Flexible observation: guidelines versus reality


  • A. M. KETTLES phd msc (health psychology) bsc (nursing) rmn rgn rnt pgcea iltm amibiol,

    1. Research and Development Officer (Mental Health), NHS Grampian, Bennachie, Royal Cornhill Hospital,
    2. Honorary Lecturer, Centre for Advanced Studies in Nursing, University of Aberdeen, and
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  • K. PATERSON rmn

    1. Ward Manager, Crathes Ward, NHS Grampian, Royal Cornhill Hospital, Aberdeen, UK
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A. M. Kettles
Ground Floor
Royal Cornhill Hospital
Cornhill Road
Aberdeen AB9 25ZH
E-mail: alyson.kettles@nhs.net


This paper reports a small-scale pilot study to introduce flexible observation of patients in an acute psychiatric clinical area where nurses have increased autonomy to make such decisions. The Clinical Resource and Audit Group document ‘Engaging People: Observation of People with Acute Mental Health Problems: A Good Practice Statement’ outlines very clearly the observation levels that should be used in acute psychiatric areas in Scotland. It also states clearly who is responsible for conducting different parts of the observation process and how such observation procedures should be conducted. The available literature recommends three observation levels with engagement and considers that intermittent or time period checks are unsafe. A small-scale action research pilot study was conducted over a period of 6 months with individual incidents (n = 57) of patients requiring increased or decreased observation levels being included in the study. There were no exclusion criteria and this was a total sample in one clinical area. The results were analysed using the Statistical Package for the Social Sciences v.14.0 using non-parametric statistics and chi square. The results indicated there has been a shift away from doctors deciding on the levels of observation towards multidisciplinary or nursing decisions regarding this aspect of care. During the pilot, there was a gradual shift away from high levels of observation. Those that were placed on increased levels of observation were on them for a much shorter time than previously and staff generally found the new recording system to be more practical. There were a number of ‘sub-levels’ of general and constant observation in use. Over the years, recording has suffered from incomplete information and this pilot is no different with 56% (n = 34) of the recording sheets had at least one section of clinical information incomplete or not filled in at all. Despite the guidelines and the subsequent training of staff in the clinical area, some nursing staff were not participating as fully as they might in the decision-making process. Fewer patients were being placed on increased observation levels. Those that were placed on observation were on them for a much shorter time than previously and staff generally found the new recording system to be more practical.