Why Do Nurses Continue to Watch Patients to Maintain Safety?

American Psychiatric Nurses Association’s Institute for Safe Environments (ISE) has been actively working to identify issues related to safe environments, explore current evidence related to those issues, and recommend strategies to promote safe, evidence-based, best practices. In 2013, Bethany J. Phoenix, then President of the American Psychiatric Nurses Association, wrote about the work of the ISE in a Board of Directors Column in the Journal of the American Psychiatric Nurses Association. She reminded readers about Florence Nightingale’s belief that promoting, establishing, and maintaining an environment in which healing can take place is one of nursing’s key professional responsibilities. Phoenix wrote that “Florence Nightingale would be proud” of the ISE’s work. The ISE’s efforts to address issues related to safety have led us to feel compelled to question the effectiveness and wisdom of the widespread practice of continuously observing people who are deemed to be “unsafe. ” Continuous special observation (CSO) is defined as an intervention in which an inpatient staff member is assigned to observe one patient at all times, including while they toilet, bathe, and sleep, to prevent violence directed toward self or others. There are some patients who, due to their high risk of suicide and inability to engage with staff, require this level of supervision. However, a vast majority of patients who receive CSO can be treated using recovery based interventions. There are many problems inherent to the use of CSO, which include control and coercion, restriction of patient privacy, symptom exacerbation, risk of compromised unit safety, and potential countertherapeutic effects. CSO is seen as a containment procedure and is often considered along with the use of restraints, seclusion, and forced injections (Bowers, 2006). CSO is based on control and is often in direct conflict with the principles of recovery and engagement. Recovery is a process of change through which individuals improve their health and wellness, live self-directed lives, and strive to reach their full potential (SAMHSA, 2015). Recovery-oriented interventions support the patient’s ability to change; however, CSO removes the control of treatment from the patient. We are convinced that we can no longer continue to practice in ways that are restrictive, intrusive, and controlling because we are at a loss for what else to do. We need help from psychiatric nurse colleagues with expertise in clinical practice, research, quality improvement, and education to work together to find better ways to keep people safe while helping them toward recovery. The practice of watching patients to ensure safety can be traced back to the early 1800s, when mechanical restraints were replaced with what was then described as “moral treatment” (York, 2009). When a nurse was concerned about a particular patient’s potential for harm and could see no other alternative, the nurse would direct an aide to watch the person and keep him safe. Nurses began seeking a physician’s order for observation in an effort to assure that staff would follow their directions. Questions about the practice of constantly watching patients can be found as early as 1884, when George Savage, the Superintendent of Bethlehem Asylum in London, reported that this intervention was implemented far too often, with too much emphasis on preventing suicide rather than actually treating patients. He criticized the practice of watching patients at all times as a defensive intervention that created an environment in which the patients described the attendants who constantly watched them as “tormentors” (Savage, 1884, p. 19). Yet, despite more than 130 years since that original critique of CSO methods, empirical evidence to support or challenge the efficacy of CSO remains limited. A Cochrane Systematic Review (Muralidharan & Fenton, 2008), completed in 2006 and updated in 2008, identified no randomized clinical trials that examined the effects of nonpharmacological containment methods including CSO in hospitalized persons with serious mental illness. Results of a retrospective study using National Health Service Trust data in London, England, provided hospital unit–level data that suggested that the number of selfharm episodes was not related to hours of CSO (Stewart, Bowers, & Warburton, 2009). However, the level of selfharm on the unit was predicted by the rate of self-harm on the unit in the prior week. Furthermore, over the course of the study, the number of hours of CSO decreased but the number of self-harm incidents remained stable. Finally, Stewart, Bilgin, and Bowers (2010) concluded, based on a literature review (nonsystematic), that the effectiveness of CSO is uncertain and indicated that additional carefully controlled research of CSO is needed. While CSO has the potential to be a healing intervention when mindfully managed by registered nurses, it is 620159 JAPXXX10.1177/1078390315620159Journal of the American Psychiatric Nurses AssociationRay and Allen research-article2015