Introduction
Aim
Definition of Terms
Management
Documentation
Special Considerations
Links
Evidence Table
Introduction
Therapeutic
engagement is the active process of developing rapport for the purposeful
gathering of information to assess mental state and risk, inform clinical
decision-making, and promote safe therapeutic care. Information gathered from
therapeutic engagement is documented as observations.
Consumer centred care
requires active interpersonal engagement to form a comprehensive understanding
and assessment of the young person.
Therapeutic
engagement is active and responsive, informs the development of care plans,
through
collaborative problem solving and crisis intervention and supports the
identification of deterioration or improvement in presentation. The process of
active engagement and observation supports a holistic model of care and
contributes to a safe and therapeutic experience directed towards recovery.
Banksia nurses have a
key role in supporting the care and recovery for young people admitted to the
ward. The active process of therapeutic engagement and observation includes the
nurse gathering objective and subjective information, attending to what they
hear, and assessment of the young person's
mental state, physical well-being and safety. This information informs
the planning and implementation of care, the effectiveness of which is determined
through ongoing engagement and observation.
Aim
This
guideline provides direction for the process and levels of therapeutic
engagement and documenting observations for young people
receiving care in Banksia.
Definition
of Terms
- Therapeutic
engagement
includes, but is not limited to, building trust and rapport, reality
orientation, crisis intervention, mindfulness, collaborative
problem solving, motivational interviewing, distress
tolerance and interpersonal effectiveness skills training
- Mental
State Examination (MSE) is
a systematic assessment and process of describing a patient's mental
state
- Milieu
the
people, physical, and social conditions and events that create an environment
or space
- Real
time
nursing documentation entered in a timely manner throughout the shift
Management
Admission
As
part of admission to Banksia, the
young person (and their family) meets with the health care team to understand
their current presentation and previous history to establish the appropriate
levels
of therapeutic engagement and observation to be provided for safe and effective
care and recovery.
During
Inpatient stay
Initial engagement at the commencement of shift should set the scene for therapeutic engagement. The nurse introduces themselves to the young person and discusses the focus for therapeutic engagement and conversations. These may include topics to be covered that pertain to reason for admission, how to manage them in the future and how they might problem solve together.
The minimum level of therapeutic engagement and observation is reviewed at least daily by either the Care Coordinator, medical staff, or the ANUM / Senior nurse. Banksia nurses can increase levels of engagement and observation at any time based on the young person's clinical needs. The nurse allocated to the patient is responsible for active therapeutic engagement and observation unless this is delegated to another nurse. Young people should always be informed when delegation occurs. When observations are increased, decreased or ceased, the allocated clinician informs the young person, and discusses the rationale for the change and what to expect.
Day-time
engagement v Night-time observations
The
levels of active therapeutic engagement and documented observation for young
people during the day when awake are;
When
a young person is asleep the priority is to let them sleep to aid recovery and
observations do not require active engagement. There are separate EMR
orders
for day-time engagement and night-time observations.
Hourly
- The minimum level of active therapeutic engagement and observation for all young people on Banksia
- Nurses should know the young people's general whereabouts at all times in or out of the ward. When on the ward, young people receive active therapeutic engagement at least within every hour
- Observations are documented within the hour
- Observations can be documented with greater frequency at the clinical discretion of the nurse
Half hourly
- The young person is engaged in active therapeutic interaction at least every half hour
- Observations are documented every half an hour
- Observations can be documented with greater frequency at the clinical discretion of the nurse
Constant visual
- May be implemented when there is deemed an increased risk to self or others
- Young people remain within visual range, no greater than 10 meters
- The nurse is in close enough proximity that they can readily engage with the young person and intervene to provide support and guidance and de-escalation
- This includes the bathroom; however, this can be delegated to a more appropriate nurse as necessary to promote dignity and gender sensitivity
- Responsibility for maintaining constant visual contact is allocated and cover delegated by the ANUM/ in charge
- The nurse is aware of the young person’s safety plan and behaviour support profile and utilises this to inform therapeutic engagement and support provided
- When the level of engagement and observation is reduced, the allocated clinician should debrief the young person, including a discussion about what the experience was like for the young person, ongoing care, etc.
Constant arm’s length
- Requires an order by the consultant psychiatrist/medical staff/care coordinator in consultation with the ANUM/in-charge. This order is reviewed each day as close to 0930hrs as practicable and following the 1300hrs handover by ANUM, the young person’s care coordinator and other members of the multidisciplinary team.
- The ANUM can implement or cancel constant arm’s length, but only in consultation with the consultant psychiatrist or medical staff and only after a Mental Status Examination (MSE) has been completed and the level of risk reviewed and documented
- In hours Banksia NUM and out of hours the Hospital Manager is notified
- 1:1 nursing allocation to enable continuous presence with the young person for immediate engagement and observation. The nurse must keep the young person within arm’s reach, including when the young person uses the toilet/bathroom. It may be appropriate to delegate to a more appropriate Nurse as necessary to promote dignity and gender sensitivity
- The nurse must keep the young person within arm’s reach, including when the young person uses the toilet/bathroom. It may be appropriate to delegate to a more appropriate nurse as necessary to promote dignity and gender sensitivity
- Nursing staff must not leave the young person unattended for any reason and be particularly aware of closely observing the young person during staff handover, meal breaks and other ward disturbances.
- A psychiatric/medical rapid review must be requested if there has been a sudden deterioration or change in symptomatology
- Responsibility for maintaining constant arm’s length is allocated and cover is delegated by the ANUM/in charge to another specified nurse
- When ceased the allocated clinician should debrief the young person, including a reflection on what the experience was like, ongoing care, etc.
Documentation
Observations are the recorded outcome of active therapeutic engagement and are documented in real time on the MH flowsheet. This includes details of the young person's whereabouts and nursing assessment, along with any other relevant information obtained from the engagement. There is a minimum of hourly documentation of observations for all young people on Banksia.
Active therapeutic engagement with young people may take many forms and the purpose of documentation of the observations is to capture trends in the young person’s condition to identify changes, inform the plan of care and guide further therapeutic engagement.
In addition, the MSE is documented every shift and when there is any change in the young person's mental state, either deterioration or improvement that may require a change to the care plan.
Special Considerations
Links
Evidence Table
Click here to view the evidence table for this guideline.
Please remember to read the disclaimer.
The development of this nursing guideline was coordinated by Sophie Linton, CNC, Nursing Innovations, and Rachel Tolan, Susan Isherwood, Laura Hainsworth, Mental Health Nurses, Banksia and approved by the Nursing Clinical Effectiveness Committee. First published September 2022.