“My partner fears for my safety every shift now.” – Enrolled nurse, acute inpatient mental health care
“A frightened bunch of young nurses who want to be good nurses but are constantly in fear.” – Mental health registered nurse with 35 years’ experience
“You see staff getting injured and leaving – some being injured permanently – physically and emotionally for the rest of their lives…” – Registered nurse providing professional supervision for mental health nurses for more than two decades
The above are mental health nurses describing to Nursing Review some of the worst of working in today’s acute inpatient settings.
Below are excerpts from submissions to the most recent ministerial inquiry into mental health – back in 1995.
“Bed numbers have been reduced to such an extent that most services now run on the seat of their pants.”
“This hospital has experienced a gradual leaching-out of experienced registered nurse staff over the last several years … replaced by nurses with reduced levels of experience in mental health nursing.”
“… seen the growth of a deep-seated defensive mentality among many staff in response to resource shortages, degenerating facilities, future service uncertainty and burn-out in the face of rising workloads and the high risk
There may never have been a ‘good old days’ in mental health.
While progress has been made in the intervening decades between inquiries, the cyclical falling in and out of the spotlight of mental health has meant that investment in services, facilities and staff has not matched the recent dramatic growth in demand. In 2016-17 more than 170,000 people used specialist mental health and addiction services – 71 per cent up on a decade earlier.
Nobody is saying that today’s services are all bad – too often stretched and stressed, yes, and staff too often feeling unsafe – but despite this, clinicians work hard to make a positive difference for their clients. And 79–80 per cent of 6,610 consumer respondents in a 2016 survey expressed overall satisfaction with the services they received and were ready to recommend services to friends and family in need.
Among those committed clinicians are mental health nursing veterans Sally McPherson and Kathryn Brankin, who a generation ago were so concerned about mental health services that they joined forces to make a submission in person to Judge Ken Mason – the chair of the 1995-96 ministerial inquiry that bears his name.
Brankin recalls that in the 1990s acute wards were often just expected to stretch to fit whoever came through the door.
“If you needed a bed you just went under the stairwell and physically pulled out a bed and moved it into an interview room or a doctor’s office.”
When she and McPherson spoke to Mason about the stress staff were under and their fears for the safety of patients being discharged too early, she had 13 years of mental health nursing under her belt.
In the 23 years since, many things have improved – including patients no longer being put in eight-bed dormitories, families included more, the decreasing use of seclusion, and increases in postgraduate study opportunities for new and existing mental health nurses.
But in recent years there have been growing reports of a mental health and addictions service, both in the community and inpatient, struggling to meet the demands being placed on it. This has resulted in some people falling between the gaps, sometimes tragically, and some staff being injured, sometimes permanently, and the announcement of the country’s sixth major inquiry into mental health now being underway.
That was then – this is now
“The pressure is completely different now,” says Brankin, comparing 1995 with now.
McPherson, who retired in mid-April after 45 years in mental health nursing, agrees. She’s been around long enough to see not only the cyclical waxing and waning in investment and support for mental health services between the spotlight of inquiries, but also a spiralling trend upwards in patient demand, acuity and assaults on staff.
“The amount of violence that nurses are exposed to over the last 15 years is much more than it ever was last century,” says McPherson. Although for much of her later career she worked in the ‘sanctuary’ of older people’s mental health, she was for decades the listening ear, as their professional supervisor, to many mental health nurses working in acute inpatient units.
“You see the people who are damaged, the people who can’t go to work, the people who are depressed, who are anxious and who are permanently injured – physically and emotionally,” she says. “And you think, [nurses] shouldn’t go to work to have that happen [to them].”
It wasn’t always like this. McPherson was a charge nurse at Christchurch’s Sunnyside Hospital in the heady days of de-institutionalisation in the 1970s and ’80s and loved the challenge and chance to innovate that it brought. “The whole of Sunnyside Hospital felt like what it was meant to be – which was a therapeutic community.”
But the health reforms of the 1990s that followed were, in McPherson’s view, too driven by balance sheet bottom lines and not enough by patient need. So after being challenged by Judge Mason during their 1995 submission to think about their roles as nurses and leaders in supporting a system they felt was too often failing clients, she made the call in the late 1990s to step back from the management path and become a clinician in older people’s mental health. It is a move she has not regretted and she is proud to have been part of Christchurch’s innovative service to older clients.
“And there is no way I would be able to survive in acute inpatient mental health services as it is now,” she adds.
Changing acuity: caring for the most unwell of the unwell
The new millennium brought with it a nationwide push for setting new benchmarks in practice standards for inpatient mental health, including minimising the use of restraint and, more recently, seclusion for clients behaving violently.
Clinicians largely agree with the philosophy and the use of seclusion has decreased by 25 per cent since 2009. But McPherson, for one, argues there should have been a matching push for ensuring minimum staffing numbers, so nurses can consistently deliver the new strategies safely.
“What they’ve brought in its [physical restraint and seclusion] place is not enough to keep staff safe,” she says. “Now staff are having to ring for the police to come and manage patient behaviour in inpatient wards, rather than staff managing that themselves.”
At the same time, she says, the focus on treating and supporting more acute mental health clients in the community means the clients who do make it “through the gates” into acute inpatient care are now the most unwell of the unwell. “I don’t think staffing has changed to reflect the increasing acuity of patients.”
Brankin adds that even though there are more nurses on the floor than in 1995, other expectations on them are up too, including faster turnaround of patients, more documentation requirements, and a lot more involvement with family members.
“It’s what we should be doing, but it [working with families] is time-consuming … that is, if families are still around and aren’t burnt out themselves.”
