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Some Ethical Practice Reflections onPsychiatric Inpatient CareMalcolm Kinney, Carol Gore & Jennifer BarnardPublished online: 07 Dec 2013.

To cite this article: Malcolm Kinney, Carol Gore & Jennifer Barnard (2013) Some EthicalPractice Reflections on Psychiatric Inpatient Care, Ethics and Social Welfare, 7:4, 423-431, DOI:10.1080/17496535.2013.852341

To link to this article: http://dx.doi.org/10.1080/17496535.2013.852341

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Some Ethical Practice Reflections onPsychiatric Inpatient Care

Malcolm Kinney, Carol Gore andJennifer Barnard

This article will add to the continuing weight of evidence that demonstratesthat the nature of mental health inpatient care in the UK, provided to people inacute mental distress, is often disturbingly inadequate and that the ability towhistle blow in these institutions remains very difficult. To this research andjournalistic undercover documentaries we add the power of personal narrativeand professional reflection.

Keywords: Mental Health; Mental Distress; Inpatient Care; Whistle Blowing;Social Work; Student; Institutionalisation; Narratives

Introduction

This paper will reflect upon the practice experience, of a social work student(Jen), her practice educator (Carol) and academic tutor (Malcolm), whilst on aplacement in a psychiatric in patient unit in the North West of England. Threestudents started on different wards; unfortunately Jen was the only studentwilling to write up her reflections. The verbal feedback from the other twostudents was largely consistent with Jen’s experiences.

The use of narratives to explore key issues in social work practice is muchunder-used and under-valued (Kohler Riesman & Quinney 2005). Here we havemuch to learn from Hornstein (2009) and Stastny and Lehmann (2007) who usemultiple international narratives of services users and practitioners. Thesereflections are very much in this tradition and add to the growing body ofevidence that firstly questions the efficacy of medically dominated mentalhealth institutions, and secondly the significant power within these institutionswhich can stifle dissenting voices.

The students were given a specific specialist induction and support for thisplacement by the tutor and practice teacher. This, however, proved woefullyinadequate and they all, to varying degrees, suffered significant distress as result

Malcolm Kinney, Senior Lecturer in Social Work and Mental Health, Centre for Social Work, LiverpoolJohn Moores University. Carol Gore, Social Worker and Practice Educator. Jennifer Barnard, Newlyqualified Social Worker. Correspondence to: Malcolm Kinney, Tithebarn Building 79, Tithebarn Street,Liverpool, L2 2ER, UK. Email: m.kinney@ijmu.ac.uk

Ethics and Social Welfare, 2013Vol. 7, No. 4, 423–431, http://dx.doi.org/10.1080/17496535.2013.852341

© 2013 Taylor & Francis

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of what they experienced. It should be emphasised that these were all very goodfinal-year students and were picked because of their abilities and passion formental health. This was an attempt by the tutor to introduce social workpractice back onto psychiatric wards. This could be considered, with the benefitof hindsight, a naïve attempt to introduce social work students (who have anovertly critical social model perspective) onto psychiatric wards and from this,start a process which would hopefully result in a more balanced professionalward culture. The hospital fully engaged with this idea and at a highermanagerial level gave full backing to it. Unfortunately this was not alwaysshared by others in the institution and culminated in a very difficult journey forthe students.

The very concerning issues raised in this paper will be familiar to aninternational audience whose mental health systems are psychiatrically domi-nated, and correlates with the inherent oppressive issues of vested powerinterests which underpin the medical model of mental health (Stastny &Lehmann 2007). It will start with a brief background to the initiative, followedby key reflections of Jen. In the final section the academic tutor Malcolm, andCarol the practice educator, will critically evaluate the key themes raised by Jenand how structurally these problems, within current service configurations, seemto be almost unsolvable.

Back Ground–Malcolm

In the UK, especially since the Introduction of the 1990 Community Care Act,social work has largely been excluded from the daily life of psychiatric inpatientunits (Ramon 1992). My own motivations for attempting to tentatively reintro-duce social workers back onto the wards was informed by my own practice ethicalmusings (Kinney 2009), very distressing family experiences of ward culture, mycontinuing work with service user groups (who provide a lot of mainly negativeperspectives on ward life) and the plethora of damning reports and writing onthese issues (Walton 2000; Mental Health Act Commission 2009). The oftenoppressive nature of this work environment was an immense challenge to thestudents and they almost left on several occasions.

