close-observation areas in acute psychiatric units: a literature review

International Journal of Mental Health Nursing (2003) 12, 165–176

INTRODUCTION

In Australia, close-observation areas are generally small(8–10 bed) units, within an acute care psychiatric facility,that are similar to what is referred to internationally aspsychiatric intensive care units (PICU). The literaturepurports that these units are designed for close observa-tion, safety, and frequent nursing interventions (Brown &Wellman 1998; Dix & Williams 1996; Ford & Whiffin 1991;Gentle 1996; Hyde & Harrower-Wilson 1994; Lehane1995; Montgomery & Johnson 1996; Tooke & Brown 1992;Warneke 1986). The units are usually locked in order toprovide greater safety and to help patients who are unableto control themselves feel secure (Sacks et al. 1982).Management of patients in these units has been stated asinvolving a broad psychotherapeutic approach (Goldneyet al. 1985).

Mental health nurses have the dual and often conflictingrole of providing a safe and secure environment for patients

and staff, while simultaneously attempting to providetherapeutic mental health nursing care. Mental healthnurses working within such units are often charged withinitiating interventions that compromise patients’ rightsand restrict their liberty in order to maintain order (Porter1993).

The National Standards for Mental Health Services(Australian Health Ministers’ Advisory Council’s National(AHMAC) Mental Health Working Group 1997) endorsesthe rights of consumers within mental health services.Integral to this is the participation of consumers and carersin the delivery of care, which is individualized, within theleast restrictive environment conducive to their safety. Thiscommitment to therapeutic partnerships between clini-cians and consumers/carers is also evident in the Standardsof Practice for Mental Health Nursing in Australia(Australian & New Zealand College of Mental HealthNurses Inc. 1995). While the mandate for use of leastrestrictive environment and individualized care isapplauded, this is often in clear conflict with the organi-zational imperative to control and ensure the safety of allpatients, staff and the community (O’Brien & Flote 1997).This is of concern for nurses working in close-observationareas where seclusion and restraint are examples of inter-ventions that raise legal and ethical dilemmas for nurseson a daily basis (Hopton 1995; Muir-Cochrane 1996) as

FEATURE ARTICLE

Close-observation areas in acute psychiatric units:A literature review

Correspondence: Louise O’Brien, University of Western Sydney,School of Nursing, Family & Community Health, Parramatta Campus,Locked Bag 1797, Penrith DC, NSW 1797, Australia. Email:[email protected]

Louise O’Brien, RN PhD Rose Cole, RN CM MNurs (Hons) Accepted May 2003.

Louise O’Brien and Rose ColeUniversity of Western Sydney, School of Nursing, Family and Community Health, Parramatta Campus, Penrith DC,New South Wales, Australia

ABSTRACT: Close-observation areas in Australian inpatient psychiatric units are locked areas usuallywithin an open ward. Despite patient acuity, and the inherent difficulties in this area, little has beenwritten that addresses either the processes or goals of containing patients, the role of nurses, or the skillsinvolved. This paper examines the literature related to close-observation areas and argues that they arehighly demanding of expert psychiatric nursing skills. Nurses need to advocate for humane, well-resourced areas, staffed with highly skilled nurses in order to fulfil the obligations of the national nursingand mental health service standards and to reduce the deleterious effects of hospitalization on patients.

KEY WORDS: acute psychiatric care, close-observation, psychiatric intensive care unit, psychiatric/mental health nursing, therapeutic process.

they balance the support for patient autonomy with theneed to maintain unit control (Fisher 1995).

These issues need to be examined in order to developnursing services in this area that are congruent with themultiple requirements of professional and service stan-dards, patient autonomy and unit control.

The purpose of this paper is to review the literaturerelated to close-observations areas in order to: (i) describethe characteristics of close-observation areas including thecharacteristics and demographics of the patients, opera-tional policies, admission and discharge criteria, themodels, design and staffing; (ii) outline the necessary skillsfor therapeutic nursing practice in close-observation areas;(iii) discuss the ethical dilemmas related to the provisionof therapeutic nursing care in this context; and (iv) rec-ommend a framework for therapeutic nursing care inclose-observation areas.

The literature search of databases CINAHL andMEDLINE initially used keywords of ‘close-observation’,and ‘psychiatric intensive care units’. A further search ofdatabases used key terms identified in the literature: ‘seclu-sion’, ‘violence and aggression in acute psychiatric in-patient units’, and ‘nursing care in close-observation units’.In addition, reference lists from relevant articles were usedto identify other literature. Little in terms of studies ofclose-observation units and particularly nursing in close-observation units in the Australian context was identified.Literature from the USA, Canada and the United Kingdomand Europe has been utilized, however, differences incontext need to be appreciated, particularly as some studiesapply to forensic and highly volatile groups of patients.

