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It’s now two years since the Healthcare Commission gave a grim portrayal of the state of NHS inpatient psychiatric wards.
Its audit of violence found almost 80 per cent of mental health nurses and 36 per cent of service users had either been personally attacked, threatened or made to feel unsafe. Moreover, one third of inpatient staff accept that they or colleagues have threatened to use medication or seclusion to control patients. Then, last year, the Mental Health Commission stated that more than half of England and Wales’s psychiatric wards were untherapeutic and unpleasant.
At the heart of the problem lies patient boredom, low staff morale, high staff turnover, mixed sex wards, no gardens or open air environments, drug and alcohol abuse on wards and poor training in the prevention and management of violence.
If this all sounds depressingly familiar, it’s because it’s amost exactly the same conclusions that the Sainsbury Centre for Mental Health reached in its 1998 survey on the quality of acute care, Acute Problems (PDF), not to mention bearing remarkable similarities to the findings of the Standing Nursing and Midwifery Committee’s 1999 report Addressing Acute Concerns.
That so little has changed in the intervening years is dispiriting to say the least, but unfortunately, not surprising. I spent many years of my clinical career trying to bring about improvements in the care given on the acute ward on which I worked. After several battles to try and introduce assessment tools, to improve the quality of care planning, to provide time for nurses to talk to patients, to help nurses manage their time to maximise their availability, to strengthen the role of the shift co-ordinator, to enhance nurses’ ability to talk to patients about medication and to improve the quality of record-keeping, I came to the conclusion that acute wards were a busted flush and my efforts were futile.
What was it that so defeated me? An institutional culture of inflexibility, closed-mindedness and sheer bloody laziness. And this wasn’t from the top down: the ward managers and their managers had a real commitment to improvement. But it seemed to me that too many nurses “on the frontline” aspired to be as crap at their jobs as the crappest nurse on the ward, instead of wanting to aim for something better; so many staff nurses looked to maximise the time spent sitting on their arses while minimising the time spent engaging with patients.
And why is this? It’s complex. I think it has a lot to do with stigmatisation of people with mental health problems, and the “courtesy stigma” those who care for them labour under. It has a lot to do with the historical neglect of acute wards, something that hasn’t really been addressed by a variety of initiatives over the years, most of which have done little else but raise expectations without increasing resources. It has a lot to do with the professional pessimism displayed towards people with mental health problems. And I suspect it has a lot to do with the enduring myth that acute work is what you do to “get a grounding in mental health” before buggering off to do something proper, and specialist and therefore more deserving of your attention.
The work of curing these ills has barely begun, and I’m doubtful that this accreditation system is going to help, especially as wards have to pay to participate and to maintain their accreditation. The grand it costs to take part could be better spent elsewhere, if you ask me.
The key, as in most things, is (to coin a phrase) education, education, education. It may sound like a cliché, but education really does broaden the mind. I see it all the time with my post-reg students, who rarely get a chance to sit back and examine their practice, discuss it with their peers, get a new angle on some old problems. They tell me they haven’t thought about x in that way before, they never knew there was so much debate about y, they hadn’t ever thought they could do z. Without decent training and education, you can have all the shiny plaques you want, it won’t change a thing.
And here I’d best stop as I’m starting to ramble.
I think it also has a lot to social conditioning within the other staff in the wards .
I have been in wards where the nurses have been there for so long and have become really cynical, telling me “they don’t teach you the real stuff at Uni” then go on to tell me the opposite of what we are taught.
“All personality disorders are time wasters and we try to get them out quick sharp”
I kid you not.
Funnily enough, we are NOT taught this at Uni.
The best wards are the ones with the newer qualified staff, in fact one ward I have been on had 5 new staff in a ward with 20 staff in total. That really shook it up!
I get pissed off when the qualified staff talk to me like I am a child who doesn’t understand anything, because they believe I haven’t yet seen “real mental health” Completely forgetting my training is 50% theory and 50% practice, with a big chunk of it attempting to link the 2.
Sorry, I got a bit ranty, but what beakie says in the post is true!
Relating something OSB said to me a while ago. I have this website to remind me how I am now and need to remind myself to stay like this and not end up the whinging old miserybags I am complaining about now!