Walton (2000) detailed the mainly negative experiences of Approved SocialWork students (now Approved Mental Health Professionals) observations of acutepsychiatric units. I was one of those students. The article was largely a criticalaccount of the inpatient services rooted in the historic inadequacies of themedical model and institutionalised poor practice. Walton (2000) developedthe view that despite seemingly more modern approaches to mental healthcare the essence of service delivery cannot change substantially for the betteruntil the premise upon which we base mental health services is re-evaluated andchanged. She was not saying anything particularly new here, but her research didreinforce similar critical perspectives. Our students spent much more time onthe wards than the ASW’s in Walton’s study, but the picture they painted was

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distressingly familiar. It almost seemed that we had placed them in a drama (attimes for them it felt more like a nightmare) similar to Ken Kesey’s (1962)wonderful fictitious depiction of an American psychiatric institution in the1960’s. It is not difficult to draw out the parallels in this and the moreacademically pertinent theories of institutionalisation (Goffman 1961).

In the UK, more recently, the issues of poor practice have continued to behighlighted via several research and social policy initiatives (Mental Health ActCommission 1999) and most graphically via an expose of three inpatient units bythe channel 4 Dispatches programme (2006). The reflections of Jen and Carol inmany ways reinforce, in very explicit and emotional ways, the continuingoppressive culture of psychiatric in-patient care. Also and very importantly thefeelings of powerlessness to object to the poor practice observed means thatmeaningful change becomes very difficult to achieve.

The student, tutor and practice educator reflections are descriptions oftheir direct practice experiences and are not, nor were ever intended to be, apiece of planned research. However, unintentional connections to participantobservation research are hard to ignore, although this could be applied to allstudents’ reflective placement experiences. I cannot thank the students andpractice educator enough for what was a brave determined approach tointroduce social work practice into a difficult organisational context. I knowtheir involvement at a very minimum positively affected the care received byseveral patients. They did something that seems to be quite difficult on suchwards: they treated everyone as an individual and enjoyed their company.

Getting this paper to publication has itself highlighted many of the issuesrelated to open and honest critical reflection. Jen and Carol have been very waryof identifying themselves as contributors as they fear it may impact on theircareer prospects. These issues will be explored in more detail in the final sectionof this paper.

The Experiences of Jen the Student

My arrival on an Acute Psychiatric ward was neither welcoming nor professional.After introducing myself, asking questions regarding where I went, did I sign inetc were all ignored for approximately 2 hours, before someone queried whyI was ‘hanging around the ward’. The staff nurses were too busy to show mearound and no one knew what to do with a student social worker on ‘their’ ward.The Nursing Assistants did not appreciate my presence and from day one andisolated me from themselves and others. I thought this may be a generalprejudice against students, or them feeling they did not have the time (whichthey seemed to have plenty of) or maybe a lack of inclination to involve studentsin the working life of the ward. However, after a couple of weeks of seeingmedical and nursing students being treated in a professional manner and theconstant jibes about how a ward was no place for a social worker, it becameevident that it was not my student status but more about my choice of career.

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I eventually gave up trying to build a working relationship with the staff on theward and spent nearly all my time building relationships with the patients andadvocating for them in the Multi-Disciplinary Team meetings. This was met withmore hostility from the staff, expressing that they felt it was inappropriate of meto talk to patients unless it was a formal review. I very rarely witnessed patientshave a review on the ward, service users only seemed to meet with their namednurse during ward rounds or when there was an upcoming tribunal. NursingAssistants (not all, but the majority) walked around the ward like prison officersworking with dangerous hardened criminals, rather than health care workerscaring for people with severe and enduring mental distress. I witnessed on almosta daily basis a Nursing Assistant engaging in arguments with service usersregarding trivial matters such as, soap or choice of food. If a service user wishedto talk about their illness they were dismissed and instructed to discuss this withtheir psychiatrist at the next ward round.

The only time Nursing Assistants seemed in any way animated was when therewas an incident on the ward. For example I witnessed a young man who sufferedparanoid delusions, which kept him awake for several nights He seemed irritable(no surprise after such sleep deprivation) and refused to talk to any of thestaff, and was responding to what seemed to be auditory hallucinations. Nobodyseemed to try and develop any sort of therapeutic relationship with him and thisseemed to add to his paranoia. No kind caring words – in fact often quite theopposite. Eventually a doctor was called to give the service user an acuphaseinjection, which partially sedated him. It seemed like he was being punished nothelped. When the doctor arrived to authorise the injection, the air was electricwith the Nursing Assistants grouped together gossiping like excited teenagers.I felt sick to my stomach as this was the only time I had seen the staff becomepassionate about their work. The acuphase did not sedate the service user, onlyslowing him down which unnerved the ward staff. They did not seem to knowof any other methods of helping him other than medication. Because of theperceived high risk he was transferred to the local Psychiatric Intensive CareUnit. Again, the staff were buzzing with excitement as the police arrived andhandcuffed the service user to transfer him. Again, I felt awful watching thisyoung man being handcuffed and taken away, because he was ill and did notrespond to medication and the staff did not have the skills to help him.

