Improving ‘observation practice’ in mental health

The Scottish Patient Safety Programme – Improving Observation Practice (SPSP-IOP) aims to extend and build on existing good practice in mental health services. In conjunction with NHS test sites, we developed innovative, person-centred guidance that changes the way we respond to the needs of acutely unwell mental health inpatients.

A need was identified to improve observation practice in mental health inpatient units. Through observation practice we aim to support services to therapeutically engage with distressed and acutely unwell patients to prevent them from harming themselves or others at times of high risk during their recovery.

With the support of six territorial boards, we developed and tested new, ambitious and innovative ways of working and engaging with people to change the response to their care, treatment and safety needs when they’re acutely unwell.

It quickly became clear from scoping with these test boards and service users that a radical change was needed in the wider culture and practice linked to observation practice.

A service user described how the improvements impacted their care: “I remember the many times that I have been on enhanced observations and how lonely it can feel when the person following me around or sitting beside me to protect me from myself had nothing to say. In fact, they seemed uncomfortable in the space they shared with me. There is something terribly sad [in] that, when at your most distressed and confused, communication can sometimes seem impossible, even with the best of nurses.

“And yet there is something liberating when, late at night, you have been walking round and round the ward in erratic upset circles, the nurse who is providing constant observation for you comes into your room and talks you through a guided relaxation session and, although the soft music that accompanies it might not send you to sleep, you feel treasured and cared for.”

Using improvement science methods, where practices are systematically examined to work out what will best facilitate quality improvement, the six boards tested new ideas including:

  • Individualised care plans.
  • Greater focus on therapeutic activity as a mechanism for meaningful engagement with individuals requiring observation.
  • Managing and recording observations.
  • Team communication.

The learning from these six test sites, along with feedback from SPSP-IOP leads contributed to new draft guidance in 2017. The guidance recommends that care, treatment and safety planning is steered by the identified specific clinical needs of the individual.

In 2017-18, the programme expanded from the initial six test sites to include the 11 mainland territorial boards and the State Hospitals Board for Scotland. All 12 of these boards appointed an SPSP-IOP lead and are actively testing the implementation of the new guidance.

NHS Ayrshire & Arran, one of the test boards, reported that, “Successful tests of change in Acute Admission Units at Woodland View have been embedded in ward culture and practice; notably the floor nurse concept*, bi-daily safety huddles and related impacts on ward culture. The ihub is working with NHS boards to develop common measures to assess the ongoing positive impact of this work on the care of mental health patients.”

*A floor nurse is a registered nurse who performs a variety of duties within a hospital, and often specialises in a particular field, for example, mental health nursing.