Mental health nursing practice in acute psychiatric close-observation areas.

Abstract

The provision of evidence-based therapeutic nursing care in close-observation units or psychiatric intensive care units, has been identified as a problem internationally. These areas of nursing practice have been the subject of considerable discussion particularly in relation to the management of aggression, violence, involuntary treatment, and seclusion. This study used a participatory action research framework to identify qualitative and quantitative measures of activity in the area. Quantitative data collected included rates of critical incidents, the use of prn medication, and the use of seclusion. These data were used as base-line data and were predicted as a measure of change. Qualitative data, collected by interview and focus groups, were used to reveal the experience of patients, relatives, and nurses in a close-observation area. Analysis of this data revealed three main themes: design and environment, lack of activity and structured time, and nursing care. The importance of this study is in demonstrating the multiple problems that exist in the provision of care in close-observation areas and the corresponding need for fundamental changes.

Full text

Page 1

International Journal of Mental Health Nursing

(2004)

13

,

89–99

F
Mental health nursing practice in acute psychiatric
close-observation areas

EATURE

A

RTICLE


Louise O’Brien and Rose Cole
School of Nursing, Family and Community Health, University of Western Sydney, New South Wales, Australia


ABSTRACT:
psychiatric intensive care units, has been identified as a problem internationally. These areas of
nursing practice have been the subject of considerable discussion particularly in relation to the
management of aggression, violence, involuntary treatment, and seclusion. This study used a
participatory action research framework to identify qualitative and quantitative measures of activity
in the area. Quantitative data collected included rates of critical incidents, the use of prn medication,
and the use of seclusion. These data were used as base-line data and were predicted as a measure of
change. Qualitative data, collected by interview and focus groups, were used to reveal the experience
of patients, relatives, and nurses in a close-observation area
themes: design and environment, lack of activity and structured time, and nursing care. The
importance of this study is in demonstrating the multiple problems that exist in the provision of care
in close-observation areas and the corresponding need for fundamental changes.
KEY WORDS:
aggression, close-observation, psychiatric nursing, qualitative research, seclusion.

The provision of evidence-based therapeutic nursing care in close-observation units or

.

Analysis of this data revealed three main



INTRODUCTION

In Australia close-observation areas are generally small,
locked (8–10 bed) units within an acute care psychiatric
facility. Close-observation areas are similar to what is
referred to internationally as psychiatric intensive care
units (PICU). The literature purports that these units are
designed for close observation, safety, and frequent
nursing interventions (Brown & Wellman 1998; Dix &
Williams 1996; Ford & Whiffin 1991; Gentle 1996; Hyde
& Harrower-Wilson 1994; Lehane 1995; Montgomery &
Johnson 1996; Tooke & Brown 1992; Warneke 1986).
The provision of evidence-based therapeutic nursing
care in close-observation units is an international issue.
Close-observation units have been the subject of con-
siderable discussion, particularly in relation to involun-
tary admission, seclusion, violence, and aggression
(McGowan
et al
. 1999; Visali



et al

. 1997; Wing

et al

.
1998). However, attention to the whole concept of close-
observation, and therefore the context in which these
issues arise, has not been given attention.
The National Standards for Mental Health Services
(Australian Health Ministers’
(AHMAC) National Mental Health Working Group
1997) and the Standards of Practice for Mental Health
Nursing in Australia (Australian & New Zealand College
of Mental Health Nurses Inc. 1995), provide benchmarks
for mental health services and for mental health nursing.
However, mental health nurses have the dual, and often
conflicting role, of providing a safe and secure environ-
ment for patients and staff whilst simultaneously
attempting to provide therapeutic mental health nursing
care (Porter 1993). The dilemmas raised by such conflict-
ing demands can only be ameliorated by the develop-
ment of clinical practice guidelines that reflect an agreed
philosophy of care and purpose for client care in such
areas.
The aim of this study was to develop an understanding
of the context and experiences of nurses, patients, and
relatives in the close-observation area and to develop
recommendations for clinical practice guidelines. This
paper presents the findings related to the context and
experiences.
Advisory Council’s

Correspondence:
Community Health, University of Western Sydney, Parramatta
Campus, Locked Bag 1797, Penrith DC, NSW 1797, Australia.
Email: l.obrien@uws.edu.au
Louise O’Brien, RN, PhD
Rose Cole, RN, CM, MNurs (Hon)
Accepted May 2004.

