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HIGH SECURE SERVICES SUPPORTIVE OBSERVATIONS

PROJECT

“An exploration of the lived experience

of patients and staff involved in

supportive observations within a high

secure environment, with the aim of using

this information to develop practice to

achieve a more therapeutically orientated

intervention to enhance the experiences,

inform policy and reduce costs.”

Final Report for the Foundation

of Nursing Studies

Project Team:

Neil McBride: Project Lead

Ceri Anderson, Jane Kirby, Mathew Savage

March 2014

The use of

supportive

observations

in a high

secure setting

Supported by the

Foundation of Nursing

Studies Patients First

Programme in

Partnership with the

Burdett Trust for

Nursing

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Project title: An exploration of the lived experience of patients and staff involved in supportive observations within a high secure environment Keywords: Supportive observations, intermittent observation, one to one observation, patients, staff experiences Duration of project: May 2012 - March 2013 Report submitted: March 2014 Project facilitators: Project Lead; Neil McBride, Charge Nurse; Ceri Anderson, Staff Nurse; Jane Kirby, Staff Nurse; Mathew Savage, Charge Nurse Contact details: neil.mcbride@merseycare.nhs.uk Summary Ashworth Hospital is one of three high secure hospitals in England. It serves the North West of England, West Midlands and Wales. It provides in-patient care and treatment for men who are deemed to be a grave danger to self or others, and are detained under the Mental Health Act 1983, (amended 2007) by a court of law, in conditions of maximum security. The services and systems within a high secure environment have historically been ones that have seen patients disempowered and marginalised and ones in which the contradictory roles of care giver and guardian often co-exist. Pulsford et al. (2013) suggest there is a clear tension for staff in high secure mental health services between promoting patients’ recovery and human rights and managing risk and security (Timmons, 2010). Supportive observation can be defined as ‘regarding the patient attentively whilst minimising the extent to which they feel that they are under surveillance’ (Department of Health, 1999, p 2) and is intended to be a therapeutic alliance between patient and staff. The project team recognised that the increase in the use of supportive observations and the resultant cost was an issue for Ashworth Hospital. The aim of the project was to gather the experiences of patients and staff involved in supportive observations, with the aim of using this information to develop practice to achieve a more therapeutically orientated intervention. It was anticipated this would enhance the experiences of both care giver and patient and also inform policy and reduce costs. A mixed approach was used combining qualitative and quantative data. This included collecting and analysing data in relation to the hours and costs involved in supportive observations, patient and staff interviews and working with stakeholders’ values and beliefs. At the end of the project there was a noticeable reduction in the use of supportive observations and a potential reduction in cost of the service that support the methods and approaches used with the key stakeholder groups. The project team believe that the key learning point from this project was that as key facilitators, they were in a position to enable change by engaging with staff and patients throughout the process and maintaining communication in a collaborative

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way that resulted in a positive outcome for all. Members of the project team have presented their work at both international and national conferences. Introduction Ashworth Hospital is one of three high secure hospitals in England. It serves the North West of England, West Midlands and Wales. It provides in-patient care and treatment for men who are deemed to be a grave danger to self or others, and are detained under the Mental Health Act 1983, (amended 2007) by a court of law, in conditions of maximum security. There are fourteen single storey semi-detached wards, which currently care for 202 male patients. Each ward provides a specific type of specialised treatment and care for its patients. Patients with similar conditions are usually grouped together based both on security and clinical needs. The wards are arranged in clusters around wide open green areas. Each ward has its own garden area. The patient’s pathway through high secure services involves four distinct phases: admission and assessment; behavioural stabilisation; treatment; and rehabilitation. The speed at which patients move through each phase is dependent upon individual response and progress. Patients who are admitted to high secure services are assessed against specific criteria and can be admitted from a number of healthcare or criminal justice facilities. These include medium secure services, courts, prisons, or other services of lesser security. Admission to high secure services follows a multi-disciplinary assessment and consideration of suitability by a panel of senior clinicians. The services and systems within a high secure environment have historically been ones that have seen patients disempowered and marginalised and ones in which the contradictory roles of care giver and guardian often co-exist. Pulsford et al. (2013) suggest there is a clear tension for staff in high secure mental health services between promoting patients’ recovery and human rights and managing risk and security (Timmons, 2010). The former NHS commissioning board now newly named NHS England state in their NHS Standard contract circular for high secure adult mental health services that “the maintenance of security is crucial to the provision of effective therapeutic interventions in secure services. A key principle underpinning the provision of secure services is that individuals should be managed in the least restrictive environment possible in order to facilitate their safe recovery. Least restrictive refers to the therapeutic use of the minimum levels of physical, procedural and relational measures necessary to provide a safe and recovery focused environment”(NHS England ,2013/14, p 4) Supportive observation can be defined as ‘regarding the patient attentively whilst minimising the extent to which they feel that they are under surveillance’ (Department of Health, 1999, p2) and is intended to be a therapeutic alliance between patient and staff. The therapeutic alliance construct refers to the collaborative aspect of the relationship between nurse and patient(s). Bordin (1979) suggests it encompasses three components which are:

the agreement between nurse and patient about the goals of treatment

the emotional bond developed between nurse and patient that allows the patient to make therapeutic progress

the resulting outcomes

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The aim of this project was to look at level 3 and 4 observations as outlined below, in the MerseyCare hospital policy (SD04) (2010). Definitions of level 3 and 4 supportive observations Level 4 (Within Arms Length): observation is required when a patient poses the highest level of risk of harm towards themselves or potentially to others, and it has been determined that this level of risk needs to be managed by close proximity of the patient with staff at all times. In context this means that the staff carrying out the observation will be within arms length, even at times when privacy and dignity may be compromised, this will be due to the high level of risk being managed. Level 3 (Within Eyesight): observations are required when a patient could, at any time, make an attempt to harm themselves or others, or where a patient is perceived as being vulnerable to others. This intervention is less intrusive than level 4 but requires the patient to be observed at all times, within eye sight, so in practice this could be from some distance away, for example from a ward office when the patient is in communal areas. Close circuit television monitoring is currently an option which could be considered for this level of intervention. The use of enhanced supportive observations within psychiatric settings appears to be on the increase (Bowers et al., 2000), despite its potentially intrusive and distressing nature (Neilson and Brennan, 2001) and despite a lack of a research base for its efficacy (Whittington et al., 2006, p 167). Van der Nagel et al. (2009) also suggest that nurses and patients may experience stress and powerful emotions when involved in interventions such as supportive observations.