CHARACTERISTICS OF CLOSE-OBSERVATION UNITS

Characteristics of the patientsPatients admitted to close-observation areas have acutemental health problems. Patients are described as aggres-sive, violent, and suicidal or a high risk of absconding (Allanet al. 1988; Brown & Wellman 1998; Citrome et al. 1994;Dennis 1997; Dix 1995; Gentle 1996; Goldney et al. 1985;Musisi et al. 1989; Rachlin 1973; Sullivan 1998a; Warneke1986; Wynaden et al. 2001). Other characteristics identi-fied in the literature include acutely disturbed (Allan et al.1988; Brown & Wellman 1998; Gentle 1996; Hyde &Harrower-Wilson 1994; Lehane 1995; Warneke 1986),acutely psychotic and destructive (Khan et al. 1987;Montgomery & Johnson 1996; Musisi et al. 1989), dan-gerous (Gentle 1996), self harming (Dennis 1997; Ford &Whiffin 1991; Sullivan 1998a) and difficult to manage(Allan et al. 1988; Ford & Whiffin 1991; Gentle 1996; Hyde& Harrower-Wilson 1994; Musisi et al. 1989).

Studies indicate that patients characteristically havediagnoses of schizophrenia, depression, mania, preseniledementia, personality disorder, alcohol and drug abuse,organic brain disorder and anorexia (Goldney et al. 1985;Hyde & Harrower-Wilson 1994; Mounsey 1979; Musisiet al. 1989; Warneke 1986; Wynaden et al. 2001).

Surprisingly, literature reports the use of PICUs as adumping ground (Gentle 1996). Inappropriate admissionsoccur even when a strict admission screening process is inplace because of community pressure and for socialreasons. Gentle suggests that nurses perceive inappropri-ate referrals result from patients being unwanted in otherclinical settings where staff cannot cope with acutely dis-turbed and difficult to manage people.

The demographic profile indicates that patients inclose-observation areas are young (mean age range 27–35.1years) and predominantly male (Dix 1995; Goldney et al.1985; Khan et al. 1987; Wynaden et al. 2001). Studies onPICUs indicate recidivism rates of 13–35% (Citrome et al.1994; Goldney et al. 1985; Musisi et al. 1989). Citrome andcolleagues, in their study of a PICU in New York, foundthat aggressive patients were more likely to be recidiviststhan suicidal patients.

Models and design of close-observation areasModels of close-observation areas vary. Some PICUs arepart of an inpatient psychiatric facility of a general hospital(e.g. Warneke 1986), while others are located within apsychiatric hospital (e.g. Goldney et al. 1985). Since therole of the close-observation area is safety and higher thanusual observation, these units are normally locked (Gentle1996; Goldney et al. 1985; Wynaden et al. 2001) however,some PICUs have been reported as being not locked(Mounsey 1979; Warneke 1986) and a small unit in the UKis reported as being intermittently locked (Brown &Wellman 1998).

The number of beds in close-observation areas alsovaries from one to two patients (Brown & Wellman 1998);five to eight patients (Dix 1995; Gentle 1996; Goldney et al.1985; Montgomery & Johnson 1996; Musisi et al. 1989);10–20 patients (Hyde & Harrower-Wilson 1994; Kavanagh1988; Khan et al. 1987; Neilson 1992; Warneke 1986); andup to 30 patients in a three level PICU in New York (Allanet al. 1988).

The design of these units has been recommended toprovide ample space (26.4 square metres/284 square feetper patient) in order to avoid the effects of crowding onaggressive behaviour (Palmsteirna et al. 1991; Wing et al.,198) and on psychotic symptoms (Khan et al. 1987). Dixand Williams (1996) recommend the core features anddesign of a PICU: a location sited on the ground floor,access to enclosed gardens, with the entrance sited awayfrom the main ward. An extra care area, general activities

166 L. O’BRIEN AND R. COLE

room, corridors with convex mirrors and avoidance ofnumerous corners are suggested. Patients should havetheir own separate bedrooms with louvre-type observationpanels, doors that open two ways, vandal-proof dimmerlight fittings and homely and safe fixtures. Disturbancebuttons should be provided.

