Introducing

1

Introducing Zonal Observations within a
Medium Secure Unit for offenders with a
Learning Disability
2

Risk and Observation

• Within less than a decade, the concept of risk
  has become a central focus of mental health
  policy and practice. Various processes of risk
  assessment and risk management are employed as
  a form of contemporary governance, attempting to
  control the actions of both service users and
  practitioners to best meet the needs of the
  organisation (Crowe and Carlyle, 2003).
• Crowe and Carlyle (2003) saw a need for nurses to
  re-examine carefully their socially mandated role
  as guardians of people at risk, if they were to
  continue to fulfil their espoused therapeutic
  role. The nurse-patient relationship, first
  described over fifty years ago, is a major
  given of nursing practice nurses spend time
  with patients and this (of itself) is therapeutic
  (Jackson Stevenson, 1998).
• Zonal observations is concerned with the
  observation and supervision of patients and how
  the nurse and patient fit into the management of
  this.

3
Observation

• Observation of patients is one of the core skills
  of nursing staff working in a health care
  setting, particularly secure care. This involves
  watching, listening and interacting with patients
  (Cleary 2003).
• Specific levels of observation are implemented on
  a multi-disciplinary basis and can be increased
  at the discretion of nursing staff, at any time
  following a change in risk either presented by
  the patient/or clinical risk assessment.
• Registered nurses are accountable to ensure
  adequate observation takes place by way of
  allocation of duties and ensuring nursing
  assistants are briefed in relation to individual
  patient care plans.

4
What are Zonal Observations and why have this
approach?

• The use of Zonal Observations is designed to
  enable patients to take on responsibility within
  the least restrictive environment or parts of the
  environment, based on a specific risk assessment.
  
• A combination of boundaries and time restrictions
  are in place to move within certain rooms within
  the ward environment, supported by the presence
  of staff who provide observation.
• By placing staff in strategic positions within a
  specified part of the ward environment, with
  associated duties and responsibilities. The
  opportunity to observe the patients as a group
  increases, whilst also allowing the opportunity
  for other staff to engage with patients for set
  periods of time.

5
What are Zonal Observations and why have this
approach?

• Staff can utilise eye contact as a means to
  communicate with one another. This provides
  visual protection and opportunities for non
  verbal communication should any given situation
  require it.
• Nurses must maintain records and constant
  observation of corridor areas when patients are
  using free time or areas of access in that
  particular zone to safeguard against possible
  misuse.
• A review of the assessment of the patient will
  take place during the handover of each shift, by
  the nursing staff on duty based on the patients
  behaviour and mood.

6

7
T O I L
Colour Key    
 
 Colour Key    Blue Area Zone 1    Green Area
Zone 2     Red Area Zone 3
Kitchen
Bedroom
Quiet Room
Cupboard
T O I L E t  
Bedroom
Dining Area
Living Area
Bedroom
SH O W E R
Laundry Room
Outside Courtyard Area
Bedroom
Green Area Zone 2      
Exit
Bathroom
Bedroom
Bedroom
Observation Windows
Lower corridor leading to more bedrooms

Nursing Observation Office
Seclusion Room
8
Zone access in relation to patient movement

• Patients will have identified zone access in
  relation to their individual behavioural and
  mental health presentation.
• Zone access will stipulate the specific areas
  that patients are granted movement within.
• The observation status of each patient will be
  included on the whiteboard of allocated staff
  duties and allocation of duties file.
• When an incident changes the Zonal observation
  level this will be signified by an (asterix)
  on the recording sheet.
• Recording sheets can be devised in accordance
  with specific policies or local procedure
  documentation.