Then there is the time spent orientating and supporting agency or new staff who are plugging the gap left by experienced staff who are on sick leave or ACC leave or who have left the service.
Safety, assaults and compassion
When things go wrong, they can go really wrong.
“I think our unit has the most disreputable reputation for having the most assaults and seclusion events – maybe in the South Island,” says Keith Knight.
A clinical nurse specialist, Knight has been in mental health nursing for 20 years. Most recently he has been working in a small inpatient unit caring for people with intellectual disabilities with challenging behaviours, alongside forensic clients being held under the Intellectual Disability (Compulsory Care and Rehabilitation) Act 2003.
Knight says the biggest issue facing the unit has been housing these two groups in an unfit-for-purpose building, resulting in the unit’s next biggest issue, the number of times staff have been assaulted, including himself.
“Head injuries are the main ones – when we get a kick or a punch to the head. Or bitten.”
Changes have been made in the care of one client, which have reduced the assaults, but Knight says the unit still has staff on extended ACC leave, and the incidents have left their mark on the predominantly mature female staff working with clients who are often large and male.
“Are we expecting 50-year-old-plus women to be rolling around on the floor? … It’s not very nice,” he says. “That then creates its own issues, with staff feeling anxious, not wanting to come to work, and fearful.”
His DHB has promised staff new, purpose-built pods to better meet client and staff needs, but that is at least two years away.
An enrolled nurse who has been working in an acute mental health inpatient ward since graduating five years ago, says every day she wonders whether this will be the day she is seriously assaulted.
“I have already been assaulted, which required time off for concussion; other times it’s the ‘not-so-serious’ slapped, spat at, verbally abused and continuous threats of assaults,” says the nurse, who wishes to remain anonymous.
“I have witnessed many assaults … that appear to be brushed under the mat or minimised. It is not okay. I have also witnessed vulnerable patients who have been assaulted by other patients.”
She says her partner fears for her safety every shift and is saving money in the hope she will leave mental health if she knows he can support her until she finds other work. The EN chose acute mental health as she wanted to care for the people “others had stopped caring for” but, says much of her shift is spent running around trying to keep her patients safe and just doing basic nursing tasks.
Staff are frequently on double shifts or extra duties and she says at times she has wanted to walk out when asked to stay, but is stopped by the fear of what would happen if she did. The EN says she can also find herself overseeing new RNs who find themselves in charge of acute wards when fresh out of training.
Another acute inpatient nurse with five years under her belt told Nursing Review that an assault at work has left her suffering panic attacks and the only thing that has stopped her moving on is the need to pass on skills and support to the new graduates staffing the wards.
Brankin, who left acute inpatient care two years ago for an inpatient extended care ward, says she has been attacked just once, when a cup of hot water was thrown over her by an older psychotic woman in the 1980s.
While she personally doesn’t feel unsafe at work, she is well aware of people at risk around her, and the impact of the lack of experienced role models for new nurses working in acute inpatient care.
“A frightened bunch of young nurses who want to be good nurses but are constantly in fear … they are thrown into the deep end…”
Brankin confesses to sometimes having compassion fatigue “up to her back teeth”, not just with patients but with her colleagues. “You want to be a good teacher and role model, but…”
Swearing, drugs and social change
Knight reiterates that some things have changed for the better this millennium. “I think we can manage people without secluding them or without putting hands on people – though not always…” And when fully staffed with the right skill mix, his specialist unit has a very good staff-to-patient ratio.
But the old hands also agree that patient acuity and demand has impacted not only on workloads and safety in the past few decades – but also social change.
“I think we’ve become a little more tolerant of staff being hit and injured then we used to be,” says McPherson. “Society’s expectations have changed and therefore what we are exposed to in hospitals has changed.”
Exposure in hospitals is now including the problematic impact of P use and synthetic cannabis on mental health presentations, which Knight believes is one of the causes behind the growing violence against staff, along with ongoing addiction issues like alcohol and tobacco in the smokefree facilities.
“Years ago when I was working in acute, if I got assaulted by a psychotic person I could be accepting of that – particularly if it was part of their delusion,” says Knight. “But not when it’s someone who has got an antisocial personality disorder who just comes and hits you because they can’t get a cigarette.”
While physical abuse is now not uncommon – McPherson has a friend who has been left slightly deaf in one ear after a patient assault that also left her with a dislocated jaw and broken teeth – she says what can really wear staff down in the adult acute mental health wards is the constant verbal abuse.
“You do expect if somebody is really upset they may go off and say “you f*** c***” or whatever, and you brush that off. But when it’s happening with every interaction and they are calling you every name under the sun, and you have other patients around adding in insults about your race, gender or age…”
Brankin agrees that verbal abuse is constant, and recalls the irony of once getting feedback that data entry staff were “really distressed” at having to input the swearing and abuse that nurses write up in patient incident forms. “I said, ‘you imagine standing there and that’s being said to you’.”
Nurses’ hopes for the 2018 inquiry?
So what do these nurses hope to gain from this year’s Ron Paterson-chaired Mental Health and Addictions Inquiry?
“That they walk a day in the shoes of both patients and staff,” suggests Brankin.
Nobody has a simple, fast solution to the complex issues faced by the sector. But they do agree that in order to sustainably recruit and retain new and experienced nurses in acute inpatient health more nurses need to feel safe at work.
And for that to happen they need not only the right pay but the right staffing numbers and the right skill mix to meet patient demand and acuity, and the right fit-for-purpose facilities to deliver the right quality care at the right time.
Nurses simply should not be scared to come to work.