Most nurses agree the general public has a distorted perception of mental health wards as dangerous and chaotic places – a stereotype unfairly perpetuated by the media.
While these beliefs may be inaccurate, violence and aggression can be a factor in some mental health settings, a fact highlighted recently by the fatal stabbing of a Croydon nurse in a mental health facility.
Such extreme cases are rare, but less serious incidents are a fact of life for some mental health nurses. And the situation is unlikely to improve unless mental health care ceases to be treated as a second-class service by those allocating NHS funding.
I spoke to Elizabeth*, a nurse who has worked on mental health wards and in police custody suites, about the problem. “I’ve been assaulted at work and I’ve seen various people assaulted at work – I’ve seen people have their hair set alight, people hit and bitten,” said Elizabeth. “And quite often I’d say that’s down to poor staffing levels.”
”I’ve seen people have their hair set alight, people hit and bitten”
“One time there were two patients on either side of the ward who started tying things around their necks, but because the whole team is dealing with one incident you can’t manage all that’s going on effectively.”
Elizabeth works on a ward with 22 beds and four staff, but sometimes a nurse might have to assist with a matter on a different ward. Since techniques to prevent and manage violence and aggression require four people, the remaining team members are unable to manage if a patient becomes violent.
Elizabeth also pointed out that the use of bank and agency staff often means not all those on a ward have been trained.
“The wards rely heavily on bank staff, but they aren’t valued”
“I used to work full-time hours on the bank… but I wasn’t trained in prevention management of violence and aggression. I really had to fight for it. The wards rely heavily on bank staff, but they aren’t valued. They don’t get the same opportunities.”
Elizabeth also said some staff do not have adequate communication or language skills to assess patients. Generally patients on an acute mental health ward should be checked every 15 minutes and, on Elizabeth’s ward, this is usually done by agency staff so permanent staff are available to defuse situations. On one occasion Elizabeth saw an observation form that simply repeated the previous one because the nurse could not write English.
Other agency staff have had no previous experience on a mental health ward, and this is frequently not communicated to staff on the team. Elizabeth illustrated the potentially serious consequences of nurses being unable to make adequate assessments by recalling a patient she saw in custody.
”They could come in with drugs, weapons”
“He said to me very clearly, ‘I’m really scared, I’ve got thoughts of killing people. I’ve got a list of people I want to kill. I’ve researched how to do it’. If I hadn’t had the communication skills to ask the right questions, that information wouldn’t have got across.”
In police custody security is rigorous. All patients are searched and items that could be used as a weapon are removed. However, on hospital wards, many patients can go on leave.
“They come back and they’re not always searched,” said Elizabeth. “They could come in with drugs, weapons. So it’s much more unregulated.”
Elizabeth highlighted inconsistencies in the application of rules for patients, which can also adds to the risk of violent behaviour. For example, although there is a blanket ban on lighters, a patient deemed ‘safe’ may be allowed to keep one, despite another patient on the ward having a history of setting fires or burning people’s hair.
“You can’t admit them because there are no beds. So you keep them at home”
A Royal College of Nursing survey last year revealed that almost half of community nurses experienced abuse in 2013/14. Elizabeth said a shortage of beds in mental health wards could play a part in this problem.
“You might have somebody in the community who is getting on well, but you know they are on the verge and they need to be admitted,” she said. “But you can’t admit them because there are no beds. So you keep them at home. And yet you keep visiting by yourself, and every time you’re visiting that risk is increasing.”
Although the government is committed to parity of esteem, funding for mental healthcare has fallen in recent years – the BBC revealed that budgets for mental health trusts fell by 2% from 2013/14 to 2014/15. Until this lack of funding is addressed the issues Elizabeth raised are unlikely to be addressed, and patients and staff will remain at unnecessary risk.
*Elizabeth wanted to remain anonymous so her name has been changed