4. Nursing Children and Young People in Specialist CAMHS Inpatient Settings
Inpatient care for children and young people is defined as a specialist service (NHS England 2018). Many chapters about care for children and young people in other such services such as cancer, cardiac or respiratory provision begin with a clear summary of what they are, why they exist and who they are for. It is almost impossible to apply this formula in a chapter about inpatient CAMHS. First of all, relatively little is written about hospital admission for children and young people with mental health problems, and much of that is based on anecdote and opinion rather than on robust evidence. The research base for the efficacy of inpatient treatment is limited for most, if not all, mental disorders affecting children and young people (Cotgrove 2013).
Secondly, historical accounts vary widely and are often contradictory. Many are steeped in the discourse of psychiatry, psychology or sociology, and parochial differences play out which can become a distraction from the debate about the role and purpose of inpatient units (see Cottrell and Kraam 2005; Williams and Kerfoot 2005). Differences in philosophy and language between agencies and the professions have sometimes made multidisciplinary and multi-agency working difficult (Wolpert et al. 2014), which in turn has limited the quality and breadth of the evidence.
Thirdly, UK national policy on which to guide commissioners, providers and professionals in relation to care in the inpatient setting has been haphazard and lacking in ambition rather than strategy for over two decades (see House of Commons Health Committee 1997; Department of Health 2014; National Audit Office 2018; House of Commons Library 2019). The debate about what to do to help young people in mental health crisis has almost exclusively been about beds or the perceived lack of these (Hillen and Szaniecki 2010; Myers et al. 2018). Future in Mind is the latest of several long-term policies that aim to improve mental health outcomes for children and young people (Department of Health 2015). Although this has provided some additional investment and raised the profile of mental health, there has been little attention to inpatient care and the main political focus of the current government to date has been on schools as part of the so-called 2020 Reforms (Department for Education 2018).
Together these issues amount to a poorly informed and confused picture regarding inpatient CAMHS. The available literature fails to answer the question of who may benefit from inpatient admission and who should do what to help. This chapter does not attempt to categorically answer these questions and provide a definitive position on why inpatient CAMHS exists. Nor does it attempt to delineate the exclusive role nurses play in CAMHS which has sometimes been about carving out territory as the separate disciplines seek to make sense of their own individual professional contributions rather than focus on the sum of the parts. Instead, this chapter offers another perspective which in time will form part of the rich but often confusing tapestry of the literature, which may or may not help clarify the future role and function of CAMHS inpatient care.
4.2 History of Inpatient Care
Residential care, confinement and treatment have long been part of the public response to the perceived needs of mentally ill, handicapped, homeless and deviant children (Parry-Jones 1998). The origins of inpatient CAMHS go back to eighteenth century poor houses of the United States (US) and workhouses of the United Kingdom (UK). The Lunacy Act of 1845 was a key milestone, affecting people with a whole spectrum of needs. Following passage of this, children with mental health, learning disability or general development needs could be transferred from local workhouses to institutions or county asylums. Case reports refer to children being frightened by dogs or being tossed by cows, non-appearance of menses and cutting of teeth as reasons for admission. Dangerous or suicidal children might be given bromide, chloroform or brandy in an attempt to manage, contain or cure them Gingell (2001).
A notable landmark in the history of inpatient CAMHS was the opening of Great Ormond Street Hospital in London in 1852. In his lectures between 1845 and 1860, Charles West, the founder of the hospital, spoke of hypochondriasis, night terrors and disorders of the highest function of the brain. Walk (1964) wrote that treatment for such conditions affecting children was separation from parents or boarding with a quiet family. Today, Great Ormond Street offers inpatient CAMHS for children with eating disorders and other mental health conditions. Parents are actively encouraged to visit rather than stay away from their children, which is a change in attitudes informed by attachment theory (see Bowlby 1951). This has not only influenced hospital child visiting policies, but has also positively informed institutional care, child custody and maternal employment.
Another landmark was the opening of the Royal Albert Hospital in Lancaster in 1870. This was originally called the ‘Royal Albert Asylum for the Care, Education and Training of Idiots, Imbeciles and Weak Minded Children and Young Person’s of the Northern Counties’. This is an early illustration of the confusion between mental disorder and learning disability which to some extent remains today. Today, the Royal Albert Hospital has evolved to become an Islamic education centre for Muslim girls, which shows how the passage of time sees changes in attitudes towards children.
