From 2005-2006 I spent 14 months working as a part-time freelance legal clerk for a firm of solicitors working in mental health. My job was to interview service users who had appealed against their detention under the Mental Health Act 1983. These service users were detained in a variety of settings, including NHS trusts, private hospitals and hostals, all over south-east England.
I interviewed them in order to be able to provide a report to the solicitors about how the service users viewed their situation.
Some of the information I wanted to know concerned the relationship between the nursing team (especially the primary nurse) and the service user. Typically, I would ask the patient how often they saw their primary nurse, how was their relationship, had the nurse discussed their care plans with them or given them any feedback on their progress.
The majority of service users were detained under Section 3 (some having been renewed at least once, for six months at a time), some were detained under Section 2 (up to 28 days), a few were detained under section 37/41 (restricted by the Home Office, typically for several months or years).
One was detained under section 25, being compelled to live in a hostel. The interviews took place in 47 separate settings altogether.
In all I interviewed 111 service users, mostly adults, but with a small number of older adults and adolescents. Of these 111, some 84 were in large NHS units, five were in small satellite NHS units and 22 were in private hostels or hospitals.
The responses from the service users suggested that inpatient nurses are finding it difficult to establish what the service users see as meaningful relationships with them.
Of the 111 service users interviewed:
- 69 (62%) could identify their primary nurse by name, while 42 (38%) could not
- 28 (25%) said that their care plans had been discussed with them, or that they knew what they were, while 83 (75%) said they had not
- 34 (31%) said that they felt they could communicate on some level with their primary nurse, while the remaining 77 (69%) could not.
In each of the three groups above, the largest number of positive responses was obtained in the private hospitals or hostels, although usually only by a few percentage points.
It would be inadequate to say that the results were due to the confused mental states of the service users. After all, these were people orientated enough to launch an appeal, and able to sit with me for up to an hour at a time to tell their stories.
Many had been in hospital for several months, offering staff significant opportunities to build up a relationship. What is more, over 95% could identify their consultant, and the majority could recall the date of their last meeting and what had been discussed between them. The figures for the primary nurses, however, were significantly lower.
One question that needs to be asked is, does this matter anyway? Innately, we know that it does.
As a body, NHS nurses have recognised the importance of communication; the KSF core dimension 1 stresses just that, and gives us examples of how we might both achieve and measure competence in it.
As nurses, we would all agree that much of the most important work in mental health wards centres around the management of risk, although how we can manage risk effectively if we are not actively engaging the service user in the process is not clear. Everything we do seems to depend upon our ability to communicate with our clients.
At a time when the role of RMNs is under scrutiny, we need to be able to justify ourselves as a profession. We have frequently heard that what sets RMNs apart is our ability to empathise and communicate with service users.
Although there were certainly examples where service users related very positive experiences of their primary nurses, the evidence does little to support the idea that inpatient nurses are, as a group, achieving this.
It is true that this is a small sample of service users’ experience, from only one part of the country. If this is generalised, however, then it is clear that inpatient psychiatric nurses are not meeting the essential needs of the service users in their care.
This identifies a problem, but it does not apportion blame or offer solutions. To move to a situation where solutions can be identified and then put in place is a challenge not only for individual nurses, but also for planners, service managers and other clinicians.
Michael Jeggo, BA, RMN, is a ward manager at East London and The City Mental Health NHS Trust
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