To be a ward-based psyche nurse, you need a really good grasp of the Mental Health Act. Ward-based nurses are the only ones who actually have the power to section patients, though only for 6 hours until a doctor can arrive. I’ll just explain a little about the Mental Health Act to give some context.
So the MHA is a really long and complicated legal act that specifies which people can be detained in hospital and other places, for how long and in what circumstances. It’s made up of lots of ‘sections’, and when one of these sections is applied to someone, they’re colloquially referred to as ‘sectioned’. Not all the sections are relevant to ward-based psyche nurses. Some give police the power to enter someone’s home and assess their mental state. Some apply to patients in the criminal justice system. Generally the ones nurses like myself would deal with are sections 2, 3, 4, 5(2) and 5(4). I won’t go into the boring details of what each section involves, they’re all just sections that are regularly used in hospital.
Other than generally knowing this stuff in detail, psyche nurses are the ones responsible for scrutinising and accepting the legal documents involved in sectioning someone. It’s our job to check all the paperwork is correct and identify any errors. Nurses are also responsible for informing patients of their rights, and ensuring they get access to legal advice, advocacy and the complaints procedure. And it’s also our job to ensure the doctors keep up-to-date with certain forms that need to be completed and reviews that should be done.
Then there’s section 5(4) which is the nurse’s holding power, as I’ve already mentioned. I’ve only had to use it once in my career. If a voluntary patient wants to leave and a nurse has concerns about their safety and wellbeing, but the patient is not willing to wait to see a doctor, the nurse can legally detain the patient for up to 6 hours until a doctor can arrive to assess them. (Usually patients are willing to wait). Basically, once you’ve assessed the patient you inform them of your intention to detain them, explain their rights to them, and then complete an official document. Once the doctor has arrived, you would interview the patient together, discuss what the action should be, and the doctor will decide whether to let them leave or detain them under section 5(2) (the former rarely happens!). It will quite often be the case that you’ll disagree with the doctor about whether or not detention is appropriate – junior doctors are extremely reluctant to allow patients to leave, regardless of what the opinion of the nurses is. I’ve literally had to argue with a doctor before, demanding an appropriate reason for detention if I’m to accept the section, when they didn’t want the patient to leave ‘just because’. It’s our job to advocate for the patients and to uphold the legalities of the MHA.
Once someone is detained under section 2 or 3, the long-term detention sections, they have the right to an appeal. They can complete forms, with a nurse’s assistance, applying first to a Tribunal and then to the hospital managers. The nurse is responsible for ensuring the patient gets access to a solicitor to represent them at the hearing/s and an advocate if they wish. Once the appeal forms have been submitted, the primary nurse for the patient will be required to write a report about the patient’s progress and presentation, and scrutinise all of the case-notes since admission to check for third-party information and things that should not be revealed to the patient and solicitor (as the solicitor will be reading the case-notes in preparation for the appeal hearing/s).
The appeal hearings themselves are really stressful, and no one enjoys doing them. They’re legal meetings, similar to an official court, that take place in the ward meeting room. A judge will lead the hearing and the solicitor scrutinises your evidence. Fortunately they’re not something that happen often: most hospital patients aren’t detained, and not all detained patients choose to appeal. On the ward I worked on there would maybe be 2-3 hearings per month, and with a large team of nurses, the chance of you being the allocated nurse to attend was small. I think I’ve probably only been in about 6 hearings in my career.
The nurse’s role in a Tribunal (I’ll just call them both Tribunals, as they’re basically the same thing, just with different people hearing them) is the same as the Consultant’s and social worker’s. We all have to present our case for whether or not the section is appropriate and should be upheld. The hearing panel will first speak to the Consultant, who will state why the patient has been detained and should remain detained. The panel members will ask the doctor to defend their decision, scrutinising their evidence and questioning their reasoning. Then the solicitor will pull apart their argument. Then it’s the social worker’s turn, and then your turn. Some panels are nice and will go easy on you, asking simple questions about what the opinion of the nurses is and whether you agree with the Consultant (you don’t have to!). But others will ask difficult questions, put you on the spot, and occasionally ask you questions that are not really appropriate, such as asking you to speculate on what might happen in the future. I’ve had to be quite firm before in stating that’s not for me to say, receiving harsh criticism from the judge. Then the solicitor will pull apart all you’ve said, asking you to back up your statements. It’s hard work!
Once the panel has heard the evidence, they deliberate and announce the decision. They may choose to uphold the section, and might offer strong suggestions to the Consultant, or they may choose to remove the section and allow the patient to leave. It’s the nurse’s job to receive this decision (the Consultant and social worker don’t have to stay for the decision), and take the patient back to the ward.
Tribunal’s can drag on, sometimes lasting for over 2 hours. But they’re an important part of the job and important in upholding the rights of patients.
Next time I’ll discuss medication.