About Adult Mental Health Inpatient Services
Whilst it is true that edited footage of a few units in one NHS organisation cannot portray a representative, accurate or complete picture of acute care it does show how bad things can get. The practices witnessed in Dispatches provide indisputable evidence of the need for immediate change at the very least in one unit, but from ImROC’s experience of working with many individuals, teams and services, this is neither an isolated nor rare situation.
There is currently an Independent Inquiry investigating the deaths which took place in mental health inpatient facilities between 1 January 2000 and 31 December 2020. This extensive and inclusive inquiry will report its conclusions in relation to the safety and quality of care provided locally and nationally to mental health inpatients in Spring 2023.
The inquiry team invites anyone with experience of using these services, their family members, friends and carers, and staff working in them to speak with them confidentially so that they are able to build a complete picture https://www.emhii.org.uk/
No doubt the final report will result in a call for action to improve the experience of all those using services by improving recruitment, training, supervision and support for front line staff and it is to be hoped that it will provide examples of good practice, excellent team work, positive organisational cultures and evidence based interventions that result in sustained recovery of people who use acute care services.
However, for those who have viewed the Dispatches programme, the need for action is already apparent. What is seen is not simply a few members of staff dealing with human distress in a cold and dehumanising manner. We are seeing the result of longstanding systemic problems beginning with a lack of agreement and understanding about the purpose of acute inpatient mental health wards between NHS leaders and different professional groups, between family members and people using services and within each of these groups.
To some extent this confusion arises out of our construction of emotional crises as a result of mental illness that requires medical treatment in a hospital. This places the doctor (psychiatrist) at the forefront of the care team with the perceived job of making a diagnosis and treating the person so that their symptoms abate and they can return home when they have recovered. Whilst this might work well in relation to physical illnesses none of the same rules apply to what we call ‘mental illnesses’.
People generally reach an acute mental health crisis when things have gone wrong in their life, whether that is problems in relationships, work, finances, housing, traumatic events and experiences, anxiety and fear about world events. A culmination of factors overwhelm an individual’s ability to cope. Whilst some of the symptoms of this overwhelmed state might be amenable to medical treatment, medications are often sedative with unpalatable side effects and they can exacerbate difficulties in thinking clearly.
What people in these inpatient wards tell us they want is: a safe, comfortable and peaceful space to make sense of things and begin to make some decisions; support to work out what might help right now and what would help us to feel safe and comfortable; people who believe in us, in our strengths and possibilities, and sure knowledge of what to expect while we are in this place. Above all we want kindness, respect and hope from people with whom we can imagine developing a trusting relationship.
This is not surprising. It is worth remembering that every single one of us has a stake in improving acute inpatient care because any one of us could find ourselves in crisis and in need of safe, tolerant accommodation whilst we resolve personal and situational stress. It is not hard to envisage the sort of healing environment and therapeutic support that we would find helpful and it is a far cry from the experience of patients shown in the Dispatches film. If we are to believe the accounts of many individuals and their families, most inpatient stays bear more resemblance to those shown in the film than the restorative sanctuary that we would want and indeed that many still expect.
In fact, there is far more research into the failings and problems of acute mental health care provision than there is into successful approaches and positive experiences (for a recent review of approaches to improve access and quality of care see Johnson et al, 2022).
Evidence suggests that inpatient wards can in themselves cause harm for people admitted to them. Examples are institutionalisation, over-stimulation, over-medication, loneliness and disconnection from social support, traumatisation and re-traumatisation, sexual harassment, assault, discrimination, crime, aggression, self harm.
Harm can also come to the staff working in them. For example sustained anxiety/fear, physical assault, discrimination, exhaustion, traumatisation, lack of training, supervision and support, powerlessness within the multi-disciplinary team, all resulting in defensive practice, burnout, high staff sickness absence, high staff turnover and low team morale. It is not difficult to recognise how a vicious cycle develops with both staff and patients responding to an unsafe, unsupportive and disturbed ward milieu with increasing conflict leading to increasing incidents and increased containment, restraint, blanket rule and a breakdown in confidence, trust and compassion among both staff and patients.
Add to this: pressure on resources, high staff vacancy rates resulting in the use of temporary/bank staff; lack of permanent staff resulting in little continuity and poor communication, reduced bed numbers leading to limited availability of beds and higher acuity thresholds required for admission, increasing rates of involuntary admission leading to a more disturbed and unpredictable ward milieu – and we have a perfect storm.
