The Atlas of Shared Learning

Case study

Reducing ‘enhanced observations’ on a mental health ward

Leading change

A Ward Manager at Harplands Hospital, North Staffordshire Combined Healthcare NHS Trust led a new approach to observation and engagement with patients on Ward 2 at the Trust. The initiative has led to improvements in outcomes, experiences and use of resources.

Where to look

The Mental Health Act: code of practice (MHA; 2008) set out the statutory requirements of empowerment and involvement of patients and carers, as well as dignity and respect. The MHA provides guidance who can represent or interested parties in a patient’s care and treatment. This includes carers, nearest relatives, advocates, attorneys and deputies. Specifically, it identifies the need to use the least restrictive options where possible when caring for a person under the Act, including the setting of care provision. Any restrictions in place should be the minimum necessary to safely provide the care or treatment required, having regard to whether this can be achieved in a way that is less restrictive of the person’s rights and freedom of action.

On Ward 2, the ward manager identified higher than expected levels of ‘enhanced observations’ in comparison with other wards at the Trust. With the support of the hospital’s senior nursing staff, there was a shared appreciation that improvements could be made to improve the experience of observations for both patients and staff. From experience and considering successful implementation in other areas, they nursing leads identified an opportunity to enhance meaningful engagement and person centeredness, ensuring timely review, minimising the length of enhanced observations.

What to change

Ward 2 at Harplands Hospital provides male in-patient facilities for the admission, assessment, diagnosis, treatment and rehabilitation of people with mental health needs.

A key principle of observation is to provide a period of safety for patients during temporary periods of distress, when they are at risk of harm to themselves and/or others. An enhanced level of observation is used when staff have assessed that the risk of self-harm or risk to others is increased, either within a ward environment and/or if the patient were to leave the ward. Although enhanced observations provide an opportunity for therapeutic intervention, they can be perceived as intrusive and can result in distress for the patient as they feel their privacy and dignity is compromised.

Prior to the change, there was an increased culture of patients being placed on enhanced observations without standardisation of associated meaningful interventions, specifically tailored care plans or structured observation reviews.

How to change

The senior nurses set up a project team including ward managers, a lead occupational therapist, matron, consultant psychiatrist, deputy director of nursing and costing accountant. This partnership approach supported inclusion of operational, quality and financial perspectives.

A review of clinical data for the previous three years suggested the Ward had higher than expected levels of enhanced observations in place. At times, the observations were being conducted by staff who had not received specific training. Staff and patient questionnaires were conducted to seek experiential feedback on enhanced observations.

The project team identified improvement opportunities in:

  • Implementation of education and training packages for staff conducting patient observations;
  • Review and redesign of clinical documentation;
  • Review of clinical pathways regarding restrictive practice;
  • Development of guidance to support staff to reduce restrictions where appropriate.

The programme was rolled out across the ward using the guiding principles of a PDSA (Plan, Do, Study, Act) cycle and the guidance and support received from engaging in an NHS Improvement Observation and Engagement Collaborative Programme.

Adding value

Better outcomes – This is an ongoing improvement programme. So far, training has been delivered to over 60 staff members, supporting proactive, personalised care with patients who may be at risk of self-harm. There is an enhanced review process for all patients on enhanced observations. Relatedly, the number of patients on enhanced observations has reduced. The multidisciplinary team (MDT) and patients are both now more empowered in decision making regarding observations. Across the ward, MDT care plans and associated observations are now discussed daily in staff meetings. Clinical incidents have also reduced.

Better experience – The ongoing improved access to relevant training for staff has seen positive feedback:

  • “There are more staff available to support patients now”
  • “I wanted to come and work on the ward as a result of the changes”

Patients have also responded well to the new approach, some examples include:

  • “My care was well coordinated and I was involved in all the decisions about my treatment”
  • “Can’t thank the staff enough, above all I was kept informed of everything”
  • “A more positive experience than previous admissions”

Better use of resources – The ward has calculated a cost saving of £1676 across an average weekend (Friday to Monday) through not needing enhanced observations when they may previously have been implemented – significant impact on patient experience as well as use of resources. Staff time can now be better utilised.

Challenges and lessons learnt for implementation

Communication has been a key to success as well as the ongoing sustainability and spread.

Encouraging stakeholder engagement from the outset is vital, including liaison and collaboration with fellow professionals such as medical colleagues and senior leaders.

Find out more

For more information contact: