Hiring and training observers can keep at-risk patients from self-harm. Installing these observers was a central part of the safety protocol a multidisciplinary group created for the ED at Massachusetts General Hospital (MGH) in Boston. Who are these individuals and how are they prepared to serve as observers?

Abigail L. Donovan, MD, associate director of the acute psychiatry service at MGH, says administrators look for applicants with some experience in mental health or a healthcare setting. “Some applicants have worked as personal care attendants, medical assistants, mental health workers, or observers in other settings,” she explains.

Typically, MGH observers complete a two-week training program developed by ED psychiatric clinical nurse specialists. “The training focuses on all aspects of patient safety, including the provision of constant observation with no distractions [such as phones or earbuds], and the provision of one-to-one observation, in the case of [patients at] high risk for suicide,” Donovan says.

Observers learn about suicide risk as well as covert behaviors and the possession of dangerous items. They also learn about the potential for elopement, ingestions, and the risk of harm patients may pose to themselves or others. Further, they learn how to respond to concerning behaviors.

Observers are responsible for communicating any behavioral or safety concerns to the supervising RN, and they scan the physical environment of care with the RN so any potentially dangerous items are removed. Also, observers monitor patients using the bathroom, and they learn how to handle psychiatric emergencies while keeping themselves safe. “Observers are also educated on an ED patient observer checklist, which is a [listing] of individual safety concerns used as a communication tool between nursing and observers,” Donovan explains.

Generally, observer training includes classroom time (mostly virtual right now because of the COVID-19 pandemic), remote slide review, and knowledge-check assignments. There also is a general hospital orientation and “shadowing,” where an experienced observer mentors a trainee.

In terms of ratios, investigators report one observer can effectively monitor up to three patients as long as he or she has good visibility on the individuals.