University Essay: Special Observation in Mental Health Nursing

This essay delves into the concept of special observation (SO) within mental health nursing, examining its historical, socio-cultural, and political contexts through the lens of Foucault's theories of power and discourse. It traces the evolution of SO from its origins to its current practices, highlighting the shift from physical restraints to modern surveillance techniques like CCTV. The essay explores the influence of socio-cultural factors, such as the rise of surveillance culture, and the ethical implications of SO, including the balance between patient safety and individual rights. Furthermore, it discusses the political dimensions of SO, emphasizing the expectations of ethical practice and the use of governmentality. The essay concludes by emphasizing the importance of therapeutic engagement and the need for mental health professionals to exert power in a way that respects patients' autonomy and promotes their well-being.

Running head: ESSAY
Observation in mental health nursing
Name of the Student
Name of the University
Author Note

1ESSAY
Introduction- Mental health nursing, commonly referred to as psychiatric nursing
refers to the appointed designation of a nursing professional who holds specialisation in
mental health and provides care and treatment to all individuals suffering from mental
distress, regardless of their age (Townsend and Morgan 2017). Mental health nurses work
within a team that comprises of medical and professional staff such as, social workers,
doctors, therapists and psychiatrists, in a range of healthcare settings, including patients
homes and/or hospitals. Furthermore, mental health nursing also focuses on a range of
biological, physical, psychosocial, therapeutic, and spiritual interventions (Orthwein 2017).
Nursing professionals generally carry out a plethora of autonomous, prescribed medication,
and interventions with patients, as part of their everyday practice. However, a crucial step of
observation lies at the centre of these interventions, which guides the mental health nurses in
their activities. While observation is an important skill for all mental health service providers,
patients who are in an acute phase of their illness often pose a risk to themselves and others.
Therefore, with the aim of preventing harm to self or others, special observation (SO) is
generally undertaken. There are four types of SO namely, Level One which is general
observation where staff monitor patients hourly during the day and night. The second level is
intermittent observation; here the patient is checked every 15 to 30 minutes. The third and
fourth levels are constant surveillance of vulnerable patients. The third stage is where the
patient is kept in close proximity and under strict supervision 24 hours per day. The fourth
stage is when the patient is within arm’s length of one or more staff at all times (Probst
2017). It has been pointed out by Foucault that the terms knowledge and power are
insidiously associated and that power replicates knowledge by influencing it in agreement
with its unidentified intentions. This essay will elaborate on SO in mental health settings, in
relation to Foucault's complete philosophy that is based on the supposition that human

2ESSAY
awareness and reality are overpoweringly historical. SO will be explained in terms of
historical, cultural, social, and political context utilising the theory by Foucault.
Historical context of special observation- SO (SO) is generally refers to a common
method that is used to assign an individual to care for a patient, identified to be at-risk, for a
certain period. SO is regularly viewed as an unfriendly and low status activity, which in turn
is delegated to untrained or junior staff (Slemon, Jenkins and Bungay 2017). It has also been
found that in present day times, SO is also conducted by non-professional carers such as,
family members of the patients, provided that sufficient support and assistance is provided to
them. However, in earlier days, the attendants and psychiatric nurse were expected to be
vigilant towards their patients, and has a history that can be traced back to as much as 300
years ago) In addition, the patients were often confined to psychiatric settings and the role of
the psychiatric nurses was focused on preventing the patients any kind of contact with the
surrounding world (Chu 2016). This was well-known during the medieval era when the
lunatics were confined to private madhouse and observed there, under circumstances when
family care was no longer possible for the aggressive patients, and/or the family carers were
not allowed to visit the patients. Furthermore, those patients who were judged to be
predominantly disturbing or violent were also confined to privately run asylums where they
were chained and their movement was restricted (Colaizzi 2016). Furthermore, the use of
physical restraint that primarily relied on the usage of chains, ropes, straps, leg cuffs,
handcuffs, and straitjackets (Rudge 2016).
However, it became progressively understandable throughout the years that such
strategies in mental health settings were direct defilements of the civil rights of patients.
Therefore, it can be suggested that one person is in control of the patient suffering from
mental distress, and keeps a track on his movement and other activities, to prevent any risk or
adverse events (Stickley and Wright 2013). Humans have been recognised as complex

