18. Does watching work? (matter for discussion)
Forensic Nursing Forum
That this meeting of RCN Congress discusses whether prescriptive observation of patients at risk of self harm and suicide is fundamentally flawed.
On this page:
- Watch the debate
- Read the progress report
- Read the debate report
- Read the background information
18. Does watching work? (MFD)Progress report
Council Committee: NPPC
Committee decision: Covered by existing work
Council member/other member/stakeholder involvement: Kevin Bell
Staff contact: ian.hulatt@rcn.org.uk
The discussion at Congress revealed variations in practice and opinion. A resource for members is already available which addresses some of the issues raised in the debate.
A fringe event is being held on Thursday 14 April (12.45pm, room 9 Upper Galleria ACC) at Congress 2011 which will update members on the results of a research project funded by the Health Foundation which is led by RCN Mental Health Forum committee members, and which specifically addresses the issue of in-patient safety in mental health settings.
Debate report
This debate attracted diverse opinions from the floor and stimulated the expression of highly emotive and heartbreaking stories of personal loss. The matter for discussion was proposed by Richard Benson of the RCN Forensic Nursing Forum.
He outlined the situation with current practices and questioned whether a blanket approach to observing those at risk of suicide and self-harm could be destructive and potentially damaging to the most vulnerable and in need.
He said: "As part of care planning we have a duty to balance concerns about patient safety against the impact that some observational levels can have. Prescriptive policies on this could constrict the ability of nurses to provide care that meets individual needs. It can lead to defensive practices through the fear of litigation." This disregards the value of observation in promoting true engagement and real help, he added.
Other speakers expressed fears that observation can sometimes be the sole part of a care package. Sharon McGinn of the Devon Branch said: "If observation is not part of a holistic approach then it is abuse, not intervention. We're nurses not jailers."
But the most poignant part of the debate came from Maureen Dolan who is a non-voting member from the Southern Trust in Northern Ireland. Her eldest son committed suicide two years ago and a short while later her other son also felt trying to take his own life was the right choice.
It took her six weeks to get him admitted for psychiatric help following the suicide attempt and she saw observation as his life line. "Because of close supervision by trained nursing staff, my son is still alive", she said. "The three weeks he was observed were a turning point. He is proof that watching does work."
Background
The concept of a prescriptive observation policy to guide the nursing care of patients at risk of suicide or self-harm has been argued to be fundamentally flawed. Policies have traditionally focussed on a direct relationship between the perceived risk that the client presents and the frequency of nursing observation. It could be said that such a risk adverse blanket approach can undermine the role of nursing and facilitate practices that fail to provide individualised nursing care.
It could be said that the nursing care of a patient at risk of self-harm or suicide should be based on a full assessment that identifies both the nature of the risk, as well as the nursing interventions that can manage and reduce this risk.
Many see patient observation as an aspect of a meaningful patient engagement that is underpinned by a patient-focused care plan, not a task to be undertaken on prescription. Better patient outcomes can occur when care plans are designed, implemented and evaluated by a multi-disciplinary team with the involvement of the patient.
Some would question whether it is appropriate for medical staff to prescribe levels of observation without discussing the proposal with the nursing team that has responsibility for conducting the observations.
Increased levels of observation may provide opportunities for increased and more creative levels of engagement - a collaborative approach which is embedded in the Tidal Model of care.
Keeping vulnerable people in our care safe is an essential part of our practice. Whether this is best achieved by rigid procedures is a question that should be addressed.
References and further reading
Barker P and Buchanan-Barker P (2005) The Tidal Model: a guide for mental health professionals, Hove: Brunner-Routledge.
Barker P and Buchanan-Barker P (2010) The Tidal Model
www.tidal-model.com
Department of Health (2007) Best practice in managing risk: principles and guidance for best practice in the assessment and management of risk to self and others in mental health services, London: DH.
www.dh.gov.uk/en/publicationsandstatistics/publications/publicationspolicyandguidance/DH_076511
National Mental Health Development Unit Acute Care Programme (2010)
The Virtual Ward
www.virtualward.org.uk/