Is Covid undoing progress with mental health care?

Bex Wainwright wasn’t expecting to spend her first night in an inpatient psychiatric ward completely alone.

But when she was admitted to Cross Lane Hospital in Scarborough in May, she was led in through the back door, to a ward where patients waited in isolation for their Covid-19 test results, and where she would stay until her own test came back negative.

“I wasn’t allowed to leave the room. The windows didn’t fully open, so to get fresh air I had to put my arm out the window. I was very lonely, and very scared.”

Wainwright passed the 24 hours she was isolated for by looking out of the window and colouring in; her phone had to be taken away to be charged. She believes she would’ve settled onto the main ward quicker if she hadn’t first been isolated.

Tees, Esk and Wear Valleys NHS Foundation Trust confirms that it asks patients to take a COVID-19 test on admission and stay in their room for up to 48 hours until their test results are received, and says it tries "to make people feel as reassured and as comfortable as possible while they await their results".

Bex Wainright would've settled better without isolation

Around the same time, Sarah Mitchell (name changed) was admitted to The Lakes inpatient unit in Colchester. She was put into isolation for two days while waiting for her Covid-19 test results, and had to ring a buzzer if she needed a drink or the toilet. It was stressful, she says, and it exacerbated her mental state.

“I slept most of the time because there was nothing to do. I asked for a book or magazine, but

was refused,” she says.

Essex Partnership University NHS Foundation Trust says it acts 'on government guidance, which includes temporary isolation while waiting for coronavirus test results for patients, to help minimise the spread of COVID-19 and protect other patients'.

Wainright and Mitchell were put into isolation along with other patients to help control the spread of the virus – but this isn’t happening

in every psychiatric setting.

“People often don’t self-isolate,” says Gary Dodson, matron of the six psychiatric wards at Wotton Lawn Hospital in Gloucester.

“This is the nature of acute psychiatry. There’s nothing we can do about that – we don’t keep people in their rooms because of Covid.”

Reducing restrictive practices (RP) in psychiatric settings, including isolation, has been a huge national talking point in recent years – RP is ‘one of the hardest topics in psychiatry,’ according to Dodson.

But with coronavirus cases still high, and restrictions in place for the foreseeable future, efforts to reduce RP will likely be hindered as more patients await test results in isolation. Can we afford to slow down progress?

Experts recognise that RP has its place as a last resort to protect staff and patients in extreme circumstances. Even recipients of RP can come to understand why it's used on them - including Alex Palmer (name changed), who had rapid tranquilisation once, and has been restrained several times when she was self-harming.

“I felt pretty awful afterwards, but looking back, I know it was the right thing to prevent me from hurting myself. It was traumatic, though; being held down and injected is a really awful experience.”

Jane Thompson (name changed) was admitted to a psychiatric unit for the first time aged 18. She was traumatised after being held down and injected with sedatives. Last year, she went back into hospital at the age of 36 and was held down and injected again.

“As someone in their mid-thirties, in this day and age, compared to a vulnerable 18-year-old back in the early 2000s, it was completely different.

“I experienced it as loving, not scary, this time. I was able to see looks of concern on people’s faces, see they were working hard to do this in a way that was going to help me.”

Up to half of all psychiatric in-patients in the UK are isolated at least once. But it’s argued that some patients are receiving ‘overly restrictive’ care, more than 30 years after the introduction of legislation preserving their right to the least restriction necessary.

“If someone is self-harming, it seems obvious that they should be stopped, but putting restrictions on them can make things more dangerous, and can wipe of peoples’ quality of life,” says occupational therapist Keir Harding.

When Harding got a job on a special security hospital, he was looking forward to the satisfaction that comes from helping people, but it didn’t turn out that way. Instead, his early career gave him insight into why some staff might be more willing to use RP.

“I was prepared for people to take my advice, to be grateful, and go off into the world and get better,” he says.

“I wasn’t prepared for people who weren’t expecting me to be useful, who’d lived with people who were supposed to look after them, but who actually hurt them.

“The majority of people working in mental health get a lot of their self-esteem from feeling useful, but if we’re working with someone whose way of coping is to hurt themselves, it’s hard to feel that.”

Harding found it easy to blame patients for how he felt; now; he sees now how staff can start to feel angry towards patients.

Staff also use RP, he says, for fear of losing their jobs. Often, they can see that their actions make things worse, but they “have a sense of something looming behind them,” Harding says. “There’s a pervasive feeling of being unsupported, and that people will scapegoat if something goes awry.”