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individuals and the psychiatric semiology is complete with manifold facets. Therefore, the
accurate method of conducting SO moves from gaining an overall impression of a patient
suffering from mental disorder, to the more investigative and diagnostic details about patient
personality and behaviour.
This can be explained by Foucault's philosophy owing to the fact that he has
developed several strands, while analysing the concept of power, and has also stated that
power is repressive, as well as productive. Thus, according to Foucault, there does not exist
any space in the community that is not under the influence of power and in the absence of
power, no individual can exist. In addition, Foucault also defies the idea that power is exerted
by individuals or crowds by the method of ‘sovereign’ or ‘episodic’ acts of command or
oppression, viewing it instead as disseminated and prevalent (Allen 2017). Therefore,
Foucault stated that power exists and comes from everywhere, and therefore in this sense is
neither a particular stricture nor an agency. Instead, he recognised power as a ‘regime of
truth’ that infiltrates the society, and is in constant mutability and conciliation (Palmer 2017).
Foucault was also keen or obsessed by the contrivance of school discipline, prison
observation, asylum surveillance, and other systems that existed in the society for the
management and regulation of populations, in addition to promotion of customs and rules
about bodily conduct.
This was followed by his postulate that the physical bodies are generally dominated
and made to perform and conduct themselves in definite ways, as a miniature of social
regulation of the larger population, through ‘bio-power’. Hence, the impact of power on
relationship plays an important role in mental health nursing and Foucault stated that power
in this context is generally legitimised through information establishing what is measured as
factual, or “discourse” (McHoul, McHoul and Grace 2015). Hence, psychiatric observations
are a routine part of clinical practice and (NHS England, 2019) in order to maintain SO on

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patients who are morbid or actively concerned in hurting themselves or others, are sexually
disinhibited, and acutely confused, might abscond, or pose a danger to other patients or staff,
it is important to promote therapeutic engagement with the patient (NHS England, 2019).
Thus, power during SO must be exerted in a manner that the patients suffering from a mental
illness feel accepted and wanted, as an individual of importance, and are also able to ferely
engage in self-expression, free from of any fear of rejection (Brighton.ac.uk 2016). In other
words, Foucault stated that humans are products of power and do not pre-exist, followed by
becoming repressed due to power.
Socio-cultural context of special observation- All people are currently living in the
age of surveillance. The British novelist George Orwell published his masterpiece 1984 in the
year 1949, and stated that “Big Brother is watching you.” Although the fact is unsettling, it is
a commonly accepted notion that presently hospital workers put on cameras for closely
observing the people who are being provided care, with the aim of preventing any untoward
incident. Video surveillance has been identified as an essential, tool for management of
security and safety within public spaces like mental health facilities and they enable the
healthcare works to conduct a 24 hour monitoring of all patients (Draper 2018). This video
surveillance has the prospect of reducing any kind of aggressive and violent behaviour from
the patients. Moreover, the recent ongoing installation of closed-circuit television (CCTV)
cameras in the psychiatric wards, with the aim of monitoring all patients present in bedrooms,
communal areas, and seclusion rooms has occurred without much dispute (Stickley and
Wright 2013). However, one major disadvantage of this SO is that it reduces privacy, which
is an aspect of utmost importance for the psychiatric inpatients (Stolovy, Melamed and Afek
2015).
The potential for using CCTVs in this manner generally influences the categorised
social governance at the mental ward level, owing to the fact that both the nursing

5ESSAY
professionals and the patients gradually become subject to surveillance and its panoptic
practices. SO of nursing staff advocates an additional advantage for all patients in protecting
them from vehement staff. Nonetheless, this procedure of SO also has the possibility for
controlling the association between the nursing staff and the patients more widely (Dašić,
Dašić and Crvenković 2017). Foucault is one of few philosopher who stated that power
should not be always considered as a repressive, coercive and negative thing, which forces
individuals from doing things that are not according to their wishes, however can also be
considered as a productive, obligatory, and optimistic force, prevalent in the society.
Furthermore, Foucault also stated that power must generally be considered as a chief
foundation of social restraint and conformity (Haugaard 2017).
In shifting consideration far from the ‘episodic’ and ‘sovereign’ exercise of power,
conventionally focussed in mediaeval states to intimidate their subjects, it was pointed out by
Foucault that a new type of ‘disciplinary power’ can be exercised in different social services
and administrative systems that had been developed in Europe, during 18th century, such as
schools, prisons, and mental hospitals (Stickley and Wright 2013). It was stated by Foucault
that the aforementioned systems of observation and assessment did not call for the need of
power or vehemence, as individuals acquired the skills to behave in predictable ways. This
social context can also be explained in terms of Bentham’s Panopticon. According to Brunon-
Ernst (2016) panopticon refers to a kind of institutional structure, in addition to a system of
control that had been designed by Jeremy Bentham, the social theorist and English
philosopher in the 18th century.
The primary concept of this building was based on the fact that all prisoners residing
in an institution must be monitored and observed by a solitary security guard, without
providing opportunity to the inmates to express whether they are being observed. This
metaphor related to panopticon prison can be utilised for analysing the social importance of

