Mental Health Service
Observation
Title
OBSERVATION OF PATIENTS WITH ACUTE
MENTAL HEALTH PROBLEMS
Policy and Procedure
Directorate/Manual
Author
Reviewer
Status
Approved By (Signature of
Director)
Clinical
B McLean
B McLean
VERSION (3)
Policy/Procedure No
Review /Copy No
Implementation Date
Last Review Date
Next Review Date
December 98
November 05
November 08
1.0
Function
1.1
This document sets out the policy and procedures required to ensure good and safe
practice relating to the observation of patients with acute mental health problems.
1.2
The key purpose of observation is to provide safety for people during temporary
periods of distress when they are at risk to themselves and/or others.
1.3
The observation of patients who are acutely ill must be seen as a skilled task
involving the assessment of the patient’s mental state and the development of a
rapport and relationship with the person being observed.
1.4
All staff who undertake observation should possess the requisite skills to do so,
have appropriate training and should understand the importance and therapeutic
aims of the duty they are carrying out.
2.0
Location
2.1
All mental health inpatient wards and clinical departments.
3.0
Responsibility
3.1
All clinical staff with a responsibility for the direct supervision or care of inpatients in
mental health wards or clinical departments.
3.2
Fife Primary Care NHS Trust recognises the challenge faced by clinical staff in
implementing an effective observation policy that maintains the necessary balance
between patient safety, care and individual needs.
The Trust is committed to
supporting and developing staff in exercising their clinical judgement and in the
performance of their duties.
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3.3
All staff need to be aware that they are accountable for their practice and, in
collaboration with other members of the multi-disciplinary team, must endeavour to
create and promote a culture where patients are treated with dignity and respect,
which upholds their individual rights and takes account of their individual needs and
wishes.
All staff required to undertake observation duties should possess the
necessary skills to do so and must ensure that the level of observation applied is
determined by appropriate consideration of the clinical risks identified and is the
least invasive and least restrictive intervention compatible with the delivery of safe
and effective care.
4.0
Operational System
4.1
Guidance Notes
4.1.1
The decision to use an increased level of observation is based on a variety of
factors. Central to it must be the risk assessment of the patient’s mental state at
that moment in time. The assessment of risk must be made taking into account the
patient’s history, behaviour, available information from third parties and, ultimately,
the professional judgement of the clinicians involved.
4.1.2
If there is difficulty in assessing risk due to a lack of information or if there is doubt
over the degree of risk posed, then the clinical team should err on the side of
caution and consider placing the patient on a raised level of observation until such
time as they are able to make an informed judgement.
4.1.3
Particular care should be taken concerning patients transferred from other
departments, hospitals or agencies. Where a patient has been under an enhanced
level of observation prior to transfer in, then it may be prudent to maintain that level
of observation for an initial period until such time as the clinical team are able to
make an informed judgement based on their own observations. The receiving staff
should ensure that all relevant details concerning potential risk and the level of
observation applied prior to transfer are noted.
4.1.4
In cases where a patient is placed on a raised observation level on admission,
particular caution should be exercised in the initial days following admission
regarding any decision to reduce the observation level.
4.1.5
Intermittent observations or ‘timed checks’ do not contribute to the safety of patients
assessed as posing a risk. They should not be used as a means of meeting a need
for an increased level of observation.
Intermittent observations may be an
appropriate measure to monitor specific aspects of behaviour for those on general
observation levels who are not deemed to pose a risk.
4.1.6
In some cases a patient’s observation needs may be beyond the ability of a
mainstream ward or department to manage, and it may be appropriate to transfer
the patient to the Intensive Psychiatric Care Unit. This decision can only be taken
following discussion by the clinical team.
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4.2
Levels of Observation and the Procedures
4.2.1
The observation status of each patient will be determined following assessment by
the clinical team. The decision will be recorded in the medical and nursing notes
and an appropriate Observation Care Plan will be drawn up.
4.2.2
All patients will be assessed as requiring one of the following levels of observation.
4.2.3
General Observation is the minimum, routine level applied to all patients where
there are no enhanced measures in place. It is intended to meet the needs of most
patients for most of the time and should be an established part of the ward routine
and followed rigorously and regularly as part of everyday practice to maintain the
safety of patients.
4.2.3
Patients on general observation are considered not to pose any serious risk of harm
to themselves or others, and deemed capable of accepting responsibility for their
own behaviour within the limits of their current mental state.
4.2.4
A General Observation Care Plan must be completed for the patient and any
specific limits or interactions set should be determined in conjunction with the
patient and documented in the care plan as necessary.
4.2.5
The staff on duty should have knowledge of the patients’ general whereabouts at all
times, whether in or out of the ward. Particular note should be made at the start
and finish of each nursing shift and at key times such as mealtimes and medicine
rounds.
4.2.6
Each ward or clinical area should have a system in place which supports the
general knowledge of the whereabouts of patients.
4.2.7
Constant Observation is used when the patient is considered to pose a significant
risk to themselves or others.
4.2.8
A designated member of staff must be constantly aware of the whereabouts of the
patient at all times through visual observation or hearing.
4.2.9
The reason for constant observation and the process that will be applied must be
explained to the patient.
4.2.10 A Constant Observation Care Plan must be completed for the patient, stating the
reason for the enhanced level of observation and documenting the specific limits
and interactions to be applied.
4.2.11 The allocation of designated observation duty should be recorded and displayed in
the ward/department office.
4.2.12 A description of the clothing being worn by patients on constant observation should
be recorded on a daily basis.
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4.2.13 Patients on constant observation will be interviewed by nursing staff and have the
appropriateness of their observation level reviewed on a daily basis in conjunction
with medical staff. The outcome and decisions arising from the daily review will be
recorded in the nursing notes. The patient may not necessarily be interviewed by a
doctor each day unless a reduction in the observation level is being considered.
4.2.14 It is essential that a patient’s privacy and dignity is respected, therefore it is not
always necessary to accompany a patient on constant observation to the toilet or
bathroom or whilst they are using the telephone. If visual contact is not maintained
then verbal contact must be and there must be immediate ease of access into the
room they are using. In these circumstances it is preferable if the member of staff
is the same sex as the patient.
4.2.15 Relatives or friends may be permitted to take a patient under constant observation
out of the ward for short periods. This can only happen following consideration by
the clinical team and such decisions must be recorded in the medical and nursing
notes. In these circumstances a clear explanation must be provided on the nature
of the observation level and the expectations placed upon them.
4.2.16 Special Observation should generally be rarely prescribed and is used when a
patient has been clinically assessed as requiring intensive and skilled intervention
as a consequence of their serious mental and/or physical state.
4.2.17 A designated member of staff must have the patient in sight and within arm’s reach
at all times and in all circumstances. In some situations more than one member of
staff may be required.
4.2.18 The reason for special observation and the process that will be applied must be
explained to the patient.
4.2.19 A Special Observation Care Plan must be completed for the patient, stating the
reason for the enhanced level of observation and documenting the specific limits
and interactions to be applied.
4.2.20 When a patient is placed on special observation status, a detailed search of the
patient and their belongings must be carried out to ensure there are no items in their
possession, or readily available, which might be used to harm themselves or others.
4.2.21 The allocation of designated observation duty should be recorded and displayed in
the ward/department office.
4.2.22 A description of the clothing being worn by patients on special observation should
be recorded on a daily basis.
4.2.23 Patients on special observation will be interviewed by nursing staff and have the
appropriateness of their observation level reviewed on a daily basis in conjunction
with medical staff. The outcome and decisions arising from the daily review will be
recorded in the nursing notes. The patient may not necessarily be interviewed by a
doctor each day unless a reduction in the observation level is being considered.
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4.2.24 At this level of observation considerations of safety take priority over privacy.