I had seen many such incidents of concern and poor practice every day on theward, with daily life being an array of what and how they can punish the serviceusers. The abuse of power, prejudices and discrimination carried out by a lot ofNursing Assistants was quite startling. Many of the service users were describedas not deserving a service, because ‘he’ll just get ill again anyway’, with nomethods or suggestions about how to prevent this happening. In contrast to thisthe Occupational Therapy department, although massively underfunded, did thebest and most humane work in the whole place. Credit is definitely due to theseoverworked staff members, who were creative and dedicated to the work theydid. It begs the question – why not let the Occupational Therapists run thewards?

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A major problem for service users was the disconnection between ward lifeand what happens after this. A plethora of teams exist to help people after theyare discharged, but all work in different ways and only interact with the serviceuser in a very ad hoc fashion. The system is disjointed, complex and veryfocussed on the medical needs of the patient. Everything in the ward roundsappeared to be to get the person to accept the label given to them and complywith the medication supplied. Very little, if any, alternative social modelthinking was expressed. Much of this I believe to be a consequence of theinadequate training of the staff involved. For me as a student social worker I washorrified at the lack of discussion of the key issues of oppression suffered bypatients and how this may have contributed to their distress. Nobody seemed tounderstand the concept of Anti Oppressive Practice and the social workers whocame onto the ward did not seem to have the power or confidence to advocatefor something different.

The ward itself was in, despite the majority of patients being informal, whatfelt like a secure hospital. Lots and lots of locked doors! It felt like a place wherepatients are put to be kept out the way of the community and not much furtherdifferent than the days of asylums. It was a bit like being trapped in an historicalhorror movie. Massive structural change is required as we cannot carry ontreating people like this.

Throughout my time on the ward, support from my practise assessor was thekey to my survival. On a daily basis I was battling with my own ethics andmorality from witnessing such poor practice. Theoretically I felt strongly towardsthe Kantian theory of Deontology (Kant 1964). This approach informs us that theactions I was witnessing were wrong and I therefore had a duty to take actionregardless of the consequences (Reamer 1990). However, the shortcomings ofthis theory became very evident to me throughout my practice. Researchers suchas Clarke and Asquith (1985) and Beauchamp and Childress (1994) have describedhow one’s duty conflicts with that of their own interests and the interests ofothers and that moral rules are not universal. Although, my duty to do somethingabout what was happening was as strong as ever, this conflicted with my owninterests to finish placement and qualify. The possible consequences of making acomplaint were to fail the placement and potential significant detrimentaleffects on my future employability. Also, the majority of staff on the wardsI believe held very different concepts to how inpatient care was given and theirpractice did not conflict with any ethical values they held. I was definitely theproverbial fish out of the water. However, I felt the overriding reason for nottaking action was a constant and rising feeling of powerlessness. The attemptsI did make to incorporate the service user’s more holistic needs on the wardswere often written off. Psychiatrist’s words were seen as law and visiting socialworkers were largely seen as a nuisance and often mocked (usually after theyhad left). This was about power and I had very little of it.

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Malcolm and Carol—Reflections/Conclusions

Drawing out key themes from these experiences is not easy as there is aninteresting interplay between the everyday micro issues of the student place-ment and how these could be addressed and the macro, seemingly everpresent, institutionalised nature of oppression. In this section, we will focusour reflections on the continuing problems of whistle blowing and the oftennegative experiences of people who suffer from mental distress when they are oninpatient wards

Carol was primarily focused on how to help the students manage a difficultplacement experience and contextualise this as an exciting learning opportunity.Her role is informed by many years of hardened experience and she is thereforemuch more philosophical about the problems faced by the students. In manyways these are vital elements of learning which with positive critical reflectionwill contribute to professional development. However did some of the concernsraised by the students go beyond what could be considered acceptable? Thestudent’s experiences were continually discussed and reflected upon in supervi-sion. So why given the many examples of very poor practice did the studentsdid not make a formal complaint? As Jen stated this was primarily related toher position as a student and therefore feeling relatively powerless. This wasexacerbated by being placed in a non social work setting. What all the studentsdid was to find a place to work which was ethically comfortable for them.This tended to be outside of the professional arena and within the places whereservices users congregated. The students also felt that this was a new initiativewhich could be jeopardised if they made too many complaints. They also knew(from the preparatory sessions before placement commenced) that such issueswere not confined to these wards, but were possibly the accepted norm acrossthe country. The question does, however, come back to how bad things need tobe before a complaint is made?

