The speaker has no conflict of Hamilton, B. & Manias, E. 2008 - - PDF document

APNA 30th Annual Conference Session 2033: October 20. 2016 Ray 1

The Effects of two Nursing Protocols on the Use of Continuous Special Observation

Presented at: APNA 30th annual Conference Presented on: October 20, 2016 Presented by: Richard Ray, MS, RN, PMH-BC

The speaker has no conflict of interest to disclose.

Objectives

• Discuss uses of Continuous Special Observations (CSO)
• Discuss Problems with CSO
• Discuss Nursing Protocols developed as an alternative to CSO
• Discuss research on how Nursing Protocols affect use of CSO

Background

Positive outcomes of CSO when staff engage the patient –Provides increased opportunity for assessment, –Provides time to establish therapeutic relationship –Staff assist patient in developing coping skills. (Cleary et al. 1999) –patients experience decreased hopelessness and suicidal thoughts and increased feelings of worth (Jones et al., 2000b; Pitula & Cardell, 1996). –Staff are able to intervene quickly and deescalate aggression and violence (Mackay et al., 2005). Purpose of CSO: Provide safety for all patients and staff while a particular patient is at risk of harming themselves and/or others (Clinical Resource and Audit Group, 2002).

Background

• Staff exert control of patient to create safety

– Consequences of staff not implementing control Hamilton, B. & Manias, E. 2008

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Continuous Special Observation based on control

• Meechan et al (2006) collected suicide data in England from

1996‐2000 There were 236 inpatient suicides – 139 on intermittent observation – 74 eloped on intermittent observation or Continuous Special Observation – 17 died on 1:1

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Background‐ Research Studies

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The City 128 Study by Bowers et al (2006)

• Intermittent Observations (as opposed to Constant

Observations) may act to reduce the rate of self harm

• Intermittent Observations are effective so long as patients

frequently participate in staffed activity sessions and adequate numbers of nursing staff are available in the milieu

• Intermittent Observations may work because it places nurses
• ut on the unit making them more accessible and visible to

patients (Bowers, L.,& Simpson, A. 2007)

Background –Research Studies

Dismantling Formal Observations and Refocusing Nursing Activity (Dodds and Bowles 2001)

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• Aim of study: Refocus nursing practice from control oriented

interventions to care oriented interventionn

• Outcomes

‐ Nurses assumed control of Observations ‐ Patients felt more engaged in treatment ‐ Self‐Harm reduced by 67% ‐ Violence reduced by 33% ‐ Staff calling in sick reduced by 60% ‐ Cost savings of 47,000 pounds

Background

• Engagement defined as being clinically involved with a

patient while the patient moves towards their clinical treatment goals

• The process of engagement involves making a human–

human connection and conveying acceptance, understanding, and tolerance

• Engaging interventions are based on demonstrating care

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Engagement

Background

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Psychiatric Nursing Availability (PNA) (2001) designed for self‐ injurious or suicidal patients

• Staff partners with patient in coping with violent impulses
• Relationship‐based: based on acceptance, tolerance and

understanding

• Patient becomes active partner in maintaining own safety

Nursing Protocols

Background

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Psychiatric Monitoring and Interventions (PMI) (2004) designed for violent intrusive, impulsive patients

• Based on removing elements of violence: Weapon, Target,

Trigger, State of arousal

• Patient allowed privacy in their own room
• Staff partners with patient in coping with violent or

impulsive behavior

• Staff interventions are focused on the entire unit
• Nurse develops individualized care plan when out of room

Nursing Protocols

Background

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• Assigned and empowered to manage a team of patients from

admission to discharge

• 24/7 accountability
• Develops and drives the plan of care with the MD
• Paired with attending psychiatrist and interdisciplinary team

Nursing Model – Primary Nursing Coordinator

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Background

3 3 2 12 21 3 5 11 11 11

5 10 15 20 25

Number of Staff Responses

Degree of Agreement "I Have Concern for My Personal Safety"

Concern for Personal Safety on CSO vs. PMI

Perception of Risk to Safety on CVO Perception of Risk to Safety on PMI

41 staff answered questionnaires on concern for safety monitoring patients on CSO and PMI using a 16 item Likert‐type scale Findings: staff rated feeling safer on PMI than CSO (p<.05).

Have the two nursing protocols reduced the use of Continuous Special Observation?

• Identify Frequency and duration of CSO prior to nursing protocols
• Indentify how PNA impacted the Frequency and duration CSO
• Indentify how PMI impacted the Frequency and duration of CSO

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Problem Statement Project Plan

• Has PNA reduced the use of CSO?
• Has PMI reduced the use of CSO?

