The perceptions and expectations of clinical staff regarding special supervision in a Maltese psychiatric hospital.

Abstract

Literature supports the fact that maintaining the safety of patients within psychiatric hospitals has long been, and still is, a challenge. A common, widely accepted organisational response to reducing adverse patient outcomes such as suicide, self-harm and violence has been special observations, an intervention which, when used in mental health care, involves the allocation of one health care worker to provide intensive nursing care to an individual for a prescribed length of time. However research calls into question the therapeutic benefits of special observation, and with constantly rising health care costs and increased vulnerability to litigation and disciplinary action within the health sector, the efficacy of this intervention becomes even more important and contentious. The aim of this study was to establish the perceptions and expectations of clinical staff regarding special supervision within a Maltese psychiatric hospital. This qualitative study adopted a descriptive, cross sectional design and a mixed mode method consisting of a census survey (n=114 doctors and nurses) complimented by elite interviews with key administrative I managerial staff (n=5) was employed. Quantitative data was analysed statistically and content analysis was carried out on the qualitative data. Results showed that special supervision is utilised locally as an intervention mainly for the prevention of suicide or self-harm amongst psychiatric in-patients. It is also used for a number of other purposes such as preventing a patient from absconding or from injuring others. The question of efficacy of this intervention when offset against both cost and clinical/therapeutic effectiveness has not been established in this local study. However the study confirms that the intervention is fraught with ambiguities and that variations in prescribing and carrying out the intervention may result from varied perceptions and mismatched expectations of clinical staff and reflect idiosyncratic practice and poorly designed policies and protocols. Malta, like most other countries is constantly involved in a process of balancing the pressures of decreasing budgets against ensuring safe and effective patient care. Despite being unable to establish the actual costs of the intervention locally, the findings showed that special supervision can be a significant cost pressure and consequently the study raised several recommended alternatives aimed at reducing costs. The collective results also showed that there is an urgent need to develop a more collaborative and systematic approach between all the stakeholders that are involved in the intervention and the study suggested management recommendations aimed at achieving this, primarily through developing an agreed and auditable local policy but also including involvement of the patient and developing risk assessments and central recording systems. Whilst acknowledging ethical limitations, recommendations for further research were suggested that included further research into use of the intervention in peripheral cases and looking to international studies to provide benchmarks for local application. Finally, the study suggested ways that existing training and experience could be better harnessed in order to provide people with the skills that they need to carry out the intervention.