In the 1940s, inpatient psychiatric units for children began to open in England. This coincided with the introduction of approved schools and borstals for delinquent children, but this was not part of any coordinated political response to the distinct needs of children. The first CAMHS inpatient units were modelled on the residential communities of the US and were mainly custodial in their aim and function. It was only later that these were to become therapeutically orientated and focused on what Cameron (1949) coined the socio-psychobiological unity of the child. There followed a rapid expansion of adolescent units until the 1980s when the concept of the ‘general purpose’ inpatient unit was introduced. Children and young people could be admitted for short- and long-term care as well as in an emergency (NHS Health Advisory Service 1985).
Most inpatient CAMHS units functioning during the 1980s operated along the lines of therapeutic communities and placed a strong emphasis on the therapeutic milieu. Twenty to thirty years ago they were often led by charismatic leaders with idiosyncratic operational policies. With little evidence base to guide them, therapeutic practice was determined by the varied experience of the staff, but often focusing on long-term therapeutic interventions for children and young people with complex needs rather than those with serious mental illness such as psychosis (Cotgrove 2013).
In the years that followed a number of high profile scandals exposed failings in the care and treatment of children, many of whom had mental health problems and disorders. The so-called ‘Pindown Scandal’ of the 1980s exposed the restrictive practice of staff in a number of children’s homes in Staffordshire. The practice of isolating, restraining and humiliating children was condemned as unethical, unprofessional and illegal (Levy and Kahan 1991). Such practice has not yet been eradicated completely as various Care Quality Commission (CQC) reports of inpatient CAMHS have highlighted (CQC 2018). Problems with overly restrictive child care have not been unique to the UK. Indeed, most research into the restraint or restriction of liberty of children and young people in mental health settings has been undertaken in the US (Wilson et al. 2015). Weiss (1990) reported on children who had died as a result of physical and mechanical restraint in the care of US public institutions. Many died of asphyxiation due to chest compression during restraint. Weiss’ influential report promoted far reaching regulations to prevent, reduce and monitor physical restraint (Masters 2017), and some of this has crossed the water to be reflected in British policy including the current focus on reducing prone restraint.
Just as interesting as the background to CAMHS inpatient care is the history of restraint in such settings. This has originated from the juvenile justice sector as well as adult mental health services, which in turn has been influenced by the practice in prisons and secure hospitals. A legal precedent for the use of restraint was established with the English vagrancy laws of the 1700s (Masters 2017) and there is much documented evidence of use throughout the ages (Mind 2013). The infamous 1960s film, One Flew Over the Cuckoo’s Nest, drew public attention to the use of restriction in mental health settings and played a largely negative role in publicising and propagating stigma and consolidating the role of restraint in mental health. Understanding the principles of least restrictive practice and applying these in day-to-day nursing care is a key part of the inpatient CAMHS nursing role (McDougall and Nolan 2017). The concept of least restriction originated in the US has been described in the international health and social care literature over many years (see Carr et al. 1999; Smith et al. 2005). It is frequently reported in conjunction with nursing practice (Muir-Cochrane et al. 2018) and is enshrined in the Mental Health Code of Practice. The code requires mental health service providers and the practitioners within them to reduce restrictive interventions including restraint, seclusion and rapid tranquillisation. It is nurses who are most commonly involved in restrictive interventions, and so it is nurses who must transform their practice. There are a number of strategies that can support nurses to reduce ward-based conflict, violence and aggression. These include Safewards which is now recognised as an international model of restraint reduction (Bowers 2014).
Derbyshire Safeguarding Children Board (2018) recently published an independent inquiry into the experiences of children and young people at Aston Hall in Derbyshire between the 1950s and 1970s. The report described children being stripped naked, put in straitjackets, drugged and sexually assaulted. Like many of its kind, this so-called treatment centre closed quietly in 2004 which reflected attitudes to care of children in the state at the time. The Cleveland Inquiry (Butler-Sloss 1987) and the abuse of children in care in Wales (Department of Health 2000) each highlighted problems that many young people had with their mental health and the use of restriction and physical abuse by staff who were charged with their care. It is possible that other such inquiries will follow, as the ongoing Independent Inquiry into Child Sexual Abuse gives the historical abuse of children in public care, the profile and attention it deserves.