Operational policiesOperational policies emphasize the short-term manage-ment of people in crisis who need containment and a highdegree of supervision and observation (Dix 1995; Gentle1996; Lehane 1995). There are conflicting views onwhether there should be strict or more liberal criteria foradmissions (Dix 1995; Goldney et al. 1985; Hyde &Harrower-Wilson 1994; Montgomery & Johnson 1996).Although Dix (1995) defines discharge criteria, otherresearch on PICUs indicates a lack of consideration of thisdomain. Hyde and Harrower-Wilson (1994) recommend apolicy package in the PICU for admission, searchingpatients and their belongings, restraint, locked door, andlow stimulating environment techniques. In an Australianstudy of nursing policy related to observational levels,Horsfall and Cleary (2000) identified an absence of atten-tion to ‘patient rights, ethical dilemmas, rationales foractions, … therapeutic goals or the legal context or con-straints’ (p. 1296). The authors also noted a lack of atten-tion to the supportive interventions of nursing, and tonegotiating nursing care with the patient. Policy aroundthe whole area of constraining patients in a locked areaseems to be limited and when present fails to provideguidance.

StaffingA high staff to patient ratio is recommended (Gentle 1996).The majority of studies on PICUs do not define the ratio,and variations exist internationally with staff to patientratios reported as 3 : 8 in Australia (Goldney et al. 1985),1.5 : 1 in the USA (Rachlin 1973) and 4 : 12 in the UK(Mounsey 1979). These ratios need to be interpreted intheir respective social contexts, as the high staff to patientratio reported by Rachlin may be indicative of the catch-ment area of the Lincoln Service (part of Bronx StateHospital) that serves an inner city area. When the staff topatient ratio decreases care becomes more custodial innature (Brown & Wellman 1998). While there is a lack ofconsensus on the ideal staff to patient ratio, other staffissues such as experience, gender and ethnicity, need to beconsidered (Rachlin 1973; Wing et al. 1998).

The experience of being in close-observationareasThe predominantly quantitative research has providedvaluable information concerning the role of the close-

observation units, the characteristics of the patientsadmitted and the staff to patient ratio. There is a limitedqualitative research regarding close-observation areas andthe experiences of the patients, nurses and the multi-disciplinary team.

Gentle (1996) conducted a qualitative study exploringnursing in a new PICU in the UK. The main issues iden-tified by the nurses were the inadequacy of both physicalenvironment and staff to patient ratio. Gentle emphasizedthat the therapeutic nature of intensive care was poorlydefined by nurses and concluded that the nurses’ vision ofa therapeutic environment was vague.

Kavanagh (1988), in a qualitative study, examinednursing in a PICU in the USA. The nurses recounted thedraining nature of their work in a highly emotionallycharged environment. They expressed difficulties copingwith intrusiveness and demands from patients, inter-ruptions to patient care, unpredictability and potentialassaultiveness, and the irrationality and distress of patients.The focus of the role was on medication administration andmonitoring. Limit setting, supportive control, and activi-ties of daily living were also a focus of care. The nursesresented the lack of autonomy in decision making and thelack of negotiation with other disciplines. They alsodescribed conflict between control and patient autonomy.Other problems elicited included a lack of coordinatedtreatment and care plans and poor interdisciplinary com-munication. Mutual support networks for nurses wererecommended, as well as managers assuming the responsi-bility for standards of care. Considering the characteristicsand the high turnover of the patients in these areas, as wellas being confined themselves, Warneke (1986) found it notsurprising that nurses have reported feeling exhaustedfrom stress.

Duffy (1995) in a study of special observation of suicidalpsychiatric inpatients in the UK revealed a focus on pre-venting self-harm, relating, assessing, interpreting behav-ioural cues, modifying behaviour, and passing time. Duffy’sstudy identified the ambivalent core issues of ‘controlling’and ‘helping’ and pointed out the non-therapeutic natureof care, which arose from adopting a custodial, paternal-istic, medical tradition. These findings are consistent withother research on suicidal inpatients’ experiences ofconstant observation that has highlighted the importance,and at times the absence, of supportive interactions fromstaff (McLaughlin 1999; Pitula & Cardell 1996). Similarly,the custodial and controlling nature of nursing care is alsoidentified in studies of mental health nursing skills in acuteenvironments (Gijbels 1995). These findings were attrib-uted to nurses’ limited time for communication, and lackof training, autonomy, support and supervision (Gijbels1995; McLaughlin 1999).

In a Swedish study Johansson and Lundman (2002)

CLOSE OBSERVATION 167

explored patients’ experiences of being detained involun-tarily in a psychiatric unit. The study revealed a paradox-ical experience that was both an opportunity, in whichrespect and caring featured, and a violation of bothintegrity and freedom. This ambiguity was explained bythe differences in nursing care. Negative experiences wererelated to difficulty in communication with staff; positiveexperiences were related to the development of relation-ships with staff.

