But…
Thanks to Writing In The Margins of my Mind for pointing out an interesting journal article, The doctor–nurse relationship from the journal Advances in Psychiatric Treatment. It’s a thoughtful piece on the differing roles of psychiatrists and mental health nurses. One particular comment resonated with me.
Daily decisions such as agreeing to a patient’s leave or the need for close observation are rarely delegated to nurses, even though in these areas doctors may have no more knowledge than their nursing colleagues. If anything, they are probably less able to make appropriate judgements because of their more distant contact with in-patients, and yet deference is paid to their ‘expertise’.
Current pilot studies delegating some of these responsibilities to nurses have shown no major difficulties, and have in fact reduced the need for expensive close nursing observations and reliance on agency staff (T. Reynolds & L. Dimery, personal communication, 2003).
The question of who should set close observations is something I’ve discussed with colleagues on the ward.
Well, I say discussed. I mean ranted. At length and high volume.
On our unit close observations are set by the doctor. A nurse can place a patient on close obs if he or she sees fit, but this then has to be discussed with the consultant, and it’s the consultant who decides when the patient is taken off the close observations again. If there’s a disagreement between the nurse and the consultant about whether the patient should be on close obs, it’s the consultant’s opinion that has the final say.
The decision of whether somebody should be on close observations is one that requires no special knowledge of anatomy, physiology, diagnostics or pharmacology. It does however, require knowledge of an individual patient, their mood and likely behaviour. The sort of knowledge that can only be built up by spending a large amount of time with them. It’s also an activity that is only ever carried out by nursing staff. Doctors don’t perform close observations.
Common sense, therefore, would suggest that the best person to make the decision should be the nurse-in-charge of the ward. Or, if one really must devolve to a higher power, the ward manager.
This isn’t just me having a moan about professional turf boundaries. I’m convinced that having close obs set by the consultant leads to a lot of bad decisions. Regularly on my ward I see patients on close obs who don’t need to be, and ones who the consultant has refused to put on close obs who should be.
If a patient is on close obs unnecessarily, then their privacy and dignity is being infringed for no good reason. I wouldn’t want to have my every moment – when I’m sat in the lounge, when I’m changing my clothes, when I’m using the toilet – being watched like a hawk by a nurse. It also takes a nurse away from helping to care for the other patients on the ward.
Even worse, if a patient is presenting a serious risk to themselves or others, and the consultant has insisted that they should not be on close obs, then that risk is not being addressed. You can put them on intermittent observations (aka timed checks) but as our resident anthropologist has pointed out, intermittent obs do little if anything to reduce risk. If a nurse is checking on a patient once every 15 minutes, then that patient is more than capable of hanging themselves, setting fire to the ward or beating up another patient in the intervening 14 minutes and 59 seconds.
Both inappropriate use of close obs and a failure to use close obs when necessary happen regularly on my ward, and all because an entirely nursing intervention, which the nurse is best placed to judge the need for, is regulated by the consultant due to an entirely misplaced “doctor knows best” attitude.
I agree. I have seen the nursing team decide that a patient should be on close observations, but to take them off requires a consultants signature. I’m not sure who would actually notice that the patient is no longer being watched before the paper is signed, but I know time is wasted trying to track down the consultant for a signature – for example, the consultant is….. um, consulted and agrees it is no longer necessary but forgets to sign a bit of paper, resulting in nurses hunting him/her down.
I have similar experiences with time out. The nursing team believe the patient would benefit with time off the ward, reducing the likelihood of becoming institutionalised, yet the Dr believes it is too soon.
It comes down to how well the Dr respects the nurses opinions I find, and there are a few who just don’t (Dr knows best), but plenty that listen to the people who spend the most amount of time with the patient.
The issue is even bigger – when you consider the lack of evidence to back close observations as an effective intervention.
Last in-pt unit I was on we had a good system. If a nurse put them on – the nurse could take them off – senior nurse on duty, much like seclusion (tho that was limited to 10 minutes – after which a medic had to be consulted and rightly so).
If a psych put the obs on – then they were responsible for removing them. Not only is it a legal thing – but it’s courtesy.
If there’s a concern or if the obs go for longer than a day or two – there’s MDT consult – tho usually limited to nursing/medical teams.
A consultant can determine that no increased obs are necessary… that’s their prerogative. If we felt otherwise, we’d still do it. And we’d arrange the extra staffing too. Our nurse managers were not only supportive but insisted we worked to our decision-making level.