Throughout the hospital the ‘Releasing Time to Care’ initiative was being implemented via the Productive Ward modules (NHS Institute for Innovation and Improvement, 2008). This resulted in the project team gathering data which suggested that there appeared to be an increase in the use of supportive observations within their services; it was thought that this may be due to the influx of young males with comorbid diagnoses, who have displayed much more destructive self harming behaviours. The project team felt that this was the basis for a further project as it was recognised that there were massive cost and resource implication for services. The project team wanted to explore the experiences of patients and staff and the time staff actually spent undertaking level 3 and 4 observations so that this information could be used to develop an appropriate therapeutically orientated intervention. The project team consisted of four individuals who were motivated and committed to challenge a culture which had an inherent reluctance to change working practices, an “if it’s not broke why change it” attitude. The team consisted of a project lead with knowledge of practice development and experience of managing a change in practice. Also involved were three ward based nurses, one of whom was a charge nurse with the experience to deal with any difficult encounters with staff, and two newly qualified, motivated nurses, who were selected to gain valuable experience through their involvement in this project. All members of the team currently work on the high dependency wards within Ashworth Hospital.

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Aim To gather the experiences of patients and staff involved in supportive observations within a high secure environment, with the aim of using this information to develop practice to achieve a more therapeutically orientated intervention. It was anticipated this would enhance the experiences of both care giver and patient and would also inform policy and reduce costs. Objectives 1) To identify and engage stakeholders in the project 2) To conduct qualitative narrative interviews with patients and staff to identify their experience of supportive observations 3) To work with patients and staff in a focus group to further understand their experience of supportive observations 4) To make recommendations based on the information gained through the project Methods and approaches The overall aim of this project was to gather patient and staff experiences in relation to supportive observations. The project team wanted to use practice development approaches (Gerrish and Ferguson, 2000; McSherry and Bassett, 2002; McCormack et al., 2013) within the project and included a range of activities aligned to changing and improving healthcare. Whilst change has always been a cultural feature within the NHS, recent modernisation and an emerging theory base for practice development has led to an increasing recognition of the term, and its ethos in promoting safe and effective person centered care (McCormack and McCance, 2010; Manley et al., 2011). Throughout the project a number of approaches were used in order to gain a thorough picture of the use of supportive observations within the high secure setting. The project team decided that it was best to opt for a mixed method approach to the project. A mixed methods approach combines both qualitative and quantitative methods in order to better answer the question posed (Andrew and Halcomb, 2009). The project team decided to incorporate the quantitative approach of gathering data in relation to the number of staff hours involved and the cost of supportive observations and combined these with the qualitative element of the values clarification exercises with all stakeholders and gathering narrative interviews from both staff and patients. A time line of the approaches undertaken during the project can be seen below:

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Table 1: Project approaches

Date Method Who involved

02/04/12 The creation of a Gantt chart for project outcomes (a Gantt chart is a type of bar chart, developed by Henry Gantt in the 1910s, that illustrates a project schedule. Gantt charts illustrate the start and finish dates of the terminal elements and summary elements of a project)

Project team

Monthly Advertising the project team’s activities through monthly newsletters. Patient and staff information and consent letters sent to all participants and responsible clinicians outlining the project

Project team

Monthly Regular meetings with the team Project lead

04/05/12 Gathering raw data with regard to the use of supportive observations across four wards, via the hospital audit systems. Calculating the number of hours undertaken by staff in the use of supportive observations, as well as the amount of time patients are involved in supportive observation interventions

Project team

May - Aug 2012

Presentations to key stakeholders

Project team members

May 2012 - Jan 2013

Further data collection consisting of:

Utilising the team culture tool via an emailed Survey Monkey to all ward based staff across the hospital

Facilitating the values clarification exercises with groups of staff across the high secure service

Creation of questions for the interview schedule

Project team members

July - Aug 2012

Interviews with staff and patients Project team members

August and September 2012

Organisation and running of patient focus groups. A joint staff and patient focus group

Project lead

Jan - March 2013

Evaluation of the project Project team members

10/10/12 28/11/12 13/03/13

Conference preparations: Nationally Internationally Nationally

Project lead N Mcbride

Gathering data - hours and costs of supportive observations Data was collected by the project leader. This data was collated from the recognised hospital audit tool - the Core Monitoring form (CM4), which collects the data associated with the use of supportive observations for the four wards identified in this project. This data is collected for

