We still lock up mental health inpatients

Did you know we still lock up mental health inpatients?

Coloured image of hand holding large bunch of keys
NHS Locked door policy — Image by Dreamstime

In accordance with the Mental Health Act (MHA 1983), our NHS acute inpatient wards should have an ‘Open Door Policy’. But sadly, we still lock up mental health inpatients.

The purpose of an ‘Open Door Policy’ is to ensure that (1) inpatients have the best possible experience of mental health services, (2) their human rights are protected and (3) they are cared for in a safe environment, in the least restrictive way (Sussex Partnerships NHS)

Principles of the MHA Code of Practice (2015), together with all recent research, also suggest that ‘Open Door Policy’ is something stakeholders (Psychiatrists, mental health nurses and patients) aspire to.

So, why do we still lock up mental health patients? Let’s find out. But first, we need to understand a few things.

What is an acute inpatient mental health ward?

Coloured image of man lying on a hospital bed behind a blue curtain
Mental Health Acute Inpatient beds — Image by Sandra Faye, The Times

An inpatient service is defined as a unit with ‘hospital beds’ that provides 24-hour nursing care. It is able to care for patients detained under the MHA, with a consultant psychiatrist or other professional acting as responsible clinician. This does not mean that all, or even a majority of, patients will be detained (The NHS Confederation, 2012)

What nurses do on acute inpatient wards

Each of our wards had upwards of twenty patients with two qualified nurses and two nursing assistants on duty on the morning or afternoon shift. (At nights, this would be reduced to two qualified and one nursing assistant). One qualified nurse would co-ordinate the shift and the other might be responsible for tasks like dispensing medication, attending ward rounds or MHA tribunals.

One nursing assistant would be on Rapid Response Duty, which means they must race to attend to mental health emergencies throughout the hospital. The last nursing assistant stayed on the floor with patients and would also carry out the hourly checks to ensure patients’ health and safety. Along with these duties, the team of four staff had to carry out all the following (and more) each shift:

Black and white image of the word  'rights' mental health
Rights under the Mental Health Act 1983
  • process new admissions; complete risk assessments and patient notes re admission, organise Section papers including reading patients’ their rights, providing relevant paperwork about these rights, offer admission packs with leaflets about Patient Advice and Liaison Services and any other support agencies, inform patients about the ward, the activities, meal times and so on. Trust me, every new admission takes anything from 90 minutes upwards so imagine the stress if there’s more than one during a shift
  • attend to any patient physical care issues or organise for appropriate department to see patient
  • plan and run the ward community meeting, encourage patients to attend, take minutes for meeting, type up and distribute
  • serve lunches to all patients, make hot drinks or ad hoc, whenever patients asked, make coffee/tea & biscuits for the ward round multidisciplinary team
  • encourage patients to attend to their hygiene and help where necessary
  • change bed linen and make beds where necessary
  • encourage patients to attend any appointments, planned groups or activities, on and off the ward
  • escort detained patients for ciggie breaks, take them out on leave for anything from going to the local cafe or taking them home to pick up necessities
  • spend some quality time with each of their 5+ patients that shift, assessing their mood and mental state, and complete their nursing notes
  • update care plans and risk assessments for their patients
  • discharge planning with some patients
  • meeting with other mental health professional and social services to discuss patients
  • carry out various audits for the Trust, Care Quality Commission, etc
  • open the ward door and answer telephone calls 100’s of times each shift
  • complete incident reports where necessary, for example, locking the door that is supposed to be ‘open’ is considered an incident, and must be recorded and reported using the Trust’s incident reporting procedure

A brief insight only

Colour image of nurse in blue scrubs, kneeling with head in hands
Exhausted and stressed mental health nurses

The above is only a brief insight into the nursing tasks to be completed during a shift. And, let me tell you, I’ve always prided myself on my work ethic, but nursing really was tough. Nurses often had to deal with:

  • patients who deny mental illness and become distressed, angry or agitated
  • patients’ unpredictable behaviours
  • increased levels of aggression and violence
  • patients refusing medication
  • inadequate facilities like staff toilets or rest room, somewhere to have a coffee or lunch
  • stroppy junior doctors, other healthcare professionals who’d deflect their patient responsibility now they’re inpatients
  • friends, family, carer’s and the world and his wife’s unwarranted complaints
  • stress or emotional exhaustion
  • lack of support, particularly where staff are each doing the work of two or three people

Our ward managers were supposed to split their role 50% management of the ward and staff and 50% with patients and offering support to staff. You can read more about The curse of ward managers here. While modern matrons were to spend 50% of their time managing two ward managers and the other 50% with patients, looking at innovative ways of improving standards of care. More about Do we need modern matrons in mental health here. If these managers and matrons supported nurses and did the jobs they got paid big bucks for, we might not need to keep locking our patients in?