I still advocate that on times medical input is warranted – or perhaps I might term that better as ‘objective’ or ‘single point decision making’ input – so a nurse manager who is insular and not “in” the moment can review equally effectively as a medic.
Single point maintains consitency. So often nurses decisions are made on emotive reasoning – and it is fallible if a nurse decides (eg) they’re just ‘attention seeking’ and don’t want to feed the behaviour and removes the obs level – leading to more attention seeking behaviour that ends in a realised risk.
Similarly, objectivity allows for a wider review of the circumstances.
The only difference between a nurse manager and a medic making the call tho is the medic will remain clinical/political influenced and the nurse clinical/financial/logistical influenced.
Ah – observations. Something proper, down home, basic psych nursing meat and drink to talk about.
Personally, I don’t think nurses should wait for medical say-so if they want to stick someone on a higher level of obs. Just do it and if the medics moan, so what? Who cares? Nobody is going to haul you over the coals for being concerned with a patient’s safety.
The difficulty comes when deciding who should be responsible for downgrading obs. I was part of a pilot in which senior nurses on the ward were able to suggest downgrading, and it worked just as well as having docs do the deciding, despite some anxieties.
However, it should be noted that observations are, as Mr Ian says, not terribly effective. Phil Barker talks about changing the emphasis from observations to engagement, as its unlikely that sitting and staring at someone for hours on end is going to do anything to ameliorate the problems that have landed them on close obs in the first place.
Kev Gournay found, way back in 99, that there was no national observation policy which standardised the use of such terms as “close obs” or “continuous care” or “level 4 obs”, all of which mean the same in different parts of the country. Ten years later, this has still to be resolved. Perhaps such a policy could delineate once and for all the responsibilities of the various players in the observations game.
Perhaps such a policy could delineate once and for all the responsibilities of the various players in the observations game.
And that’s the very reason they won’t.
I think I read the Barker stuff – or something of that ilk. What is apparent from my own observations is that many nurses just don’t seem to know how to engage a patient – either in a clinical, social or purely entertaining way.
I’ve seen a number of nurses doing special who were hit ….. they usually didn’t see it coming cos they had the newspaper in front of their face at the time.
I’ve seen a number of nurses doing special who were hit ….. they usually didn’t see it coming cos they had the newspaper in front of their face at the time.
I think we could file that under the category of “pretty much asking for it”.
My opinion is that close obs should only be used in an attempt to ameliorate potential harm to the patient, either through suicide or disinhibition. Aggressive and violent patients? Well, you’re just providing them with a handy target, there are other ways of dealing with it.
Given that the purpose of obs is to prevent harm to the patient, the person carrying them out should be very skilled in engagement, which is sadly not often the case as the job gets delegated to the most junior staff members or even agency staff of varying degrees of crapness. Where I worked, we’d book the agency cabbage, but we allocated close obs to a team of permanent staff nurses to do in rotation, while the agency was allocated to the less acutely unwell patients on the ward.
I would hope (but know it doesn’t always happen) that nurses would be able to judge whether the patient is able for engagement as it isn’t always a good option on close obs, but can be brilliant in certain circumstances, rather than just staring!
We would be in serious trouble if a magazine/book/paper was being read when on obs.
Also, where I have worked, the person on the obs is rotated regularly amongst registered nurses and the nursing assistants. The new or inexperienced NA would not be asked. Again, it’s a judgement call, if the staff member was engaging with the patient in a constructive or helpful manner, they wouldn’t have to leave because the clock had hit the hour.
The plan should be individualised care.
Finally, in answer to the query about the bath, a female would be asked, but would not sit and stare at the patient in the bath, probably be side on to them to allow some privacy.
I still think that if a nurse can put a patient on close obs, they should be able to decide to take them off it as well.
Do male nurses still get to watch, sorry observe, female patients having a bath, like they used to, while other staff wrote stuff in the notes about the patient being reluctant to have a bath but forgot to mention why?
I do hope this particular and uneccessary indignity no longer happens.
No, that would normally be done by a female member of staff.
Not only would that be a violation of the patient’s dignity, but it would also expose the male member of staff to all kinds of allegations.
Although, even if I were being observed by a female staff member, I would still absolutely refuse to bathe under observation.
Z said: “No, that would normally be done by a female member of staff. Not only would that be a violation of the patient’s dignity, but it would also expose the male member of staff to all kinds of allegations.”
It wasn’t uncommon on a PICU in South London not so long ago. When was it “outlawed”, if that’s the right word?