Consequently, this will require the member of staff to accompany the patient to the
toilet or bathroom therefore courtesy and discretion must be exercised and it is
preferable that the member of staff should be the same sex as the patient.
4.2.25 Under normal circumstances, a member (or members) of staff will not be expected
to undertake special observation duty for more than one hour at a time.
4.2.26 Only qualified staff will undertake special observation duty and an individual will not
be expected to observe more than one patient on special observation at any one
time. The special observation of a patient is the only responsibility of a designated
member of staff whilst allocated that duty.
The member of staff must not be
expected to undertake other duties at the same time.
4.2.27 Should the designated member of staff have to leave special observation duty for
any reason, then they must ensure that the responsibility is passed over to, and
accepted by, an appropriate member of staff and that the change is recorded.
4.3
Changing Observation Levels
4.3.1
In an emergency the senior nurse in charge of the ward may increase a patient’s
observation level without consulting the clinical team but should consult with
appropriate medical staff as soon as possible.
4.3.2
The reasons for such a decision must be recorded in the nursing notes and a new
appropriate observation care plan must be completed.
4.3.3
A reduction to a patient’s observation level must be a team decision and should not
be made without discussion with the senior nurse in charge of the ward and the
patient having been seen by a doctor and, normally, the change approved by a
Consultant.
4.3.4
The reasons for such a decision must be recorded in the medical and nursing notes
and a new appropriate observation care plan must be completed.
4.3.5
Reductions to observation levels over the course of a weekend should only be
made when the circumstances enabling a reduction have been clarified in advance
by the clinical team.
4.3.6
The agreed changes in behaviour that would facilitate a reduction and the specific
procedures to be followed must be recorded in the medical and nursing notes and
the observation care plan.
4.3.7
Otherwise, observation levels determined by the clinical team on a Friday should,
generally, not be reduced until the following Monday, particularly if the decision has
been confirmed by a Consultant.
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4.4
Principles of Care
4.4.1
The observation applied to any individual patient must be set at the least restrictive
level, for the least amount of time within the least restrictive setting.
4.4.2
Enhanced observation should be applied with the understanding and consent of the
individual and staff must endeavour to follow this in practice (refer to appendix 1 –
Notes on Consent).
4.4.3
However, the Trust also has a duty of care to individuals and, in the absence of
consent, staff may apply raised levels of observation if it is assessed that not doing
so would place the patient or others at significant risk. In such cases, it is essential
to consider and put in place the necessary authority to support the action (refer to
appendix 1 – Notes on Consent).
4.4.4
If an informal patient actively resists being subject to raised levels of observation to
the extent that they place themselves or others at risk, particularly in circumstances
where they consistently attempt to leave the ward, then recourse to the provisions of
the Mental Health (Care and Treatment) (Scotland) Act 2003 may have to be
considered if the relevant criteria can be met (refer to appendix 1 – Notes on
Consent).
4.4.5
All patients admitted to a ward must be provided with general written information on
the observation policy and procedures in operation.
4.4.6
Patients subject to raised levels of observation must be provided with written
information on the specific measures being applied to them.
4.4.7
There is no formal appeal concerning observation levels but patients have the right
to discuss formally with staff any disagreements and views they have on the
observation level being applied and, if desired, they can involve someone such as a
relative, friend or someone from an advocacy service.
5.0
Relevant Forms / Documents
5.1
5.2
5.3
5.4
5.5
5.6
5.7
Appendix 1 – Notes on Consent
General Observation Care Plan
Constant Observation Care Plan
Special Observation Care Plan
Patient Information Leaflet (General information for patients and carers)
Patient Information Sheet (Constant specific)
Patient Information Sheet (Special specific)
6.0
References
6.1
6.2
Nursing Observation of Acutely Ill Psychiatric Patients in Hospital (1995)
Engaging People – Observation of People with Acute Mental Health Problems
(2002)
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