Chapter 9: Madness and the law

Case Study: The acute ward

Jon is a newly qualified mental health nurse working on an inner city acute ward. The doors are routinely locked and levels of conflict on the ward are high, with frequent recourse to use of physical restraint. Jon is disappointed at the small amount of time he finds he has for talking with service users. This is the part of the job he likes the most but it always seems to be squeezed out by the demands of paperwork, giving out medication or attending meetings of one form or other. Sometimes, Jon feels he spends more time administering the system and recording risks than actually doing anything tangible about them. The atmosphere on the ward is often tense, rather than therapeutic and staffing levels are always stretched, with high numbers of bank and agency staff. It is difficult to feel a proper sense of being in a team.

One sectioned patient is cooperative most of the time, and is even grateful for some aspects of being detained on the ward, as he says this is a form of respite from the stresses of his life. He is occasionally paranoid, but quite often lucid too. When he is most anxious he can get hostile and aggressive. The only thing he will not cooperate with is medication. The care team want him to take oral medication which he has refused up to now. He has been informed that if he continues to refuse then he will be injected with depot medication. The team have discussed how they will do this and plan to use physical restraint in a few days to give the injection unless he begins to comply with the oral medication. Jon has a number of misgivings about this approach. He feels that the intention to forcibly inject is being rushed, and may not be justified given the general level of cooperation with this patient, which could form the basis for a different approach, perhaps CBT. He also is vexed by the contradiction with other ward policy, which states that the use of physical restraint should be a last resort.

How should Jon proceed in his discussions with the team? What factors are important in these discussions?

› Possible answer

Jon’s views are compatible with a compassionate, person-centred care approach. He is correct to point out the contradictions with last resort policies. There is a risk here of actually causing more conflict and perhaps violent exchanges. At the very least, there is a real risk of spoiling the trust and cooperation that already exists. When patients are cooperative but refuse some aspects of psychiatric care, we would be better advised to explore the reasoning behind a lack of concordance, in this case medication refusal.

The ward appears to exist in a state of constrained resources, not least staffing. We also know that modern services attempt to limit inpatient stays. The relative urgency in the plan to impose depot medication may be part of these trends, but neglects a long-term appreciation of how to achieve consensual concordance. An interesting observation about planned restraint when agency staff numbers are high is that the people doing the restraining may not be present into the future, leaving others to pick up the pieces of spoilt relationships. Jon’s instinct for a psychosocial alternative fits with wider criticisms of a lack of a range of non-medical alternative treatments in the system as a whole.