Changing culture

Does acute mental health care have to be institutionally dehumanising? I have seen enormous compassion displayed in coercive environments. I have seen staff and patients working together collaboratively and authentically, irrespective of the legal authority compelling them to do so. I have seen situations that have arisen in the context of a patient’s distress that have been met with great tenderness and validation. Yet we still have the testimony of survivors describing the abusive and authoritarian treatment that they have experienced as inpatients. We have registered mental health nurses joking about the sedating effects of rapid tranquilisation on social media. And we have people within the profession who think doing that is OK.

Nurses have long been involved in the delivery of 24/7 patient care in mental health settings. It is fair to say that without nurses, at least within the current context and set up of health services, inpatient care would cease to function properly. With a long history of deference to authority (i.e. psychiatrists), the profession has made attempts to move away from its fiercely conservative and defensive roots. Despite this, great swathes of mental health nursing remain shrouded in a misplaced tribalism, in which many of its gatekeepers accept and enjoy an almost permanent state of regression back to the key jangling days of the asylum. They delight in the forcible administration of potent neuroleptics and sedatives as if this is somehow a testament to their status and prestige as an RMN, rather than taking the time to converse and engage with the people that they are supposed to be caring for. They are vehemently resistive to change or being told to do something differently, and for goodness sake don’t get them started on psychology.

I suppose the question is why? Why does the profession still display these paternalistic attitudes and uncaring behaviours? Indeed, the Independent Mental Health Act review interim report found that patients receiving inpatient care were vulnerable to coercive mistreatment, coercive reward and punishment systems for access to open air, leave or family contact, deprivation of their human rights and abuse.

The problem often lies in the culture of a team. This culture has often been cultivated and developed over a period of time. There are usually a number of very senior (and very intimidating) clinical members of nursing staff who have been there for years. They are often jaded. They have stalled in their professional development and no longer attempt to actively improve their practice. They treat patients with disdain. Yet their seniority means that their opinions and attitudes are afforded greater weight than their more junior and progressive counterparts. Newly qualified nurses enter into this environment and the reproachful and nasty behaviour is shocking to them but they do not have a manager who is willing to do anything about it. Over time, this behaviour becomes normalised. Soon, those newly qualified members of the team are part of the problem. When this is mirrored throughout inpatient settings across the country, we can start talking about this culture having a demonstrable effect on an institutional level. Whilst all this is happening, the patients suffer.

I don’t believe the people who are saying that joking about the administration of IM medication is a way of “offloading” or “dealing with the stress of the job”. I find it unsettling that something as serious as injecting someone with medication against their will should be treated with anything but humility and respect. We have been entrusted with an enormous power that has the capacity to – even when used correctly and appropriately (and it often isn't) – be a traumatic and damaging experience. I believe it to be a dereliction of our professional and personal ethical standards to laugh about the possibility of haloperidol and lorazepam providing staff with “a silent night”.

These sorts of jokes and attitudes will continue to go unchecked unless we have strong leadership and management who are willing to do something about it. Make examples of the ringleaders, show them that sort of behaviour is harmful to patients and brings the profession into disrepute. Identify the skilled and compassionate professionals that you have within your service (because believe me, they do exist!) and encourage them, get them into positions of seniority and make sure they are supervised well. Encourage a culture within the team where it is normal for staff and patients to call out bad practice without fear of being labelled a troublemaker. Provide a space for the people using the service to air worries and concerns without fear of being pathologised. Encourage and nurture psychological approaches of dealing with anger and distress, talk about the iatrogenic harm of inpatient care and work on ways to address the inherent power imbalance. Give staff and patients the tools to engage in proper co-production at every level of care. Help create advanced directives. Co-write clinical records. Show staff that there is a right way of doing things around here.

In answer to my opening question – no, I don’t think that acute mental health services have to be inherently dehumanising. I know and see good practice everyday, and am deeply proud when my colleagues demonstrate their skills and talents as communicators and caring individuals. But that doesn’t change the fact that many within the profession do not seek to modernise or to treat the people within their care as equals. It doesn’t change the fact that many people are experiencing poor and abusive treatment in the name of care. Individual practitioners need to stick their heads above the parapet and shout about this – we must recognise that yes, there is a very real and apparent power dynamic but we do not have to actively contribute to it. We don't have to drive an even greater divide between staff and patients. We must act in solidarity and use this power to call out bad practice when it is difficult for a patient to do it themselves. We must remain humble and open to the possibility that we may be the cause of a patient's distress, and be ready to say sorry and learn from our mistakes. Until we can provide an environment of safety and surety, where everyone is treated with the humanity they deserve, inpatient services and mental health nursing will continue to be found wanting.


Thank you to @m4delen for your comments and recommendations before publication.