Mental Health Nursing

172 Acute Mental Health Nursing
Special Observation. As well as the difference in the number of levels of
observation recommended, and the terminology used, a further variation
between the two practice statements is that the SNMAC guidance recommends
the use of intermittent observation, whereas the CRAG/SCOTMEG guidance
does not. This difference is a significant one, and represents differences
in opinion amongst many mental health practitioners regarding the
usefulness of intermittent observation, which involves the regular checking
of patients’ whereabouts at timed intervals (e.g., every 15 or 30 minutes).
Intermittent observation can be seen as being less intense and less intrusive,
particularly when the intensity of observation is being reduced.
However, there are a number of negative concerns regarding such
‘timed checks’. These focus on the view that the use of intermittent observation
is unsafe, because an individual can carry out risk behaviours during
the gaps between observations, and that this therefore does not fulfil the
purpose of observation. It seems likely that the revised Scottish guidance
will continue to not recommend the use of intermittent observation in the
revised guidance document. Such concerns are also highlighted in the Safety
First report (DoH, 2001), which reported that 18% of all in-patient suicides
occurred when patients were being observed at intervals of 5–30 minutes.
The report states that ‘intermittent observations, in particular, are of unproven
benefit even when they are carried out properly’ (p. 146). The report
recommends that patients who are at present placed under intermittent
observation should be under continuous one-to-one placement, or that
alternative approaches should be adopted such as having areas of the ward
being constantly observed or the ward exit. However, it should be noted
that the effectiveness of such alternatives are also unproven.
The decision-making process
Both the SNMAC guidance and the CRAG/SCOTMEG good practice statement
recommend that, wherever possible, decisions about observation
should be made jointly by the multidisciplinary team. Such a decision
should be based upon an assessment of risk, using an evidence-based risk
assessment tool, a consideration of the patient’s history and an interview
with the patient and his/her carer or advocate (as requested by the patient).
Decisions regarding observation are made at various stages of the procedure:
whether or not observation is required; on which level of observation
to place a patient; whether to either increase or decrease the intensity
of observation; and when to terminate observation. These decisions should
also be reviewed regularly. The SNMAC guidance recommends that a
patient’s observation status should be reviewed by a doctor and the primary
nurse or ward sister/charge nurse every day (including weekends). For the