Yonge (1989) used a descriptive qualitative method toinvestigate the meaning of constant care (one-to-one) fornurses and patients in Alberta, Canada. The patients iden-tified the following helpful nursing actions. The nurseprovided structure, communicated respect, taught specificskills and demonstrated caring. The nurses described theirrole as building therapeutic relationships, creating a senseof privacy and managing violent and angry patients. Thenegative aspects of constant care included being watched,not having sufficient privacy, and lack of continuity of staff.This study stressed the negative custodial nature of the useof security staff and highlighted the nurses’ lack of aware-ness of family members’ needs. The nurses expressed theirconcerns regarding the unsafe environment, getting relieffor medication administration, unskilled staff, assess-ments, and matching the gender of the patient and thenurse.

MENTAL HEALTH NURSING SKILLS ANDCLOSE-OBSERVATION AREAS

A number of skills have been identified for mental healthnursing practice in close-observation units: assessment,risk assessment and management of aggression, pre-vention of violence, pharmacological management andcollaboration (Allan et al. 1988; Brown & Wellman 1998;Montgomery & Johnson 1996; Winship 1998).

AssessmentIn a study of the special observation of suicidal patientsDuffy (1995) found that there was a lack of systematicassessment by nurses and a lack of research-based instru-ments for assessment. There are developments in the UKfor nursing assessments in psychiatric care (Hussein et al.1997; Woods et al. 1999). The Behavioural Status Indexhas been used for treatment planning in high securitypsychiatric care. This index addresses issues of assessmentof risk, insight, communication and social skills (Woodset al. 1999). In addition, Hussein et al., in a study of a nurse-led clinic, examined the nurses’ ability to carry out clinicalassessment in psychiatric care. A model of skills in relationto technical, human, conceptual and design componentswas utilized. Furthermore, Dennis (1997) and Farrell et al.(1998) have developed models of care for patients who are

at risk of absconding, for assessment of decreasing close-observation need, and for management of agitation inpsychotic patients. The development of evidence-basedmodels, however, is clearly lacking.

Risk assessment and management of aggressionA number of studies have focused on risk assessment inrelation to the management of patient aggression (Fox1998; Hyde & Harrower-Wilson 1994; Littrell & Littrell1998; McNiel & Binder 1995; Whittington & Wykes 1996).Controlling the ward milieu, adequate staffing, andadequate space are environmental factors that can preventviolence and assault and are necessary for developing atherapeutic milieu (Katz & Kirkland 1990; Lanza et al.1994; Nijman et al. 1997; Nijman & Rector 1999; Warren& Beadsmoore 1997; Wing et al. 1998). Hyde andHarrower-Wilson (1996) identify the nurse as the keyperson for assessing risk through the systematic collectionof objective ratings for decisions regarding level of obser-vation required and the management of violence.

Sheridan et al. (1990) and Grassi et al. (2001) noted thatviolent patient behaviour was generally related to frus-tration engendered by enforcement of rules, denial ofprivileges or conflict with other patients and that very fewincidents were related to psychiatric symptoms.Saverimuttu and Lowe (2000), in a study of aggressiveincidents on a PICU, described aggressive incidents asreactions to forced compliance. Violence in acute close-observation areas thus appears to be socially drivenbehaviour rather than emanating from intrinsic mentalstatus problems of the individual.

An interesting finding from an Australian study byOwen et al. (1998) was that the relative risk of violence andaggression increased with an increased number of nursingstaff and decreased with an increased number of youngstaff (under 30 years of age). These findings are notreflected in the clinical practice guidelines produced bythe Royal College of Psychiatrists (Wing et al. 1998) thatrecommend adequate staff ratios and trained and experi-enced staff, and need further exploration.

Nurses need to recognize the interactional dynamics ofviolence as well as possess suitable assessment anddecision-making skills for preventing and promptlymanaging violence and aggression using least restrictivemeasures. Given the characteristics of patients in close-observations areas, ways need to be provided for the safeventilation of anger and the structured use of energy(Finnema et al. 1994; Gillig et al. 1998). A therapeuticmilieu, therapeutic practices that are evidence-based,adequate resources and continuing professional devel-opment are recommended (Lendemeijer & Shortbridge-Baggert 1997; Muir-Cochrane & Harrison 1996;Muir-Cochrane 1996; Sullivan 1998a).