The problems of whistle blowing in social care culture are not new or confinedto mental health (GSCC 2009). The dangers of challenging poor practice can bevery damaging to the whistle blower (Davies 2009) and although legal stepshave been taken via the Public Interest Disclosure Act 1999 (Direct Gov 2010)the cultural determinants which often mitigate against complaining appear toremain very strongly in place. These issues in the UK have again become veryhigh profile following the recent media expose of significant abuse of individualsin a nursing home for people with learning difficulties (http://www.bbc.co.uk/news/uk-13611089). This home would have had a whole shelf of policies andprocedures, just like the ward Jen was on, designed to stop such incidents andfacilitate complaints and whistle blowing. Jen spoke about her feelings ofpowerlessness and a staff group which did not blow the whistle because it did notactually see the poor everyday clinical practice. What was unethical to her wasthe accepted practice of ward staff. This is a continuing problem and it wouldappear that the only time we publicly reflect on the ethical nature of social careis following media exposure.

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It is interesting that this health trust has won awards for including serviceusers in all aspects of its managerial culture, including staff recruitment,research and patient advocacy. They are on many levels concerned with thepatient experience. Unfortunately they, like many other institutions, are definedby a theoretical approach which often means they literally cannot see thefundamental problems in front of them and will therefore continue to struggle tohelp people who are in mental health crises. Jen and the other students wereobserving what was happening through the lens we as academics had given themi.e. anti-oppressive practice. Nurse students worked from more medicallyfocussed perspectives and as Jen pointed did not therefore have the same levelof ethical sensitivity. I can fully empathise with this (Kinney 2009) as the positionof social work, potentially advocating of the social model in services dominatedby pathological approaches to practice, may be at best marginal and at worstcomplicit with significant oppressive practice (McLaughlin 2008). On a morepositive note some health trusts in the UK are opening themselves up to criticalexamination and some positive changes are taking place. Unfortunately progressremains very slow.

Another very emotive element of Jen’s writing was her description of thepetty rules and regulations (formal and informal) on the wards and the lack ofappropriate training given to staff. In this context the staff’s ability to engagepatients in any form of meaningful therapeutic relationship was very difficult.What she describes is classic institutionalisation (Goffman 1961). He describespatients being stripped of all vestiges of individuality and having it replaced witha label over which the patient has little or no control. This is not confined topatients and Jen also felt the pressure of institutionalisation and acknowledgedthe acute dangers of such submersion. Tolerating negative oppressive practice,without taking action, can lead to it becoming normalised and eventuallypossibly a part of our own practice. Also the recourse to chemical restraint for‘rule breakers’, as she so rightly points out, has strong historically definedcorrelations to the use of coercion as a form of cure (Szaszm 2007). Herconclusion is that we require a massive structural change to mental healthservices. Many service users and critical thinkers would whole heartedly agreewith this (Stastny & Lehmann 2007; Hornstein 2009). Carol was invaluable here inusing critical reflection to help the students focus on the positives especially interms of their own progression and the work they were able to do withindividuals. The bigger issues are ideologically defined and relate to a muchlonger term struggle to incorporate the social model into mental health serviceprovision. As social workers we can be part of this struggle by allying ourselves togroups who advocate for such positive change. It should, however, be noted thatsocial/recovery model rhetoric is strongly incorporated in much of contemporarysocial policy (DOH 2009). Unfortunately the translation of this to genuineempowering in patient services appears to be very difficult to achieve. All threestudents felt marginalised oppressed and struggled to engage with the wardculture. Interestingly it was the patients they most enjoyed working with and itwas they who helped them survive. It would appear that Walton’s (2000)

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reflections that the more things change the more they remain the samecontinues to have strong resonances in today’s mental health culture.

These are complex problems with no easy answers, as demonstrated by thecontinuing enquiries into abusive institutional practice. In conclusion it wouldappear that two key issues need to be addressed to minimise the often abusivenature of institutional care. Firstly the need for a clear expression of the valueswhich underpin the organisation and how these are translated into staffrecruitment and training. Secondly an organisational culture which has built inaccountability which is reflected in continual self-critical reflection and supportedby meaningful independent advocacy arrangements for patients/residents.

All the students demonstrated great resilience and despite great challengesbenefitted from this practice experience. The role of Carol in providing goodcreative critical reflective supervision was invaluable.

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Direct Gov (2009) Available on: http://www.direct.gov.uk/en/Employment/ResolvingWorkplaceDisputes/Whistleblowingintheworkplace/DG_10026552 [13 May 2013].

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