An NHS 'Observation' policy without mentioning how to interact? ... in 2019? Surely not!

I was recently sent a copy of a newly ratified (in July 2019) NHS policy on 'Procedures for Observation and Engagement' for staff of a NHS mental health and learning disability trust 'in all acute units, inpatient settings and residential areas where service users may be observed by staff'. This policy states that: 'Observation and engagement is a skilled clinical intervention' and that 'Effective observation is underpinned by continuous attempts to engage the service user therapeutically'.

All well and good I hear (imagine) you saying, but below I will list the number of mentions in this 'observation' (which gets 138 mentions!) and 'engagement' (which manages a paltry 19 mentions) policy of the possible 'Fundamentals of Communication' through which any 'engagement' could be developed for service users with communication or social impairments (e.g. because of a learning disability, autism or mental health condition):

So, for 'Interaction' = 0 mentions - so how about, in alphabetical order:

'Attunement' and/or 'tuning in' = 0 mentions 

'Enjoyment' and/or 'pleasure' = 0 mentions  

'Eye contact' = 0 mentions  (although having someone in 'eyesight' = 14 mentions!)

'Facial Expression' and/or 'Smiling' = 0 mentions 
'Joining in with' and/or 'mirroring' and/or 'echoing' = 0 mentions 

'Joint focus' = 0 mentions 

'Sequencing' (as in 'sequencing' communicative actions) = 0 mentions   

'Touch' or 'physical contact' = 0 mentions   

'Turn taking' = 0 mentions.  

Well then, how about 'rapport': well, that got 1 mention as 'therapeutic rapport', as opposed to normal, run-of-the-mill, sociable rapport. 

So how about 'sociable' and/or 'social' ... you're probably there before me = 0 for both!

Even the use of words like 'conversation' and/or 'talking' (i.e. for those who could use symbolic language to develop and sustain some sort of conversational exchange or engagement), for both (oh no, here we go again) = 0 mentions. 

However, 'Activity' does get 6 mentions in a half-page section called 'ENGAGEMENT' where 'Consideration should be given to the use of activity, discussion and distraction techniques ...'. Hardly much there in terms of any useful detail, I'm sure you'll agree.

Now obviously this is a necessary and important area of 'policy' if we want to create therapeutic 'engagement' (remember = 19 mentions) during periods of care requiring some level of service user 'observation' (=  138 mentions). However, to me this 31 page policy is woefully unbalanced in terms of not sufficiently pointing staff to proactive (= 0 mentions) social engagement, and lacking in any useful procedural guidance on how staff should use their 'fundamental communication' skills to enact some form of therapeutic engagement with service users with communication or social impairments. This made me think: 

a) it evidences a particular therapeutic (no, actually overly medicalised) NHS mindset that sees engagement as a specialised professional skill set not naturally available to all staff through the sensitive use of their 'Fundamentals of Communication' (either intuitively, or via some method of training or mentored support) 

b) it is such a missed opportunity to set out how to achieve more sociable 'engagement' and genuine 'rapport' with some of our service users who struggle to use language for sociable or therapeutic engagement (if the two can be truly separated) ... or due to the level of their impairments, have no access to the sociable use of language.

Now, I am in no way calling out any of the genuinely dedicated NHS staff who developed this policy (it is probably just a development of a previous one) ... but to me it evidences a de-personalising institutional perspective that can at times skew how we see (or 'observe' = 138 mentions!) and provided engagement for some of our most challenging service users. 

However, I am not utterly downcast by this. It is my experience generally (and more specifically in the adoption of Intensive Interaction by the brilliant staff on our learning disability inpatient units) that policy tends to follow positive develops in practice, and not the other way around (although often too slowly for my liking). Things are changing, and it is the staff who work directly on the units that are driving this change forward - and hopefully future iterations of this policy will acknowledge and then follow the successful adoption of the more proactive social engagement strategies of Intensive Interaction.

p.s. Wishing you a merry and interactive Xmas and New Year!