Louise O’Brien, School of Nursing, Family and

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L. O’BRIEN & R. COLE

LITERATURE REVIEW
The experiences of nurses and patients
Few studies have examined the experiences of patients in
PICU. Patients in one study identified the following
helpful nursing actions: providing structure, communi-
cating respect, teaching specific skills, and demonstrating
caring (Yonge 1989). The negative aspects of constant
care included: being watched in the bathroom, not
having sufficient privacy, and lack of continuity of staff.
Other research has highlighted the absence of supportive
interactions between nurses and patients (McLaughlin
1999; Pitula & Cardell 1996) and the lack of awareness of
the needs of the family members by nurses (Yonge 1989).
Johansson and Lundman (2002), in a qualitative study,
described patients’ experiences as ‘ambiguous’. Patients
reported ‘not being seen or heard … loss of liberty and
… violation of integrity’, however, they also reported the
experience of ‘respect and caring and opportunities to
take responsibility.’ (p. 639).


Therapeutic care in close-observation
environments
Several studies have elucidated comment from nurses on
the therapeutic nature of care in close-observation – type
environments. Duffy’s study (1995) of special observation
of suicidal psychiatric patients, pointed out the non-
therapeutic nature of care that arose from adopting a
custodial, paternalistic, medical tradition. In other stud-
ies, nurses were unable to describe the therapeutic
nature of care in a PICU (Gentle 1996) and did not
acknowledge the importance of developing relationships
with patients (Kavanagh 1988). In contrast, in a constant
care study, nurses described their role as building thera-
peutic relationships, creating a sense of privacy, and
managing violent and angry patients (Yonge 1989).
Some argue that the non-therapeutic nature of care in
close-observation reported by nurses can be attributed to
nurses’ limited time for communication, lack of training
in communication skills, lack of nursing autonomy, and a
lack of support and supervision from administration
(Gijbels 1995; McLaughlin 1999). Many authors argue
that the creation of a therapeutic milieu is an essential
element of therapeutic nursing care (Delaney 1992;
Gentle 1996; Hyde & Harrower-Wilson 1994; Neilson
1992). Nurses, therefore, might be in the invidious posi-
tion of having inadequate support, resources and skills to
develop the most fundamental basis of their work; a
therapeutic milieu.
Nurses have identified many issues of concern to
themselves. These include the inadequacy of the physical
environment for providing security, inadequate staff–
patient ratios, exhaustion due to stress, difficulty getting

relief for medication administration, the lack of auton-
omy in decision-making, unskilled staff, a lack of coordi-
nated treatment and care plans, poor interdisciplinary
communication, little negotiation with other disciplines,
assessments, and matching the gender of the patient and
the nurse (Gentle 1996; Kavanagh 1988; Warneke 1986;
Yonge 1989).

Mental health nursing skills and close-observation
areas
Skills that have been specifically identified in the litera-
ture for mental health nursing practice in close-
observation units include: assessment, risk assessment
and management of aggression, prevention of violence,
and pharmacological management and collaboration
(Allan
et al
. 1988; Brown & Wellman 1998; Montgomery
& Johnson 1996; Winship 1998).
Duffy (1995), in a study of the special observation of
suicidal patients, found that there was a lack of systematic
assessment by nurses and a lack of research-based instru-
ments for assessment. Studies on risk assessment and the
management of aggression and violence in patients, have
reported that the safety of acutely disturbed patients
needs to be maintained, whilst still providing therapeutic
care, and this depends on a milieu conducive to both
containment and empathy. Violence in acute close-
observation areas appears to be, at least in part, socially
driven behaviour, for instance as a reaction to forced
compliance and does not necessarily emanate from
intrinsic mental status problems of the individual (Saveri-
muttu & Lowe 2000; Sheridan
Harrower-Wilson (1996) identify the nurse as the key
person for assessing risk through the systematic collec-
tion of objective ratings for decisions regarding level of
observation required and the management of violence.
The factors that have been identified as important in
preventing aggression and violence include: establishing
appropriate environmental features, preventing over-
crowding, ensuring adequate staffing levels, providing
activities for patients, developing protocols and policies
for seclusion and use of medications, improving staff to
patient interaction, supporting staff, and offering staff
development including control and restraint training that
emphasizes preventative measures such as verbal de-
escalation, behavioural contracts, and de-escalation tech-
niques (Fenton
et al
. 2000; Katz & Kirkland 1990; Lanza
et al
. 1994; Nijman
et al
. 1997; Nijman & Rector 1999;
Warren & Beadsmoore 1997; Wing
ever, evidence suggests that management of aggressive
incidents still relies on control and restraint,
(
prn
) medication, seclusion (Harris & Morrison 1995),
and nurse training focusing on containment rather than
preventative measures (Gentle 1996; Winship 1998).