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the hospital dash board system, which is a visual tool to show levels of supportive observations used on all wards for quality assurance targets set by the commissioning bodies for mental health services. This data allowed the team to calculate the number of hours undertaken by staff in the use of supportive observations, as well as the amount of time patients were involved in this intervention. Six months of data was collected as a baseline (June - November 2011). Once the project was completed the project team collected a further six months data (August 2012 - January 2013) from the same four wards. Collecting the information pre and post project allowed the team to compare the use of supportive observations pre project, and then immediately after the project for a six month period. The data collected was the total number of hours that patients were on supportive observations, as well as the cumulative hours spent by nursing staff on supportive observations. The total of staff hours spent in supportive observation exceeded the total of patient hours because some patients required a higher than 1:1 ratio. The results are shown in the findings section. Team culture tool At the beginning of the project, the team wanted to gauge how ward staff across the hospital felt about the team they currently worked in and to analyse how this might affect the outcome of the project. In order to achieve this, the team sent out a team culture tool, adapted from Pritchard and Dewing (1999) (see Appendix 1). It consisted of 24 questions discussing the topic of team working and was sent to all 471 staff across the fourteen wards in high secure services in the form of a Survey Monkey distributed via e-mail (see Appendix 2). A total of 265 surveys were returned, equating to a 56.26% return (see Appendix 3). The survey was also repeated after the project with a lower response rate of 50.42%. The project team believe that this might be due the to the austerity demands of the National Health Service, as well as cost improvement plans which have commenced in high secure services and which have affected all the workforce. Values and beliefs clarification exercises The next stage for the project team was to identify and analyse the current values and beliefs of the individual stakeholders in the project. The project team wanted to identify what type of action or factors may influence the progress of the project, whether it would produce a significant outcome and what effect it would have on actual attitudes and behaviours, in the practical sense rather than just in the academic sense (Royal College of Nursing, 2008). To achieve this, the team decided to use a values clarification exercise (Royal College of Nursing, 2007). To seek engagement with the stakeholders, the project leader initially attended a high secure service governance board meeting, presented the outline of the project and asked if the project team could facilitate a values clarification exercise with all other professional groups which made up the patient care team. This was agreed and the project team started making contact with the various stakeholder groups. This exercise was facilitated with the following professional groups representing the patients’ care team (PCT) within the hospital:

Patients

Nurses

Senior managers

Psychology team

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Responsible clinicians

Social workers

Occupational therapists Because the project team was inexperienced in facilitating this exercise, they asked the FoNS practice development facilitator to work with them initially to show them how to work with the tool. The first session was with the senior management team and the FoNS facilitator asked each member of the team to think about and then answer the following questions individually:

I believe the purposes of supportive observations are:

I believe I can achieve this purpose by:

I believe the factors that help are:

I believe the factors that hinder are:

Other values and beliefs that are important to me are: The answers were written down on paper and then shared orally with the other group members in a structured way to enable everyone to voice their values and beliefs. Once this had been achieved, the group was then asked to use the answers to the questions to move towards creating a statement starting with: “We believe the purpose of supportive observations are: ...” The group achieved this and the statement can be found in the findings section. The project team observed the facilitation of this exercise and used the situational facilitation model as outlined by Hersey and Blanchard (1996) to reflect on their observations and to decide how they would facilitate this exercise in the future. Using this model, facilitation styles are split into four domains, ‘encouraging style, coaching style, supporting style or a directing style’. It became evident that the project team facilitators had various skills in relation to facilitation, but predominately each team member had one style that they were more comfortable with. This allowed each project team member to pair up with another with different skills to facilitate the subsequent sessions. The facilitation approach used by the FoNS facilitator was then used by the project team and each stakeholder lead was contacted and dates were made for the sessions. Two members of the project team facilitated the values clarification exercise with each of the other six professional teams across the high secure services. Each discipline specific group was well attended with an average of 75% of people from each department attending the sessions, confirming the importance of the topic from their own perspective Staff and patient interviews Interviews were conducted by the project team; the first group to be interviewed consisted of patients from the four identified wards who were currently being cared for via supportive observations, or had previously been on supportive observations; the second group was the staff involved in the use of supportive observations across the same four wards.

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The project team developed an interview schedule to facilitate the capturing of experiences through the interviews. Initially the project team formulated open ended questions to try and avoid ‘Yes’ or ‘No’ replies and to tease out valuable information from the personal experiences of each person. As suggested by Parahoo (2006) the project team first piloted the interview questions with a small group of participants similar in characteristics to the intended respondents. This pilot highlighted some minor problems that the project team hadn’t anticipated, such as issues with the wording of the questions. It was necessary to be more direct in the questions, to avoid any ambiguity or uncertainty in meaning of the individual’s answers. The team also designed supplementary questions to each question to gain more information (see Appendix 4). The questions differed for staff and patients, for the staff it was the experience of carrying out their duties with a patient who was under their direct care, whilst on supportive observations and for the patient it was their personal experiences of being observed under such intrusive observation levels. As it was such a personal experience, it was hoped that the qualitative aspect could capture these experiences and identify themes. Out of 202 patients within the hospital during the month of the interviews, 30 interviews were conducted (14.9%). The interviews were recorded on a digital dictaphone and at the end of each interview; a brief reflection of the interview was also recorded by the interviewers to capture the thoughts and insights of the interviewer. The recordings were then typed up and the project team undertook a thematic analysis to examine if any common themes were emerging (see Findings section). The project team then advertised and offered the same opportunity to nursing staff, who regularly undertook supportive observations. The demand and response was quite high, and the team decided to limit the interviews to 30 nursing staff to match the number of patient interviews (See Findings section). Patient focus groups After the individual interviews were completed, the project team arranged patient focus groups to build on the findings of the interview and to gain a greater understanding of patient experiences by allowing them to share their own experiences in a small group setting, within a semi- therapeutic environment supported by a facilitator for each group. Patients from every ward were invited to attend, supported by ward based staff. To attract patient’s interest, the team utilised an advertising campaign using the Olympics and football as themes to attract patients to the focus groups. It was decided that a member of the project team would address the monthly patients forum, to disseminate the work that was about to commence. Each ward was approached with colourful, attractive posters, meant to gain interest. The first focus group attracted 20 patients from a range of wards, some of whom had taken part in the individual interviews. The focus group was held in a communal area located within the hospital, as it was felt that an off ward area might encourage a greater level of participation. There were some practical challenges to organising the event; each patient had to be cross referenced against other patients, who they may come in contact with, as some