Prevention of violenceThe evidence-based clinical practice guidelines from theRoyal College of Psychiatrists (Wing et al. 1998) focus onthe prevention of violence by identifying features of theenvironment for promoting good practice and include pro-tocols and policies for seclusion and use of medications.These guidelines signify the importance of the context,collaboration, and supporting structures and processes foreffective psychiatric care. Grassi et al. (2001) suggest thatthe low incidence of violence in Italian psychiatric unitsrelates to a number of possibilities including selection ofclients, attention to the problem of aggression in policy andeducation, a good physical environment and the provisionof a comprehensive psychiatric service offering continuityof care and liaison across the service.

Harris and Morrison (1995) incorporate an interactionaltheory of aggression and violence and argue that violencecan be managed without coercion through negotiation andcollaboration, instead of control. Shepherd and Lavender(1999) from the UK emphasize that the management ofaggressive incidents still focuses on control and restraint,pro re nata (PRN) medication and seclusion and recom-mend the need for structured activities for patients,improved staff to patient interaction and staff support.

Fenton et al. (2000) identified containment strategiesfor the management of acutely disturbed in-patients thatinclude changes to observation levels, increased staff topatient ratios, locked wards, de-escalation techniques andthe use of behavioural contracts. The value of psychologicaltechniques for least restrictive measures (e.g. verbal de-escalation, limit setting, ‘quiet time’, removal from stimuli,stance, touch, eye contact, diversional activities) as well asPRN medications is well documented in the literature onviolence and aggression (Canatsey & Roper 1997; Lanceeet al. 1995; Lehane & Rees 1996; Martin 1995; McDonnell1996; Morales & Duphorne 1995; Paterson et al. 1993;Richmond et al. 1996; Visalli et al. 1997; Whittington &Wykes 1996).

Control, restraint and seclusionControl and restraint of patients are expectations placedupon nurses working in close-observation areas.Marangos-Frost and Wells (2000) conducted an ethno-graphic study in Canada and concluded that nurses per-ceived the use of restraint as a decision dilemma withtension between the need to maintain the safety of theidentified patient, other patients, staff and the unwelcomeoption of restraint. Bonner et al. (2002) conducted a qual-itative pilot study of nurses and clients involved in restraintepisodes. Both patients and nurses indicated that the inci-dents were distressing, and that they recreated previoustraumatizing events.

Control and restraint training has been identified as a

strategy for preventing and minimizing assaultivebehaviour although research indicates that the focus of thistraining remains on containment and not on preventativemeasures (Gentle 1996; Winship 1998). Staff training hasbeen proven to be inversely associated with the incidenceof assaults in the USA (Infantino & Musingo 1985), toincrease staff confidence in dealing with aggression inAustralia (McGowan et al., 1999) and significantly reducesbehaviourally expressed fear and aggression among staff inthe UK (Phillips & Rudestam 1995). To the contrary, stafftraining demonstrated no effect in the Netherlands(Nijman et al. 1997).

Seclusion has been indicated for containment and iso-lation and to decrease sensory input and is used for theprevention of violence (Gutheil 1978) however, seclusionhas been identified as a potentially traumatic experiencefor patients (Cohen 1994; Herman 1992; McGorry et al.1991; McGorry 1992; Norris & Kennedy 1992). The dele-terious and distressing impact on patients is well docu-mented (Meehan et al. 2000; Norris & Kennedy 1992; Tooke& Browne 1992). Seclusion is described as being punitive(Farrell & Dares 1996; Martinez et al. 1999; McDonnell1996; Tooke & Browne 1992) and controlling in nature(Lendemeijer & Shortbridge-Baggert 1997; Morrison1990; Muir-Cochrane & Harrison 1996; Muir-Cochrane1996; Sullivan 1998a). Seclusion has a distressing impacton staff (Outlaw & Lowery 1992). Nurses are often reluc-tant to recommend its use and the lack of consistent judge-ments among nurses has been highlighted (Holzworth &Wills 1999).

Extensive systematic literature reviews regarding seclu-sion have been attended (Alty and Mason 1994; Bower et al.2000; Fischer 1994; Lendemeijer & Shortbridge-Baggert1997; Sailas & Fenton 2000). Sailas and Fenton (2000)conclude, ‘in the absence of any controlled trials in thosewith serious mental illness, no recommendations can bemade about [the] effectiveness, benefits or harmfulness ofseclusion and restraint’ (p. 13). Seclusion is recommendedfor emergency situations (Cashin 1996; McMillan 1993;Wilson 1993) and as an alternative, intense observation isrecommended (Lehane & Rees 1996; McCoy & Garritson1983; Muir-Cochrane 1999; Walsh & Randell 1995).

