Did you know we still lock up mental health inpatients?
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?
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:
- 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
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
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?
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.
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
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.