The question is, what can be done to improve this situation. As Tracy and Phillips (2022, p.167) reflect in their editorial on acute care ‘We might not have chosen to start from where we are but … the longest journey begins with a single step’. And although we await the report from the Mid Essex public inquiry, we cannot delay improvements when we already have a good idea about what needs to be improved.
What the Dispatches film fails to do, is provide suggestions for improving the experience and outcomes for patients on acute units. Whilst some basic principles provide the foundation for a safe and purposeful admission, these are noticeably lacking in the footage shown.
Reducing Restrictive Practice
One of the most concerning aspects of the Dispatches film is the number of serious incidents and the high level of close observations carried on over long periods of time. Ligaturing was seen as a routine event, spoken of as ‘naughty’ behaviour; close observation was the expected response with immediate restraint if the patient attempted any kind of self-harm. This is all a long way from best practice and does not comply with policies, guidance or research findings.
The incidence of conflict varies ten-fold across different inpatient wards – regardless of level of acuity – and the use of restraint is rare to non existent in some units. Learning from good practice several interventions have been developed to reduce conflict and the use of restrictive practice on acute inpatient wards.
These all focus on improving communication and relationships between inpatients and staff, modifying the physical environment, introducing more meaningful activities, increasing shared decision making in care planning and safety plans, effectively debriefing (with staff and patients involved) following incidents. Some go further, introducing peer support workers into teams to embody hope and possibility, engage with patients in mutual and reciprocal recovery focused relationships; developing respectful, valuing relationships with family and friends, supporting re-engagement in community relationships, activities and resources. By changing culture and practice more generally, conflict is reduced.
In spite of their being evidence based interventions in existence, coercion and conflict remain rife in services. ImROC is aware of nurses being faced with threatening situations and feeling unsafe; psychiatrists explain the impact of working in a risk averse and blame culture. There is widespread fear and misperception that restraint and containment keep people safe when research demonstrates that collaborative safety planning and relational risk management are more effective in keeping all people involved safe.
Even where teams are keen to systematically reduce restraint they are hindered by low staffing levels with no time to implement new activities; lack of permanent staff and particularly bank and agency staff not knowing about planned approaches. The burden of non-clinical administrative tasks, and the unpredictable nature of acute wards all mean that any initiative to improve practice and culture at the front line needs to be understood and supported at all levels of the organisation and across all relevant departments. This is not merely an issue of the individual practice of front line workers.
Baker, J; Berzins, K; Canvin, K; Benson, I; Kellar, I; Wright, J, et al (2020) Developing a service user centred co-designed patient safety intervention for acute mental health wards: A mixed methods process evaluation. NIHR HS & DR award, ongoing project http://fundingawards.nihr.ac.uk/award/NIHR128070
Bowers, Len; James, Karen; Quirk, Alan; Simpson, Alan; Sugar; Stewart, Duncan; Hodsoll, John (2016). Reducing conflict and containment rates on acute psychiatric wards: The Safewards cluster randomised controlled trial (vol 52, pg 1412, 2015). International Journal of Nursing Studies. 58. 10.1016/j.ijnurstu.2015.12.006.
Duxbury, J; Thomson, G; Scholes, A; Jones, F; Baker, J; Downe, S; Greenwood, P; Price, O; Whittington, R; McKeown, M (2019) Staff Experiences and understandings of the R$EsTRAIN Yourself initiative to minimise the use of physical restraint on mental health wards. International Journal of Mental Health Nursing, 28(4) 845=856. ISSN 1445-8330
Johnson, S; Dalton-Locke, C; Baker, J; Hanlon, C; Taylor Salisbury, T; Fossey, M; Newbigging, K; Carr, S.E; Hensel, J; Carra, G; Hepp, U; Caneo, C; Needle, J; Lloyd-Evans, B. (2022) Acute psychiatric care: approaches to increasing the range of services and improving access and quality of care. World Psychiatry 21 (2) 220-236) DOI:10:1002/wps.20962
LeBel, J; Duxbury, J; Putkonen, J; Sprague, T; Rae, C; Sharpe, J (2014) Multinational experiences in reducing and preventing the use of restraint and seclusion. J Psychosoc Nurs Ment Health Serv. 52, 22-9 DOI:10:3928/02793695-20140915-01
Tracy, D.K and Phillips, D,M (2022) What is good psychiatric care (and how would you know)? World Psychiatry 21 (2) 166-7 DOI:10:1002/wps.20958