Seclusion and restraint report is vague on workforce improvements.
The review of seclusion and restraint in acute mental health units and emergency departments makes no mention of vital workforce issues raised by the NSWNMA.
These include the lack of clinical nurse educators, the statewide shortage of psychiatric intensive care (PICU) beds, excessive workloads and inadequate skill mix.
Some of the review’s positive recommendations lacked substance.
For example, the review said all mental health inpatient services “must have 24-hour, everyday on-site supervision from accountable management representatives. This supervision must include in- person rounding on every shift”.
Mental health nurses point out that units attached to public hospitals may already be supervised by a person doing rounds every shift.
However, that person often has no mental health qualification and no understanding of what they are supervising.
Some nurse unit managers of acute mental health services have no mental health experience, yet are expected to understand the complex management of mental health patients and lead the nursing team effectively.
The review recommended that NSW Health develop and implement minimum standards and skill requirements for all staff working in mental health.
However, as Jack Schwartz, a veteran of 40 years mental health nursing, points out, the review does not say what those minimum standards should be.
Seclusion is already a last resort
Jack is president of the Coffs Harbour mental health branch of the NSWNMA and delegate to the union’s mental health reference group.
“The inquiry did not sufficiently recognise the implications of a lack of qualifications, training, and experience,” he says.
“On my unit fewer than half of the nurses working have been trained in prevention and management of aggression, or sensory modulation, and de-escalation techniques.
“No one likes to seclude anyone – if only because of all the paperwork involved.
“If someone is secluded it is pretty much done as a last resort.
“The ministry wants trauma-informed care but nurses working in mental health often do not have the expertise in counselling to do this appropriately.
“The review fails to recognise that 80 per cent or more of nurses in mental health units are not psychiatrically trained and therefore don’t know how to deal with a lot of behavioural problems.
“The health system did away with psychiatry as a nursing specialty because general nurses were paid less.
“NSW Health does not train mental health nurses any more. They train List A nurses who may later gain a mental health endorsement.
“By then they are already working in a mental health ward and are usually not equipped with the knowledge they need.
“Often they don’t have the experience and skills to cope without the need for seclusion.
“Because of this lack of training they often take the easy way out of situations, which creates problems for nurses who stick to protocols.”
Use of unskilled staff is problematic
Jack says the use of enrolled nurses and assistants in nursing has added to the problems facing RNs.
“AiNs are unregulated and have minimal training; they have no skills to complete a mental health assessment and therefore cannot do a risk assessment of the patient.
“This puts the patient and the AiN at risk. It robs the patient of the quality of care that an RN, can provide and creates more work for the RN who has to closely supervise the AiN.
“This takes away valuable time that the RN should be spending with their own patients. AiNs have a place in health, but not in acute mental health.”
Smoke-free policy puts patients and staff at risk
The inquiry called for “an immediate reinvigoration” of the implementation of the NSW Health smoke-free policy, “which includes increasing the knowledge and use of nicotine replacement therapy”.
However, Jack says patient reaction to the policy has put patients and staff at risk while funding for nicotine replacement has declined.
“Easily half our ‘aggro’ happens because we don’t allow people to smoke. As far as most patients are concerned, nicotine replacement is not the same.
“Cigarettes get smuggled in and problems arise when we have to take away their lighters and cigarettes. No matter how we try to stop patients from smoking they will find a way to smoke.
“The review report was obviously written by people who don’t actually work in a mental health unit and are taking a pie-in-the-sky view of things.
“For example, they recommend a staff member sit outside the seclusion window and monitor the patient visually for at least an hour immediately following seclusion.
“If you put someone in there because they have just attempted to assault you and your fellow workers, that patient is irate as can be.
“Now you are going to stare at them through a window for an hour? That would just be a red rag to a bull.
“The abuse you would get for that hour would give you post-traumatic stress.
“It is a ridiculous suggestion.”
The review says all mental health units should have “a multidisciplinary team with the skills to deliver a therapeutic program and environment on an extended-hours basis”.
However, budget constraints have eroded day programs and evening programs in mental health facilities.
The review was critical of nurses having to make decisions about seclusion “with limited external scrutiny”.
Jack says the nurse often knows more about the patient’s mental and physical state than the on-call psychiatrist.
If the ministry wants more supervision of nurses it must employ more resident psychiatrists and resident psychologists, he adds
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