Analysis

Do nurses know how to use the Mental Health Act?

Illustration of nurses thinking

Care Quality Commission finds legislation is not used as intended due to lack of staff awareness

  • RCN says nurses need time to learn how to advocate for service users
  • Concerns over lack of understanding when applying Mental Health Act Code of Practice
  • Some healthcare providers have not yet updated training to reflect 2015 code

Mental health nurses in England must be given more time for training in the use of the Mental Health Act (MHA) 1983 if they are to advocate effectively for people under their care, warns the RCN.

Under the act, people may be formally detained in hospital in the interests of their own health or safety, or for the protection of other people.

They can also be treated in the community, but are subject to recall to hospital for assessment, treatment or

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Care Quality Commission finds legislation is not used as intended due to lack of staff awareness

  • RCN says nurses need time to learn how to advocate for service users
  • Concerns over lack of understanding when applying Mental Health Act Code of Practice
  • Some healthcare providers have not yet updated training to reflect 2015 code
Illustration of nurses thinking
Picture: iStock

Mental health nurses in England must be given more time for training in the use of the Mental Health Act (MHA) 1983 if they are to advocate effectively for people under their care, warns the RCN.

Under the act, people may be formally detained in hospital in the interests of their own health or safety, or for the protection of other people.

They can also be treated in the community, but are subject to recall to hospital for assessment, treatment or both under a community treatment order.

However, a recent review by the Care Quality Commission (CQC) of the MHA Code of Practice found that the legislation is not being used as intended due to a lack of awareness and understanding of the statutory guidance among providers.

The code of practice helps nursing professionals and others to interpret and apply the MHA to decision-making in day-to-day practice, and to provide safeguards for involving and protecting people using mental health services.

It also includes guiding principles that should always be considered when decisions are being made about care, support or treatment in services that detain patients under the MHA.

Applying the principles of the code

The CQC review, requested by the Department of Health and Social Care (DHSC), found that providers lack understanding about how to promote, apply and report on the guiding principles in the code, which was last updated in 2015.

1983

The year the Mental Health Act became law in England

The watchdog also found that providers do not support staff well enough for them to have meaningful and productive conversations with patients.

Two of the key recommendations made following the review are that the DHSC should:

  • Develop standardised resources, support and training for patients, carers and staff so that they understand how the code applies to individuals, practice, services and local partnerships.
  • Improve the usability of, and access to, the code, making it digitally accessible and taking into account how it is intended to be used in practical situations involving patients and their care teams.

The review found some good practice in staff training in the code, but its size and breadth make it difficult to plan and deliver such training effectively.

‘Shortages are so severe that nurses even encounter difficulty attending Mental Health Act tribunal appeals’

Catherine Gamble, RCN professional lead for mental health

Furthermore, some providers had not yet updated their training to reflect the 2015 update.

Shortages leave units understaffed

RCN professional lead for mental health Catherine Gamble says widespread staff shortages mean nurses are not released for regular training because units cannot cope without them.

49,551

new detentions under the Mental Health Act 1983 were recorded in 2017-18

Source: NHS Digital

‘As this review outlines, it’s important that mental health nurses are afforded the time to keep up to date with legislation, such as the role of approved or responsible clinicians.

‘Shortages are so severe that nurses even encounter difficulty attending MHA tribunal appeals.’

Ms Gamble highlights that the MHA does not emphasise the importance of education in topics such as human rights and mental capacity.

‘As a result, nurses working in different parts of England receive training of varying quality,’ she says.


RCN professional lead Catherine Gamble

‘Not training nurses properly means they underuse their holding powers, where they exist, and cannot be effective advocates for people in their care.

‘Mental health nurses form the largest professional group in mental health services, and their expertise in accessing and supporting diverse and hard-to-reach communities is under-utilised.’

Meaningful engagement

Other CQC review recommendations include promoting the use of the guiding principles to improve practice, and to enable meaningful engagement with families and carers, and making sure that the code gives clear and consistent guidance on providers’ governance arrangements.

‘Being under a section of the MHA should not exclude the good use of the code of practice and especially the guiding principles’

Keith Ford, Northumbria University programme lead for mental health nursing 

The CQC looked at a sample of 40 reports in which MHA reviewers raised concerns with providers about the involvement of patients, carers and relatives in decisions about their care and treatment.

more detentions in the 18-34 than in the 50-64 age group

In about half of these reports, providers said they would carry out audits and reviews, and seek feedback from patients and staff to address the lack of involvement. However, of the 40 cases in the sample, only ten providers identified a need for further staff training and development.

The review says training and development is essential for staff, ‘to give them the skills and knowledge they need to be able to engage effectively with patients, and involve them in decisions about their care and treatment’.

‘Providers need to consider how they support staff to have meaningful and productive conversations with patients, so that they better understand individual patients’ goals, and how patients can use their qualities and strengths to take ownership of their recovery.’

Role of the service user in recovery

Northumbria University programme lead for mental health nursing and senior lecturer Keith Ford says it is a concern to hear of such variation in practice.

Dr Ford says: ‘Obviously in nurse education, we are always advocating the role that the service user can play in recovery.

‘Being under a section of the MHA should not exclude the good use of the code of practice and especially the guiding principles.

‘We try to get that across to our student nurses.’

He adds that, following use of the MHA, a debrief, articulation of what protocols are in use and good communication with the service user could help lessen distress.

A DHSC spokesperson says the CQC review was requested to clarify how the code of practice was being used and to find opportunities for improvement.

She says: ‘We will factor their findings into our ongoing work to improve mental health services.’

History of the code of practice

  • 1993 – covers: assessment; admission in hospital; guardianship; treatment and care in hospital; leaving hospital; and standards for people with a learning disability, and children and young people under the age of 18 (135 pages)
  • 1999 – includes guiding principles and reflects changes in law and policy (115 pages)
  • 2008 – contains guidance relating to the Mental Capacity Act (2005) and Human Rights Act (1998), as well as developments in law, policy and practice (394 pages)
  • 2015 – now with new sections on the role of the Care Quality Commission, complaints and commissioning, and guidance to reflect and embed developments in areas including restrictive interventions, seclusion, use of police powers and use of community treatment orders (459 pages)

The five guiding principles in the Code of Practice

When the new code was published in April 2015, providers were asked to ensure they were applying it and its guiding principles by October of that year. These principles are:

  • Give treatment in the least restrictive way and help people to be as independent as possible
  • Empower and involve patients
  • Respect patients, families and carers
  • Help people get well
  • Make fair and efficient decisions

Further information

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