The Evolution of Practice Changes in the Use of Special Observations

In acute psychiatric settings, it is common practice to increase the intensity of observations of patients who present with self-injurious thoughts, who are at risk of injuring others, or who exhibit behaviors that adversely impact the overall milieu. These intense observations are intrusive and may result in untoward stimulation of the patient. Nurses at an urban academic medical center addressed the problem of intrusive and overstimulating levels of observation by developing two practice changes using intuitive knowledge combined with input from current nursing literature. The first change was designed to move from observation to engagement. The second change was designed to decrease patient agitation related to intense observation. This article discusses the potential adverse consequences associated with the use of intense levels of observation and describes two protocols that have contributed to a reduction in the use of seclusion and restraints, as well as staff members' reported perceptions of feeling safer and experiencing improved job satisfaction.