et al

. 1990). Hyde and







et al

. 1998). How-

pro re nata

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MHN IN A CLOSE-OBS AREA

91

Seclusion has been reported as clinically indicated for
containment and isolation and to decrease sensory input
(Gutheil 1978), however, seclusion has been identified as a
potentially traumatic experience for patients (Cohen 1994;
Herman 1992; Marangos-Frost & Wells 2000; McGorry
et al
. 1991; McGorry 1992; Norris & Kennedy 1992), and
deleterious and distressing for patients (Meehan
2000; Norris & Kennedy 1992; Tooke & Brown 1992) and
staff (Outlaw & Lowery 1992). Seclusion is described as
being punitive (Farrell & Dares 1996; Martinez
1999; McDonnell 1996; Tooke & Brown 1992) and con-
trolling in nature (Lendemeijer & Shortbridge-Baggert
1997; Morrison 1990; Muir-Cochrane 1996; Muir-
Cochrane & Harrison 1996; Sullivan 1998a). Bonner
(2002) found that physical restraint was an experience that
traumatized both nurses and patients. Patients felt ‘dis-
tressed and ignored’ prior to incidents and ‘isolated and
ashamed’ afterwards (p. 465).
Although pharmacological management in PICU has
been described in the literature (Allan
Goldney
et al
. 1985; Hyde & Harrower-Wilson 1994,
1996; Khan
et al
. 1987; Musisi
1986), the specific autonomous skills required by nurses
have not been identified. This is of concern considering
the trend for rapid tranquillization, including the use of
long-acting Zuclopenthixol Acetate (Clopixol Acuphase;
Lundbeck Australasia, NSW, Australia) for the acute
management of violent and psychotic patients (Coutinho
et al.
2000). The serious sequelae that can result from its
misuse has been documented (Hughes 1999; Malhi
1999; Nygaard
et al
. 1994). The use of long-acting antip-
sychotic medication that induces prolonged sedation
raises ethical issues related to autonomy, conflict of
rights, informed consent, restraint, and treatment (Fit-
zgerald 1999). These issues have serious implications for
nurses who administer and monitor the medication.



et al

.

et al

.

et al

.

et al

. 1988;





et al

. 1989; Warneke



et al

.



Ethical decision-making processes
Research on nurses’ ethical decision-making in psychiat-
ric nursing practice points out the importance of the
context, cultural, and managerial milieu of the workplace
for supporting nursing practice (Fisher 1995; Lutzen
1990). Many studies have suggested that an organiza-
tional ideology that emphasizes control and restraint,
which is the case in many closed wards (Muir-Cochrane
& Harrison 1996; Muir-Cochrane 1996) or hospital rules,
and practices that disregard patients’ autonomy, will
undermine the therapeutic value of care and create
ethical dilemmas for nurses (Lutzen 1990; Muir-
Cochrane & Holmes 2001; Sullivan 1998b).
Close-observation units are clearly arenas of nursing
work that raise multiple and complex issues. Whilst many
of these issues have been individually discussed, there

are few studies that comprehensively review the context
of close-observation areas and very few studies that
describe the experience of the participants in the area.

METHOD
Research design
This project was conducted in a framework of participa-
tory action research which has been identified as valuable
for research that aims for changes in practice through
problem solving approaches (Kemmis & McTaggart
1988). It is particularly useful for examining multidimen-
sional activities in the contexts in which they arise. It
enables collaboration and involvement of participants
and has conceptual similarities to change theory and
quality improvement processes. Two groups were
involved in the process. The primary Research Reference
Group was composed of experienced mental health
nurses who developed the initial question, the design of
the study, applied for ethics approval, and oversaw the
research process. The Critical Reference Group was
composed of health-care professionals, health service
managers of various disciplines, and community repre-
sentatives who provided a critical perspective from signif-
icant professional and community leaders. The data were
collected during 2000 and 2001.


Setting
The context of the study was an eight-bed close-
observation area within an acute inpatient general hos-
pital psychiatric facility, part of a comprehensive mental
health service. Problems related to the incidence of
aggression and injury, and issues of control and restraint
had been identified both by nurses working in the area
and by patients who had been admitted to the area.


Participants
Invitations were extended to patients and their relatives
who had been cared for in the close-observation area of
the inpatient psychiatric unit at least 2 months previ-
ously. The purposeful selection of patients as participants
was dependent on the clinical judgement of local health
professionals in identifying potential participants. Nurses
in the unit were accessed via personal invitation, verbally,
and in writing.


Data collection and analysis

Quantitative data collection
use of seclusion, use of
staff-critical incident forms, and use of security, were
collected from patient records, incident reports and
security manager’s records. Data related to seclusion

Quantitative data, measuring
prn
medications, patient and

Page 4

92

L. O’BRIEN & R. COLE

and
a calendar month of 31 days. The research group
identified these measures as key indicators of activity
and the index month as not atypical of activity in the
area. The use of security was reported over 151 days
(5 months).

prn

medication administration were collected over

Qualitative data collection
senting patients, relatives, carers, and nurses provided
qualitative data via interviews and focus group interviews.
Interviews with patients, relatives, and carers were struc-
tured around the experience of being in the close-
observation area from the participant’s perspective. The
interviews lasted from 30 minutes to 2 hours. All inter-
views were audio-taped and a written record of groups
was maintained. The focus groups identified issues from
the participants’ perspective. These groups were facili-
tated by the chief investigator and were not audio-taped
in order to decrease formality. The research assistant
took notes of proceedings.