Pharmacological managementAlthough pharmacological management in PICUs hasbeen described in the literature (Allan et al. 1988; Goldneyet al. 1985; Hyde & Harrower-Wilson 1994, 1996; Khanet al. 1987; Musisi et al. 1989; Warneke 1986), the specificautonomous skills required by nurses have not been iden-tified. Hyde and Harrower-Wilson (1996) report a protocolfor rapid tranquillization that emphasizes attempts at low-stimulus environment techniques prior to administrationand the importance of vital observations and care of the


sedated patient. Usher and Arthur (1997) from Australia,present a model for the management of the effects ofneuroleptic or antipsychotic medications. Tools, such as aself-rating scale for measuring neuroleptic side-effects, arebeing used in the UK by acutely disturbed patients them-selves, and by multidisciplinary team members, withoutspecialist training (Day et al. 1995). Considering theadministration of PRN medications is an autonomousnursing action, expert knowledge of psychotropic drugs,their effects and side-effects is essential.

The trend for rapid tranquillization, including the useof long-acting Zuclopenthixol Acetate (Cloxipol Acuphase)for the acute management of violent and psychoticpatients, and also the serious sequelae that can result fromits misuse, has been documented (Hughes 1999; Malhiet al. 1999; Nygaard et al. 1994). Fitzgerald (1999), whileacknowledging the potential benefits of this medication,also raises the ethical issues related to autonomy, conflictof rights, informed consent, restraint and treatment. Long-acting medications that cause prolonged sedation wouldseem to be contrary to the standard of ‘least restrictiveenvironment’ in which to care for people with mentalillness. Evidence-based guidelines for the administrationof psychotrophics in close-observation areas are needed toensure that continual assessment occurs in order to detectside-effects, reduce morbidity and mortality and protectthe rights of patients.

CollaborationInextricably linked to the provision of therapeutic nursingcare is collaboration with multidisciplinary team members.Few studies of the role of the multidisciplinary team in close-observation areas were identified. Studies have outlined themembers of the multidisciplinary team and have stressedthat teamwork is important for clinical assessments and forthe development of policies. Daily meetings, formal multi-disciplinary rounds and treatment conferences, and com-munity meetings with staff and patients are recommended(Allan et al. 1988; Dix 1995; Gentle 1996; Goldney et al.1985; Hussein et al. 1997; Kavanagh 1988; Moore et al.1995; Musisi et al. 1989; Neilson 1992). Kavanagh (1988)identified the problem of a lack of communication betweennurses and other clinicians as well as a lack of collectivedecision making with care planning. The specific roles andskills of the members in relation to close-observation areashave not been articulated in the literature.

Literature that specifically addresses collaboration withpatients and relatives in close-observation areas was notidentified although Australian government policy advo-cates consumer participation in all levels of mental healthservice provision. Mutual trust and respect have been iden-tified as necessary precursors to any collaboration (Connor1999).

ETHICAL DECISION-MAKING PROCESSES

Research on nurses’ ethical decision making in psychiatricnursing practice point out the importance of the culturaland managerial milieu of the workplace for supportingnursing practice (Fischer 1994; Lutzen 1990). Lutzen(1990) in a study of the therapeutic relationships experi-enced by psychiatric nurses in Sweden, discussed thetension arising from ‘moral sensing’ and ‘ideologicalconflict’. Moral sensing described the moral reasoningprocess that maintained the patient’s autonomy. The nursesdescribed that their moral sensing was not endorsed inhospital rules and practices, thus the ideological conflict.Ethical decision-making studies, regarding restraint use,has highlighted the importance of unit factors such aspatient composition, staffing policies regarding restraintand the professional attitudes of staff (Marangos-Frost &Wells 2000). Lutzen and Schreiber (1998) describe how anon-therapeutic environment mitigates against ethicalbehaviour.

Ethical decision making is affected by the attitudes thatstaff develop towards particular patient groups who selfharm and exhibit violence (Lancee et al. 1995; O’Brien1998). Nurses’ behaviour tends to be driven by an organi-zational ideology that emphasizes control resulting in theneed to enforce rules rather than to facilitate therapy(Morrison 1990). Morrison attributes this to ‘the traditionof toughness’ that is prevalent in nursing care in psychiatricsettings. Control has been identified as being a centralcomponent of nursing care provided on closed wards(Muir-Cochrane & Harrison 1996; Muir-Cochrane 1996).Sullivan (1998b) asserts that this emphasis on control incontinuous observation areas is repressive and counter-productive and will undermine the therapeutic value ofcare and Duffy (1995) suggests that an emphasis on controlalso affects the professional autonomy and decision makingof nurses.