9
Zone Staff Responsibilities

• Communication staff allocated to zone need to
  communicate with each other to ensure the
  whereabouts and activity of patients within their
  care, liaise with nurse in charge with regard to
  any problems and report any untoward activity.
• Engagement should be an integral aspect of
  observation. Professionals cannot fail to
  observe if actively engaged with the person in
  their care (Barker and Cutcliffe 1999 2000).
• This will be done via the unit walkie/talkie
  communication system. Each zone will be issued
  with a walkie/talkie radio to enable this.
• Recording zone staff will complete records of
  observation for patients as identified

10
Zone 1 staffing ratio

• At least 2 staff members will allocated to Zone 1
  at all times when patients are in the area.
• If patients are between zones1,2 or 3, a member
  of staff will be in zone 3 and maintain direct
  eye contact with staff in zone 1.
• Patients allocated Zone 1 access will have their
  movements restricted to Zone 1 from waking in the
  morning to retiring to bed at night. Instances
  when a Zone 1 patient require access to Zone 2
  e.g. the bathroom for hygiene purposes, or toilet
  access, one member of staff should escort them.
  At this stage responsibility will shift to the
  staff member responsible for that particular
  Zone.
• Patients must inform staff allocated to Zone 1
  should they require to move to Zone 2 or 3 and
  this is dependant on the patients risk
  management plan at any one time.

11
Zone 2 staffing ratio

• 1 member of staff will be allocated to Zone 2 to
  enable all patients who have access, can use
  these areas. Staff will then document records of
  observation throughout the time span that
  patients are using this area (during waking
  hours). Staff allocated to this zone can also
  complete the related duties aligned with this
  zone.

12
Zone 3 staffing ratio

• 1-2 staff members allocated to Zone 3 to enable
  those patients who have access, to use this area.
  Access to these areas can be time allocated and
  planned to ensure the safety of both patients and
  staff. Staff will then document records of
  observations throughout the time span patients
  use this area (during waking hours). The whole
  zone can be observed from the nursing office,
  making this the base for any Zone 3 assigned
  staff.
• Free Time will be allocated when patients have
  time within their rooms. This is flexible and
  determined on an individual basis for each
  patient by the clinical team.

13
Risk assessment in relation to managing the Zone
Plan

• It is flexible and can be individualised to fit
  in with any clinical regime, procedure or
  routine.
• During staff meal breaks, critical incidents or
  other occasions that may require staff resources,
  all patients may require restricted access to
  Zone 1. This will be established by the Nurse in
  Charge or Manager at that particular time or day.
• It encourages a flexible approach to the clinical
  environment.
• The zonal access for each patient will be
  assessed and discussed weekly in an MDT form.
  Evidence based from the previous week will be
  discussed and zone access allocated.

14
Benefits (Based on verbal feedback and some
information from returned evaluation
questionnaires)

• Provides the least restrictive, yet safe and
  secure system for observing patients within the
  clinical area.
• Enables staff to better manage the social and
  physical environment, so preventing the person
  from acting harmfully towards self or others.
  (Barker and Buchanan-Barker, 2004).
• Removes the need for obtrusive observation
  management systems such as 11 nursing.
• Patients report a preference of being managed
  within this system.

15

• Staff members have reported positively on the
  system citing benefits such as-
• Easier means to communicate with colleagues
• A feeling of having more staff resources
• A removal of the intensity of 11
  nursing/observation
• Feeling of better security and safety
• Patients have reported similar benefits-
• Feelings of having better access to staff
• Feelings of having greater access to the unit
• Feelings of increased privacy

16
Formal Evaluation of the system

• The zonal observation system was initially run
  for a three month trial period
• Verbal feedback has been received via staff
  meetings, staff handovers and clinical
  supervision sessions
• Verbal feedback has also been received via
  patients forums and meetings
• Formal Evaluation is currently being sought -
  this is by way of feedback and evaluation
  questionnaires
• Questionnaires have been given to staff members
  and patients alike

17
References

• Barker P and Buchanan-Barker P (2004) The Tidal
  Model A guide for mental health professionals
  London Brunner Routledge
• Barker P and Cutcliffe J (1999) Clinical risk A
  need for engagement not observation. Mental
  Health Practice 2(8) 8-12
• Cleary M (2003) The challenges of mental health
  care reform for contemporary mental health
  nursing practice Relationships, power and
  control. International Journal of Mental Health
  Nursing 12(2) 139-47
• Crowe M Carlyle D (2003) Deconstructing risk
  assessment and management in mental health
  nursing Journal of Advanced Nursing43(1)19-26
• Jackson S and Stevenson C (1998) The gift of time
  from the friendly professional. Nursing Standard
  12 (51) 31-33