A total of 42 participants repre-

Qualitative data analysis
views were transcribed verbatim. The chief investigator
read and re-read the transcribed interviews before
identifying tentative themes. Themes and emerging
subthemes were then coded from the transcripts, using
a qualitative data management program, Ethnograph
V5.0 (Qualis Research Associates, Denver, CO, USA).
The hand-written notes of the focus groups were
typed. The data were organized into the facilitator’s
questions and then problems/issues identified from the
participants’ perspective. These data were subsequently
analysed with the interview transcripts.

The audio-tapes of the inter-

Ethical considerations
The Ethics Committee of the University of Western
Sydney and the appropriate area health service, granted
approval for this study. All participants were informed of
the purpose of this study and were provided with a written
information form before a written consent was obtained.
Participation in this study was strictly voluntary.


RESULTS
Quantitative data
In total, 88 patients (79% male) were admitted to the
inpatient psychiatric facility during the index month. On
a total of 42 occasions, 20 patients were secluded. The
seclusion rate using The Royal Australian and New
Zealand College of Psychiatrists (2000) Psychiatry Clini-
cal Indicators was 17% and Thompson’s method (cited in
Hafner
et al
. 1989) was 23%. The documented time that
the seclusion episode lasted ranged from 10 to 75 min
with a mean of 45.8 min (SD = 17.1).
Figure 1 shows the reported reasons for which seclu-
sion episodes occurred, with multiple reasons being per-
mitted for each episode. The most common reason for
seclusion was agitation (16%).
There were no therapeutic nursing interventions doc-
umented in the medical records of patients in 29 (69%)
seclusion events. Documented therapeutic interventions
(30% of seclusion events) included: seven (54% of inter-
ventions)
prn
medication administrations; one (8% of
interventions) counselling; three (23% of interventions)
limit setting; and two (16% of interventions) encouraging
the patient to rest.





0
Agitation
5
10
15
20
25
30
35
40
45
50
Uncooperativeness
Disorderly conduct
Disruption of therapeutic milieu
Past history of physical violence
Non-verbal menacing behaviour
Violence against staff
Threats of violence
Verbal abuse
Psychotic
Damage to property
Self harm
Violence towards non-staff
Other reason
Percentage
Reasons N = 115
Patients N = 42
18
43
31
12
33
12
1
2
2
5
10
29
14
10
29
38
10
24
2
55
14
2
5
2
5
11
4

FIG. 1:
seclusion episodes.

Reported reasons for

Page 5

MHN IN A CLOSE-OBS AREA

93

There were 119 administrations of
during the index month. There were five (24%) patients
who received one
prn
medication administration, three
(14%) patients who received three
administration, five (24%) patients who received three to
seven
prn
medication administration, and two (10%)
patients who received between 19 and 20
administrations.
Table 1 provides an account of the reason for medi-
cation administration, allowing for more than one reason
for each administration. In 14% of
the nurses provided no documented reason in the
medical record of the patient. The most prevalent reason
for
prn
medication administration was for agitation
(23%).
In 23% of
prn
medication administrations there was
no documented outcome of giving medication. In 18% of
administrations there was minimal or no effect, 22% had
a good result, 15% of the patients settled, 8% were
sleeping, and 4.2% were resting.
The critical incident forms that were reviewed pro-
vided so little descriptive data that to use them for
statistical research to review risk or to improve care
would be impossible. An audit of use of security staff
provided equally ambiguous and vague information. The
use of security staff seemed to be high (101 security
incidents in 151 days), however, almost 80% of these
incidents were described as ‘psychiatric’ and revealed no
useful information.

prn

medications



prn

medication



prn

medication

prn

administrations,





Qualitative data
Analysis of interviews, discussions, and focus groups
focused on three major themes: design and environment,
activity and structure of time, and nursing care.


Design and environment
ronmental features cited were physical features, facilities,
and safety and privacy.
Physical feature problems included the fish-bowl
design. Whilst this design clearly has advantages related
to observation, communication, and safety, it also has
disadvantages. Nurses work under the gaze of others,
patients can see nurses who refuse to communicate with
them, and meetings take place about patients without
their involvement.
Medication administration was compromised because
staff in close-observation did not have direct access to
the medication room. There were insufficient bathrooms
and toilets, no doors on some bedrooms, no curtains on
windows, and insufficient recreational spaces and activi-
ties. There was no direct access to meal reheating or
beverage-making facilities. There were no staff hand-
washing facilities. A woman whose husband’s condition
deteriorated in the close-observation area said: ‘He was
hungry, he was sleep deprived, he was dirty, … poor
bugger.’ (Wife)
All participants described the close-observation area
as like a prison. There was a lack of personal space and
privacy. The whole area was traumatized when other
patients, staff, and visitors witnessed a patient involved in
restraint or seclusion:

The three major design and envi-

(There is) a feeling of tension and it’s extremely (distress-
ing) … it’s non-therapeutic for the clients … because it’s
so small. Whenever there’s … any sort of difficulties … if
there’s aggressive outbursts or seclusion – it’s so open
and on view to everyone that it traumatizes the whole
(area) … (Nurse).
Great concern was raised about the lack of privacy and
security. This section deals with security as a design
problem although it is evident that this issue reaches far
beyond the design of the area.


