. Unfortunately, the terminology used to describe formal observation differs widely among researchers (Duffy, 1995, Manna, 2010) and practitioners (Bowers et al., 2000, Jayaram et al., 2010). Even the term formal observation has not been consistently used in the literature. There seem to be two key points on which definitions vary: (1) the frequency and intensity of formal observation (for example, intermittent observation or continuous observation) (2) the purpose of formal observation (for example, surveillance or therapy). The aim of this section is to sensitise the reader to the inconsistent use of terminology and definitions in this area of literature.
The frequency and intensity of formal observation
The nomenclature around the frequency and intensity of observation varies considerably in the literature (Duffy, 1995, Manna, 2010) and among practice environments (Bowers et al., 2000). Terms such as formal observation(Manna, 2010)special observation(Duffy, 1995) andenhanced observation(Cox et al., 2010) often appear in research papers. Some of these terms (for example, enhanced observation) are used to describe the most intense forms of nursing observation (for example, one or two nurses observing an individual who is within arm’s length) whereas other terms (for example, formal observation) are regularly used to refer to continua that typically range from general observation to continuous observation. A review of the observation policies of 26 mental health trusts in the United Kingdom (UK), for example, showed that 25 trusts had between two and six levels of observation in their inpatient units, with minimal overlap between the trusts in the names given to each level of observation (Bowers et al., 2000). As an example, the term formal observation can encompass three levels of observation:
•routine or general observation (that is, the person is within a locked unit or is receiving hourly checks)
•15 to 30-minute checks
•constant or continuous observation (that is, the person is within the vision of nurses, or within arm's length, at all times; Manna, 2010).
The purpose of formal observation
For almost 35 years formal observation has been used in many psychiatric facilities as a means of surveillance (Cutcliffe and Barker, 2002). Under the direction of medical staff, the emphasis of formal observation has traditionally been on the safety of the person and those around them(Manna, 2010). This focus on safety is seen as a response by increasingly risk-averse organisations to high-profile tragedies. In an attempt to prevent adverse outcomes, formal observation is commonly prescribed when someone has self-harmed or attempted suicide (or has been assessed as having the potential to do so), has acted aggressively or has displayed potential for absconding (Bowers et al., 2000).
The use of formal observation as a risk management measure has attracted significant criticism (for example, Cutcliffe and Barker, 2002, Dodds and Bowles, 2001, Duffy, 1995). First, formal observation is resource intensive and the observation of one person may mean that the nursing needs of others are compromised (Dodds and Bowles, 2001). Second, the ordering of formal observation by medical staff restricts the professional freedom of nursing staff to use their skills and judgement in the care of inpatients (Dodds and Bowles, 2001). Third, formal observation can create tension between nurses and people receiving care (Dodds and Bowles, 2001). Fourth, formal observation usually undermines nurses’ attempts to develop therapeutic relationships and results in people’s rights being violated (Duffy, 1995).
Although descriptions of formal observation tend to focus on the extent to which individuals are being observed (or watched), there is evidence to suggest that this practice encompasses a broader range of tasks than only surveillance (for example, Cleary et al., 1999, Fletcher, 1999, MacKay et al., 2005). Interviews with six registered mental health nurses revealed that constant or special observation involved six practices: (1) intervening (2) maintaining the safety of the individual and others in the ward (3) prevention, de-escalation and management of aggression and violence (4) assessing (5) communication (6) therapy (MacKay et al., 2005). Other studies have shown there to be two main aspects of constant observation: control (or keeping the person safe) and building a therapeutic relationship (Fletcher, 1999, Vråle and Steen, 2005). These two aspects may incorporate three therapeutic actions (ventilating thoughts and feelings, backing off and explaining what is happening) and two controlling actions (preventing harm and avoiding the person; Fletcher, 1999).
These studies suggest that, in practice, formal observation may represent a balance between keeping people safe and developing therapeutic relationships (Fletcher, 1999, Vråle and Steen, 2005). Some writers have contended that these twin objectives do not fit comfortably together, arguing that formal observation represents a role conflict between paternalism and promoting autonomy (Cox et al., 2010, Duffy, 1995). Other writers maintain that, in some psychiatric facilities, the balance may be tipped firmly in favour of safety (that is, under control; Barre and Evans, 2002). These writers use psychodynamic theory to explain how some senior staff can split off (or remove) the anxiety-provoking situation, which formal observation can be, through allocating the task to junior colleagues (for example, students). In turn, these junior staff may cope with their anxiety through avoiding the situation as much as possible (for example, by sitting in the person’s doorway reading a magazine) rather than actively engaging the person receiving care in a therapeutic relationship.
Although these studies provide insight into what it means to undertake formal observation, they also emphasise the point that the practice of formal observation differs markedly among psychiatric facilities (Bowers et al., 2000). What remains unknown is the extent to which the practice of formal observation differs among facilities and whether the role differs depending on the intensity of the observation. From the findings of these studies, however, it seems evident that specialist skills and experience are needed to perform this role, which adds weight to the view that student nurses and family members may not be adequately prepared to undertake formal observation (Bowers et al., 2000), especially of those deemed to be at high risk.
The effectiveness of formal observation
The effectiveness of formal observation (surveillance) in psychiatric inpatient units in reducing adverse patient outcomes has yet to be established (Manna, 2010). There has only been a minimal amount of research conducted in this area, and the study designs that researchers have used have been relatively unsophisticated. In this section the effectiveness of formal observation in decreasing aggression, self-harm and the refusal of medication will be considered.
Formal observation and aggression
Only one study has produced data on the effectiveness of formal observation in reducing aggression (Dodds and Bowles, 2001). This study has perhaps the strongest research design in the literature on the efficacy of formal observation (a one-group, pre-test – post-test design). It investigated the effect of discontinuing formal observation on several key outcomes including aggression (measured as violence on the ward). The discontinuation of formal observation (surveillance) occurred at the same time as decreases in absconding (down 46 per cent), deliberate self-harm (down 67 per cent) and violence on the ward (down 33 per cent). Although these statistics are impressive, the changes cannot be attributed with any confidence to the cessation of formal observation. At the same time formal observation was discontinued, the ward underwent other substantial changes, which included appointing a new nurse manager, reducing the number of beds from 28 to 21, changing the gender composition within the ward from mixed-sex to male-only consumers, focusing on care interventions rather than those based on control (for example, formal observation) and promoting a professional culture among nursing staff. It is highly conceivable that these changes influenced consumer outcomes as much, if not more so, than discontinuing formal observation. Furthermore, without an equivalent ward that did not undergo these changes acting as a comparator condition, it is impossible to say for certain whether the outcomes were due to the changes within the ward or to influences outside of the ward.