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Staffing issues affecting care on acute psychiatric wards

2007; Elsevier BV; Volume: 370; Issue: 9582 Linguagem: Inglês

10.1016/s0140-6736(07)61068-x

1474-547X

Udani Samarasekera,

Mental Health Treatment and Access

Recent changes to mental-health services have taken their toll on inpatient care in the UK. Acute psychiatric wards have lost experienced staff and money to community mental-health teams, and, as a result, some have become untherapeutic and unsafe. Udani Samarasekera reports. Violence, verbal abuse, sexual harassment, and boredom—might be some of the challenges you would expect from life on the city streets, not an environment where people are supposed to receive supportive care. Recently, however, several reports have revealed that these are some of the experiences of patients on acute psychiatric wards in England and Wales. In 2004, a survey by mental-health charity Mind, found that of 200 current or recent service users, 51% reported being verbally or physically threatened during their stay, 20% reported physical assault, and 18% sexual harassment. A National Audit of Violence 2003–05, undertaken by the Royal College of Psychiatrists, backed up these findings. The audit found that over a third of service users had been attacked, threatened, or made to feel unsafe, and almost a half had witnessed this on the ward. Experts say that recent changes in mental-health services have unwittingly fostered ward environments that are at best counter-therapeutic and at worst dangerous. Inpatient care used to be the main environment in which people with mental-health problems were treated, but nowadays there is a greater emphasis on care in the community, and many large psychiatric hospitals in England and Wales have been shut down. Although the move away from institutionalisation and towards community treatment or smaller care homes is a positive development, the knock-on effects for inpatient care have been negative. Human resources on wards have definitely felt the impact of the changes. Around a quarter of wards have lost staff to better paid, more attractive jobs in the community. “Staff have gone to the sexiest part of the service, that is community mental-health teams, and inpatient wards have been largely depleted of talented, experienced people”, says Graham Thornicroft, a professor of community psychiatry at the Institute of Psychiatry, King's College London, UK. This staff drain means that wards have become more and more reliant on bank and agency staff. The lack of continuity has affected staff morale, but also put the safety of some service users at risk. “Agency and bank staff are unlikely to be trained in the management of violence and aggression, and proper control and restraint procedures”, says Emily Wooster, a policy officer at Mind. Trevor Turner, a consultant psychiatrist at Homerton Hospital in east London, who has worked with Royal College of Psychiatrists' research unit on an accreditation scheme for mental-health wards, says that inpatient care has lost out to forensic services, such as medium-secure units, as well as community services. He says that the government's “over-focus” in this area has drained funds away from inpatient care and bed cuts on acute wards have gone too far. “Now staff try not to admit people” and “there is a high pressure to move people through [the wards] quickly”, he says. The move towards community care and the subsequent reduction in beds has meant that the threshold of severity for hospital admissions—especially in inner city areas—has increased. “Patients on wards are more likely to be acutely ill, have severe personality disorders, and often have comorbid conditions, such as drug or alcohol addiction”, says Angela Greatly, chief executive of the Sainsbury Centre for Mental Health—a research and advocacy charity. Mental-health experts say that it is this mix of people with severe mental-health problems, being nursed by an insufficient number of inexperienced staff working under pressure, that has exacerbated problems on wards. But staffing issues are not the only thing worrying mental-health advocates—some say poorly designed wards are compromising sexual safety. In 2005, a study by the National Patient Safety Agency found that 122 sexual incidents had been reported on mental-health wards in England and Wales over a 2-year period, including 19 allegations of rape. Wooster says that a lack of single-sex accommodation is to blame for these appalling statistics. Trusts are supposed to provide single-sex accommodation, defined as separate sleeping areas for men and women, segregated bathroom and toilet facilities for men and women, and safe facilities in mental-health wards. “The Government says that 99% of trusts provide single-sex wards. But, in 2006, a report by the Healthcare Commission showed that 55% of mental-health wards, are still mixed sex. So while trusts are meeting the letter of the law they are not meeting the spirit of it”, says Wooster. The Government has recently allocated £30 million towards improving sexual safety on mental-health wards but Wooster is concerned that the money might not go to the wards most in need. “Because trusts have been invited to bid for the extra funds, the money is not targeted at problem wards”, she says. Although funding to eliminate the environments that put patients' safety at risk is paramount, mental-health advocates say that this money is not enough. They believe that wards need to be therapeutic, as well as safe for service users. “Some wards are good, but it is very variable”, says Wooster. Even those who work on wards admit they may not be up to scratch. In Acute Care—a 2004 study by the Sainsbury Centre for Mental Health—22% of staff admitted that their ward environment does not promote positive mental health. “We found that fewer than 20% of wards had access to psychological therapies and this is unlikely to have changed”, says Greatley. So what can be done to improve inpatient care? Greatly believes that there needs to be more attention on the patients' day, and that this attention should include recreational activities, as well as evidence-based therapies. At the moment many service users have nothing to do “other than take