THERAPEUTIC NURSING CARE IN CLOSE-OBSERVATION AREAS

Literature regarding the nature of therapeutic nursing carein close-observation areas is lacking. Gentle (1996), as pre-viously stated, described the therapeutic vision as beingvague. A therapeutic ethos has been described as non-punitive in nature and for staff to be understanding of dis-turbed behaviour (Brown & Wellman 1998; Mounsey1979).

Therapeutic relationships and interactions are recog-nized as being valuable for patients in acute mental healthenvironments and hence are a necessary nursing skill(Gabbard 1992; McLaughlin 1999) and expert nursingpractice is related to the commitment of nurses to engaging


in these relationships (McElroy 1996). Therapeutic rela-tionships are stressed as being important for increasingpatients’ self control (Allan et al. 1988; Hyde & Harrower-Wilson 1994; Montgomery & Johnson 1996). Hyde andHarrower-Wilson (1994) described the nature of thera-peutic interaction as being compassionate, respectful andgentle and these authors and others noted that the milieuwas important for helping reduce tension and aggression(Khan et al. 1987; Musisi et al. 1989). The milieu needs tobe secure, calm, structured, supportive and non-intrusive(Gentle 1996; Hyde & Harrower-Wilson 1994; Neilson1992). Wilshaw (1997) describes the significance of inte-grating the therapeutic approach of the helping relation-ship into mental health nursing care.

Therapeutic mental health nursing involves provisionof a therapeutic milieu, the development of therapeuticrelationships and specific interventions appropriate for thepatients’ behaviour (Delaney 1992a). Cutcliffe (1997)describes the attitudes/philosophy, knowledge, skills androles of expert psychiatric nurse practice as a caring com-mitment, empowerment, critical reflection, research-based knowledge, therapeutic relationships, effectivecommunication, partnerships and advocacy. While thesedescriptions of expert nursing care provide broad pre-scriptions, what is needed is definition of their applicationto the close-observation area and evaluation of the effectof their implementation.

A framework for therapeutic nursing care inclose-observation areasGunderson (1978) defines five essential therapeuticprocesses that can be used to provide a framework for thera-peutic mental health nursing care in close-observationareas. Although much has changed in mental health caresince the writing of Gunderson’s paper, the functions ofthe therapeutic process remain constant, and these func-tions have as much relevance now as when written.Delaney (1992a, 1992b) adapted this framework for theorganization of child inpatient psychiatric nursing andCreedy and Crowe (1996) advocated this framework forthe organization of adolescent inpatient psychiatric care.The following framework, based on Gunderson’s,Delaney’s and Creedy and Crowe’s works, is recommendedas appropriate for nursing in close-observation areas.

Containment functions to sustain the physical and psy-chological well-being of patients, removing the burdens ofself-control or feelings of omnipotence (Gunderson 1978).Skilled mental health nursing can provide a containingmilieu, utilizing prevention and early intervention skillsand least restrictive measures to ensure the safety of thepatients in close-observation areas. These skilled inter-ventions need an understanding of the environment, andthe rapid, calm response to potential disruption. There

needs to be a high level of agreement between staff aboutthe level of tolerance for behaviours and the acceptableintervention hierarchy for escalating behaviours.

Support functions to make the patient feel secure, com-fortable, less anxious and less distressed. Nurses need todevelop therapeutic relationships with patients and becompassionate, respectful and gentle (Hyde & Harrower-Wilson 1994). Support is not an elusive concept but afocused, intentional attempt to understand the world ofthe patient and to be emotionally available to them(Delaney 1992a). It requires conscious attention to theevents that led to hospitalization, and how the patient feelsabout their admission and treatment. It involves inter-ventions aimed at alleviating distress and discomfort andthe provision of information. In addition, there should beaccess to consumer and carer advocates, a multidisciplinaryteam approach and the involvement of relatives/significantothers (Musisi et al. 1989).

Structure provides for the organization of time, placeand person, which functions to reduce anxiety, and containmaladaptive social behaviours. The environment of close-observation areas needs to be secure, structured, low-stimulating, non-intrusive and supportive (Gentle 1996;Hyde & Harrower-Wilson 1994; Neilson 1992). However,low/non-stimulating does not translate to lack of inter-action, structure and activity. While there is no identifiedevidence of the optimal level of activity for differentpatient groups or individuals, the provision of a non-chaotic, and predictable environment would seem to makesense. Written unit guidelines, and expectations and limitsof behaviour, developed in collaboration with consumersand carers, need to be available to patients, carers and rel-atives as well as respective hospital advocates.