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A 12 year retrospective review of the 15 minute round document form from 9/1999 to 9/2011

PNA Implemented 2001 PMI developed 3/2004 Move to new Unit 9/24/11 Initiation of study 9/1/1999

15 Minute Round documents

• Descriptive analyses

– frequencies, percentage, mean, median and standard deviation

• Interrupted time series analysis
• Wilcoxon two‐sample test

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Analysis Findings

CSO and Nursing Protocols

Hours

10 20 30 40 50 60 70 2002 2003 2004 2005 2006 2007 2009 2010 2011* PNA PMI CSO

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Findings

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100 200 300 400 500 600 200… 200… 200… 200… 200… 200… 200… 200… 200… 200… 200… 200… 200… 200… 200… 200… 200… 200… 200… 200… 200… 200… 200… 200… 200… 200… 200… 200… 201… 201… 201… 201… 201… 201… 201…

Hours Monthly Median Total CSO Duration Per Patient

• Episodes of CSO

– Increasing trend by .05 per month prior to Nov 2005 (P=.0083) – Decreasing trend by .07 per month after Nov 2005 (P=.0111)

• Median Episode Duration (hours) for CSO

– Before Nov 2005: 66 (range 9.75‐484.75) – After Nov 2005: 33 (range 8.25‐226.7), p=0.0004

Findings

• Episodes of CSO

– Increasing trend by .05 per month prior to Nov 2005 (P=.0083) – Decreasing trend by .07 per month after Nov 2005 (P=.0111)

• Median Episode Duration (hours) for CSO

– Before Nov 2005: 66 (range 9.75‐484.75) – After Nov 2005: 33 (range 8.25‐226.7), p=0.0004

5 10 15 20 25 30

Quarterly number of PMIs

Number of PMIs

Findings

10 20 30 40 50 60 70 2002 2003 2004 2005 2006 2007 2009 2010 2011* PNA PMI subjects in seclusion

Number of PNAs PMIs and Seclusion Incidents

Nursing Protocols and use of Locked Seclusion

Hours

Findings

Mean number of hours on CSO

Hours

500 1000 1500 2000 2500 3000 3500 2002‐2005 2006‐2011 2010‐2011 2011*

3392 1906 1209 569

Differences between CSO and Nursing Protocols

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• Constant Special Observation (CSO)

– Ordered by Physician based on Physician interview – Intervention based on control to decrease risk – Intrusive ‐ often resulting in adverse outcomes – Costly to implement and poor use of nursing resources

• Nursing Protocols

– Ordered by Nursing based on 24 hour ongoing assessment – Intervention based on Engagement – Designed to treat individual patient needs – Patient is able to develop alternative coping skills – increases staff presence on unit

Discussion

Secondary Outcomes

• Employee satisfaction increased

– Employee satisfaction 4.04 in 2005 to 4.65 in 2009 – “Is there appropriate staffing to deliver safe care?”

3.54 in 2005 to 3.88 in 2009

Discussion

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Why did PMI make more impact on CSO?

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Discussion

• PMI implemented much more frequently than PNA
• Protocol influences number of staff out of the nurses station

and in milieu – City 128 study findings indicate close supervision decreases the CSO by placing more staff in the milieu with patients

• PMI Interventions directed towards the patient and the entire

milieu

• PMI interventions designed to provide patient safety to in the

milieu which can be viewed by patients as caring intervention – Caring interventions influences hope

Limitations

• Design was not a randomized controlled study
• Small sample size ‐ Research conducted on one 17 bed unit
• The primary researcher worked on unit throughout study

– Conducted research in 2007 on staff’s perception of safety employing PMI compared to CSO – Paper published in 2011 ‐ The Evolution of Practice Changes in the Use of Special Observations. Archives of Psychiatric Nursing 25 (2), 90‐100

Conclusion

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• Safety can be achieved by:

– having staff out on the unit With Patients – using intermittent observations and engagement

• Constant Special Observation emphasizes control
• Protocols emphasize care and engagement to treat patients
• Reduction in Constant Special Observation supports mission of NMH

– Improves best patient experience – Improves best employee experience – Improves financial performance

Questions?

References

Bowers, L., Whittington, R., Nolan, P ., & D Parkin S., (2006) The City 128 Study OF Observation and Outcomes on Acute Psychiatric Wards. Report to the NHS Service Delivery and Organization Program. City University, London. Bultima, J., Getzfrid, M., Slade, M., (1996) Defining Professional Practice: The Evolution of the RANA Model. Journal of the American Psychiatric Nurses Association 2 117‐126 Cutcliffe, J. R., & Stevenson, C. (2008) Feeling our way in the dark: The psychiatric nursing care of suicidal people: A literature review. International Journal of Nursing Studies 45 (6) 942‐953. Dodds, P ., Bowels, N., (2001) Dismantling formal observation and refocusing nursing activity in acute inpatient psychiatry: a case study. Journal of Psychiatric & Mental Health Nursing, 8 (2), 183‐188. Mechan, J., Kapur N., Hunt, IM., et.al (2006) . Suicide in mental health in‐patients and within 3 months of discharge. National clinical survey. British Journal of Psychiatry, 188, 129‐134. Polacek, M., Allen, D., Damin‐Moss, R., Schwartz, A.,Sharp, D.,Shattell, M., Souther, J., Delaney, K. (2015) Engagement as an Element of Safe Inpatient Psychiatric Environments Journal of the American Psychiatric Nurses Association 21 181‐190.

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References (Continued)

Ray R., Perkins E., Meijer B., (2011) The Evolution of Practice Changes in the Use of Special Observations. Archives of Psychiatric Nursing 25 (2), 90‐100. Savage, George (1884). Constant Watching of Suicidal Cases’ The British Journal of Psychiatry, Vol. 30, 17‐19 Whitehead, E., & Mason, T. (2006) Assessment of risk and special observations in mental health practice: A comparison of forensic and non‐forensic settings. International Journal of Mental Health Nursing 15 (4) 235‐241.

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Thank You