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