The aim of this assignment is to reflect on and critique the outcomes of an assessment and therapeutic intervention, which I have recently observed whilst on placement.
Reflection is a process that enables us to revisit a previous experience providing an opportunity to explore our experiences and link in to such, relevant research and theory in order for us to gain more knowledge. John (1995) states that the purpose of reflection is to promote desirable practice through the practitioners understanding and learning about his/her lived experiences (Boud, 1998)
The model of reflection I have chosen to use for this piece of work is one developed by Gibbs (1999). I have chosen this model because I feel that its structure provides me with a framework, which I am able to utilize in order to develop my understanding of a given situation. The model is cyclical and consists of six questions; it is these questions that will guide me through the reflective process.
As with any piece of work that refers to others names of all those discussed have been changed so that confidentiality can be maintained in line with the NMC Code of Professional Conduct (2002).
Description: What happened?
Whilst on my current placement I have been involved with the care of a 71-year-old lady who I shall refer to as Mary.
Mary has a long psychiatric history; her first contact with services was in 1981, when she was treated for a paranoid psychosis. Since that time Mary has come into contact with services for many different reasons, depression, dependency on drugs and alcohol, somatic complaints and various self harming behaviours. Over the years Mary has been given many diagnoses, the ones that are currently mentioned in her care plan are, dependent personality disorder and somatization. She also suffers with type 2 diabetes.
Through various assessments it has been established that Mary has always had a dependent personality with low self esteem but Mary’s problems appear to have been exasperated by the death of her husband 15 years ago, her bereavement seems to have been a trigger to her dependency on various drugs (prescribed and illegal).
Mary was admitted to hospital in March 2001 following an accidental overdose (due to dependency on psychotropic drugs); having spent 8 months on an acute ward Mary was then transferred to the rehabilitation unit, which is where she now resides as a voluntary in-patient.
When Mary was admitted to the rehabilitation unit she underwent a full psychosocial assessment (so I am led to believe), this enabled staff to identify her needs. The prioritised need identified in this case was to maintain Mary’s safety, due to her self-harming behaviours. In order for staff to maintain Mary’s safety she was placed on close observations (constant). Mary has been on close observations for long periods of time throughout her stay on the unit, currently she has been on close observations for 5 months.
As a student I am unable to be directly involved in the close observation of a client, but I have chosen to reflect on this intervention because I am aware of the problems/issues that have arisen both for the client and the staff, whilst the staff have tried to maintain Mary’s safety for such a long period of time.
Feelings: What was I thinking and feeling?
On reflection, my initial feelings towards the whole situation were very negative ones. I could not see any potential therapeutic benefit for the client through being observed in this manner, and surly requiring this level of observation should she not have been in an environment which was more adapt to her needs? After discussing this care of this client with other members of staff, it became apparent that the staff had little or no time at all for this lady.
Whilst thinking about my own feelings in more depth, I began to discuss issues surrounding observation with a health care assistant that had been involved with the observation of Mary. He talked about his experience of being the ‘guard’ and how he had to follow her round, he made a joke about how he had strategically placed chairs around the unit so that he always had somewhere to sit, and his main issue was the boredom involved how he had no one to talk to. What he said confirmed what I was thinking, there was only one reason for Mary being observed and it was not for her benefit.
Everything we are taught throughout our training sounds brilliant in theory, then we go out into practice, and that’s what’s reality. I found it upsetting to watch this lady walk-up and down being ‘gaurded’ I observed no therapeutic engagement at all.
Evaluation: What was good and what was bad about the experience?
Although a very negative experience it has been a positive learning experience. It’s hard to believe that practice as such continues today, but litigation plays a big part in today’s society, and some people will do anything to prevent it. I feel that through observing what I perceive to be extremely bad practice has given me an opportunity to go out and gain the knowledge I need so that when I am involved in a similar situation in the future I will act in what I believe to be a professional manner.
Whilst on placement I did not once observe a qualified member of staff being involved in the intervention of close observations with Mary, even though this would have been a wonderful opportunity for staff to spend one to one time with her. ‘Encouraging communication, listening and conveying to the patient that they are valued and cared for are important components of skilled nursing observations’ (SNMAC, 1999), yet the task of ‘observing’ is rarely done by qualified staff. It is seen as a job that no one wants, which is often delegated firstly to agency staff and then to health care assistants.
Although I do accept that Mary’s safety was the most important issue within this situation, I feel that the approach that was adopted in this case was detrimental to the well being of the client. But my rational to support my opinion on that goes back to fact that I don’t feel that Mary was given a comprehensive assessment originally. If she had have been staff would have been in a better position to address her needs.
Analysis: What sense can I make of it?
So why was Mary on close observations? I feel that because of the way that she has presented to services over the years with various different presentations, she has taken on the label of a ‘difficult’ patient (it was not uncommon to hear professionals refer to her as a cantankerous old cow). There has been some research done surrounding nurse’ perceptions of the ‘difficult client’ (Breeze and Repper, 1998), the client that displays inappropriate behaviours, does not respond to interventions, has a diagnosis of personality disorder, does not conform and is a threat to the nurse’ competence. Mary is seen as all of those.
When Mary was admitted, her risk assessment highlights all of these issues, but no one takes the time to figure out why she is like she is, or what it is that she really needs. It’s easier to place her under close observations so that she does not have the opportunity to act out any of her traits. But what I do not understand is why did not qualified members of staff become involved in the intervention and utilize the time to try and understand the cause of Mary’s obvious distress.
Conclusion: What were the outcomes of the situation?
As for Mary I have seen her self-harming behaviours adapt, now that she has realized that drinking to much water is detrimental to her health that is now a new learnt behaviour. Mary has acknowledged that she enjoys the attention she receives through self-harming. So are we not, by continuing to observe her, being controlled to some extent by her? We are doing what she enjoys, she has all the attention she needs 24 hours a day. To me, this is what appears to be a lady who does have a dependent personality, who after the death of her husband needed someone or something to depend on, and by accidentally taking an overdose and being admitted to hospital, has learnt that if she exhibits self-harming behaviours will get attention. Would it not be to everyone’s benefit to try and find another way of managing Mary’s behaviours?
Interestingly there are recent studies that report the findings of alternatives to close observations. Barker and Cutliffe(2001) report that when observations are reduced and engagement is used not only are incidences of self harm reduced by two thirds, violence on wards is also reduced, staff sickness levels fall, and there is no increase of suicides in the corresponding period (18 months).
But not only do I feel that the intervention had a negative effect on the client, there are other clients on the ward that are being neglected when so much time is spent ‘observing’ Mary, perhaps everyone would benefit from a more focused therapeutic engagement.
Action plan: If a similar situation arose again what would I do?
I do accept that there will be occasions when the use of close observations will be an essential requirement for a client’s safety, but I am well aware that this intervention can be carried out poorly by unqualified (and probably some qualified) staff.
I have managed to find a little research about the use of close observations in mental health care, most of it is negative but there are some positive findings. Bowers et al (2000) in reporting findings from a literature review states, ‘that the procedure and practice of observing people is mostly based on pragmatism and tradition….there has been no empirical research carried out in the English speaking world’. I now intend to find out more information about the studies, where the use of close observations has been discontinued, and the outcomes for both staff and client’s has been positive. Perhaps it is time for a change, and if the evidence supports the use of an alternative to close observations, we should take this into account, after all our actions should be evidence based.
I hope that through broadening my own knowledge in this area, I will be able to inform my own practice and that of others who I will work with.