Why letting go is so hard: A rapid ethnographic study of enhanced observations in acute mental health wards

Background Inpatient observations are a cornerstone of risk management and practice in mental health care units in the UK, despite questions about their effectiveness in keeping people safe and evidence highlighting their financial cost, resource burden, and impact on patient privacy and dignity. Observations themselves may exacerbate mental health symptoms and increase risk to patients and those around them. Method Drawing upon ethnographic data collected across three wards in two NHS Trusts in England, this study explored staff and service users’ perceptions and experience of observations, how observations are routinely conducted, and the organisational social, and cultural influences shaping their use. Results We found that i) observation practices were largely driven by fear, ii) staff experienced tensions between managing patient risk and recovery, iii) staff worked variably within and beyond policy boundaries, and iv) the institution culturally embedded observational practices that often inhibited rather than enabled safe care. Conclusion We argue that enhanced patient observations are ritualised in mental health inpatient units, sustained and persistent as a default safety strategy, despite often being disconnected from therapeutic goals and sometimes causing iatrogenic harm. We position enhanced observation as a potential target for de-implementation and call for better engagement with why observations are used.