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patients cannot be in contact with each other because of clinical and security risk issues. This decision is made at the meetings of the regular patient care teams. Members of the project team had to cross check for any such eventualities. The team also had to organise the escorting arrangements, to allow patients to attend without disrupting the staffing compliments on the ward. This organisation needed to be completed within a set time scale, as patients had to be back on the wards for set times during the day, so it was important to plan the focus groups with as much precision as possible. Thankfully the project team achieved this with minimal disruption to patients, staff and the running of the wards. On the day, patients were split into smaller groups supported by a member of the project team to prompt and guide discussions if needed, using the same interview questions. The patients then fed back the information from each group on what was discussed and ideas of how to improve the experience of being on supportive observations. The feedback was generally positive and patients were happy that the subject was being addressed and all of them hoped it could be improved in some way. The focus group was a success as it allowed patients to share their experiences, and they certainly appeared to be more open and honest in their views than on previous occasions. All this information was transcribed to form part of the patient experience. At the end of the first focus group, the patients fed back that regular meetings like this would be beneficial. Collaboratively, with the facilitators, the groups came up with issues around supportive observations that could be discussed at further patient focus groups. It was from this initial success and feed back from the patients that the team organised a second patient focus group. The second patient group was attended by 24 patients and was used to discuss the issues that had been raised in the previous focus group. It was paramount to the team that this type of event was a useful tool in gathering information. Again, feedback at the end of the group was generally positive with some new ideas raised including current practices and a review of the supportive observations policy. In total, the project team organised and ran four focus groups with the last session run as a joint patient and staff session. It was hoped by the project team that this would allow the sharing of both staff and patient experiences together in small groups and would enable closer partnership working in developing solutions to some of the themes that were emerging. These were instrumental in maintaining a high profile campaign within the hospital. Findings Gathering data-hours and costs of supportive observations The data that was collected pre and post project relating to the hours and costs of supportive observations is presented in Appendix 5. The project team was hoping for a reduction in observation hours, which appears to have been achieved, with data showing an average decrease of 69.4% in the use of supportive observations across the four wards and a similar reduction of staff cumulative hours spent on supportive observations, with an average of 65.5% across the four wards. As noted before, staff hours spent on supportive observation will sometimes be higher than patient hours as some forms of observation require more than one member of staff.

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The project team believes this reduction in supportive observations is due to the methods used within the project particularly the values clarification workshops with all the key stakeholders, staff and patient interviews and focus groups. These methods have enabled a greater understanding on the part of staff of the lived experience of supportive observations and this has stimulated them to think about the use of supportive interventions and the possibility of using alternative interventions with patients and thus the reduction in their use. The project team have observed and experienced that staff are feeling more empowered to take individuals off supportive observations, rather than waiting for the care teams to make that decision. Staff are now considering other forms of interventions, such as increased engagement and meaningful activities where clinically appropriate. In addition to all the information, thoughts and perspectives of those who took part, it was also crucial for the team to gain some facts surrounding the costing of supportive observations within the hospital. The project team decided to collate the cost to service in the use of supportive observations for the six month period prior to the project and a similar period after the project was complete. The figures were examined across the four high dependency wards involved in the project, two from the personality disorder service and two from the mental illness service. As a baseline figure the project team have costed this on an hourly basis, for a band 5 registered nurse mid point scale, as this would be the minimum requirement for the use of supportive observations on a 1:1 ratio. It has also been costed for a band 3 mid point nursing assistant, which may have been utilised in 2:1 observations for the same number of hours to give a comparable cost for service (see Figure 2 below).The figures show that there was a total estimated cost across 4 wards for a six month period of £709,275 pre project, compared to £245,797 post project, estimating a saving of £463,478 for a band 5 nurse and £295.576 for a band 3 nurse for service. This is the data for the four wards involved in the project and only based on one nurse so there is potential that this figure of savings would increase greatly across all fourteen wards and staff involved in supportive observations within the hospital. Figure: 2 Band 5 mid point for a six month period

Ward A Ward J Ward K Ward L Total

Pre Cost: Pre Cost: Pre Cost: Pre Cost: Pre Cost:

£266,686 £146,107 £203,980 £92,502 £709,275

Post Cost: Post Cost: Post Cost: Post Cost: Post Cost:

£62,568 £55,349 £104,390 £23,490 £245,797

Estimated saving for the 6 month period: £463.478

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Figure: 3 Band 3 mid point for a six month period

Ward A Ward J Ward K Ward L Total

Pre Cost: Pre Cost: Pre Cost: Pre Cost: Pre Cost:

£196,617 £107,719 £150,387 £68,198 £522, 921

Post Cost: Post Cost: Post Cost: Post Cost: Post Cost:

£46,129 £40,806 £76,963 £17,318 £227,345

Estimated saving for the 6 month period: £295,576

Team culture tool The full results from the team culture tool survey can be seen in Appendices 6 and 7. The survey suggests that the current workforce does have similar values, interests and beliefs, and is not ruled by standards of the past. There is a strong view (79.7%) of a community spirit within teams and mutual co-operation and harmony. This survey was completed pre and post project; however the post survey results (see Appendix 7) showed an overall small decrease in percentages. The information collated from this survey sent to all staff via the regular project newsletter to all staff and presented to senior management, to reinforce that the current workforce is proactive and prepared to work collaboratively together for the benefit of the patients they care for. In figures 4 and 5 there are a couple of examples of the responses to the pre and post team culture tool statements. Figure 4: Pre project:

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Pre project:

Figure 5: Post project

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Post project

Values and beliefs clarification exercise In total, seven values and beliefs exercises were facilitated with the stakeholder groups identified as part of the patients care team (patients, nurses, senior managers, psychology team, clinicians, social workers and occupational therapists). The initial prompts were used to come up with an agreed purpose or ‘mission statement’ for each group.