Jessa, I meant to ask you, do mental hospitals in the USA have mixed sex wards like most of the NHS hospitals in the UK? If so, are female patients protected from any sexual predators they might otherwise be expected to socialise with, or warned in advance of anyone it might be best to avoid? I have known so many women over her who have been sexually harassed or molested or worse, only to be advised, when they complained, that they had to remember the men were mentally ill, or else the were told it was their own fault. (I am aware that women can be sexual predators too and that sex on acute wards can be consensual, although the setting is often far from romantic, and usually involves a bathroom or toilet.
Sorry if this is a bit off topic, but what are nurses who happen to observe or be aware of inappropriate behaviour between the sexes supposed to do?
It’s never been outlawed per se, just that it’s something that would be considered very poor practice.
Personally, if I was asked to special a female patient having a bath, I’d simply refuse. Apart from anything, I’d be very worried about what kind of allegations could be made against me due to being alone in a private room with a naked, mentally disordered female patient.
As for the question of sexual predation, if it were to happen on my ward, I’d look to get the predator moved to another ward. If that wasn’t possible, I’d put him on close obs.
From my experience in US mental health care, wards are always mixed. I’ve spent about half of my inpatient time on eating disorder specific or self-injury specific wards, though, where the population is predominantly female, at least when I was there. Bedrooms are single sex, though. In just plain old hodgepodge acute wards, the gender mix has been more equal. I’ve never encountered the sexual predator problem as far as I know, although it is entirely possible that I simply wouldn’t have noticed.
Background: Things happened to jessa that all mental health care professionals have called “sexual abuse” but jessa objects to the term. All the same, these things did impact jessa in ways that sexual abuse might impact someone. Jessa is 24, she does not date, she does not want to date, she thinks of herself as asexual (as in “not sexual”, not as in “autonomously reproducing”), she would like her uterus removed because she does not like it when her uterus reminds her of its existence. Jessa simply does not do nudity. Yes, this has caused some problems in mental health care.
Though I haven’t been on one-to-one, which is how I hear of close obs, strip searches have caused me difficulty. Once, I gave in and sobbed for hours and all the nurse said was, “now that wasn’t so bad was it?” when it quite obviously was so bad. The rest of the time I did not give in and the nurses would say things like, “If you don’t want to be searched, you need to keep yourself out of the hospital,” or, “I could lose my job if you don’t let me search you.” In some places, it has also been standard practice to keep the bathrooms locked and I had to keep the door ajar while a staff person sat outside. I was able to tolerate this for going to the bathroom, I would drape things around me, but I just didn’t bathe.
That was all tangent, sorry; obviously I have some axes to grind.
“We would be in serious trouble if a magazine/book/paper was being read when on obs”
I have had to kick people when they have started snoring whilst on constant obs before. Usually the patient is so bemused by this they don’t bother to make full use of the opportunity, luckily.
Otherwise, our system is pretty much as Mr Ian says. It never really occured to me that they should always be done by a doctor, because there is almost never one around when the decision needs to be made. On the odd occasion a female is placed in seclusion (which is on a male ward) the staffing ratio is changed so that there is always one female member of staff on. Usually female staff do female constants, but male patients tend to get watched by anyone (dependant on risk, obviously).
It is extremely disconcerting being stared at or snored at but I imagine it must be quite difficult to judge the kind and amount of engagement a patient under observation would appreciate because each individual is different. As for newpapers/ magazines etc a lot of nurses do seem to spend a lot of time reading them on the wards when they’re not actually observing anybody specifically.
I find Z’s answer about putting predators on close obs, if it is not possible to move them to another ward, reassuring. I remember being encouraged to go for walks in the grounds with the bastards and then being too scared to protest when I was dragged into the bushes, but that was when date rape was still known as free love.
Sexual predation would be a trigger for referral to PICU in my opinion. Moving them just to another ward would likely just move the problem to other women/men on those wards. PICU has the staff to manage it more effectively.
Here’s a story pertinent to this discussion
http://www.psychminded.co.uk/n.....rse002.htm
That story shows why, in my opinion, intermittent observations are simply a waste of time. Even if the the staff had properly observed the half hourly obs, the intervening 29 minutes and 59 seconds would have been more than enough time for the patient to kill himself.
Intermittent obs should, in my view, be intermittent in the sense that the time between observations should not be predictable by the patient for that very reason. So, between 5 and 15 minutes. However, I think intermittent obs are generally there as a sop to the anxieties of the nurses and doctors than anything else, sort of like a staging post between close obs and general obs.
Half hourly obs would be a complete waste of time.