In this section
Definition of Terms
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.
engagement is active and responsive, informs the development of care plans,
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.
guideline provides direction for the process and levels of therapeutic
engagement and documenting observations for young people
receiving care in Banksia.
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
of therapeutic engagement and observation to be provided for safe and effective
care and recovery.
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.
levels of active therapeutic engagement and documented observation for young
people during the day when awake are;
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
for day-time engagement and night-time observations.
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.
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.