Staff and patient perspectives on therapeutic engagement during one‐to‐one observation

Abstract

Accessible summary What is known on the subject? One‐to‐one observation uses continuous staff observation to safeguard patients judged likely to harm themselves or others. Policies increasingly mandate that staff engage therapeutically with patients during one‐to‐one observation. Yet not enough is known about factors facilitating or impeding such therapeutic engagement. What does this paper add to existing knowledge? This study enriches existing literature on one‐to‐one observation through integrating the perspectives of staff of different levels of qualification, and patients of different diagnostic and risk profiles. Whilst previous research has highlighted the occurrence of counter‐therapeutic staff‐patient interactions, integration of patient and staff perspectives in the current study has demonstrated that patient and staff often attribute the causes differently, with each apportioning blame to the other, leading both parties to feel misunderstood, and staff lack confidence to overcome these challenges. A novel finding was that rapport‐building via simple demonstrations of compassion and conversations about everyday things, was viewed as an essential prerequisite to encouraging patients to open up about their experiences of emotional distress, whilst implementation of techniques drawn from psychological interventions was viewed as less important than staff's core relational skills. What are the implications for practice? Therapeutic engagement during observation can enhance its risk management aims, providing thought is given to understanding and negotiating complex dynamics between staff and patients. Supervision for staff conducting observations should focus on building rapport in preference to emphasizing psychological intervention (e.g. DBT), and should enable staff to reflect on better understanding and managing their own emotions towards “hard‐to‐engage” patients. Abstract IntroductionPolicies increasingly focus on staff‐patient interactions during one‐to‐one psychiatric nursing observations as an opportunity for therapeutic engagement – yet if and how this is feasible is unknown. AimThis study aimed to integrate staff and patient perspectives to determine what factors facilitate or impede therapeutic engagement during one‐to‐one observation. MethodThematic analysis of qualitative interviews with 31 psychiatric inpatient staff at different levels of seniority and 28 inpatients spanning a range of diagnoses and risk profiles. ResultsNegative experiences of observation were characterized by a reciprocal dynamic where both patients and staff withdrew from interactions, having felt the other did not want to engage with them. Staff and patients agreed that these difficulties could be overcome when staff showed patients that they cared, gradually building trust through simple demonstrations of compassion and ‘normalizing’ conversation about everyday things. This approach helped patients to feel safe enough to open up about their distress, which in turn helped staff to better understand their expe...

Evaluation of an alternative model for the management of clinical risk in an adult acute psychiatric inpatient unit

“…While observation activities are seen as necessary for maintaining patient safety, many nurses recognize the practice as intrusive, nontherapeutic, and potentially dehumanizing and distressing for patients (Holyoake ; Insua‐Summerhays et al . ). Moreover, visual observation is adverse to a core concept of recovery‐focused care, co‐production, which recognizes the patient as an equal partner in care planning, rather than a passive recipient (Clark ).…”

“…A recurring theme is that nurses report struggling with the conflicting demands of adhering to safety protocols while maintaining a therapeutic environment for the patient (Insua‐Summerhays et al . ; Lees et al . ).…”

“…A number of qualitative studies have examined nurses' and patients' attitudes towards observation practices (Berglund et al 2016;De Santis et al 2015;Holyoake 2013;Insua-Summerhays et al 2018;Lees et al 2014;Stewart et al 2015). A recurring theme is that nurses report struggling with the conflicting demands of adhering to safety protocols while maintaining a therapeutic environment for the patient (Insua-Summerhays et al 2018;Lees et al 2014). While observation activities are seen as necessary for maintaining patient safety, many nurses recognize the practice as intrusive, nontherapeutic, and potentially dehumanizing and distressing for patients (Holyoake 2013;Insua-Summerhays et al 2018).…”

“…A recurring theme is that nurses report struggling with the conflicting demands of adhering to safety protocols while maintaining a therapeutic environment for the patient (Insua-Summerhays et al 2018;Lees et al 2014). While observation activities are seen as necessary for maintaining patient safety, many nurses recognize the practice as intrusive, nontherapeutic, and potentially dehumanizing and distressing for patients (Holyoake 2013;Insua-Summerhays et al 2018). Moreover, visual observation is adverse to a core concept of recovery-focused care, co-production, which recognizes the patient as an equal partner in care planning, rather than a passive recipient (Clark 2015).…”

“…However, the element that appears from patient accounts to transform the practice into a beneficial experience is the degree of positive engagement with the observer. When observers were perceived as empathetic, nonjudgemental, and willing to help, the experience was seen as reassuring and therapeutic, while observation by persons who act bored, inconvenienced, or do not interact at all with the patient was rated as highly distressing and objectifying (Berglund et al 2016;Insua-Summerhays et al 2018;Stewart et al 2015). An Australian survey by Lees et al (2014) noted that while both nurses and patients recognized the importance of positive staff-consumer engagement as a therapeutic tool, they also reported that this engagement rarely occurred.…”