Mission statement of patients who have experienced supportive observations “First you hate it, then you get used to it, then you like it and then you depend on it.”

Nurses “We believe the purpose of supportive observations is to provide a safe supportive alliance between staff and patient, to prevent harm to self or others, by building a meaningful therapeutic relationship, between each other, and to support the patient through a potential crisis, in the least restrictive manner and time. It is clear that the word observing is less meaningful than engaging and nursing staff should access the person’s lived experience.”

Senior managers “We believe the purpose of support observations is a multi disciplinary approach in maintaining safety and managing risks through additional therapeutic engagement and support to those who are experiencing a crisis, to promote recovery.”

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Psychology team

“We believe that supportive observations should be used in the least restrictive manner, with respect for the individual’s dignity wherever possible, based upon a thorough risk assessment. Supportive observations must be based upon the assessment of the function of the individual’s behaviour and support recovery, stabilisation and psychological well being. Supportive observations should be a collaborative process between the patients, the care team and ward staff, to ensure the safety of everybody. Staff delivering supportive observations need to be supported, trained, motivated and managed.”

Responsible clinicians “We believe the purpose of supportive observations is to prevent harm to self or others for the shortest period.”

Social care workers “To observe and support the patient in a collaborative process, by reducing stress and/or symptoms. This hopefully, leading to a reduction in the risk of harm to self, or others. This could be for a short term crisis period or for longer term needs.”

Occupational therapists “Supportive observations should be a recovery focused multi disciplinary approach to enable safe and supportive engagement in meaningful occupation throughout the care pathway.” The patients care team are generally the people who make the decisions about when individuals are prescribed supportive observations; so the project team felt it was important to understand their values and beliefs on the subject. Once the mission statements had been agreed, they were sent out to all of the disciplines who were asked for further feedback and comments. None of the disciplines wished to change or alter their initial statements. Patient and staff interviews Patient interviews The project team listened to the recorded tapes and found that the information was rich in personal feelings for all concerned. The depth of feelings ranged from feelings of sadness, hopelessness, anger and on the other hand, the feeling of being safe. However, what was even more interesting were the responses of patients who had experienced supportive observations both in the past and more recently. They were able to give a good account of the differences in the use of supportive observations over time. Most patients had both positive and negative experiences to share about the use of supportive observations for example: Positives included:

“I feel safe when on obs”

“Staff are there to talk to me”

“There was always someone there when I wasn’t well”

“I would have killed myself if I was not on obs”

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“There are more things to do if you’re on obs”

“It’s a good way to get to know staff” Negatives included:

“I was on them for too long”

“I hated being watched all the time, it was like big brother”

“I can’t sleep because my door’s open and people are watching me at night”

“They were pointless, no-one told me why I was on them and I could have self-harmed if I wanted to anyway”

Other information that emerged from the interviews included:

92% of the patients stated they preferred staff they knew to undertake supportive observations, whilst the other 8% did not mind either way, believing it made no difference

The majority felt gender or age made no difference but a few mentioned they only wanted males observing them when showering or using the toilet

84% of patients interviewed felt that the observations were necessary at the time and 76% felt that they were supported when being observed

Most of the patients could not come up with any alternatives to supportive observations other than “time out in a clear room” or “a more stringent risk assessment”

One patient did not like younger people being on his observations stating “My son is 24; it was like my son was watching me – it made me feel stupid”

When discussing privacy and dignity, the majority of patients felt their privacy was being breached but most of these understood why and felt it necessary; “staff are only doing their job, I’ve self-harmed in the shower before so understand why they have to watch me”

Ninety-two percent felt that they were not involved in the original decision to be put on observations and only 40% said their care plan was explained to them and they knew what they had to do to come off observations

When asked what could be done together to come off supportive observations, most talked about an increase in engagement with staff, more understanding of why they are on observations and what they needed to do to come off them. One patient felt that people were on observations for too long and “it’s easy to fall into the trap of long-term support”

Sixty percent of patients thought that they should be observed at level 3 observations (within eye sight) rather than level 4 (within arm’s length)

When asked for alternatives, some patients said they would prefer staff to just check every few minutes when in the shower rather than constantly watch

Staff interviews When asked of their understanding of supportive observations the most common answers from staff were:

“To observe and manage risk”

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“To prevent harm to self and others”

“To help a patient when in crisis”

Other information that emerged from the interviews included:

When asked about their role in supportive observations the two most common themes were risk assessment and therapeutic engagement with patients

Despite the policy stating that the longest amount of time on supportive observations is two hours, 64% of staff interviewed did not know this, and most felt that this was too long and an hour would be more sufficient, particularly with patients who are difficult to engage or asleep

When asked why observations go wrong, the majority felt it was due to “complacency”, “lack of vigilance” and “staff being distracted” and felt that rotating staff undertaking observations would help alleviate this problem

Another issue staff raised was not having a full understanding of the patient and the feeling that a hand-over of the patient’s recent presentation and risks should be done when commencing observations

When asked if it is purely observational rather than supportive, 44% of staff interviewed felt it was, but the majority were in agreement and believed that an increase in engagement in activities would be more beneficial to the patient

Staff felt some of the helping factors included:

“Knowledge of patient’s history and risks”

“Successful risk management”

“Regular care team discussions and reviewing levels of observations”

Some of the hindering factors included:

“Patient becomes reliant”

“Staff were on hand to meet patients needs 100% of time”

“Risk averse – nursing staff and rest of care team frightened of the consequences of a patient not being on observations”

