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Presenting the case for acute mental health wards

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During the past 10 years, acute mental health admission wards have come under increasing scrutiny. This has not generally cast acute wards in a positive light (Standing Nursing Midwifery Advisory Committee (SMAC), 1999), describing them for the most part as non-therapeutic and suggesting that they offer little privacy and minimal staff contact for patients.

Abstract

VOL: 99, ISSUE: 11, PAGE NO: 26

Trevor Barre, BSc, RMN, is lead nurse, Brent Mental Health Services, Central and North West London Mental Health NHS Trust

Roger Evans, MSc, RGN, RMN, is assistant locality director and nursing lead, North Camden, Camden and Islington Mental Health and Social Care NHS Trust

During the past 10 years, acute mental health admission wards have come under increasing scrutiny. This has not generally cast acute wards in a positive light (Standing Nursing Midwifery Advisory Committee (SMAC), 1999), describing them for the most part as non-therapeutic and suggesting that they offer little privacy and minimal staff contact for patients.

Furthermore, acute wards have been subject to more than a decade of continual change. The gradual reduction in beds caused by the asylum closure programme and the adoption of a community-focused philosophy mean that psychiatric wards now care almost exclusively for patients who have severe and enduring mental health problems.

There is a corresponding increase in the numbers of detained patients and pressure to discharge (Gournay et al, 1998). The service user movement has also increasingly found its voice.

The large psychiatric institutions of the past were the origins of the psychiatric nursing profession and its traditional seat of power. Since their gradual closure, acute wards have been seen in an increasingly unflattering light - even though in the traditional asylums they were seen as the most prestigious area to work in. This has contributed to the erosion of the prestige of the acute mental health admissions ward, both in terms of staff recruitment and retention, and the nature of the nursing role.

The National Service Framework for Mental Health, sees acute wards as one among several 24-hour services. However, demoralisation and poor self-esteem in acute ward teams now appear to be the norm. The erosion of general psychiatry as an attractive career choice in nursing has resulted in problems with the recruitment and retention of appropriately trained staff (Mental Health Act Commission, 1997).

The aim of this article is not to idealise acute wards - the intention is to show that they can still be of benefit to patients.

Safety and containment
In some ways the primary aim of acute admission wards, which can be described as that of ensuring the safe management and resolution of acute distress, has changed little over the years. Patient safety can be maximised by the containment that an effective acute ward can offer. This concept can be described by its origins in psychoanalytical thinking around the mother-baby relationship. As Obholzer (1994) describes: ‘If all goes well, the mother processes or ‘metabolises’ the baby’s anxieties in such a way that the feelings become bearable; we then say that the anxieties have been ‘contained’.’

Flynn (1998) argues that when a severely disturbed patient is treated in an inpatient setting, the setting provides certain opportunities for ‘supportive containment’ of the patient.

The concept of containment has particular relevance for the nursing role, although some nurses may not like the suggestion that they are ‘mothering’ their patients in any way. However, the concept of containment can help us to understand the way that the institution can benefit patients and help them to grow.

 

Containment may include the use of physical restraint. According to Winship (1998) the restrained patient may experience ‘a new synthesis of safety and containment if the restraint is delivered with care and insight on behalf of the nursing team’. Thus, the term ‘holding environment’ can be used in a more positive sense, as part of a therapeutic process.

Acute wards house - or ‘warehouse’, from a more cynical perspective - most patients in the acute phase of their compulsory stay. More effective acute wards contain the considerable anxieties of the patient, his or her loved ones, and, sometimes, the community at large. As Gabbard (1991) argues, many patients are only treated in a hospital precisely because they are too much of a burden for a single individual or family to contain without considerable support.

In short, acute wards contain patients that other services cannot manage or place. This relieves the other services of their anxieties, but can lead acute ward staff to feel that they are a kind of ‘last chance saloon’, left to manage everything that comes their way.

Acute wards do not have enforceable criteria for admission or referral and this may leave staff feeling vulnerable and exposed. The authors would argue that the current definition of a specialty is the ability of the service to say ‘no’ to a particular patient or group of patients defined by the presenting problem(s). We argue that acute general psychiatric wards are a specialty and should be acknowledged as such by all stakeholders.

