Introduction
Aims of the study
Materials and methods
Design
Inclusion criteria
Recruitment and sampling
Data collection
Interview analysis
Quality assurance and reflexivity
Results
Patients (N = 28) | |
Gender | |
Male | 15 (54%) |
Female | 13 (46%) |
Ethnicity N (%) | |
White | 14 (50%) |
Asian | 7 (25%) |
Black | 6 (21%) |
Mixed race | 1 (4%) |
Age (years) | |
Range | 18 to 66 |
Mean (sd) | 37 (15) |
Primary diagnosis N (%) | |
Personality disorder | 10 (36%) |
Bipolar disorder | 9 (32%) |
Schizophrenia or schizoaffective disorder | 5 (18%) |
Major depressive disorder | 4 (14%) |
Reason for observation N (%) | |
Risk to self | 18 (64%) |
Risk to others | 6 (21%) |
Risk to self and risk to others | 4 (15%) |
Length of time on observation N (%) | |
≤7 days | 12 (43%) |
>7 days | 16 (57%) |
Staff (N = 31) | |
Gender N (%) | |
Male | 15 (48%) |
Female | 16 (52%) |
Ethnicity N (%) | |
White | 17 (55%) |
Asian | 3 (10%) |
Black | 11 (35%) |
Mixed race | 0 (0%) |
Years worked in mental health | |
Range | 1 to 25 |
Mean (sd) | 7 (7) |
Job role N (%) | |
Unqualified nursing staff | 12 (39%) |
Qualified nursing staff | 9 (29%) |
Clinical team leader | 2 (6%) |
Ward manager | 3 (10%) |
Modern matron | 1 (3%) |
Consultant psychiatrist | 3 (10%) |
Consultant clinical psychologist | 1 (3%) |
Theme 1 The conflict between privacy and safety
Sub-theme 1.1 Invading privacy
Sub-theme 1.2 Providing safety
Theme 2 A damaging intervention versus a short-term solution within a positive risk-taking framework
Sub-theme 2.1 A damaging intervention
Sub-theme 2.2 A short-term solution within a positive risk-taking framework
Theme 3 Decisions made without the patient versus a collaborative and individualised approach
Theme 3.1 Decisions made without knowing or involving the patient
Theme 3.2 A collaborative and individualised approach
Theme 4 A stressed and fractured workforce versus a team approach
Sub-theme 4.1 A stressed and fractured workforce
Sub-theme 4.2 A team approach
Discussion
Strengths and limitations
Implications for clinical practice and research
Findings | Considerations raised by patients and staff |
---|---|
Interviewees felt continuous observation was best used as a short-term intervention within a positive-risk-taking framework | Ensure that only patients with severe levels of risk are placed on continuous observation Frequently re-evaluate risk during observation Be open to taking positive risks during or as an alternative to continuous observation Keep the duration of continuous observation to a minimum |
Interviewees felt continuous observation had the potential to be iatrogenic | Consider the potential negative effects of continuous observation for the individual patient, including distress caused by privacy restrictions, reinforcement of risk-taking behaviour, reduced self-efficacy and negative relationships with staff |
Interviewees felt good decision-making required a thorough knowledge of the individual patient | Avoid knee-jerk or blanket reactions to risk behaviour Thoroughly evaluate all aspects of a patient’s presentation, including past reactions to continuous observation, and the potential benefits and risks of observation for their overall recovery |
Interviewees emphasised the importance of communication and collaboration between staff and patients | Communicate sensitively and empathically with patients to explain what observation entails Discuss the reasoning behind any decisions Acknowledge the difficulties of being observed Build mutual trust to enable agreement on taking positive risks within observation Take patients’ views about being observed and about their level of risk into account where possible, whilst acknowledging that some patients may seek to hide their level of risk or lack capacity to weigh up the pros and cons of observation whilst they are acutely ill |
Interviewees emphasised the importance of a supportive and cohesive staff team | Involve all team members in reaching an agreement about patients’ level of observation Present a united front when communicating team decisions to patients and do not communicate any disagreements between staff Hand over information gained from observation to the rest of the team Encourage each-other to take positive risks and avoid a culture of blame Encourage staff to discuss difficult experiences with the team, in managerial supervision sessions, and during reflective practice Ensure that there are sufficient staff on the ward for observation shifts to be frequently rotated, and for adequate attention to be given to other patients |