High Secure Services Supportive Observation Project

HIGH SECURE SERVICES The use of supportive SUPPORTIVE OBSERVATIONS observations PROJECT in a high secure setting “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: Supported by the Foundation of Nursing Neil McBride: Project Lead Studies Patients First Programme in Ceri Anderson, Jane Kirby, Mathew Savage Partnership with the Burdett Trust for Nursing March 2014 25 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: [email protected] 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 1 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 2 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

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