There weren’t doors – (patients) especially women, were
really distressed about their safety and their privacy – and
considering a lot of them, I guess, had come in with
sexual abuse issues – the women were feeling very unsafe
– (Nurse).
There were a lack of private areas for visitors and
nurse counselling activities. Overall, the design and envi-
ronment was not conducive to safety or comfort.


Activity and structure of time
plained about the lack of activities, which resulted in
both patient and staff boredom.

All the participants com-

When I went in the last time – I just wandered around – I
was agitated. The only outlet you’ve got … is the tele-
vision and if you don’t want to watch television because
you’re agitated and can’t sit still then there’s nothing
there. (Patient.)

TABLE 1:

Reported reason for

prn

medication administration

Reason Frequency% of responses
No reason documented
Insomnia
Disturbed behaviour
Excessive demands
Irritability
Disruptiveness
Disorganization
Agitation
Hostility
Threatening behaviour
Psychotic/hallucinating
Assault
Abusiveness
Other
Total
23
12
6
4
15
14
7
4
2
9
2
7
3
11
39 23
95
16
10
10
6
2
8
1
4
14
1
167100

Page 6

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L. O’BRIEN & R. COLE

The patients stated that they appreciated structure
and some kind of routine for their day. The activities the
participants liked included: spending time talking with
the nurses and other patients, doing things with the
nurses, playing cards, doing puzzles, artwork, and listen-
ing to music. The nurses experienced conflict between
the need to provide structured activities and the need
to adhere to the dominant approach in the unit based
on the maintenance of a low-stimulating environment,
which discouraged activities.

Nursing care
The patients’ experience
strongly in every patient’s description of their experience
of being in close-observation. Four aspects of nursing
care featured: therapeutic versus controlling nursing
care, nurse–patient interaction, seclusion, and security-
assisted interventions.
Patients were keen to emphasize that they knew what
was happening around them and could differentiate
therapeutic from controlling care:

Nurses and nursing care featured

Even though you’re really sick you still know what’s going
on. I really wonder … if these nurses who were contemp-
tuous don’t realize that you can recall it all – there’s still a
part of you that knows what’s going on. (Patient)

A number of the patients described two kinds of
nurses, the ‘kind’ and the not so kind; the ‘contemptu-
ous’. Most patients described a split of almost 50 : 50,
however, some patients indicated that they did not feel
cared about by anyone that they encountered. ‘A good
nurse treated you as a human being with respect – they
didn’t treat you with contempt’ (Patient). The good
nurses: ‘they’ve got time to talk to you whereas the
cranky ones – when you know they’re on you know you
haven’t got a hope … of being able to talk to anybody’
(Patient).
Patients described being upset, scared, frightened,
anxious, stressed, agitated, aggressive, angry, distressed,
confined, isolated, and very lonely and that these feelings
were not addressed by nursing interventions. When
asked to describe their experience, one of the most
frequent comments was: ‘Close-obs is very lonely’
(Patient) and ‘Basically I was just left to my own devices
– being observed and written about.’ (Patient.) Patients
needed to talk to the nurses because they were feeling
upset about being admitted to the close-observation area:

Any wonder you get aggressive and have to be put in that
seclusion room because they’re not talking to you and …
(they are in) conversation between themselves and you’re
pacing up and down with nothing to do and getting agi-
tated and aggressive – of course you’re going to end up in
[seclusion]. (Patient.)

The patients lacked information about close-
observation and the process of treatment. Patients
needed to know why they were there, how long they
would be there, and what kind of criteria were used to
assess their readiness to move out of close-observation.
The patients recalled seclusion experiences as being,
isolated for a prolonged length of time, restrained, forc-
ibly given medications, and coping with restricted inter-
actions with staff.

They (took me to the) seclusion room and they threw me
on the bed. The security guard held me by the neck and
the nurse pulled my pants down and injected me with
some drug which I don’t know what it was – I don’t know
the name of the drug but I was unconscious for
12–16 hours. I (know) I reacted wrongly to this other
nurse. I think I did need medication but I was never
asked (Patient).

The patients complained about the frequent presence
of security staff who were involved in the restraining of
patients for forced medication administration and
seclusion.

