Engagement and Formal
Observation.
Trust Policy, History, Context and
Interpretation
Engagement and Observation Policy
2014 Historical overview
Original policy written in 2002. Policy consultation process took
place across the Trust (service users, carers, staff, managers)
New Policy written July 2005, reviewed 2007 policy standards
added, training powerpoint, and competency document. Reviewed
2011 (NHSLA)
Move away from `Observation` to `Engagement`.
2014 Currently being reviewed in light of Professor Len Bowers
findings and the implementation of the Care Delivery System
(SLaM).
Engagement and observation
what the original policy said…..
Reasons why nurses find enhanced observation difficult
Reasons why patients find enhanced observations difficult
Factors related to these:Environment
Clinical Skills/ Clinical Leadership
Availability of structure/ activities/ alternatives
Clinical supervision
Boundaries
Expectations
Changes Made….
1. Intermittent observations can only be instigated when
reducing levels of observations from an enhanced
status.
2. Senior Nurses to be included in the rota for enhanced
engagement of patients.
3. Visual Handover of patients to take place from the shift
co-ordinator to the shift co-ordinator on each shift
change.
4. Caringly Inquisitive Behaviour by nurses
5. Intentional Rounding
Rationale for the changes made in
the original policy:- Number 1
A number of incidents had occurred within the trust on in patient
wards
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•
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Attempted suicide
Suicide
Self Harm
An audit of all Board Level Inquiries was completed during 2004/5 and any
incidents where patients were undergoing `special observations` as they
were called then were reviewed.
Many of these incidents occurred whilst patients were undergoing ` 15
minute checks`. Move away from 15 minute checks as patients were
able to monitor this quite easily and commit acts of self harm and
suicide.
Rationale for changes…Number 2
• Patients who are in need of the most skilled nursing, the most unwell
patients are often being cared for by the most junior staff, or by staff
who do not know them very well, resulting in limited social or
therapeutic conversations.
• Patient experiences of enhanced observation described as
dehumanising and distressing. (local and national evidence) Some
nurses would just sit and read a newspaper, would not talk to the
patient, no engagement at all.
• Ward managers, deputies, practice development nurses, and
other senior nurses will be on the rota for the observation/
engagement with patients.
Encourage role modelling and reflection on practice during the shift.
Rationale for changes…Number 3
• During the review of serious incidents in 2004/5 we found that many
of the most serious incidents where patients had harmed
themselves or committed suicide were taking place during the
handover period between 1-3p.m.
Very few qualified nurses were actually on the ward with the
patients.
• RMNs were sometimes in the office for a couple of hours before
actually seeing a patient, sorting out paperwork, answering the
phone, many administrative tasks.
• At the beginning of every shift it will be the responsibility of the
nurse in charge to carry out a visual handover to the nurse in
charge of the next shift, of all the patients on the ward, also the
whereabouts of the patients on leave.`
Number 3…..Visual Handover
This is about ensuring that nurses are clear about their
level of responsibility when taking over a shift. To know
how their patients are, and where they are.
This does NOT replace the verbal handover, but will
need to be locally implemented.
`Intentional Rounding`- term used by David Cameron to
encourage senior nurses to visually see and monitor
patients every hour.
Reassuring for the patients and the Nurse in Charge to
be visible at the beginning of the shift.
Intentional Rounding & caringly
inquisitive behaviour in the
policy….
Communicating with someone, assessing their mental well being, Being
present, helpful, listening, and supportive
A service which is experienced by service users as acceptable, accessible
and helpful.
Encourages nurses to be curious and seek out patients who are not
attending routine activities, such as groups and meals.
Acknowledges and respects individuals autonomy, identity, strengths and
viewpoint.
Attends to wider social needs and aspirations, cares about a person`s `well
being`
Changes in Documentation..
Observation record
Observation care plan
Epjs Observation care plan
Visual Handover recorded on the handover record
sheets (some areas completing this now)
Records kept locally of completion of Engagement and
Observation competency document, and completion of
training.
Current records of intentional rounding to inform ward
staff about patients views.
Intermittent Observations…
Patients tolerate intermittent observations better than
within arms length or within eyesight observations, and
every attempt should be made to reduce levels of
observation from within eyesight and within arms length
to intermittent as soon as possible.
Engagement with the patient should take place
approximately four times an hour, but at irregular
intervals, trying to avoid 15 minute checks.
Named levels of observation
Within arms length
Within eyesight
Intermittent
General
Process of reviewing observation
levels..
MDT ( Doctors and Nurses)
Reviewed on each shift.
Changes to levels of enhanced observations can take
place when the risk factors have been reduced. This has
to be completed and recorded prior to change of status.
Senior clinicians involvement, expertise, advice,
presence on the ward.
Encouraging for junior staff and for patients.
Senior Nurses
Ward managers, deputies, practice development nurses,
and other senior nurses will be on the rota for the
observation/ engagement with patients.
Encourage role modelling and reflection on practice
during the shift.
Reviews of all patients on enhanced levels of
observation with Doctors and Nurses.
Resources….
• Multi disciplinary presence on the wards at key handover times,
review meetings and community meetings.
• Care Delivery System being rolled out across all in patient wards.
• Review structures/ activities on the wards. How many patients have
a structured activity programme, and how is this maintained.
• How are the social areas used to their full advantage
• Benefits of skilled activity co-ordinators.
• Use of training resources/role plays/ facilitated reflection sessions
• Clear philosophy on each ward stating expectations of staff and
patients related to specific behaviours.
• Nurse Consultant. Supporting Safe and Therapeutic services… how
often is this resource being used.
Current policy review includes….
1. Adding Caringly Vigilent Behaviour by nurses
2. Adding Intentional Rounding
3. Changing the use of Intemittent Observation.Use at any
point during the patient admission rather than as a
reduction from more enhanced observations.