Patient Assessment and Monitoring

Identifying patients at risk to injure themselves or others, and thereby ensuring this does not occur, is a primary outcome of nursing interventions. Therefore, assessment and monitoring are key components to safety. Nurses must be out in the milieu providing them opportunities to make assessments based on increased interactions over time with patients. The patient risk assessment must be conducted within a relationship based on engagement identifying risk factors, particularly those risk factors which can be modifiable through treatment. There is a long history in psychiatry of using “observations” to monitor patients at risk to prevent untoward events from occurring. Intermittent observations are used to monitor patients at a specified frequency, whereas constant observations are used to monitor patients continuously. Recently, there has been increased concern regarding the therapeutic value of these practices and if they do establish safety. These prescribed “observations” are often implemented in a mechanical manner; hence they must be implemented in a relationship based on engagement. Finally, nursing staff must be out in the milieu for engagement to occur. The following articles highlight areas of concern regarding assessment and monitoring.

Predicting suicide following self-harm: systematic review of risk factors and risk scales
Chan, M., Bhatti, H., Meader, N., Stockton, S., Evans, J., O’Connor, R., . . . Kendall, T. (2016). Predicting suicide following self-harm: Systematic review of risk factors and risk scales. British Journal of Psychiatry, 209(4), 277-283. doi:10.1192/bjp.bp.115.170050
“Twelve studies on risk factors and 7 studies on risk scales were included in this study All of the tools reviewed had a low positive predictive value (PPV) and significant numbers of false positives. The authors assert that it is a false assumption to use risk assessment scales to predict risk. Rather, risk assessment must be conducted during a thorough evaluation.”

Safety in psychiatric inpatient care: The impact of risk management culture on mental health nursing practice.
Slemon A., Jenkins E., Bungay V. Safety in psychiatric inpatient care: The impact of risk management culture on mental health nursing practice. Nursing Inquiry. 2017;e12199 https/10.1111/nin.12199
“This article describes the culture of risk management in psychiatry in which nurses must exert control to diminish the risk of untoward events from occurring. This has created an environment in which intervention are implemented as a defensive manner to mitigate risk. The articles then describe that many of the interventions used currently in psychiatry have their origins from the asylums of the 1800s in which patient units were locked, if patients were at high risk to injure themselves or others they would be restrained, secluded or placed on a constant watched. These interventions were designed to control patients to create safety and there are little differences regarding how they were implemented then and now. “

Constant Watching of Suicidal Cases
Savage, George (1884). Constant Watching of Suicidal Cases’ The British Journal of Psychiatry, Vol. 30, 17-19
George Savage, the Superintendent of Bethlem Asylum and editor of the British Journal of Psychiatry, first wrote about the concerns of constant observations in 1884. He described that these observations were used to reduce the risk of suicide and blame that the asylums did not do enough to prevent suicides. He also wrote how constant observations created increased stress, paranoia and agitation in the patients watched and that these patient’s conditions would improve if not watched so closely. These same concerns are still currently expressed.

National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (NCISH). In-patient Suicide Under Observation
Appleby, L. Kapur, N., Shaw, J. Windfuhr, K. Williams, A. Flynn, S…. Tham, S. (2015) National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (NCISH). In-patient Suicide Under Observation. Manchester: University of Manchester

“This article describes a 6-year study in the UK of inpatients being monitored on intermittent observations or continuous special observation (CSO). The study revealed the current observation levels are not working. Interventions based on engagement must be incorporated into the treatment of high-risk patients. The study describes the problems associated with CSO. They are intrusive and restrict the patient’s privacy. They increase agitation in the patients watched and place the staff watching them at risk. The study describes the problems with how CSO is implemented. Staff do not always observe the patient. Staff implementing the procedure are often the least trained and unfamiliar with the unit. Staff do not engage the patient which eliminates the therapeutic value of CSO. The authors emphasize that alternative interventions need to be developed and specifically recommended the interventions described in the Safewards model of conflict and containment.”