The relatives’ and carers’ view
expected the nurses in the close-observation area to be
compassionate and caring and to treat patients with
respect and dignity and to respect the patient’s privacy.
The experience of relatives and carers of the close-
observation area was marked by: active distancing by
nursing staff, lack of information, and stress. Relatives
acknowledged the difficult work of nursing staff and recog-
nized that many problems were related to poor resourcing.
Relatives and carers described the communication
with the nurses as a process of ‘active distancing’ that
resulted in them feeling irrelevant and resented by the
nurses. Relatives and carers complained about their lack
of involvement in the care of the patient, noting that they
could be good sources of information for accurate assess-
ments and treatment plans for the patient:

The relatives and carers

They tended to ignore me … there was no caring of me
as a spouse. One registered nurse attempted to gain a
relationship with (my relative) … the rest, it was very
much keep your distance, ignore. (Relative.)

All of the relatives and carers emphasized their need
for information about the rules and regulations and daily
routines of the close-observation area, staff identity, roles
of staff, treatment, medications, who to contact to obtain
information, complaints procedure, and hospital and
community support services. They stressed that this
information should be provided pro-actively.
All the relative and carer participants experienced
stress with the admission of people to the close-
observation area. Stress was related to being uninformed

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MHN IN A CLOSE-OBS AREA

95

about what was happening, feeling guilty about the
patient’s illness, feeling unwelcome, and not being
included in processes related to admission, treatment, or
discharge planning.

The nurses’ experience
ipants was marked by: feeling under-valued and lacking
support, working with competing philosophies of care,
working without theoretical frameworks for practice, and
having inconsistent skills.
Clinical nursing guidelines were broad, personally
interpreted, and applied idiosyncratically. The nurses
described lack of communication and collaboration with
medical and nursing colleagues about care-plans, admis-
sions, and removal of patients from the area. Decisions
were made about interventions without consultation.
There were inconsistencies with relief; nurses being left
for many hours without a break. Inexperienced staff were
often rostered to the area, and rostering to the area was
perceived as a punishment.
The nurses identified a polarization of beliefs about
the care of patients. There was conflict between a thera-
peutic and controlling, ‘zero-tolerance’ philosophy of
care. Whilst some nurses stressed that their role was care,
counseling, advocacy, alleviation of distress, and ‘being-
there’ for the patients, others saw their role as maintain-
ing control, medication administration, and observation.
The lack of a common philosophy of care resulted in
power plays that could result in dangerous situations.
Nurses experienced a conflict between having to partici-
pate in controlling practices as evident in the following
compelling description by one of the nurses:

The experience of the nurse partic-

I said, ‘I’ll go and explain to him what’s going to happen’
– that we need to do this to actually calm him down a bit
and give him a bit of time out and he (another nurse) said
‘oh no don’t tell him – we’ll just call security and they’ll
be up in a minute and we’ll just come and do it’. There’s
no choice. I felt that that was a breech of that person’s
rights … whether or not they may have needed to get
them to calm them down, I think we should have at least
explained the options. (Nurse.)

Some nurses questioned the use of seclusion, and felt
compromised by being involved:

… the whole issue of seclusion and how very high the
seclusion rate is … in comparison to other places. When
I actually questioned that recently, the response was
‘Well, what they do is intervene well before there is any
problem. That’s why it’s high’ – I mean I think that shows
an appalling lack of understanding of mental health
nursing itself. (Nurse.)

At times some nurses demonstrated strength in not
conforming to the dominant philosophy, the ‘zero toler-
ance’ evident in the nursing practices by other nurses in
the close-observation area, but admitted they felt they
had to do this covertly:

In a lot of ways I didn’t conform in a sense – but I tended
to do things more autonomously when they weren’t
around – like they’d say I want this done this way and I’d
say ok but I would quietly go to the patients and I would
do it just the way I thought … so I learnt to manipulate
my environment so that I could have some autonomy and
personal relationships with patients. (Nurse.)

‘Zero tolerance’ was described as providing no choice
for the patient who has to ‘toe-the-line’. The following
excerpt illustrates the implications of ‘zero tolerance’:

There were staff who had zero tolerance and it was ‘you
will do as you’re told’. The aggression rates actually
increased – there was more verbal abuse (from the
patient to the staff). (Nurse.)

Injustices reported by the participant nurses included
a range of incidents including demeaning, humiliating
and derogatory comments by nurses about patients’ phys-
ical appearance, denying privileges, coercion, intimida-
tion, sedation, and threatening patients with the Mental
Health Act or seclusion.
The nurses identified the lack of a nursing theoretical
framework within which to develop policy and make
clinical decisions and a lack of a consistent model of care,
as being problematic. Nurses described the current formal
and informal rules of practice as being unsatisfactory
because they were undocumented and experientially
learned. Consequently, there were inconsistencies in the
way nursing was provided in the close-observation area
with little accountability for standards of practice and care.
There were clearly inconsistencies in the skill level of
staff, with agency and occasional staff frequently rostered
into the area. New graduate nurses were rostered with
similarly inexperienced staff.