Locked door was the norm on our wards

coloured image man looking at sweat on his shirt under his arm
Running around on chaotic MH wards

Despite MHA guidelines and NHS policies, the doors to our wards all remained permanently locked. They were kept locked, only until they were opened to let people in or out, which went against our Trust’s ‘Locked Door Policy’.

Following visits from our Patient Advice and Liaison Services (PALS), our modern matrons were to lead on reducing of restrictive practices (locked doors). They were each to discuss with their two ward managers and teams to look at effective ways of ensuring the doors were unlocked at all times.

Having forgotten her own days as a nurse on a busy, chaotic ward, our dumbass matron decided alone to initiate her own impossible survey. Staff were document every time the door was opened, if it was locked straight after, and why. This would require someone sitting there, pen and notebook in hand, every minute of every day!

So, why were our doors locked?

Blurred colour image people dashing through glass doors
Constant stream of visitors on mental health wards

Not kidding! That’s how often our doors were opened, not only for patients but for multidisciplinary staff, students doctors and nurses, the cooks, the cleaners, and the handymen. There was also the uninvited solicitors, carers, family or friends and other visitors who had to be let in and out.

Uninvited patients from other wards came to visit no one in particular and we couldn’t know of any possible risks they might pose. If we needed this information we had to call their own ward to ask. Strangers would also attempt to come onto the wards, to see if they knew anybody? We’d also have the local drug-pushers attempting to sell their wares or exchange a spliff for sex in the toilets. Our vulnerable patients were open to many potential risks from these and other groups of visitors.

You’d even see the odd pastor or priest, the occasional phlebotomy nurse or the Chief Executive, who always demanded to know why the door was locked.

We had the opportunity to show him when we requested that he came to spend the day on our ward. Staff had already pre-warned not to help him (I never said I was an angel), to let him answer the phones, the doorbell and any queries. He was to be given the same responsibility a new nurse or student would have on their first day.

Imagine this lump of lard huffing and puffing up and down the ward all shift, in between the constant phone calls and finding the recipients of those calls. Picture if you can, his frustration and the sweat forming under his arms when he couldn’t identify patients’ leave status to allow them to leave. Think red face when a new student pointed out this was all clearly written in large black letters on the whiteboard in front of him.

The end result — doors stayed locked.

Final thoughts

Pros and cons of open door policy — Image by DLPNG.com

I agree there are many benefits and advantages for patients and visitors if all wards remain open, but what of the poor nursing staff? Guess who’d all be up in arms if a vulnerable patient is sexually assaulted or abused because no one noticed the perpetrator entering the ward? And guess who’d get the blame?

I’m all for least restrictive practices like having an ‘Open Door Policy’ if, and only if, either managers and modern matrons step up or the staffing levels are increased.

Over to you

Clipart.com

What’s your thoughts on acute inpatient mental health ward doors permanently being left open? Would you feel safe? I look forward to reading your comments and answering any questions.

Author: mentalhealth360.uk

Mum to two amazing sons. Following recovery from a lengthy psychotic episode, depression, anxiety and anorexia, I decided to train as a Mental Health Nurse and worked successfully in various settings before becoming a Ward Manager. I am a Mental Health First Aid Instructor and a Mental Health Awareness Trainer, Mental Health First Aid Youth and Mental Health Armed Forces Instructor. Just started my mental health from the other side blog.

22 thoughts on “We still lock up mental health inpatients”

  1. It’s interesting! I agree with the wards being locked, because I find it odd that anyone without a reason would show up and hang out! I mean, of course friends and family members should have visitation abilities if it’s best, but just anyone? Weirdness. That’s so odd. “I just want to see if I know anyone…. HERE AT THE MENTAL HOSPITAL!” Well, if the visitor does know someone, then that patient’s privacy just got destroyed. Huh.