The ward environment
Victorian institutions featured separate male and female areas. Modern acute wards are mixed and this is perceived as a problem by many. The government’s vision, Modernising Mental Health Services (Department of Health, 1998) includes the elimination of mixed-sex areas, as well as the ideal of having female-only wards.

Other initiatives are also taking a ‘back to basics’ approach. The creation of modern matrons and housekeepers employs the traditionalist terminology often used when acute inpatient care is discussed. Initiatives such as the King’s Fund’s ‘Enhancing the Healing Environment’ programme further emphasise that the acute ward environment is finally getting attention, and it is encouraging that mental health trusts have been asked to nominate nurses to lead the process.

Gabbard (1991) feels that ‘nurses must attend not only to individual clients but also to the group and the environment as a whole’. He argues that the creation of a healing, therapeutic environment is an achievable goal for nurses.

Therapeutic work
The therapeutic environment provides five important functions: ‘structure, involvement, containment, support and validation’ (Gunderson, 1978). We believe that acute wards can and do continue to provide a service, which includes all five of these functions.

Architects are becoming increasingly specialised in designing and building mental health facilities. They aim to balance the often conflicting demands of ensuring a building is both therapeutic and safe. Examples of collaborative working with service users and mental health professionals were given during the design process of new units at a Sainsbury Centre Conference in March 2002 ‘The Psychiatric Ward - Can it be Caring and Therapeutic?’.

The ward setting is unique in its potential to provide patients with a multiplicity of human contact. Although nurses can be seen as the orchestrators of the environment, the importance of other personnel should be highlighted. Gabbard (1991) mentions that follow-up interviews with discharged patients showed that ‘certain patients found a member of the housekeeping staff, the grounds crew, or the food service team to be a key person in the healing process’.

To this, of course, should be added the support that can be gained from contact with other patients. It may be the case that nurses are being therapeutic, but lack adequate time for reflection on their work and are thus unable to identify and articulate the nuances of their role to a wider audience.

However, there are concrete examples of good practice within one of our trusts. There has been a highly successful collaboration between a family intervention project and a ward: the practical benefits of this being that all new patients are offered a family assessment and subsequent family work on the ward, facilitated by the ward staff. In addition, the wards have undergone a realignment of staff establishments to enhance multidisciplinary team working and allow a better use of psychosocial interventions.

Our opinion of the therapeutic potential of acute mental health wards is that they offer unlimited opportunities for positive relationship building among staff, patients and carers over a 24-hour period. They allow a sense of staff cohesion, which involves the development of common goals and approaches, and which is ultimately of benefit to the patient. All aspects of the environment, structure and routine can potentially be therapeutically exploited. Work can be spontaneous allowing the opportunity for informal exchanges to be maximised. Nurses have been seen as ‘travelling companions’ rather than ‘travel agents’ for patients, and this role has been highlighted in discussions about therapeutic communities (Watson, 1992).

Conclusion
The demands on acute wards have become complex in the past 10 years and the expectations of key stakeholders have become much higher. There is the expectation that newly qualified nurses must: safely manage the most disturbed patients; offer talking treatment; possess a knowledge of evidence-based interventions; promote service user and carer involvement; manage complex systems; and be responsible for promoting a learning environment. It may be reasonable to conclude that these expectations are unrealistic given the experience, grade and training of ward nurses.

A polemical suggestion is to invert the current career pathway. The authors’ view is that the newly qualified nurse could initially be placed in a community mental health team/crisis resolution team (CMHT/CRT) at grade D or E, allowing a grounding and consolidation of his or her knowledge and skills. The nurse would then progress through the clinical grading structure, with the aspiration of becoming an F or G-grade nurse within the clinical specialty of acute inpatient mental health. Elements of this view may be seen in current policy initiatives such as the recent DoH policy document: Adult Acute Inpatient Provision, (DoH, 2002), a central theme being that wards should have a stated therapeutic purpose. This might go a long way to combating the demoralising ‘warehouse’ function of acute wards as described above.

Acute wards have many positive therapeutic aspects. If improvements are to be made, they must build upon these elements. In the short term, practical enhancements towards practice must be made, for example, the introduction of family interventions in which other members of the family are included in the overall treatment plan.

However, in the longer term, changes must be fundamental and address the purpose, goals, structure, and target patient group of acute wards. The above suggestion around career pathways would help wards to be a more nurturing environment for patients and staff, particularly at a time when the spotlight is on the NHS generally and mental health specifically.

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