“Lack of knowledge of patient” Patient focus groups The project team believe that the use of patient focus groups was a great success in engaging with historically, such a difficult patient group. The group discussions only focused on the personal experiences of being on supportive observations, this was the direction the project team wished to highlight, however there was no need to guide or prompt the patients to discuss such issues. The engagement was free flowing between all the patients and it was encouraging as facilitators to sit and listen to such an emotive topic. The groups were held away from the ward environment, and this provided a more relaxing atmosphere for the patients that attended. The use of healthy refreshments was an added incentive to attend the focus groups. The project team felt that it was a positive outcome to have a good number of patient’s attend the groups but were also surprised and reassured to see how open and honest the

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patients interacted with each other and members of the project team. It was felt by the project team that this openness and frankness on the part of the patients showed they felt more empowered and they gradually began to lead on discussions and ask about how they could be involved in the development of services further. The information discussed during the focus groups was recorded on flip charts, and patients fed the comments back to each other, in small groups, the information gathered was utilised as a basis for further focus groups. The project team believed it was important to maintain an interest amongst the patients, by listening to their experiences and then sharing them in future focus groups. Some solutions that evolved from these groups were:

patients would like to be involved in the training of staff in the use of supportive observations

patients expressed that they wished to be involved in the analysis of the policy on supportive observations and how this could be improved especially around the times spent on observations

patients talked about whether the use of documentation of supportive observations could be reduced or changed to enable a more therapeutic relationship between patient and staff member

Patients asked for more individualised care plans to be flexible in approach for each person to address any privacy and dignity issues

Discussion High secure services are governed by procedural security and nursing staff may be seen by patients as custodians (Pulsford et al., 2013), rather than someone with whom they have a therapeutic relationship. In addition, in a high security setting the project lead has observed that nursing staff have historically felt disempowered in the decision making process where decisions are usually made by the multidisciplinary group mainly influenced by the responsible clinician, a view supported by the data collected during staff interviews. The team wanted to explore the experiences of staff and patients in an attempt to breakdown these historical and procedural barriers. The patient and staff interviews, alongside the patient focus groups, were a powerful vehicle for sharing experiences and starting a critical debate amongst staff. The values clarification exercises with all the stakeholder groups enabled people to really focus on the purpose of supportive observations and start to raise a consciousness amongst staff about the reality of how these were being carried out in practice. In addition to these methods, alongside the project, there had been the recent introduction of reflective practice groups by the practice development team, within all fourteen wards in the high secure services environment. These groups provided a reflective space and enabled staff of all grades to reflect and critically discuss issues in clinical practice. The provision of these groups was an additional opportunity for staff to reflect on and discuss supportive observations and agree different ways in which to work with patients. As a result of all these methods, which have revealed some interesting opinions and discussions around such an emotive topic, data shows that the use of supportive observations has been reduced with an estimated reduction in costs. The methods have also enabled all disciplines of staff to discuss supportive observations with each other in a more constructive way, leading to more creative alternatives.

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At times it was difficult to maintain interest and motivation in the project, which may have been due to the extended length of time, and the fact that the team only had a couple of days each month to complete the vast amount of work required including data collection and thematic analysis, and organising regular meetings with staff and patients. However, after reviewing progress together as a team, along with the support from the FoNS facilitator and the constant revisiting of the Gantt chart, it was easier to see the progress. On reflection it was felt that an alternative approach that may have been more effective would have been to have two members of the teams solely concentrating on the completion of the project. Conclusion The project team set out to gain an understanding of the narrative experiences of both staff and patients alike. The methods used with the project have resulted in a greater understanding of the feelings and thoughts of patients and staff who were involved in supportive observations. The process has generated discussion, which has stimulated change in an institution that was once culturally opposed to new ways of working. It has empowered nurses to be more creative in their thinking, and led to a change in working practice, for the good of the patients and staff. Now people are thinking outside the box, for the benefit of all. It was also the experience of the project team that the facilitation of the project enabled critical dialogue across the organisation and enabled staff to consider and work with alternatives in practice. The data collected suggests that this has resulted in a reduction in the use of supportive observations and an associated potential reduction in cost by service. The project team believe that the main learning point from this project was that by acting as facilitators, they were able to enable change by engaging with staff and patients throughout the process and maintain communication in a collaborative way that resulted in a positive outcome for all. Members of the project team have presented their work at both international and national conferences. Recommendations

The formulation of a working party, to include patients, to explore the supportive observation policy, in more detail, and look for possible amendments to the current supportive observation policy. This may include the reduction of time factors, in supportive observations from two hours to one hour

A supportive observations monitoring group and review process for patients who are on supportive observations. To include more involvement by the responsible clinician and senior nurses in the introduction of supportive observations and in its review process.

The use of zonal observations, to help reduce cost and manpower resources (Carr, 2012)

Individualised care plans to be flexible in approach to addressing any privacy and dignity issues

Patient involvement throughout the process

The reduction of the documentation of supportive observations, to enable a more therapeutic relationship between patient and staff member

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The formulation of a shared training package, in the use of supportive observations, which should be delivered by staff and patients, in the form of workshops and role play.

Daily reviews rather than weekly care team reviews

Positive risk taking

Engagement in meaningful activities, rather than just being a mechanical task

Empowerment of nurses to be more confident in reducing supportive observations Acknowledgements The project team would like to thank the Foundation of Nursing Studies for its support, in particular the Patients First Facilitator, who kept us focused throughout and supported. We would also like to thank the In-patient services, who supported us with time and resources and the psychology services in supporting the project with secretarial support in collecting data and the transcription of interview tapes. Finally, we would like to thank the senior management team, who organised the financial costs associated to the patient focus events, as well as release of key staff to undertake the project in earnest. References: Andrew, S. and Halcomb, E.J. (2009) Future challenges for Mixed methods research in nursing

and the health sciences. In Andrew, S. and Halcomb, E.J. (Eds.) (2009) Mixed Method Research in Nursing and the Health Sciences. UK: Wiley-Blackwell. pp 217-224.

