Mental health comment

Our acute problem

June 6, 2005

To alleviate the culture of violence on inpatient psychiatric wards exposed by a Healthcare Commission audit last month, psychologists should have more of a role in care, argues Rufus May. There should also be more service user "consultants" helping manage wards and training of staff. But above all, says May, we need more non-medical residential alternatives to hospital care.

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What is the state of psychiatric hospital inpatient care at the present time in England? My experience, gleaned from working in hospitals and training staff across the country, is that violence is a big problem both from service users to staff and vice versa. Violence towards service users by staff can be understood as the organised violence of control and restraint and forced medicating. Underlying this is the problem that ward environments are unstimulating places where there is little choice about treatment approaches and generally a lack of meaningful activities. Also where violence is used it is rare any kind of truth and reconciliation process takes place.

Two reports were published last month that shed research light on this question: Acute Care 2004 (by the Sainsbury Centre for Mental Health) and The National Audit of Violence 2003- 2005 (by the Royal College of Psychiatrists on behalf of the Healthcare Commission). What do they tell us and what do they not tell us?

For me the National Audit of Violence is a more meaningful report. Whereas Acute Care surveyed the views of 303 ward managers across the country, a rather bias sample one might argue, the National Audit of Violence was more comprehensive in its sources of information. It aimed to gather the views of 50% of staff (of all disciplines and levels of training) and aimed to gather the views of 20 service users per ward. Involving 203 wards, whilst mainly focussing on acute wards, it included elderly, learning disability and secure wards in its research.

The Audit of Violence found many wards to be unsafe environments in their layout and design. It read: "Great efforts should be made to upgrade and improve wards in ways that optimise safety." It sensibly recommends involving service users and staff in the future design of residential units. What both reports neglect - perhaps understandably given who is carrying them out - is the possibility that hospital-based institutional care is a fundamentally flawed way to provide a safe and healing environment for people experiencing distress and confusion.

One can argue the growth of crisis resolution/home treatment assertive outreach and other specialist community teams is an attempt to create alternatives to hospital. Despite these developments across the country people are asking (and have been asking for the last 20 years) for small person-centred (non-medical) residential alternatives to hospital. The government is not listening to this demand.

Pragmatically, one can argue that while we still have psychiatric hospitals we should do our best to improve them. However, as both reports show, there are considerable obstacles that need to be tackled. The Audit of Violence report states that "staff were fire-fighting as they struggle to work with an increasingly unwell population, some of whom have a dual diagnosis". The level of street drug use and alcohol use by people in hospital admissions was a problem highlighted by acute ward staff. This is likely to be influenced by the high levels of boredom found on many psychiatric wards. There was a general sense that more must be done to prevent people using street drugs and alcohol but the report was vague on ways to achieve this.

The Audit of Violence found inadequate staffing on wards with high vacancies and inexperienced leadership. In this context it argues "providing a therapeutic environment can become impossible". Numbers of agency/bank nurses are flagged up as a problem by both reports. On respondent said: "I feel unsafe dependent on who I am working with. Most bank staff are unaware of issues in mental health therefore it is often left to you as possibly the only regular staff to try and keep things safe. Continuity of care at night is so important". The Audit of Violence found that many staff were being attracted to better paid and higher status jobs in the community mental health teams. It recommends raising the status of inpatient work to that of community work.

This may be easier said than done. In my experience community work is not only valued more, it is more meaningful. Community psychiatric nurses get the opportunity to work more holistically with service users. This fact combined with the greater continuity of client work means the job is a more rewarding one. As Lucy Johnstone (2000) observes the pressure to work in more medicalised ways is far greater in hospital wards. Working in a medicalised way is depersonalising for both sides of the caring game. The ward culture is slowly changing in parts of the country but it is up against many decades of institutionalised medical/control culture. If ward staff had the opportunity to work in more holistic ways with service users, using alternatives to medication and thereby giving service users more choice the job would likely to become more rewarding.

At present the pressure on bed numbers means that staff are under pressure to "get the patient medicated and stable" as soon as possible. This makes the work more coercive which in turn breaks down the trusting relationship between client and staff member making ward life more demoralising for both parties.

An area the Audit of Violence report misses is the subjectivity of violence. Many service users experience compulsory treatment as violent. The Audit of Violence report failed in general to capture this perception. One not very well asked question did look at the possibility that staff were violent to service users. Between 5 and 27% of service users felt that such violence was not dealt well with by staff. 0-46% of non-clinical staff felt this was a problem and 3-27% for nursing staff. A good question that was asked was "do staff ever wind you up?" 35% of acute ward service users thought so, 46% of forensic service users whereas only 6% of small group home residents felt they were wound up by staff.

The problem of defining violence is not looked at. For example, the staff member who stated "I have never observed staff being threatening or violent towards service users" is likely to have been involved in countless restraints and forced injections yet is in denial that this is a violent process. Yet the person on the receiving end may have a very different perception even if they are not able to name overtly it as violence.

An interesting question that was asked was "Do you think that staff threaten to use medication or 'seclusion' to control service users?" 30% of nursing staff agreed and 48% of service users thought so.

The report highlights examples of good practice where staff have moved away from observation and spend meaningful time with service users. Previously research has shown this emphasis on being with and doing with service users and less about paperwork and observation reduces the level of violence, and increases the level of satisfaction of all involved (e.g. N. Bowles et al. 2002).

The level of boredom in many wards is shown by both reports. The Acute Care report found that in 40% of wards, ward managers said that social and leisure activities were only occasionally available. The Audit of Violence found that 35% of service users were dissatisfied with the choice of therapies available in the day this rose to 48% in the evening and 52% on the weekend.

