Unwritten blanket rules on inpatient mental health wards

I am working on the Mental Health Safety Improvement Programme, a national programme focussed on reducing the use of restrictive practice on inpatient mental health wards.

I work with 14 wards across the North West Coast, and through coaching sessions we examine potential causes of incidents requiring restrictive practice and devise change ideas to test. Our aim is to reduce the frequency of these incidents and the use of restrictive practice, leading to a better ward environment for patients and staff.

One theme that keeps coming up is that of unwritten blanket rules. Those rules that have seemingly been around forever and nobody knows why they started but everyone adheres to them because they’re so embedded. Some of these rules can lead to an increase in violent or aggressive incidents as patients are understandably frustrated when told that they can’t have a hot drink after 8pm or that the TV must go off at 10pm, with no logical explanation.

Being overly risk-averse is a major factor in the creation of unwritten blanket rules. Of course, it is important to consider possible risks, however each patient should have their own individual risk assessment conducted so that they are supported in the least restrictive way possible according to their needs.

One older people’s ward has a bespoke, dementia-friendly garden that was quite costly, however after a patient unfortunately had a fall, access to this garden was completely stopped for all patients, with the door being closed and locked at all times even during summer. It remained this way for around 18 months and was soon thought of as ‘normal’ until a new ward manager came into post and questioned the logic behind this decision.

On acute wards there are often blanket rules around self-harm risks, for example on admission all patients have items such as headphones and phone chargers removed from their possession even if they have no history of ligaturing. This sort of rule causes frustration and anxiety, both of which can escalate to violent or aggressive outbursts.

Staff are also affected by these rules as tensions can arise when they question the reasoning behind them. As unwritten rules are not official policy, people act differently on them which leads to inconsistent care for patients and again, this leads to them becoming unsettled and can potentially result in incidents occurring that require the use of physical restraint, seclusion or rapid tranquilisation.

I am encouraging wards to use an ‘unwritten rules box’ in their offices or staff rooms so that staff can anonymously put forward unwritten rules that need to be reviewed. I also speak to patients to gain their perspectives and see whether they have any rules that they would like to raise for discussion. Suggestions are then taken to staff and community meetings and it is decided whether to ‘keep, tweak or bin’ each rule.

It is hoped that by talking about these blanket rules and examining whether they are really necessary, we will reduce the number of incidents that arise from frustration and therefore also reduce the use of restrictive practices used on the wards.

Heather Morrison

Innovation Agency Mental Health Project Manager

@HeatherNWC