Bowers, L., Gournay, K. and Duffy, D. (2000) Suicide and self-harm in Inpatient psychiatric units, a national survey of observation policies. Journal of Advanced Nursing. Vol. 32. No. 2. pp 437-444.

Bordin, E.S. (1979) The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, Research and Practice. Vol. 16. No. 3. pp 252-260.

Carr, P. (2012) Using zonal nursing to engage women in a medium secure setting. Mental Health Practice. Vol. 15. No. 7. pp 14-20.

Department of Health (1999) Practice Guidance: Safe and Supportive Observation of Patients at Risk. Mental Health Nursing. “Addressing Acute Concerns”. Standing Nursing and Midwifery Advisory Committee June 1999.

Gantt, H.L. (1910) Work, Wages and Profit, published by The Engineering Magazine, New York, 1910; republished as Work, Wages and Profits, Easton, Pennsylvania, Hive Publishing Company, 1974, ISBN 0-87960-048-9.

Gerrish, K. and Ferguson, A. (2000) Nursing Development Units: Factors Influencing their Progress. British Journal of Nursing Vol. 9. No. 10. pp 109-118.

Hersey, P. and Blanchard, K. (1996) Management of Organizational Behaviour: Utilizing Human Resources. Englewood Cliffs, NJ: Prentice Hall.

Manley, K., Hills, V. and Marriot, S. (2011) Person-centred care: Principle of Nursing practice D. Nursing Standard. Vol. 25. No. 31. pp 35-37. February 7 2011

McCormack, B. and McCance, T. (2010) Person-centred Nursing: Theory and Practice. Oxford: Wiley-Blackwell.

McCormack, B., Manley, K. and Titchen, A. (2013) Practice Development in Nursing and Healthcare. (2nd Edition) Chichester: Wiley.

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McSherry, R. and Bassett, C. (Eds.) (2002) Practice Development in the Clinical Setting: A Guide to Implementation. Cheltenham, UK: Nelson Thornes.

MerseyCare Hospital Policy (2010) SD04: Policy and Procedure for the Management of Clinical Risk through Supportive Observation. Accessible at: http://www.merseycare.nhs.uk/Who_we_are/Policies_and_Procedures/Policies_and_Procedures.aspx

Neilson, P. and Brennan, W. (2001) The use of special observations: an audit within a psychiatric unit. Journal of Psychiatric Mental Health Nursing. Vol. 8. No. 2. pp 147-155.

NHS England, (2013/14). NHS Standard Contract for High Secure Mental Health Services (Adults) Particulars, Schedule 2- The Services, A- Service Specification C02/S/a

NHS Institute for Innovation and Improvement (2008) Releasing Time to Care: The Productive Mental Health Ward. Warwick: University of Warwick.

Parahoo, K. (2006) Nursing Research: Principles, Process, and Issues. (2nd edition). China: Palgrave Macmillan Ltd.

Pritchard, E.J. and Dewing, J. (1999) A Multi-Method Evaluation of a Service for People with Dementia [RCNI Report 19]. Oxford: Royal College of Nursing Institute.

Pulsford, D., Crumpton, A., Baker, A., Wilkins, T., Wright, K. and Duxbury, J. (2013) Aggression in a high secure hospital: staff and patient attitudes. Journal of Psychiatric and Mental Health Nursing. Vol. 20. Issue 4. pp 296-304.

Royal College of Nursing (2007) Workplace resources for Practice Development. London: Royal College of Nursing Institute.

Royal College of Nursing (2008) What is a principle? How do I use this in practice? London: Royal College of Nursing Institute.

Timmons, D. (2010) Forensic psychiatric nursing: a description of the role of the psychiatric nurse in a high secure psychiatric facility in Ireland. Journal of Psychiatric and Mental Health Nursing. Vol. 17. pp 636–646.

Van der Nagel, J., Tuts, K. and Noorthoorn, E.O. (2009) Seclusion: the perspective of nurses. International Journal of Law and Psychiatry. Vol. 32. No. 6. pp 408-412.

Wadsworth, Y. (2005) Everyday Evaluation on the Run (3rd Edition). Walnut Creek, CA: Left Coast Press.

Whittington, R., Baskind, E. and Paterson, B. (2006) Coercive measures in the management of imminent violence: restraint, seclusion and enhanced observation. Chp 8 in Richter, D. and Whittington, R. (Eds.) (2006) Violence in Psychiatry; Causes Consequences and Control. New York: Springhouse.

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Appendix 1 Team Culture Tool (Pritchard and Dewing, 1999) Think about the culture of YOUR TEAM. Your team could be the staff you work with on a ward or in a community based team. Read through the list (a. to l.) below and circle the number on each question that identifies the nearest to where you think YOUR TEAM is. This questionnaire should take from 5 - 15 minutes to complete.

a) People in my team have dissimilar values, interests and beliefs

1 2 3 4 5 People in my team share values, interests and beliefs

b)People in my team break rank and go it alone

1 2 3 4 5 People in my team pull together

c)Individuals in my team operate alone and there is conflict between them

1 2 3 4 5 There is community spirit and co-operation in my team

d)My team is ruled by standards of the past

1 2 3 4 5 My team is ruled by visions of the future

e)Meetings are an aspect of the culture in my team

1 2 3 4 5 Working in small teams is an aspect of the culture in my team

f)In my team there are winners and losers, them and us

1 2 3 4 5 People confront and move beyond their differences in my team

g)My team is anti-change

1 2 3 4 5 My team is change oriented

h)There is weak co-ordination in my team

1 2 3 4 5 There is strong co-ordination in my team

i)My team is inward looking and is focused on itself

1 2 3 4 5 My team is outward looking and does not focus on itself

j)My team is dominated by routine and systems

1 2 3 4 5 My team is creative and ideas dominated

k)People do not reflect about their work in my team

1 2 3 4 5 People reflect about their work in my team

l)There is disagreement in my team

1 2 3 4 5 There is harmony in my team

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Appendix 2

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Appendix 3

HSS Nursing Survey: Supportive Observations Survey Responses Rates

Ward Staff Survey Sent To

Staff Absent from Duty for

full Survey Period

(Annual leave/ Maternity, Training,

Sickness, Unpaid leave, etc.).

