Engagement and Formal Observation.

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Engagement and Formal Observation.

• Trust Policy, History, Context and Interpretation

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Engagement and Observation Policy 2014
Historical overview

• Original policy written in 2002. Policy
  consultation process took place across the Trust
  (service users, carers, staff, managers)
• New Policy written July 2005, reviewed 2007
  policy standards added, training powerpoint, and
  competency document. Reviewed 2011 (NHSLA)
• Move away from Observation to
  Engagement.
• 2014 Currently being reviewed in light of
  Professor Len Bowers findings and the
  implementation of the Care Delivery System
  (SLaM).

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Engagement and observation what the original
policy said..

• Reasons why nurses find enhanced observation
  difficult
• Reasons why patients find enhanced observations
  difficult
• Factors related to these-
• Environment
• Clinical Skills/ Clinical Leadership
• Availability of structure/ activities/
  alternatives
• Clinical supervision
• Boundaries
• Expectations

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Changes Made.

1. Intermittent observations can only be instigated
   when reducing levels of observations from an
   enhanced status.
2. Senior Nurses to be included in the rota for
   enhanced engagement of patients.
3. Visual Handover of patients to take place from
   the shift co-ordinator to the shift co-ordinator
   on each shift change.
4. Caringly Inquisitive Behaviour by nurses
5. Intentional Rounding

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Rationale for the changes made in the original
policy- Number 1

• A number of incidents had occurred within
  the trust on in patient wards
• Attempted suicide
• Suicide
• Self Harm
• An audit of all Board Level Inquiries was
  completed during 2004/5 and any incidents where
  patients were undergoing special observations
  as they were called then were reviewed.
• Many of these incidents occurred whilst
  patients were undergoing 15 minute checks.
  Move away from 15 minute checks as patients were
  able to monitor this quite easily and commit acts
  of self harm and suicide.

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Rationale for changesNumber 2

• Patients who are in need of the most skilled
  nursing, the most unwell patients are often being
  cared for by the most junior staff, or by staff
  who do not know them very well, resulting in
  limited social or therapeutic conversations.
• Patient experiences of enhanced observation
  described as dehumanising and distressing. (local
  and national evidence) Some nurses would just sit
  and read a newspaper, would not talk to the
  patient, no engagement at all.
• Ward managers, deputies, practice development
  nurses, and other senior nurses will be on the
  rota for the observation/ engagement with
  patients.
• Encourage role modelling and reflection on
  practice during the shift.

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Rationale for changesNumber 3

• During the review of serious incidents in 2004/5
  we found that many of the most serious incidents
  where patients had harmed themselves or
  committed suicide were taking place during the
  handover period between 1-3p.m.
• Very few qualified nurses were actually on
  the ward with the patients.
• RMNs were sometimes in the office for a couple of
  hours before actually seeing a patient, sorting
  out paperwork, answering the phone, many
  administrative tasks.
• At the beginning of every shift it will be the
  responsibility of the nurse in charge to carry
  out a visual handover to the nurse in charge of
  the next shift, of all the patients on the ward,
  also the whereabouts of the patients on leave.

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Number 3..Visual Handover

• This is about ensuring that nurses are clear
  about their level of responsibility when taking
  over a shift. To know how their patients are, and
  where they are.
• This does NOT replace the verbal handover,
  but will need to be locally implemented.
• Intentional Rounding- term used by David
  Cameron to encourage senior nurses to visually
  see and monitor patients every hour.
• Reassuring for the patients and the Nurse in
  Charge to be visible at the beginning of the
  shift.

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Intentional Rounding caringly inquisitive
behaviour in the policy.

• Communicating with someone, assessing their
  mental well being, Being present, helpful,
  listening, and supportive
• A service which is experienced by service
  users as acceptable, accessible and helpful.
• Encourages nurses to be curious and seek
  out patients who are not attending routine
  activities, such as groups and meals.
• Acknowledges and respects individuals
  autonomy, identity, strengths and viewpoint.
• Attends to wider social needs and
  aspirations, cares about a persons well being

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Changes in Documentation..

• Observation record
• Observation care plan
• Epjs Observation care plan
• Visual Handover recorded on the handover
  record sheets (some areas completing this now)
• Records kept locally of completion of
  Engagement and Observation competency document,
  and completion of training.
• Current records of intentional rounding to
  inform ward staff about patients views.

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Intermittent Observations

• Patients tolerate intermittent observations
  better than within arms length or within eyesight
  observations, and every attempt should be made to
  reduce levels of observation from within eyesight
  and within arms length to intermittent as soon as
  possible.
• Engagement with the patient should take place
  approximately four times an hour, but at
  irregular intervals, trying to avoid 15 minute
  checks.
•  

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Named levels of observation

• Within arms length
• Within eyesight
• Intermittent
• General

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Process of reviewing observation levels..

• MDT ( Doctors and Nurses)
• Reviewed on each shift.
• Changes to levels of enhanced observations
  can take place when the risk factors have been
  reduced. This has to be completed and recorded
  prior to change of status.
• Senior clinicians involvement, expertise,
  advice,
• presence on the ward.
• Encouraging for junior staff and for
  patients.

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Senior Nurses

• Ward managers, deputies, practice development
  nurses, and other senior nurses will be on the
  rota for the observation/ engagement with
  patients.
• Encourage role modelling and reflection on
  practice during the shift.
• Reviews of all patients on enhanced levels of
  observation with Doctors and Nurses.

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Resources.

• Multi disciplinary presence on the wards at key
  handover times, review meetings and community
  meetings.
• Care Delivery System being rolled out across all
  in patient wards.
• Review structures/ activities on the wards. How
  many patients have a structured activity
  programme, and how is this maintained.
• How are the social areas used to their full
  advantage
• Benefits of skilled activity co-ordinators.
• Use of training resources/role plays/ facilitated
  reflection sessions
• Clear philosophy on each ward stating
  expectations of staff and patients related to
  specific behaviours.
• Nurse Consultant. Supporting Safe and Therapeutic
  services how often is this resource being used.

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Current policy review includes.

1. Adding Caringly Vigilent Behaviour by nurses
2. Adding Intentional Rounding
3. Changing the use of Intemittent Observation.Use
   at any point during the patient admission rather
   than as a reduction from more enhanced
   observations.