Individualized, integrated multidisciplinary treatmentplans can provide the necessary structure and consistencyfor the patient (Sutherland 1996). However, the focus ofnursing goes beyond the utilization of individual care plansto incorporate the use of skilled interventions, and plannedactivity aimed at maximizing the therapeutic effect of themilieu.

Involvement encourages the active participation of thepatient with the social environment, which functions tostrengthen ego and modify aversive interpersonal patterns(Gunderson 1978). Involvement refers to the way in whichpatients can be actively engaged in the environment. Itrequires skilled nursing judgement to assess the approp-riate level of involvement for individual patients. Involve-ment can be encouraged by actively seeking out of patients,establishing relationships, using informal and formal groupprocesses, and encouraging social skills and the devel-opment of confidence (Gunderson 1978). Since there is alack of evidence-based literature regarding what inter-ventions are appropriate for patients in close-observation


areas, nurses need to evaluate interventions that have beenproven to have a beneficial effect on acutely disturbed,agitated, psychotic and depressed patients in othersettings. For example, activities such as movement,exercise, massage, relaxation, music, artwork, and diver-sional activities have proven to be effective with specificpatient groups (Aldridge 1994; Allen 1999; Gagne & Toye1994; Lee et al. 1993; Quinney 1997; Stewart et al. 1994).

Validation functions to affirm the patients’ individual-ity and to maintain their integrity (Lutzen & Nordin 1994).Consumer literature emphasizes the importance of beingvalidated as a person: ‘medication and superficial supportalone is not a substitute for the feeling that one is under-stood by another human being’ (Pollack 1989; p. 319).Nurse–patient relationships can enhance a sense of self byreflecting hope (Kirkpatrick et al. 1996) and believing inpatients’ ability to get better (Davidson 1992).

This model of therapeutic process provides directionand focus for nursing care in close-observation areas. It isbased in psychodynamic theory, provides definition for thenursing role, and can be utilized within a multidisciplinaryteam approach while maintaining the autonomous contri-bution of nursing to patient care.

DISCUSSION

Despite the cost and difficulty of managing close-observation units, and the possible detrimental effects topatients, relatives and staff there are few conclusions thatcan be reached from the literature. While there is aplethora of literature related to control, aggression, re-straint and seclusion this was seldom linked to the milieuin which it occurs: the close-observation area. Clearly thereare recommendations regarding the ambience, size,models and design of the areas, however, there are few rec-ommendations regarding operational policy or positivegoals and treatment plans. What recommendations wereidentified generally failed to link the need for adequateresourcing to their realization. Studies related to the expe-rience of nurses and patients in close-observation areaswere sparse. Studies of nursing skills and interventions inclose-observation areas recommended specific skills nec-essary for nursing in this area which were aimed at assess-ment and risk assessment, management of aggression,prevention of violence, pharmacological management andcollaboration. Studies related to the milieu recommendedadequate staff, and the prevention of crowding. Thesestudies did not provide a framework for care related togoals and directions for care.

Education, a supportive unit context and institutionalculture, along with an adequate number of skilled staff,was identified in the literature as being essential for theprovision of therapeutic mental health nursing care.

Therapeutic nursing care frameworks and policies forclose-observation units, developed in collaboration withconsumers, carers and the multidisciplinary team were notidentified in the literature. Recent literature related totherapeutic process, and how this can be operationalizedby nurses in close-observation units was not identified.Given the imperative to meet the National Standards forMental Health Services (Australian Health Ministers’Advisory Council’s National (AHMAC) Mental HealthWorking Group 1997) and the Standards for Mental HealthNurses in Australia (Australian & New Zealand College ofMental Health Nurses Inc 1995) and the evidence thatinpatient care in close-observation areas can be trauma-tizing for patients, there is an urgent need to adopt andoperationalize philosophies and frameworks for nursingcare into practice, policy and protocol. Nursing needs toreintroduce a therapeutic approach to practice in close-observation areas that will define its role and contributionto the multidisciplinary team approach to patient care.Changes in practice need to be evidence-based and eval-uated, and linked to skill and resourcing requirments, inorder to ensure quality nursing care for patients in close-observation areas.

ACKNOWLEDGEMENTS

The University of Western Sydney Research GrantsScheme funded this study. We would like to thank KarenCooper for providing assistance in revising this paper.

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