Potentially unlawful substitution of mental health and learning disabilities nurses in UK in-patient services – the realities on the ground

We share the concerns of our members that this substitution could compromise patient safety and quality of care and potentially violate the NMC Code, as well as legal requirements outlined in the Mental Health Act 1983 (England and Wales), Mental Health (Care and Treatment) (Scotland) Act 2003, and the Mental Health (Northern Ireland) Order 1986.

To gain further insight into this matter, we surveyed our RCN Mental Health Forum members working in in-patient mental health services across the UK, including those in the NHS and independent sectors.

The questions

1. Do you know if there are any intentions to replace mental health or learning disabilities nurses with other types of registered nurses or allied health professionals in your ward, unit, or services?
2. Have there been any shifts in the past year where NO registered mental health or learning disabilities nurses were present in your ward or unit?
3. Can you tell me how often there are NO registered mental health or learning disabilities nurses on duty in your ward or unit?
4. If there are NO mental health and learning disabilities nurses available, which registrants will be on duty instead?

Responses

We received a total of 608 responses from nurses across the UK. England (n = 465), Northern Ireland(n = 28), Scotland (n = 76), Wales (n = 45), and others (n = 9). Mental health nurse (n = 495), Learning disabilities nurse (n = 53), Adult nurse (n = 39), Children's nurse (n = 1), Student nurse (n = 22), Nursing support worker (n = 13), Other (n = 44).

Respondents reported working in a variety of settings: In-patient mental health (Adult) (n = 349), In-patient learning disabilities (Adult) (n = 52), In-patient mental health (Child and Adolescents) (n = 53), In-patient learning disabilities (Child and Adolescents) (n = 15), and Other (n = 228). Working in NHS (n = 463), independent sector (n = 114), and other areas (n = 49).

Findings

When looking at ‘other’, we received many responses from members who do not work in in-patient services, such as acute hospital trusts, the community, specialist services, and liaison and diversion. Although these responses give invaluable insight into the challenges these members face within other service areas, this report only concerns those working in or supervising in-patient mental health services. When removing these respondents, we were left with 394 members working across in-patient mental health settings (including older adult mental health).

Two-thirds of respondents said they were unaware of any intentions within their organisation or service to replace mental health or learning disabilities nurses with other types of registered nursing staff or allied health professionals. However, 34% of nurses reported knowing that such intentions exist.

Although two-thirds of respondents reported not knowing of any plans within their place of work to replace mental health or learning disabilities nurses, only 57% of respondents could confirm that they have had mental health and learning disabilities nurses on every shift over the past twelve months.

Hugley concerning, almost one-third (n = 110) of respondents said there had been shifts over the past twelve months where no registered mental health or learning disabilities nurses were present in their ward or unit. Equally worrying, over 15% of respondents seemed unaware of the type of registrant they were working with on shift, selecting the option of unsure.

It is worrisome to discover that the substitution of mental health and learning disabilities nurses with other registered (or unregistered) roles is not perceived as an uncommon event by many individuals. Only 21% of those surveyed considered it to occur rarely. Approximately 40% of respondents indicated that this substitution occurs sometimes, while almost 30% (n=44) reported that it happens often. More than 5% of respondents stated that this substitution always occurs.

It is a widespread problem across the UK that other healthcare professionals are replacing mental health and learning disabilities nurses. In England, we surveyed 290 individuals working in or overseeing in-patient services for mental health or learning disabilities and found that 34% reported there being occasions where no registered mental health or learning disabilities nurses was on their ward or unit within the last year.

Similar findings were reported in Northern Ireland (37%, n = 7), Scotland (24%, n = 12), and Wales (35%, n = 13), but none of the UK Overseas Territories (n = 1) and the Channel Islands (n = 4) respondents reported experiencing these issues.

The issue of seeing role substitution amongst mental health and learning disabilities nurses persists within the NHS (26%, n=77/301) and the independent and voluntary sectors (37%, n=38/104).

A worrying discovery has revealed that only 37% of respondents (n = 22) working in or supervising child and adolescent mental health or learning disabilities in-patient services reported shifts in the past year where there was a registered mental health or learning disabilities nurse at all times in their ward or unit. This was compared to adult mental health or learning disabilities in in-patient services, which was 67% (n = 263).

Limitations

We make every effort to ask the right questions to gather accurate information from our members. However, some individuals may interpret the questions differently than we intended. For instance, when we asked if there had been any shifts in the past year where NO registered mental health or learning disabilities nurses were present in your ward or unit, it is possible some respondents may have excluded themselves and selected yes.

However, there will always be instances when a single registered mental health or learning disabilities nurse is the only registrant on their ward at a given time (for a whole shift or temporarily). Therefore, we would have expected to have seen close to a 100% response rate for yes, but this was not the case. Additionally, out of the 110 respondents who saw the substitution in the past twelve months, 15 were not registered mental health or learning disabilities nurses.

To maintain anonymity, we did not ask for details of the organisation or region from respondents. Nor did we ask them for any identifiable information. This approach was carefully considered and the most appropriate to encourage anonymised and open reporting.

The questionnaire was sent only to RCN members and received a significant response rate. We did not link the responses to any single member to maintain anonymity. Therefore, we cannot guarantee that the responses came from only RCN members or that individuals did not submit multiple responses. Nevertheless, the breath of responses assures us this is not the case.

Conclusion

UK nurses working in mental health services have expressed concern about the replacement of mental health and learning disabilities nurses in adult, older adult, and child and adolescent in-patient services.

Along with key stakeholders, we have scrutinised the legal and professional implications of such actions if they have or were to occur and have produced a Royal College of Nursing Position Statement on the substitution of mental health nurses in in-patient mental health wards across the UK.

The RCN urges providers of in-patient mental health services to take immediate action to ensure that their workforce planning recognizes and protects the crucial role of mental health and/or learning disabilities nurses and that all healthcare professionals employed by them understand the legal requirements for detention and restraint.

We also encourage all RCN members to speak up and report (i.e. Datix) any planned or ongoing substitution of mental health and learning disabilities nurses in in-patient services.

Stephen Jones, UK Professional Lead for Mental Health
In collaboration with the RCN Mental Health Forum