VOL: 97, ISSUE: 05, PAGE NO: 38
Olajide Ajetunmobi, MBBS, MRCPsych, is specialist registrar in psychiatry, Brandon Mental Health Unit, Leicestershire and Rutland Healthcare NHS TrustUnder section 5(4) of the 1983 Mental Health Act, psychiatric nurses have the power to detain psychiatric inpatients who are liable to harm themselves or others. Although nurses generally agree on the usefulness of this power, studies have found that they rarely use it.
Under section 5(4) of the 1983 Mental Health Act, psychiatric nurses have the power to detain psychiatric inpatients who are liable to harm themselves or others. Although nurses generally agree on the usefulness of this power, studies have found that they rarely use it.
A literature review revealed only limited research on this aspect of the Mental Health Act. In a study of 25 events over a two-year period, Ashmore (1992) found that the use of nurses' holding power varied widely according to the time of day, with the highest incidence of its use also associated with high nurse staffing levels. Lovell et al (1998) found the same 24-hour variation in use when they studied 25 section 5(4) applications.
This study, the largest of its kind to date, was carried out at Leicester General Hospital Brandon Unit. This 175-bed psychiatric unit provides acute and specialist psychiatric services for the 2,000 patients who are admitted every year.
The study aimed to identify the factors associated with nurses' use of section 5(4) by examining all the cases that occurred over a 16-year period.
Data on all section 5(4) applications from July 1983 to July 1999 was gathered from medical records and medical and nursing notes. It included the admission date, the date section 5(4) was applied, time on and off section 5(4), the patient's diagnosis and a history of past admissions.
There were 180 section 5(4) applications over a 16-year period: 104 (58%) were women and 76 (42%) were men. This represented an annual incidence of 0.6% and an average of 11.3 events a year (with a range of one to 17). The annual frequencies show no change in the trend of nurses' use of the section over the 16 years.
The frequencies of section 5(4) applications in the various age groups are shown in Fig 1. The highest frequencies were in the 20-24 and 25-29 age groups. Their combined total of 72 cases constituted 40% of nurses' use of the section. There were more men than women in the 20-24 age group (19 out of 32) and under-20 age group (nine out of 13). All the others had more women than men.
Trends and cyclical variation
There was no seasonal variation in the use of section 5(4): 46 (26%) of the applications occurred in winter, 42 (23%) in spring, 45 (25%) in autumn and 46 (26%) in summer. Similarly, no monthly variation was observed and there was an average of 15 applications a month over the 16-year period.
A comparison of applications and days of the week (Fig 2) also showed little variation. The fewest were made on Fridays (19 applications), with most on Mondays (31 applications).
Section 5(4) applications over a 24-hour period
There was a wide variation in the use of section 5(4) over the 24-hour period. Fig 3 shows the likelihood of an application being made at any hour of the day, with low, medium and high periods of likelihood.
The low period was from 10pm to 8am and accounted for 15 section 5(4) applications (8%). The medium period covered two distinct time frames, from 8am to 12pm and from 8pm to 10pm, and accounted for 60 applications (34%). The high period of likelihood was from 12pm to 8pm, representing 105 applications (58%), with a peak between 2-4pm.
There was also an early morning surge in the number of applications, between 7-9am, with dramatic falls between 12-1pm and 4-6pm.
The study examined section 5(4) applications in relation to patient diagnosis. The 180 patients involved had been diagnosed as follows:
- 57 (32%) with schizophrenia;
- 38 (21%) with depressive disorder;
- 33 (18%) with bipolar affective disorder;
- 32 (18%) with personality disorder;
- 12 (7%) with organic confusional states;
- 2 (1%) with dementia;
- 4 (2%) with puerperal psychosis;
- 2 (1%) with anorexia nervosa.
Both patients diagnosed with anorexia were women, as were 78% of those with personality disorder (25), 71% of those with depressive disorder (27) and 55% of those with bipolar affective disorder (18).
Length of admission
In 138 cases (77%), section 5(4) applications occurred during the first month of admission, of which 97 (55%) took place during the first week (Fig 4). Forty-four applications (24%) were made on the day of admission and 25 (14%) the day after.
Discussion of findings
An annual incidence of 0.6% confirms that nurses working in psychiatric inpatient settings rarely use section 5(4). This may be because a doctor is on call 24 hour a day.
As reported in previous studies, most applications were for women (58%). Although men were over-represented in the under-20 and 20-24 age groups (69% and 59% respectively), they were outnumbered by two to one (68% versus 32%) in the 25-29 age group.
The preponderance of women in most of the diagnostic categories, particularly personality (78%) and depressive disorders (71%), is consistent with current opinions on the epidemiology of these psychiatric disorders.
The wide variation in the application of section 5(4) over a 24-hour period, with 58% between noon and 8pm (peaking between 2-4pm), reflects the fact that this is the time when patients are at their most active and levels of noise and activity on the ward are at their highest.
Correspondingly, the period with fewest applications,10pm to 8am, is when most patients are asleep and nurses have more time to talk to patients about their problems.
The early morning surge observed in this study correlates with a period of increased activity and noise, with patients waking, staff arriving and the changeover of nurses taking place. The troughs between 12-1pm and between 4-6pm correspond with meal times.
A quarter of all section 5(4) applications occurred on the first day of admission, with a further 14% on the second day. This confirms that the first few days are the most unsettling for patients, particularly the first 48 hours.
Section 5(4) applications represent one of many outcomes of an emergency on a psychiatric ward. This study confirms many of the findings of earlier studies, most notably that the likelihood of an application varies according to the time of day. This has implications for nurse managers in terms of staffing levels during these periods.
The finding that over a third of section 5(4) applications occurred within 48 hours of admission also has implications for the management of new patients, many of whom should perhaps have been sectioned under the Mental Health Act.
Finally, most of the patients in this study were women. The reason for this is not clear and more large, multicentre research studies need to be carried out on this aspect of the Mental Health Act to increase our understanding of the factors that influence the use of section 5(4).
- A sister article, 'Medical response times to section 5(4)' appears on: www.nursingtimes.net