Sitters, or therapeutic companions, have been hired for years to help look after patients who have difficulty caring for themselves. Family members and physicians have requested sitters to stay with patients who are suicidal, suffer from dementia-like symptoms, or are at risk for falling. Although sitters were helpful, providing them for patients in hospitals was expensive in terms of the cost of wages, orientation, and nurse staff frustration.
At Pardee Hospital, there were times when sitters weren't available to watch patients. When this happened, hospital costs skyrocketed because overtime was paid to staff members who had to replace a sitter. Then, if no one on staff could work overtime, Pardee had to reassign a nurse from the unit to act as a companion. This left fewer staff members to care for patients in the unit and added an unfair burden to the remaining staff. The issue was further compounded when physicians who requested sitters were reluctant to discontinue the order. The request remained in effect for the patient's entire visit whether they actually needed someone to stay or not. A cascade effect was then created; other families spotted companions with patients and asked for someone to constantly observe their loved one.
No more sitters
In mid-2007, the Nursing Leadership Council took action to reduce sitter use, recommending that sitters be provided per policy or nursing assessment rather than by physician order. This was neither an evidence-based nor serendipitous decision. It was based on the following three factors: the financial costs of providing sitters had escalated beyond reason, pulling nurses from their regular shifts was unacceptable, and there was no evidence that sitters actually prevented patient harm.
On October 1, 2007, physicians stopped writing orders for sitters. Per policy, constant observation sitters are now provided for patients in the hospital on involuntary commitment (court order), on suicide ideation/attempt precautions, or in behavioral restraints. With RNs able to make decisions regarding patient safety, sitters are now rarely recommended.
Every nurse, nurse assistant, and unit secretary is required to complete an annual competency test on suicide precautions. Once the test is passed, anyone on the nursing staff can be assigned as a sitter, if needed. Any other associate interested in working as a therapeutic companion completes the sitter education and suicide precautions exam and is entered on the sitter list.
Pardee Hospital implemented an online safety incident reporting system on January 6, 2006. The data in Table 1 are presented for 21 months before (January 6, 2006 to September 30, 2007) and 42 months after (October 1, 2007 to March 31, 2011) the change in physician practice. Table 1 shares data on census, falls, and fall-related fractures. Sitter hours are included in the nursing hours per patient day and aren't billed separately. Patient days are used to stratify the results.
Although the risk of not providing sitters as fall precautions was unknown, Table 1 shows that there was no increase, but a decrease in fall and fall-related fracture rates since implementing the “no sitter orders.” Pardee Hospital now uses fewer companions and the nurses report that they appreciate not losing essential coworkers to a sitter assignment.
Pardee cares for a significant elderly population, many of whom are frail and have symptoms of dementia. Sitters are rarely provided for these patients and then only for a short time based on a nursing assessment. Nurses, instead of companions, help prevent patient harm through: setting bed alarms, putting fall precaution magnets on patient doors and fall precaution stickers on ID bands, providing slip-resistant socks, and encouraging family members to stay with their loved ones when possible.
Assessing fall risk and delegating direct observation of patient activity is within the RN scope of practice and doesn't require a physician order. Research found some facilities, like Pardee Hospital, where the decision to initiate or discontinue sitters was based on nursing assessment, not physician order. Experts point out that constant observation isn't evidence-based practice, and there are no data to show that it's cost-effective.1–5
Empowering nurses to decide on proper patient care has helped lower hospital costs and staff frustration. The “no sitter order” had positive results at Pardee Hospital, compelling evidence for all facilities to limit the use of therapeutic companions. Nursing staffs are well equipped to handle safe patient care; the data from Pardee Hospital's study are proof.
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3. Rausch DL, Bjorklund P. Decreasing the costs of constant observation. J Nurs Adm
4. Torkelson DJ, Dobal MT. Constant observation in medical-surgical settings: a multihospital study. Nurs Econ
5. Harding AD. Observation assistants: sitter effectiveness and industry measures. Nurs Econ