Comments included "I get bored stiff. The only option seems to be TV or sleep" and "I find boredom gives me too much time to think which doesn't help the depression". Suggestions for activities by service users included aromatherapy, hairdressing, exercise and bingo. The Audit of Violence report is critical of the large amounts of paperwork staff are expected to fill out and the lack of emphasis on meaningful activities.

Similar problems were found in how involved service users felt in decision making in their care. 29% of people felt dissatisfied with their involvement in their care and support. This was even worse in secure settings (41%). Power issues were highlighted with this comment; "Some staff treat me with respect. They rule we don't. Staff are in charge, we are not equal." In my experience an obstacle to greater equality between staff and service users is the medical terminology and prescriptive approach to care still entrenched in the culture of hospitals. All staff, including psychiatrists, need training in more holistic ways of seeing the people they are trying to help. This would come from involving "experts by experience" in training much more than is currently the case. Both reports failed to recommend this as a strategy to improve the understanding of psychiatric staff. This was disappointing.

The Audit of Violence suggests there is a need for quality training, on prevention and the management of violence. The reports show that debriefing and conflict resolution is not happening consistently in services. Conflict resolution is a subject nursing staff in Bradford have expressed interest in doing training on and we aim to include ideas of truth and reconciliation into the training process.

To summarise, the National Audit of Violence has shown there are real problems in making psychiatric wards safe and peaceful places for both staff and service users. It report emphasises the need for more meaningful activities for service users. The report argues ways have to be found to enable staff to spend more time in one to one contact with service users, "doing the job they were trained to do". I would question this assumption that staff are trained to spend time in one-to-one contact with service users. When it comes to helping people who are self harming, hearing voices or having unusual beliefs, I think nursing staff are often poorly trained to engage with these experiences. One of the problems is that across the country involving experts by experience in psychiatric training is still not happening.

In Bradford we have sought to introduce a culture of recovery into the local psychiatric hospital. We run a recovery self help group that all inpatients are invited to. This is also a place where we can pick up on dissatisfaction about ward culture and where possible we try and respond to the suggestions made by service users. For example, we are setting up a series of training events for staff that will look at the broad range of ways people learn to cope with and recover from states of distress and confusion. We are also in the process of organising for a Tai Chi class to take place on a weekly basis.

I think both reports show the intrinsic problems in a medicalised institutional form of care for people in psychological crisis. Fundamentally people are not given choice in how to manage their crisis and pursue their recovery. The reports also give some indication of how the emphasis on risk management (e.g. locked doors, the growing use of secure units and observation) appears to be associated with actually making ward environments more unsafe. The Audit of Violence does give examples of what it sees as good practice and clearly the picture is not all doom and gloom. Although I think there are some fundamental problems in trying to make the warehousing of people in distress and confusion therapeutic, while we continue to have hospital based psychiatric care we have a duty to try and improve it.

I would like to see more psychologists involved in inpatient care and more user consultants involved in the management of wards (and training of staff). I also think we have to recognise that funding for holistic residential community based alternatives to hospital (that work in partnership with experts by experience) is needed to create more choice for people in need of a place of safety. A national conference 'Alternatives What Alternatives' will be looking at this on July 22 in Birmingham. The National Audit of Violence does help provide evidence for some of the issues that need to be raised and acted upon about the state of inpatient psychiatry.

However we need more than the usual institutional methods to create change in this area. We need to raise awareness of the lack of therapeutic care that gives people choice in the public arena. These are human rights issues. For this reason The Great Escape Bed Push is planned: A team of people will symbolically escape a psychiatric hospital with a bed and eventually join a demonstration against the oppressive use of force in psychiatric treatment on July 14 in Manchester at 1pm in Piccadilly Gardens. To find out more about these awareness raising strategies visit www.kissit.org.

Healthcare Commission's audit on violence in psychiatric and learning disability inpatient wards and units (pdf)
Sainsbury Centre For Mental Health's Acute Care 2004 report (pdf)

* Rufus May is a clinical psychologist with Bradford District Care Trust's assertive outreach team, and honorary research fellow with the centre for community citizenship and mental health at the University of Bradford. Rufusmay.com

References:
* Johnstone, L. (2000) Users and Abusers of Psychiatry. Brunner and Routledge.
* N. Bowles et al. (2002) Formal observations and Engagement, a discussion paper. Journal of psychiatric and Mental Health Nursing.

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See also:
May 25, 2005: One third of mental health staff have threatened to use medication or seclusion to control psychiatric patients' behaviour - findings released in Healthcare Commission audit exposing culture of violence on wards
Mental health comment
Feb 7, 2005: Compassion not compulsion - psychiatric treatment by force amounts to state-sponsored violence, says Rufus May.

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A service user, and preparing to help manage the NHS

Comment from: Owen Gilroy, Leeds Mind Executive/Service user, Leeds
Date: January 15, 2007

I gave been admitted into hospital ten times. I have used community services, and cared for a bipolar family member . I have worked as a service user representative for Leeds mental health trust, have a degree in philosophy and am a member of the Leeds Mind executive.

I currently am being interviewed for an NHS graduate management training programme. I think Rufus May "hits the nail on the head" when he talks about the need for user consultants.

There is far too much importance placed on community mental health roles and positions which have indeeed led to many experienced and highly-trained staff leaving hospitals for community work.

There are very serious problems as regards drugs theft and violence in psychiatric hospitals. I think this points to a need for service users with drug problems to be housed seperately to those without.

I think that visitors should be extensively vetted and searched.
I think also that staff members should be extensively educated in communication skills, especially body language communication.

I also think that a lot of conflict is derived not only out of boredom but also from lack of abundant sources of good healthy food. Many fights break out in the canteens of psychiatric wards.

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