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

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: Introduction Policies 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. Aim This study aimed to integrate staff and patient perspectives to determine what factors facilitate or impede therapeutic engagement during one-to-one observation. Method Thematic 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. Results Negative 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 experiences and work with them to find solutions. Implications for practice Engagement during observation could be facilitated if staff receive more supervision in understanding difficult dynamics that impede rapport-building and in managing their emotions towards patients they experience as "hard-to-engage".