DISCUSSION

This study has identified serious and highly concerning
problems in the provision of therapeutic care in this
close-observation area. It may be argued that length-of-
stay in close-observation is brief and there is no value in
providing therapeutic programs, however, the reality of
length-of-stay for many patients may be longer than
anticipated. In addition, even for short length-of-stay
patients there is a need to provide an environment that,
at the very least, can contain their distress and support
them through their treatment to prevent the negative
sequelae of a traumatizing environment.
The analysis of the qualitative data provided a power-
ful picture of the experiences of nurses, patients, and
relatives in the close-observation area. There was a high

Page 8

96

L. O’BRIEN & R. COLE

level of agreement across participants about design and
environmental problems and the problems associated
with lack of activity and structure. The data related to the
third theme arising from the data of nursing care were
presented from the separate perspectives of patients,
relatives and nurses. There was a high degree of agree-
ment across groups that there were difficulties with
nursing care, however, each group brought their unique
perspective.
This study has identified design and environmental
problems that are not just aesthetic problems but prob-
lems in design, such that the area does not ensure patient
privacy and security, nor does it provide adequate space
for promoting acutely ill patients’ mental health. The use
of the area as a reception area for newly admitted
patients and their escorts makes the provision of a safe,
predictable environment impossible. All participants
commented on the lack of comfort. There was a lack of
basic facilities and spaces to provide appropriate nursing
care. The literature clearly identifies that the design and
environmental features of a unit must provide security,
privacy, comfort, and ample space to create a therapeutic
milieu (Dix & Williams 1996; Gray & Thomas 1998;
Lanza
et al
. 1994; Nijman
et al
Yonge 1989). Without these features nursing care cannot
be therapeutically effective.
The findings of this study identified a lack of activity
and structure in the close-observation areas. There were
no individual care plans incorporating the needs of
patients beyond medication and their status as a close-
observation patient. Nurses disagreed over the appropri-
ateness of structured activities for patients. The strongest
imperative seemed to be to provide a low stimulating
environment, however, this appeared to be translated
into no activities and lack of therapeutic intervention.
This is despite the literature that recommends the inclu-
sion of recreational facilities (Dix & Williams 1996;
Goldney
et al
. 1985; Mounsey 1979; Musisi
it promotes the development of rapport (Mounsey 1979)
and helps structure time (Duffy 1995).
The participants commented on the lack of a defined
structure/routine for the patients’ day in the close-
observation area that was related to mental health needs.
The nurse and/or team-leader on duty arbitrarily decided
rules. Patients and families indicated that predictable
routines prevent patient confusion and a structure allows
for patients to monitor their own behaviour, an obser-
vation that is supported by the literature (Allan
1988; Gunderson 1978).
The responses from patients and relatives about
nursing care indicated the importance of good nursing
care for people being admitted to the close-observation
area. The interviewer did not ask specifically about




. 1997; Wing

et al

. 1998;



et al

. 1989) as

et al

.
nursing care. The views of the patients and relatives were
offered spontaneously. Whilst there were comments
about other disciplines, specifically medical staff, the
patients and relatives saw nurses as the most important
factor of care in this area.
Data that confirms that patients did not receive ade-
quate observation and nursing interventions by highly
skilled nurses, was present in the descriptions provided
by patients, relatives and nurses. Therapeutic nursing
care was not provided on a consistent basis. Some
nursing staff in the close-observation area espoused the
importance of therapeutic relationships, however, again
stressed that only the minority of staff would see this a
priority; a finding that is reflected in the literature
(Kavanagh 1988; Yonge 1989). The importance of devel-
oping a therapeutic relationship between nurses and
patients in PICU is documented in the literature (Allan
et al
. 1988; Hyde & Harrower-Wilson 1994; Montgomery
& Johnson 1996; Yonge 1989).
The patients felt alone and unsupported in the close-
observation area because they were left to their own
devices, had little interaction with nurses, and there was
a lack of structured activities for them. Patients described
either nurses who treated them with respect or nurses
who demeaned them and treated them forcefully with
early and high-level interventions aided by an over-
presence of security staff. The number of seclusion
events was high. The literature documents the over-
zealous use of seclusion in acute mental health nursing
(Gijbels 1995; Sullivan 1998a). The patients in this study
identified the need for therapeutic interventions to
prevent seclusion and the value of such intervention is
well documented in the literature (Muir-Cochrane &
Harrison 1996; Muir-Cochrane 1996).
The needs and role of family members were generally
not recognized by staff. Family members felt that there
were few proactive attempts to involve them or provide
them with information. Many nurses ‘actively distanced’
themselves from family. This contributed to an extremely
stressful experience for family members. Other research-
ers have reported similar findings in PICU (Musisi
1989; Yonge 1989).
The nurses described nursing in the close-observation
area as a negative experience because their role was
devalued, there was inappropriate staffing (inexperienced
staff and use of agency and ‘occasional staff’), and incon-
sistency with relief and rostering was often used as a form
of punishment. International literature reports similar
findings in close-observation areas (Allan
Brown & Wellman 1998; Kavanagh 1988; Montgomery
& Johnson 1996; Warneke 1986; Yonge 1989). The
nurses provided a compelling account of the polarized
differences in philosophy of care amongst the nurses,



et al

.

