Special observations in forensic psychiatric practice: gender issues of the watchers and the watched

Balancing security and care: Gender relations of nursing staff in forensic psychiatric care

This study departs from the built-in tension of the dual goals of forensic psychiatric care in Sweden, which are to protect society as well as to care for patients. The majority of violence that takes place is perpetrated by men. Therefore, the views of nursing staff on violence as a gendered phenomenon have an impact on the care provision. There is a need for further knowledge of how norms of violence are intertwined with the construction of gender. The aim of this study was to use a gender perspective to demonstrate the views of nursing staff on security and care and the consequences for their relationships with patients. The study adopts an ethnographic approach, with data consisting of field notes from participatory observations and interviews with nursing staff at two maximum-security clinics. We show how the perceptions of nursing staff about gender relations are based on heteronormative thinking, which affects their practice. This implies that if gender is ignored in relation to the dual goals, there is a risk of perpetrating patterns of unequal conditions. Therefore, it is vital to make gender visible to counteract unequal conditions for nursing staff and address patients' individual care needs.

What to look for during constant observations: Expert consensus and a tool for observations recording

WHAT IS KNOWN ON THE SUBJECT?: Supportive observations is the practice of closely monitoring patients who are acutely unwell in order to keep them safe. There are no formal guidelines for nursing staff on what to observe during observations. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: A consensus of expert opinion suggests that the clinically meaningful behaviours in supportive observations focus on six factors: agitation, self-harm and suicide, violence, negative influence, disengagement and positive behaviour. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: These aspects of patient presentation should be a part of the decision-making discussions about observations. The Mersey Care Supportive Observations Recording Tool that emerged from this consensus may assist with recording the relevant information. Abstract Introduction Supportive observations are common in mental health care but there are no guidelines on best practice or what should be documented in observations records. Aim To develop expert consensus on the important aspects of patient presentation that inform clinical decision-making about observations and to develop a recording tool from this consensus. Method A Delphi methodology was used to consult an expert panel of mental health clinicians and academics to agree on what aspects of patient presentation during constant observations are important in informing clinical decisions. Thematic analysis was applied to the agreed item set to extract common aspects of presentation and behaviour. Results The panel considered 118 individual items across three rounds of consultation and agreed that 51 items were important to clinical decisions about observations. Thematic analysis found six man themes: agitation, self-harm and suicide, violence, negative influence, disengagement and positive behaviour. Subthemes were used to create the MerseyCare Supportive Observations Recording Tool (MSORT). Discussion These data represent the first expert consensus on the aspects of patient presentation that are important to clinical decisions. Implications for practice Consensus items should be recorded in observations records and be considered in decision-making about observations. The MSORT may aid observations recording.

The Impact of Nursing Protocols on Continuous Special Observation

BACKGROUND

Continuous Special Observation (CSO) is commonly ordered for patients at risk to injure themselves or others and involves assigning staff to monitor one patient at all times. CSO is intrusive, costly, and often has deleterious effects on patient care. Two nursing protocols were developed as alternative interventions to CSO. The first protocol, Psychiatric Nursing Availability (PNA), was designed to treat patients having suicidal or self-injurious thoughts. The second protocol, Psychiatric Monitoring and Intervention (PMI), was designed to prevent violent and impulsive behavior. These protocols had their genesis in a model that encourages nursing autonomous decision making.

OBJECTIVE

Identify the impact PNA and PMI had on the number of CSO and their duration.

STUDY DESIGN

Nine-year descriptive retrospective analysis of CSO, PNA, and PMI. The data were collected from the unit 15-minute rounding sheets. Descriptive analyses were performed. Interrupted time series analysis was used to determine how the protocols affected frequency and duration of CSO.

RESULTS

PNA did not significantly affect CSO; however, PMI did affect its use. There was a downward trend in the number of CSOs after PMI was implemented by 0.07 episodes per month ( p = .0111). The median duration of CSO dropped from 66 hours to 33 hours after PMI was implemented ( p = .0004).

CONCLUSION

PMI had the greatest impact on CSO. PMI had a secondary effect of increasing staff availability on the unit that affected CSO's use. The model of nursing care may have influenced this reduction in CSO.

Panoptic power and mental health nursing-space and surveillance in relation to staff, patients, and neutral places

Mental health nurses use manifest and latent approaches for surveillance and observation of patients in the context of mental health care. Patient spaces in mental health organizations are subtly linked to these different means of surveillance. This article investigates these approaches, focusing in particular on the variety of spaces patients occupy and differences in the intensity of observation that can be carried out in them. The aim is to elaborate on space and surveillance in relation to the patients' and nurses' environment in psychiatric nursing care. Places where patients were observed were operationalized and categorized, yielding three spaces: those for patients, those for staff, and neutral areas. We demonstrate that different spaces produce different practices in relation to the exercise of panoptic power and that there is room for maneuvering and engaging in alternatives to "keeping an eye on patients" for nurses in mental health nursing. Some spaces offer asylum from panoptic observations and the viewing eyes of psychiatric nurses, but the majority of spaces in mental health nursing serve as a field of visibility within which the patient is constantly watched.

Latent or manifest observers: two dichotomous approaches of surveillance in mental health nursing

Background. Surveillance is a central activity among mental health nursing, but it is also questioned for its therapeutic value and considered to be custodial. Aim. The aim of this study was to describe how mental health nurses use different approaches to observe patients in relation to the practice of surveillance in psychiatric nursing care. Methods. In this study, Spradley's twelve-step ethnographic method was used. Results. Mental health nurses use their cultural knowing to observe patients in psychiatric care in various ways. Two dichotomous approaches were identified: the latent and the manifest approach. Discussion. Different strategies and techniques for observing patients are structured along two dichotomies. The underlying relationships between these two different dichotomous positions transform the act of observing into surveillance. This is further developed in a theoretical model called the powerful scheme of observation and surveillance (PSOS).

The evolution of practice changes in the use of special observations

In acute psychiatric settings, it is common practice to increase the intensity of observations of patients who present with self-injurious thoughts, who are at risk of injuring others, or who exhibit behaviors that adversely impact the overall milieu. These intense observations are intrusive and may result in untoward stimulation of the patient. Nurses at an urban academic medical center addressed the problem of intrusive and overstimulating levels of observation by developing two practice changes using intuitive knowledge combined with input from current nursing literature. The first change was designed to move from observation to engagement. The second change was designed to decrease patient agitation related to intense observation. This article discusses the potential adverse consequences associated with the use of intense levels of observation and describes two protocols that have contributed to a reduction in the use of seclusion and restraints, as well as staff members' reported perceptions of feeling safer and experiencing improved job satisfaction.