- Anthropologists on the Psych Ward: The Gift Economy
- Anthropologists on the Psych Ward (2): Tea Ceremonies
- Anthropologists on the Psych Ward (3): Care Plan Talismans
- Anthropologists on the Psych Ward (4): Timed Checks
- Anthropologists on the Psych Ward (5): Quantum Distortions in Time
- Nursing Research: Is it a load of old wibble?
Since the live chat box on this page has seen a bit of debate on the subject of “timed checks” on psychiatric wards, I think we should bring back our resident anthropologist, Professor Humphrey G Escobar of Miskatonic University. He was kind enough to take a break from his extended fieldwork in the brothels and coffee houses of Amsterdam to speak to us.
Professor Escobar writes:
Let us consider the following scenario.
A patient has begun responding to command hallucinations telling him to light fires. This has caused an incident where he set light to a small pile of papers in his bedroom. Because of this, the nurse-in-charge decides to put him on 15 minute timed checks. This requires a member of staff to check on his whereabouts every 15 minutes.
Before we analyse further, a bit of background information. Timed checks are part of an escalating series of observation levels that mental health nurses can use in order to keep a close eye on patients who may be a risk to themselves or others.
The levels are usually as follows:
General observations – The patient is on the ward with no particularly structured set of observations. He’s there. The nurses are there. Hopefully they might say hi to each other.
Timed checks (also known as intermittent observations) – a nurse or healthcare assistant will check up on the patient at regular intervals, usually every 15 or 30 minutes.
Close or constant observations – A member of staff must keep the patient in his or her line of sight at all times.
Special observations – a member of staff must keep within arms-length of the patient at all times.
Now let us return to our patient who is lighting fires. He is checked every 15 minutes. This leaves the rather obvious objection that in 14 minutes and 59 seconds, the entire ward could be a raging inferno. Common sense would therefore dictate that he is either liable to start lighting fires, in which case he should be at least on close obs, or he isn’t, and should be on general obs. There doesn’t seem to be any practical use in this case for timed checks.
So why does the nurse do it?
The answer lies on the practical real-world domain, but in the domain of abstract quality as they are applied to events and intentions. The abstract quality being invoked is that of having “done something”. This is rather like the quality of a piece of wafer in the Catholic mass changing to being the Body of Christ, even though to all intents and purposes nothing has changed. Likewise, the chances of the patient lighting a fire are virtually unaltered, but the nurse has acquired the abstract quality of having “done something”.
I recently invoked this same quality when dealing with my wife. She was annoyed with me for giving students extra credits in exchange for permitting me to carry out acts of bukkake on them. She felt this was poor practice as both a lecturer and as a husband. I therefore invoked the quality “done something” by offering to finally getting around to clearing out the garage.
I must confess it didn’t work. I believe her last words to me were, “I’ll see you in the divorce courts, you unprofessional, perverted freak.” Oh well, looks like I’m single again. Who’s up for a creamy shower, ladies?
Hey, who’d have thought I would, again, learn something from the Mental Nurse site. This time it isn’t quite related to nursing. Bukkake. Nice. Thanks Prof!
Do many units still use timed checks?
The last 3 I worked in didn’t, for 3 main reasons :
1) They don’t work. As you said, they can assess risk at one point in time then leave oodles of time without mitigating risk. Either it’s worthy of observation or it isn’t, episodic 15 or 30 minutes observation generally isn’t useful (and good nursing evidence supports this view that it’s ineffective).
2) They disempower the patient. It’s now nursing staff who take ownership of the risk, not the patient. Sometimes that’s necessary (e.g. in some psychotic patients). Most of the time patients aren’t going to be on the ward forever so, when discharged in the community, they’ll have to contain and manage risk largely by themselves . . . best foster that on in-patient units too then. Let ‘em take some responsibility for not hurting themselves or lashing out at others, and if they do get thoughts/feelings of that then approach a nurse for assistance in de-escalating risk if they can’t do it themselves.
3) They don’t work. Really. Another reason for not working is that folk see risk as “managed” because there are regular observations, reducing an index of suspicion and vigilance that would otherwise be present.
PS : Why doesn’t his post have any tentacles?
Pads out the notes though, don’t it?
Shrink
The tentacles will return.
A similar thing applies to assessment scales. We employ one called PANS (Positive and Negative symptoms of psychosis) which takes the form of a structured or semi structured set of interview questions followed by a rating scale which gives you a score for positive, negative and general symptoms of psychosis. The nurse consultant in our team is adamant that the questionnaire be read to the patient exactly as it is written rather than used as part of an informal interview technique because she says this improves inter assessor reliability.
The reliance on PANS to me seems to be an attempt to quantify the un quantifiable and fulfils the same purpose as a care plan talisman as well as the need to have “done something. In my opinion Assessment scales and risk assessments very quickly become a substitute for, rather than an aid to professional judgement and are generally not worth the paper they are written on.
Generally I find if I’m using a mini-mental or whatever scale then I find reading back through the answers and looking to see what was got wrong or right is more important than the number at the end.
I think you should demand that it should be renamed Positive and Negative Treatable Symptoms, if only because that would give you the acronym PANTS.
On the ward I work in (in Australia) one nurse religously fills out what are essentially ticky boxes on sticky paper for each patient depending on their obs level -the options are 15/60, 30/60, 60/60 and general (3 times per shift). At the end of the shift it gets stuck in the patients chart. Pointless- definately. Apparently it was the result of a coroners decision. It’s pointlessness is only exceeded by the invalid and unreliable suicide and aggression ‘risk screens’ we fill out. They just give management data to put in graphs.
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