et al

. 1988;

Page 9

MHN IN A CLOSE-OBS AREA

97

exemplified in the differences between therapeutic
philosophy and a philosophy of ‘zero tolerance’ and
forced early intervention using security staff. The find-
ings in this study are consistent with the literature on
ethical problems experienced by mental health nurses in
acute facilities, that is, the conflict between ethical
behaviour and adherence to the dominant culture (Duffy
1995; Fisher 1995; Muir-Cochrane 1996).
The nurses identified the advanced skills required
in close-observation areas as therapeutic engagement,
assessment, risk assessment, communication, de-
escalation, and managing the milieu. This is consistent
with the literature (Allan
et al
Harrower-Wilson 1994; Khan
1999; Musisi
et al
. 1989; Winship 1998). Nurses in this
study identified inconsistencies in the skill level of nurses
in the close-observation unit as a significant problem.
The participant nurses identified many administrative
issues which prevented the development of a therapeutic
relationship with patients. The close-observation area
lacked a philosophy of care, and policies and procedures
to prescribe nursing actions. There was a lack of multi-
disciplinary communication and collaboration with treat-
ment planning, despite the literature stressing the
importance of this for development of policies and treat-
ment programs/plans (Allan
Musisi
et al
. 1989).
The collection of quantitative data in this study
achieved two outcomes. The first was a measure of seclu-
sion and
prn
medication use that can be compared in a
further study. The second was to draw attention to a
number of problems: (i) the high rate of seclusion; (ii) the
paucity of documentation related to outcomes of inter-
ventions and therapeutic interventions when used; (iii)
the lack of explanation or education of patients and/or
relatives about seclusion and
poor standard of documentation related to critical issues.


. 1988; Duffy 1995; Hyde &
et al
. 1987; McLaughlin





et al

. 1988; Kavanagh 1988;





prn

medication; and (iv) the

CONCLUSION

Clearly, problems in close-observation areas are not
confined to this facility and problems do not arise in a
vacuum. The context of the development of general
hospital psychiatric units, the downsizing of tertiary spe-
cialist psychiatric facilities catering for very disturbed
patients, and the increased acuity of patients in hospital,
are all factors that have contributed to difficulties experi-
enced in nursing in close-observation areas of general
hospital psychiatric units. In addition, changes to the
focus of psychiatric care have also had an impact. The
trend towards admissions to diagnose, medicate, stabi-
lize, and discharge has seen the loss of interest in the
provision of inpatient therapeutic programmes. The
focus is on medication and other physical treatments and
not on individual or group therapy (Gallop & O’Brien
2003; Luhrmann 2000). Whilst this would appear to
make sense, given the increased efficacy of medication
and the provision of community treatment, what has
happened is that the provision of a therapeutic milieu (an
environment of safety and care) has also been lost as a
focus of treatment. In addition, despite the increased
acuity of patients there has been no increase in resources
to care for this most vulnerable group of patients.
The responsibility for change in the way people are
cared for in close-observation areas of acute psychiatric
facilities is multidisciplinary. However, the importance of
nursing care in this area is clearly identified by all the
participants in this study. Mental health nursing care is
the most important intervention in this area of care, and
as such, mental health nursing needs to develop clinical
practice guidelines specific to this area of nursing.

Strengths, limitations and further research
This study has highlighted multiple problems in a close-
observation area resulting in a serious threat to the
physical and psychological safety of patients, relatives and
nurses. The data have provided valuable information that
can be used to create recommendations for the direction
and measurement of change. The use of mixed qualita-
tive and quantitative method of data collection provided
both a snapshot of activity and an in-depth understanding
of the experience of being in the area for clients, relatives
and nurses. The major limitation of this study was that it
was confined to one unit at a particular point in time.
Whilst the results of this study have provided impetus for
change to this unit, these changes need to be evaluated
and further collaborative research is needed to develop
and evaluate clinical practice guidelines for this area of
mental health nursing.


ACKNOWLEDGEMENTS

The University of Western Sydney funded this study with
in-kind contribution from the local area health service in
the form of staff time to collaborate in the study. The
research group gratefully acknowledges the patient, rela-
tive and staff participants and the Critical Reference
Group members. The authors gratefully acknowledge
Karen Cooper for her critical comments and assistance in
producing this paper.

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