Safewards: a new model of conflict and containment on psychiatric wards
Bowers (2014) Safewards: a new model of conflict and containment on psychiatric wards Journal of Psychiatric and Mental Health Nursing, 21, 499–508
“This article explains a model which describes the nature of why conflict (aggression, rule-breaking self-harm) happens on units and staff interventions which are sometimes based on containment (time-outs, forced medications, seclusion, constant observation etc.) The model portrays a dynamic relationship between conflict and containment interventions. Containment interventions often lead to more conflict behavior. The model illustrates six domains where conflict can rise: the staff team, the physical environment, outside hospital, the patient community, patient characteristics and the regulatory framework. The model shows that staff can reduce both the occurrence of conflict and the resulting containment measures by engaging the patient in coping with the original problem which rests in one of the six domains. An important concept of the model is the staff must intervene early to prevent conflict occurring in the first place. Staff must not only know the patients they are working with but also be present in the milieu to provide timely interventions.”

How do PICU nurses spend their time? A pilot study
Haw C., Kotterbova E. (2016) How do PICU nurses spend their time? A pilot study. Journal of psychiatric Intensive Care 12 (1) 19-26

“This article describes a research study in which nurses were observed while they worked. Each activity was timed and assigned to one of seven main categories. Nurses only spent 30% of the time in direct patient care with 12% of this time involving medication administration. Nurses spent only 1% of their time in individual 1:1 sessions with their patients. The authors concluded that nurses need to spend more therapeutic time with their patients.”

A modified grounded theory study of how psychiatric nurses work with suicidal people.
Cutcliffe, J. R., Stevenson, C. Jackson S., Smith P., (2006) A modified grounded theory study of how psychiatric nurses work with suicidal people. International Journal of Nursing Studies (7) 791-802.
“This article describes a research study to examine the effects of nursing interventions on patients who have recently attempted suicide. The authors believe that nursing care in psychiatric units is often associated with the mechanical process of observations and wanted to determine what nursing interventions, if any, were helpful to patients who experienced suicidal thoughts. The authors conducted semi-structured interviews on twenty patients who had recently attempted suicide and analyzed the data using modified grounded theory. Results indicate that patients with suicidal thoughts have become “disconnected from humanity” and the nursing interventions “re-connects the patient back to humanity.” The authors describe depressed patients as having unresolved psychosocial issues which are perceived by the patient as overwhelming. These persons feel that no one can understand their problems and eventually come to believe that they are a burden on others. As a result, they withdraw from others and have the perception that their life has no value and no one cares about them. They become “disconnected from humanity.”
The nurse helps the patient “reconnect back to humanity” through establishing a warm, supportive, nonjudgmental relationship based on acceptance. The most important aspect of the nursing interventions is demonstrating care and concern about the patient. One of the most important interventions to demonstrate care is just being with the patient. The nurse spending time with the patient demonstrates they care about the patient and will not abandon them. This caring relationship inspires the development of hope. Through this relationship, the patient discovers that they can connect with another human. The nurse acts as an ambassador in reconnecting the patient with humanity”

The Evolution of Practice Changes in the Use Special Observations.
Ray, R., Perkins, E., Meijer,B. (2011) The Evolution of Practice Changes in the Use Special Observations. Archives of Psychiatric Nursing. 25 (2), 90-100.
“This article discusses adverse effects of Continuous Special Observation (CSO) and two alternative nursing protocols designed to treat high risk patients. The first protocol, Psychiatric Nursing Availability (PNA) is designed to treat patients having suicidal or self-injurious thoughts. This protocol emphasizes developing a relationship based on engagement and making staff available for the patient to discuss distressing thoughts or impulses. The second protocol, Psychiatric Monitoring and Intervention (PMI) which is also based on engagement is designed to prevent violent and impulsive behavior. The patient is allowed privacy in their room. In the day room, staff support the patient with impulse control.”

The Impact of Nursing Protocols on Continuous Special Observation

Ray, R., Perkins, E., Roberts, P., Fuller E. (2017) The Impact of Nursing Protocols on Continuous Special Observation Journal of the American Psychiatric Nurses Association 23 (1) 19-27.
“Two nursing protocols were developed as alternatives to Continuous Special Observation (CSO). The first protocol, Psychiatric Nursing Availability (PNA) is designed to treat patients having suicidal or self-injurious thoughts. The second protocol Psychiatric Monitoring and Intervention (PMI) is designed to prevent violent and impulsive behavior. The authors conducted a nine-year descriptive retrospective analysis of CSO, PNA and PMI. Results demonstrated PMI had the greatest impact. Both protocols had a secondary effect of increasing staff availability on the unit which may have increased safety and reduced CSO use. The authors eliminated the use of CSO for violent patients or patient behaviors which disrupt the entire unit. These patients become more symptomatic and agitated when watched at all times and their behaviors do not impact others when they are alone. These two protocols place the staff out on the milieu available not only to the person on PNA/PMI but also to the rest of the patients on the unit. PMI interventions are focused on the entire unit milieu and patients may view these interventions as caring. Caring interventions are associated with hope which might also increase unit safety. This study reinforces when nurses take an increased role in unit decision making, there is a reduction in CSO. “