6ESSAY
SO by means of CCTV cameras in mental health settings and other confined spaces (Philo,
Parr and Burns 2017). In 1990, the operation and design of a shopping mall had been
reviewed by Mike Davis, along with the CCTV cameras, centralised control room, and
security guards. It was concluded that such SO imitates shamelessly from the well-known
design of panopticon.
Political context of special observation- It is expected by all political figures that
mental health services will be delivered in a manner that shows adherence to the ethical
principles of autonomy, beneficence, and non-maleficence. In other words, political
organisations expect that mental health services will not do any harm to the patients, and will
enhance their emotional wellbeing (Ong-Flaherty et al. 2016). Thus, the delivery of mental
services in this manner prevents further deterioration of health and also helps in recovery of
the patients. However, SO of patients suffering from mental illness, particularly through the
use of bodily restraint results in psychological trauma to the patients and also causes physical
injury. In this sense, the nurses act like agents of observation and social control and play an
important role in exerting control.
In the later works, Foucault also invented the now significant notion of
governmentality. Foucault stated that the term governmentality refers to the “art of
governing,” which is not merely limited to state politics level, but encompasses governing a
wide assortment of persons and objects such as, complete populations at the most intellectual
level and the thoughts and desires of individuals at micro level (Lemke 2015). Foucault also
stated that unlike the concept of disciplinary power that is primarily directed at the
preparation of separable bodies, the organisation of wider populations banked on biopower,
which in turn is commonly understood as the strategies and measures that control death, birth,
health and illness. Thus, it was suggested by Foucault that biopower comprises of a
technology of power that facilitates governance of entire population and encompasses

7ESSAY
monitoring of human body, by utilising the anatomo-politics related to the human body
(Gunaydin 2017). Furthermore, according to Foucault, modern power generally gets encoded
into different social practices, in addition to human behaviour, which in turn is marked by the
gradual acquisition of human subjects to subtle expectations and regulations of social order.
The term sovereign power means that a governing body has complete right, without
the involvement of any outside bodies, over a particular polity. It has been established by
Foucault that during the 18th century, sovereign power was generally exercised by the King,
in front of the crowd, for brutally punishing deviant people in a spectacular, barbaric and
revolting ritual (Ristić and Marinković 2016). One common example of such sovereign
power was the dismaying torture of Damien, where the concept of supremacy was staged in
front of people, by holding extreme political act, and resulted in the display of public
humiliation and physical torture. Hence, Foucault mentioned that there is a definite hazard
when the noticeable feature of punishment is repressed and substituted with an unseen
procedure, one that is generally made imperceptible to the society, nonetheless gradually
becomes powerful and visible to individuals, who observe this exhibition within the walls of
the organisation (Prozorov 2016). Founded on a structure of micro-penalties, the
contemporary disciplinary organisation of a psychiatric hospital generally displays seclusion
as a core component of a disciplinary composition, through which the display of punishment
is recurrently imposed on the patients, such that others are able to visualise the power of the
healthcare professionals.
Impact on mental health nursing and contribution to change- Underlying the account
that Foucault gave for power relations, regarding prisons, asylum, hospitals and schools, the
contemporary mental health nursing has undergone several changes. Taking into
consideration the fact that Foucault questioned the history, which prioritised political analysis
and power relations over the actual and lived experiences of the patients and the doctors,

8ESSAY
current forms of psychiatric practice undermine psychiatric power (Stickley and Wright
2013). The major change that has been brought about in current psychiatric practice is the
advent of the concept of shared decision making. This generally encompass a procedure for
reaching a mutual decision by the patient and the doctor, on the course of treatment that
needs to be followed, in addition to the steps that must be taken by the patient for enacting
the plan (Slade 2017).
In place of special observation, the concept of clinical supervision has also gained
attention in recent years where the practicing mental health nurses develop their professional
practice by fostering regular communication with their senior colleagues, with the aim of
valuing the individual decisions and choices of the patients. Power balance can be maintained
in current psychiatric practice by focusing on five core elements namely, (i) fostering active
participation between care professionals and patients, (ii) information sharing, (iii) issue
definition, (iv) negotiation about management options, and (v) deferment or decision (Kirby
2019). There must be an equal split of power between the mental healthcare professionals and
the patient, in addition to the presence of a negotiated agenda for the care process.
Furthermore, the patient’s values must be explored, with the professionals playing the role of
advisors for the implementation of standardised care guidelines and procedures.
Conclusion- Thus, it can be concluded that in the domain of mental health care,
patients were earlier considered incapable to act according to their best interests, and were
confined to asylum since they were considered violent and threatening. The traditional mental
health practice was based on power relations, where restraint was imposed on them, and they
were brutally punished as well. Taking into consideration the explanation proposed by
Foucault, it can be stated that the action of restraining deviant persons within the mental
health settings was deliberated an act of universal ethics, which in turn was a component of a
broader system of control and an authoritarian arrangement that served to control

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individual/group behaviours. Hence, contemporary mental health practice is based on the
contradictions of Foucault and is delivered in a manner that aims to strike a power balance
between the patients and the healthcare professionals.

10ESSAY
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