Funnily enough, Azulinebloo, I was just about to comment on the difference between lectures and life on an acute ward too.
The thing I found most disheartening about my acute placement was that I’d just come from a university setting, where innovation, originality and person-centred care are actively encouraged, and was plunged straight into a stagnant NHS acute ward where all those things were discouraged in flavour of laziness, conformity and downright pig-ignorance.
The critics of nurse education are right. University doesn’t prepare you for life on the average acute ward, so lets add the following lectures to the university curriculum:
CBT Skills 1: How to use “paperwork” as an entirely spurious excuse for not talking to patients
CBT Skills 2: How to say “Can you stop hanging around the office door please” in a suitably condescending manner.
Communication: The art of slagging off your colleagues.
Change management and innovation: How to ensure that anyone who suggests it is mercilessly bullied until they have to be transferred to another ward.
On a more serious note though, perhaps we should have lessons on:
Working with challenging RMN’s
*Skills to be condescending without sounding condescending to staff.
*How to deal with office politics – spotting the difference between a two faced bitch and a bitch, and how to deal with it.
*How to work with patients without the burnt out old hacks noticing and giving you “proper” work in the form of paperwork
*Learning when to keep your mouth shut and when to fight your corner.
*15 years experience alone does not make a “good nurse”
*How to separate the wheat from the chaff
I am a bit fed up with it all. Many nurses say the basis for MH nursing is in the under 65 acute setting, but I have never felt so patronised, and annoyed at the attitudes in any of my other placements!
I WANNA GO BACK TO OVER 65′S!!
Some of the best mental health nurses I’ve worked with have been on the elderly wards. Being on an elderly ward has not stopped them from going on to take highly prized and sought after jobs on our new Crisis Team.
Acute is a speciality, just as rehab is a speciality, just as elderly care is a speciality, just as CAMHS is a speciality.
Anyway, more lectures for our new “revised” curriculum:
Law: Why the Human Rights Act does not apply to you.
Service Improvement: If the oldest NA on the ward has been doing it this way for 20 bloody years, then there’s no conceivable reason why service might be improved by doing it another way.
Evidence-Based Practice: Why it’s all just “poncey book-learning” and not how we do things round here.
If this thread continues in this vein, I might revise it into a full-blown post of its own.
In defence of the “inflexible and closed minded”, particularly the 20 year N.A`s, I`m just curious as to how we expect people to respond when the Trust reconfigures 5 times in 8 years, when the paperwork is changed incessantly at the whim of a muppet with too little in their in-tray rather than in response to clinical requirement and when exciting and innovative ideas to take patients hill walking, mountain biking, oyster harvesting, mushroom picking ( I could go on ) are perenially and disdainfully dismissed.
We do have a core of people who no longer see any value in change and who seek the path of least resistance as it attracts the minimum amount of criticism. I suspect management and qualified nurses are simply reaping what they have sown.
A familiar complaint OSB, but not something that pertained in my situation.
And I too would have problems with suggestions to turn acute wards into Butlins, complete with redcoats leading patients on days out.
The key to it Beakie is to have a wide range of potential therapeutic activities to hand depending on your patient profile. “Butlins” days out may well be quite legitimate for long term patients awaiting placement who have sadly lost touch with the contemporary world. Physical challenges will be wholly appropriate for those experiencing weight gain on anti – psychotics. Psychiatrists may feel that medication suffices, psychotherapists may feel their couch suffices and as far as I can see the Health and Safety Gestapo would like us to place our mattresses on the floor and stay in bed. All I`m calling for is some boldness and imagination.
[...] Wot I done today by beakie [...]
I tend to think that if people are well enough for days out, then they are well enough to go home and that little tolerance should be extended to those people charged with getting them home who are dragging their heels about it.
I’m all for boldness and imagination, and in my experience a great deal of that resides in the kind of NAs zarathustra talks about, not necessarily in the staff nurses where you’d hope to find it.
[...] I’ll just reprise some comments made previously in a post by Beakie. What was it that so defeated me? An institutional culture of inflexibility, closed-mindedness and [...]