medication and watch TV”, she says. To reduce pressure on beds, Greatly thinks that the mental-health and social-care system need to link up more effectively and work in a more integrated way. “Wards, primary care, social care services, and housing trusts need to develop support packages for people with mental-health problems. They need to ask: Do they have a job? Do they have somewhere to live? Do they have a support network of friends and family? Do they have access to recreational activities?” Some patients need help with all aspects of life, she says. PanelLife on the wards29-year-old Sarah Miller has been on five different psychiatric inpatient wards and two medical wards in England and Wales since her early 20s. Sarah has been admitted to hospital—and has gone voluntarily—when her post-traumatic stress disorder, agoraphobia, and bipolar disorder has become too severe to be treated in the community.On her first ward experience, she remembers just being shocked by the fact that she was on a psychiatric ward. She says she was “baffled by the strict regime” in place. She remembers that the staff would not show her around the ward. “You were expected to find out where things were by talking to other patients.” But, she says, “you would not be treated in the same way on a medical ward”.Several aspects of the ward made her feel unsafe. The bathroom did not lock. And, although she was in an all women sleeping area she could hear male nurses at night and the door that led to the male section was left wide open.Sarah recalls being frustrated by the lack of interaction with staff. “No one was working with me to get me out of my state”, she says. “There was very little to do on the wards to occupy our days. Most staff stayed in the office and only seemed to be treating those who had a psychotic episode.”Sarah described one incident involving a nurse who “shouted at her” and “dragged her” across the visitors room. Sarah complained about the member of staff but says: “People didn't get it when I complained. They just thought I was being hysterical.” She says that “something needs to be done about the culture of abuse on wards”. She believes tackling the design of wards, providing activities to alleviate boredom, and pro-active nursing are all key to good inpatient care. “You are in there to be treated, not just observed”, she says. 29-year-old Sarah Miller has been on five different psychiatric inpatient wards and two medical wards in England and Wales since her early 20s. Sarah has been admitted to hospital—and has gone voluntarily—when her post-traumatic stress disorder, agoraphobia, and bipolar disorder has become too severe to be treated in the community. On her first ward experience, she remembers just being shocked by the fact that she was on a psychiatric ward. She says she was “baffled by the strict regime” in place. She remembers that the staff would not show her around the ward. “You were expected to find out where things were by talking to other patients.” But, she says, “you would not be treated in the same way on a medical ward”. Several aspects of the ward made her feel unsafe. The bathroom did not lock. And, although she was in an all women sleeping area she could hear male nurses at night and the door that led to the male section was left wide open. Sarah recalls being frustrated by the lack of interaction with staff. “No one was working with me to get me out of my state”, she says. “There was very little to do on the wards to occupy our days. Most staff stayed in the office and only seemed to be treating those who had a psychotic episode.” Sarah described one incident involving a nurse who “shouted at her” and “dragged her” across the visitors room. Sarah complained about the member of staff but says: “People didn't get it when I complained. They just thought I was being hysterical.” She says that “something needs to be done about the culture of abuse on wards”. She believes tackling the design of wards, providing activities to alleviate boredom, and pro-active nursing are all key to good inpatient care. “You are in there to be treated, not just observed”, she says. Others think that creating a specialist approach to inpatient care will be an important step towards dealing with the all the changes that have occurred in the field. And some hope that this might help attract more staff into the inpatient setting. “The education system needs to create an acute-ward specialty culture. We need to give it some status, because it has been lost with all that has happened”, says Turner. Freeing up nurses' time, so they can interact with patients more will also help make wards more therapeutic. Thornicroft believes reducing the “form filling” that has substantially increased in recent years will help to acheive this goal. Turner agrees that bureaucracy and the Government's “mangerialist agenda” needs to be addressed. “There is a bizarre disparity between the number of staff working on wards and the number of documents being written about them”, he says. But maximising the time spent with patients will only be part of the solution. Teaching existing staff, as well those in training, to give therapeutic care will be crucial to ensuring patients are placed on the road to recovery. As Thornicroft says, the skills of staff need to improve, so that they are “not just giving tablets”. “They need to learn cognitive behavioural therapy and family interventions. At the moment training in these skills is very patchy”, he says. Mental health: neglected in the UKIn this week's Special Report, The Lancet publishes a series of features that take the pulse of mental health in the UK. The reports show that all is not well. Full-Text PDF Marjorie Wallace: campaigning for people with mental illnessOliver Sacks' glowing review of The Silent Twins in The New York Times helped propel Marjorie Wallace's book on to the bestseller list 20 years ago. The story of the twin girls who refused to speak to anyone apart from each other and Wallace, who was at that time a journalist working for the UK's The Times newspaper, is dark and compelling. After a string of crimes, including arson, June and Jennifer Gibbons were committed to Broadmoor Hospital, one of the UK's highest security psychiatric hospitals. Full-Text PDF