The use of special observations: an audit within a psychiatric unit

Observation is a fundamental skilled nursing intervention. Special observation is an intensified and often prolonged form of this intervention. Depending upon their nature, and the circumstances under which they are carried out, special observations may invoke varying degrees of stress in both the observer and the observed. They may also raise important ethical and significant financial questions. In psychiatry, special observations are usually imposed where a patient is assessed as representing some degree of risk to themselves or others because of their behaviours or potential behaviours. Special observations vary in their degree of intrusiveness and restrictiveness, and may arouse strong emotions in the patient and staff. Patients may be denied privacy for their most intimate needs, and staff may become a focus for patients' acting-out behaviours. Special observations may be medically imposed with minimal consultation with nursing staff, and where there is no nursing and medical staff agreement on their need, nursing staff may at times feel frustrated and powerless to reduce the patients' discomfort with their situation. This paper presents a study into the use of special observations on psychiatric inpatients across a range of clinical settings. The literature on special observations is reviewed, and the findings of an audit into the documentation of special observations is presented and discussed. The study sites comprised two open acute wards, one elderly functionally mentally ill assessment unit which also treats patients with eating disorders, and a secure high dependency unit, which provides rehabilitation within a secure environment for patients with severe and enduring mental illness.