Staff Available to Complete Ward Survey

Full Responses Per Ward

Partially Responded

Opted Out Did Not Respond

Response Rate Per

Ward (% of Full

Responses)

Arnold 40 Nil 40 28 Nil Nil 12 70%

Blake 42 2 40 22 Nil Nil 18 55%

Carlyle 33 3 30 17 Nil Nil 13 56.67%

Dickens 30 2 28 13 2 Nil 13 46.43%

Eliot 31 4 27 11 3 Nil 13 40.74%

Forster 27 2 25 10 3 Nil 12 40%

Gibbon 32 5 27 14 1 Nil 12 51.85%

Hazlitt 29 1 28 19 1 Nil 8 67.86%

Johnson 41 3 38 21 Nil 1 16 55.26%

Keats 40 2 38 22 Nil Nil 16 57.89%

Lawrence 44 3 41 26 2 Nil 13 63.41%

Macaulay 38 3 35 20 Nil Nil 15 57.14%

Newman 34 1 33 17 3 Nil 13 51.51%

Tennyson 41 Nil 41 25 Nil 1 15 60.98%

Total 502 31 471 265 15 2 189

100% 6% 100% 56.26% 3.18% 0.42% 40.13%

The overall rate of return for the HSS Ward Survey is 56.26%

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Appendix 4

Patient Questions

1. What is your personal experience of supportive observations?

Positives

Negatives

Staff/appropriate/warranted/age/gender?

2. Can you tell me your understanding of why you are being observed by a nurse?

Necessary

Alternatives

Did you feel supported + Why

Collaborative, where you involved in the decision?

What level of engagement did you have with the staff?

Could it be improved?

3. What can we do together to reduce supportive observations and promote your independence?

4. How do you feel you benefited from supportive observations?

Were you offered any post supportive care?

5. How can we maintain your privacy and dignity whilst on supportive observations?

Staff Questions 1. Can you tell me what your understanding of what supportive observations is?

Role

Maximum time to observe

How do you feel when on supportive observations?

2. What impact do you have during supportive observations?

How do you engage with the patient?

Is it purely observational?

3. Are supportive observations always necessary?

Can you think of any alternatives?

4. Can you tell me what experiences of supportive observations is?

5. What helps or hinders in reducing supportive observations?

What keeps patients on supportive observations?

Why do they go wrong?

Staff/gender/appropriate/warranted/age?

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Appendix 5 Gathering data Hours of supportive observation undertaken Data collection: Pre data for the use of supportive observations. Ward A Figure: 1

Period: Pre data Jun-Nov 2011. Total Hours: 20242.07 Patients on supportive observations. Total Hours: 21233.01 Staff cumulative hours spent on supportive observations. Post data for the use of supportive observations. Ward A

Period: Post Data Aug 2012-Jan 2013. Total Hours: 3903.8 Patients on supportive observations. Total Hours: 4981.58 Staff cumulative hours spent on supportive observations. This represents an 80.7% decrease in patients requiring supportive observations. This represents a 76.5% decrease in staff hours undertaking supportive observations.

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Pre data for the use of supportive observations. Ward J

Period: Pre data Jun-Nov 2011. Total Hours: 11317.1 Patients on supportive observations. Total Hours: 11632.8 Staff cumulative hours spent on supportive observations. Post data for the use of supportive observations. Ward J

Period: Post Data Aug 2012-Jan 2013. Total Hours: 4563.33 Patients on supportive observations. Total Hours: 4406.78 Staff cumulative hours spent on supportive observations. This represents a 59.6% decrease in patients requiring supportive observations. This represents a 62.1% decrease in staff hours when undertaking supportive observations.

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Pre data for the use of supportive observations. Ward K

Period: Pre data Jun-Nov 2011. Total Hours: 16240.5 Patients on supportive observations. Total Hours: 16240.5 Staff cumulative hours spent on supportive observations. Post data for the use of supportive observations. Ward K

Period: Post Data Aug 2012-Jan 2013. Total Hours: 6815.4 Patients on supportive observations. Total Hours: 8311.35 Staff cumulative hours spent on supportive observations. This represents a 58% decrease in patients requiring supportive observations. This represents a 49% decrease in staff hours when undertaking supportive observations.

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Pre data for the use of supportive observations. Ward L

Period: Pre data Jun-Nov 2011. Total Hours: 7364.85 Patients on supportive observations. Total Hours: 7364.85 Staff cumulative hours spent on supportive observations. Post data for the use of supportive observations. Ward L

Period: Post Data Aug 2012-Jan 2013. Total Hours: 1520.33 Patients on supportive observations. Total Hours: 1870.3 Staff cumulative hours spent on supportive observations. This represents a 79.3 % decrease in patients requiring supportive observations.

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This represents a 74.6 % decrease in staff hours when undertaking supportive observations.

Appendix 6 :Supportive Observations: Pre -project Survey Results – All Wards

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Appendix 7

Supportive Observations: Post-project Survey Results – All Wards

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