Every mental health provider is struggling with RP and would like to reduce it, says Amar Shah, a consultant forensic psychiatrist and chief quality officer at East London NHS Foundation Trust. That's why he decided to try something that's never been done before

With a group of experts, patients who’ve experienced RP, clinicians and researchers, Shah formed the Reducing Restrictive Practice Collaborative in 2018, on behalf of the Royal College of Psychiatrists and NHS Improvement.

“This is the first time in England that a systemic approach has been applied with the aim of improving any mental health issue in this way,” Shah says.

Staff and patients from 38 psychiatric wards met regularly over 18 months to discuss restraint, seclusion and rapid tranquilisation, and test new ideas.

Staff at the Irwell ward in Greater Manchester started talking to patients about their service.

Dr Shah

“Patients told us they found ward rounds, where a patient’s treatment is spoken about, extremely stressful,” says Lianne Holland, project lead for the programme in Irwell.

They started asking patients before ward rounds which staff members they wanted to be involved, and what they did and didn’t want to talk about.

“If a patient was asking for significant leave and we know their condition doesn’t support that, it’s about allowing staff to have a conversation with the patient beforehand so it doesn’t come as big shock,” Holland says.

“On a psychiatric care unit, people are extra cautions of risk. But hearing from those with lived experience, we realised the importance of little things that staff take for granted.”

After two years, 24 of the 38 wards saw one improvement or more, and 17 saw all three types of RP fall. NHS Improvement will now evaluate the programme, and Shah hopes it can then be applied across the country.

“Every ward has been able to talk about relationships changing on the wards. There’s more trust, openness and collaboration between staff and service users. They’ve been reducing doors and locks on wards to remove psychological barriers," Shah says.

Holland hopes improvements on her ward continues.

“It’s easy to put changes aside when the ward is busy. There’s natural resistance where we haven’t got the time, resources or staffing to implement something. But we have to listen to patients. If we can improve patients’ experiences on the ward, we can improve their recovery, and it will make our jobs better, as well.”

The alternative - an understaffed ward that uses RP because there's no time to work out alternative measures - can be detrimental.

“It’s difficult working in a system that’s quick to use RP,” says Dan Warrender, former psychiatric nurse and now lecturer in mental health nursing at The Robert Gordon University in Aberdeen.

“It can be really uncomfortable for staff. I was at a stage where I couldn’t have continued to do that for too long.”

Staff need time to debrief and reflect after RP incidents, Warrender says, as RP can be traumatising, especially for patients with borderline personality disorder, who tend to be women, who’ve often been traumatised by men.

“If they’re restrained, it can be a re-traumatising event that reminds them of powerlessness they’ve experienced from rape and sexual abuse. When I was working on a psychiatric ward, we weren’t good enough at recognising or managing the trauma we inflicted," he says.

Staff also need more training, says Harding.

“When my colleagues told me a patient was just attention-seeking and manipulative, I believed them. But when we hear that something is ‘just’ anything, we’ve stopped thinking.

“It was only much later in my career that more experienced colleagues said, ‘Why would someone act like that? Maybe you’re hurt because you can’t help someone in massive distress’.

“If we don’t train students for this, they get it on the job from people who also haven’t had training in this," Harding says.

Many experts seem to agree that encouraging culture changes on wards to use alternatives to RP will require more funding for the NHS to increase staff teams and reduce waiting times.

"RP will keep happening until NHS waiting times are reduced," says St George's Mental Health Trust’s consultant psychiatrist, Mudasir Firdosi.

“There’s always a shortage of beds, so, increasingly, more unwell patients come into hospital because they’ve had a longer wait, and when they come to us they’re not in a good state, which increases the chances of having to use RP,” he says.

Wotton Lawn Hospital tries to pair newly qualified nurses with more experienced ones, so they can continue their learning. In the last three years, the hospital has seen a gradual reduction in RP, and a move towards lower level interventions instead, such as placing a hand on a patient’s shoulder and guiding them down a corridor, Dodson says.

“If you want to have a practice that moves away from RP you have to have adequate staffing and the ability to engage individuals in meaningful activity,” Dodson says. “If I was to implore the government, I’d say they need to invest in facilities and staffing if they truly want to move away from RP.”

Holland, who works in the Irwell ward, has seen firsthand that being short-staffed is one of the main reasons RP is used more than necessary.

“Everywhere is really struggling with finding a regular staff team, and inconsistencies in the team and its approach can lead to conflict with patients and staff, " she says.

“You also get a lot of new starters and newly qualified staff who don’t have the confidence or experience to implement alternative measures. It’s also about getting to know and recognising our patients as human beings.”