Failure of the Capacity for self-soothing in women who have a history of abuse and self-harm.
Gallop, R. (2002) Failure of the Capacity for self-soothing in women who have a history of abuse and self-harm. Journal of the American Psychiatric Nurses Association, 8, 20-26

“The article reviews the purpose of self-harming behavior. It describes the development of the person’s sense of self (according to Winnicott) and the effects that trauma can have on it. The author discusses the neurobiological impact of trauma. The abuse survivor experiences intense emotions as a result of the abuse and how they often exhibit panic, anxiety, dissociation, and somatization. The author describes how emotional pain is experienced as worse than physical pain and the abuse survivor’s only coping skill is to self-injure. The article describes the adverse consequences of using containment procedures, such as observations. The authors state, “If the focus of nursing care is to stop the self-injury then the self-injury becomes the battleground.” (Page 25). The author describes that the patient’s impulse to self-injure may lead the nurse to use forced medication or restraints. This recapitulates the trauma. Finally, the author describes the nurse’s role in helping the patient cope with the physiologic and emotional symptoms caused by the abuse, emphasizing the importance of engagement when working with those who self-injure, as well as demonstrating that the nurse understands how real the emotional and physical pain the patient experiences is. “

From task to intervention: rethinking mental health observation practice in Scotland.

Mark Gillespie and Samantha McEwan (2019) From task to intervention: rethinking mental health observation practice in Scotland. British Journal of Mental Health Nursing 8:1, 28-33
“This article describes problems related to constant observations. How these observations are designed to prevent patients deemed at risk to harm themselves from doing so. However, the authors point out that most patients who do commit suicide on inpatient units were deemed to be at a low risk and were monitored less frequently. Observations were described as awareness checking and had no therapeutic impact on the patients yet these observations were implemented in response to patient crisis. The authors discussed nursing interventions based on patient specific needs which provided nurses direction with patient care. Of importance, these nursing interventions led to a greater presence and visibility of nursing staff. Because of the increased visibility of the nursing staff and proactive interventions, patients at higher risk were more easily identified and supported resulting in a reduction of constant observations”

The Impact of Milieu Nurse–Client Shift Assignments on Monthly Restraint Rates on an Inpatient Child/Adolescent Psychiatric Unit

Magnowski, S. R., & Cleveland, S. (2020). The Impact of Milieu Nurse–Client Shift Assignments on Monthly Restraint Rates on an Inpatient Child/Adolescent Psychiatric Unit. Journal of the American Psychiatric Nurses Association, 26(1), 86–91. https://doi.org/10.1177/1078390319834358

“This article describes a research study on a 20-bed unit in which one of three nurses was assigned to be the “milieu nurse.” This nurse’s role was to provide cognitive milieu therapy and nurse presence. The other two nurses would provide the individual care for their patients. The Authors found that this intervention significantly reduced the use of restraints. They believe the milieu nurse provides the ability for consistent structure, providing early identification and intervention of crises.”

Evaluation of an alternative model for the management of clinical risk in an adult acute psychiatric inpatient unit
Harrington, A., Darke, H., Ennis, G. and Sundram, S. (2019), Evaluation of an alternative model for the management of clinical risk in an adult acute psychiatric inpatient unit. Int J Mental Health Nurs, 28: 1102-1112. https://doi.org/10.1111/inm.12621
“The authors describe a new model of care in which patients who would have been placed on intermittent observations would receive intermittent engagement contacts based on a risk assessment. Engagement was defined as direct interaction to assess mental state and risk. The contact nurse in collaboration with the team would complete an initial comprehensive assessment and determine the frequency of engagements that shift. The frequency of engagements could change throughout the shift based on any changes in the assessment. The new model was associated with significantly reduced rates of absconding and seclusion however rates of aggression, deliberate self-harm, and sexually inappropriate behavior were non-significantly decreased.”