    I think maybe long-term living units could be more open. I worked at one residential treatment facility that wasn’t locked. If the kids ran off, you’d have to chase them through the neighborhood. (That was always fun.) But since it was their home rather than their temporary place to stay (they’d be there a few years perhaps), I approved of them feeling more free than they would if locked up.

    But the other place I worked had kids with a higher level of violence, and their building and halls were always locked up.

    The times I was in the mental hospital, it was probably best that the units were locked up. I wanted to get out so I could finish the job (complete suicide), so if you’ve got people like that, it’s probably best to keep them under lock and key until they’re feeling better.

    1. Lol, I love the way you put that – just hang out lol 🙂
      Oh yes, our long-term living units for adults are open and people can come and go as they please. I’ve not heard of kids living in them tho’? Are they permanently staffed? Doh! They would have to be lol!

      Apparently, the research shows that there is no difference in suicide figures, whether the doors are open or locked? That people don’t tend to go out to commit suicide?

      Well, I’ve known several patients that left our wards and killed themselves by suicide and killed others!

      And I’m sure, just like you, patients felt safer with the doors locked! I know I would. Caz x

    1. No – all patients are ‘locked in’ I suppose, both patients who are voluntary and sectioned. I was going to make that clear but my post was getting rather long……….. Thank you for asking Kenneth.

  2. When I worked on an inpatient unit, all of the psych units at that hospital were open door. There were some patients who were certified under the Mental Health Act that we knew were going to try to take off, and even when we were being careful it was easy for people to slip out. Then we’d have to call police to find them and haul them back to hospital. It wasn’t therapeutic and it wasn’t a good use of resources.

    As a patient, the locked door didn’t really change anything unless I was thinking of taking off. It was restrictions and limitations on autonomy on the unit that set the tone, not whether the door was locked.

    1. Wow, you had open doors. I can imagine, as I know how easily our patients slipped out even with locked doors! Myself and our charge nurse normally snuck out to find the patients – knowing where they’d be. We really tried not to involve the police, cos they weren’t as forgiving as us. It often made me chuckle, as long as they were safe.

      I understand the restrictions and limitations on autonomy and how it could set the tone. Thank you for your input Ashley.

  3. Interesting that they used to have a locked door policy even on a physical-illness ward in Salisbury. But it was a joke because when I visited the ward as a volunteer, I’d never have to wait more than a minute for somebody to hold the door open for me. I wonder what their formal policy actually was?

    1. Wow! I suppose it was locked for patient safety but it obviously didn’t work there, cos you got in lol.
      I remember when in an A&E bay, being treated, I could see from the bit of open blue curtain and I saw a ‘couple’ go into another curtain and take the person’s bag. I was screaming for the nurses and when one arrived all she said was “There’s not much we can do!” I let the other patient know who took her bag and had to let her get on with it because the staff didn’t seem to care! And shamefully, I thought “this isn’t my fight” but I was in pain and exhausted 🙁

    1. Hi, No, all Psychiatrists would have to do another 2 years foundation studying while working and getting paid. Another 3 years core psychiatry training, you’d work and train in a number of different sub-specialties within psychiatry. This way, you’ll gain a broad understanding of the specialty.

      Core training lasts three years, these are referred to as CT1, CT2 and CT3. By the end of CT3 you need to have completed your MRCPsych exam so that you can apply to the next stage of training.

      Higher Psychiatry Training normally takes three years, known as ST4, ST5 and ST6.

      Then you can apply for Consultant posts. As a consultant psychiatrist, you are able to work independently (though you will still be working in a team). You may also lead a team of other professionals in managing the care of patients.

      I hope this clarifies it for you. It means they are generally way more knowledgeable than your normal psychiatrist. Caz

      1. Hope it helped and now understand how much training they have to go through. If you just visited a private psychiatrist, I’d certainly want to know his level of training and knowledge 🙂

  4. It seems really strange to allow just anyone to come visit patients at a mental hospital. I’m pretty sure you can’t just stroll through a hospital full of post-surgery patients checking to see if you “know anyone” there. Even if they are people who know the patients, there should be some limits to access for the patients’ well being, not to mention that of the staff.

    1. You’d think so and that’s why we kept our doors locked. Our patients were, of course, vulnerable and I believe ‘visitors’ who wanted to find ‘someone they know’ were well aware of the nuances of the wards; staff were busy, there was always a lot going on. You wouldn’t be believe the amount of times we ‘found strays’ that someone had let in!

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