Key messages

  • Nursing observation is a method of gathering information about inpatients to assist in decision making.
  • Observation can be practiced on several levels but is always based on the same underlying principles.
  • Nursing observation is particularly vital for patients in seclusion or under restraint.

The Nursing observation through engagement in psychiatric inpatient care guideline provides direction for the observation of people receiving care in all Victorian mental health inpatient units, including principles of seclusion, practices and levels of observation, observation during seclusion and restraint, and observation of physical health.

What is nursing observation?

Nursing observation is the purposeful gathering of information from people receiving care to inform clinical decision making.

It involves a person-centred approach to actively engage with people receiving care and their families and carers.

The goal of nursing observation is to develop rapport, and contribute to assessment and recovery.

Principles of nursing observation in psychiatric inpatient care

Engaging with people during purposeful observation contributes to nurses fulfilling their duty of care.

There are several principles that underlie the practice of nursing observation:

  • observation is multifaceted
  • observation and assessment are interrelated
  • observation is grounded in therapeutic engagement with the person
  • nurses appreciate how inpatient environments influence behaviour
  • observations are communicated between colleagues
  • there is a clear process of documentation that is timely and descriptive.

Reasons for initiating nursing observation in psychiatric inpatient care

Observation can be initiated for several reasons, including when people:

  • may benefit from periods of concentrated therapeutic engagement
  • have physical health issues that need to be managed
  • pose a risk to themselves or others.

Levels of nursing observation in psychiatric inpatient care

All Victorian inpatient mental health services must have explicit policies on observation types and frequencies, and communication of observations.

For example a policy may specific four levels of observation:

  • Constant (arm’s length) – periods of one-to-one nursing observation, with the person within an arm’s length of an experienced nurse at all times
  • Constant (visual) – periods of one-to-one nursing observation, with the person within the vision of an experienced nurse at all times
  • Intermittent – an experienced nurse (or mentored, less experienced nurse) engages with a person at regular intervals. The identified risk factors and purpose of observation will determine the frequency (for example, several times per hour) and pattern of observations (for example, equal or random lengths of time between observations)
  • Negotiated – nurses negotiate the frequency of engagement with people who do not have identified risk factors requiring intermittent or constant observation.

Observation during seclusion in psychiatric inpatient care

Although seclusion practices are strongly discouraged, seclusion rooms remain in use in mental health services.

People in seclusion require vigilant visual observations and any observation must comply with Victoria’s Mental Health Act 2014 and the Chief Psychiatrist guideline, Seclusion in approved mental health services.

This observation requires monitoring breathing, movement and levels of agitation.

Experienced nursing staff need to engage with people in seclusion and discuss with them the observation practices that are occurring.

Observation during restraint in psychiatric inpatient care

Physical and mechanical restraint requires specific attention.

Reporting and recording of restraint must be consistent with the legal requirements of the Mental Health Act.

Nurses have specific responsibilities for the physical monitoring of a person in any form of restraint.

This involves monitoring vital signs and physical integrity. It includes but is not limited to:

  • blood pressure
  • pulse
  • temperature
  • movement
  • breathing
  • skin integrity
  • nutrition and elimination.

Positional asphyxia can occur if a person being restrained is placed in a position that compromises their breathing and as a result they do not get enough oxygen. A lack of oxygen can lead to disturbance in cardiac rhythm and death may result.

Other considerations for nursing observation in psychiatric care

The guideline also addresses other considerations, including:

  • assessing physical health
  • monitoring medication
  • lifestyle and psychosocial assessment
  • providing care for older people
  • psychosocial functioning
  • safety
  • self-harm
  • aggression
  • absconding.