Despite numerous public inquiries into the care and treatment of young people with mental health problems, little changed up until the 1980s when a key report entitled Bridges Over Troubled Waters was published (Horrocks 1986). This made recommendations about service models and access. However, it was to be another decade before Together We Stand was published by the Health Advisory Service (1995). This recommended that a four-tier model for CAMHS provision was proposed to guide the commissioning, role and management of CAMHS. In the 20 or so years that followed the tiered model failed to give any widespread traction to political or service development and was often conceptually misunderstood (Joint Commissioning Panel for Mental Health 2013). Following publication of Future in Mind (Department of Health 2015), there was a move away from this framework towards the Thrive model as part of the current transformation of children and young people’s mental health services. Whether this brings some systematic focus to who does what for which young people remains to be seen.
4.3 Inpatient Care Today
Inpatient units for children and young people are commissioned to provide assessment, treatment and crisis care for children and young people with complex, persistent or severe mental disorders (NHSE 2018). However, as practice rather than policy or strategy has determined, factors that lead to inpatient CAMHS admission are not only the acuity or chronicity of the child or young person’s mental health difficulties, but also lack of response to community treatment, breakdown in therapeutic relationships and level of risk to self or others.
As with many aspects of specialist CAMHS, the planning of inpatient care has been ad-hoc rather than strategic. This is partly due to the history of commissioning and uncertainty about whether planning should occur locally, regionally or nationally and whether clinicians should be included or excluded in that process. It is generally accepted that the current distribution of inpatient beds is failing to meet need (NHSE 2014; Frith 2017) but whether that means there are too many or too few beds is another matter which is difficult to specify without attention to the wider pathway. In a review of child and adolescent mental health services more generally, the CQC (2017) found a significant mismatch between demand and capacity for inpatient admission. Of course demand is not the same as need, and many argue that most children and young people never require hospital admission.
There is a common misconception that CAMHS care and treatment and hospital admission are synonymous, a widely held belief that has helped maintain the historical neglect in commissioning such services. Use of the terms ‘Tier 4’ and ‘inpatient’ are often used interchangeably. The growing media attention on the emotional health and well-being of children and young people has been spuriously linked to a lack of inpatient services. The most recent specifications for commissioning highly specialised services aim to dispel this conceptual misunderstanding by including ‘non-admitted care’ including crisis intervention, home treatment, step-down care and other alternatives to hospital admission (NHSE 2018). However, access to non-admitted care remains poorly defined and patchy in reality within the commissioned English services and across the wider UK.
These factors combinedly mean that the predominant model of intervention for young people in mental health crisis or with serious mental illness remains one of hospital admission. This is despite evidence that alternatives to admission such as intensive community and day care, outpatient treatment and home-based services can often be more effective, cheaper and acceptable to young people and families (McDougall et al. 2008). Gaps in access to hospital, intensive community and home-based services for children and young people have historically led to care or containment in settings such as paediatric wards, adult mental health wards or police custody (Department of Health and NHS England 2015).
At the time of writing this chapter, inpatient CAMHS is receiving much public attention. Media stories about young people in police cells and children travelling many miles from home to receive hospital care have generated concern about access to help for children and young people in mental health crisis. The rapid increase in young people being admitted to inpatient units or other inappropriate settings has been confirmed in various reviews and reports (McDougall 2014; NHS England 2014; Home Affairs Select Committee 2015). An independent report from the Mental Health Taskforce (2016) was published in response to the Five Year Forward View for Mental Health. This included specific recommendations for children and young people, including ending the practice of sending young people out of their local area for acute inpatient care as soon as possible. Various ministerial statements were to follow, with the latest stating a commitment to eliminate inappropriate placements to inpatient beds for children and young people by 2021 (Prime Minister’s Office 2017).
Whilst a range of positive outcomes and user satisfaction have been reported (Jacobs et al. 2004; Tulloch et al. 2008), inpatient mental health care for children and young people has received much public scrutiny and a significant amount of bad press in recent years. The CQC has found many services requiring improvement and some have been judged inadequate or closed. This is because they have been unsafe or because the providers have failed to improve regulated quality standards. The Quality Network for Inpatient CAMHS (QNIC) sets a number of minimum quality and best practice standards that apply directly to registered nurses and the practice of health care assistants or support workers who currently provide the majority of direct care in CAMHS inpatient units. The standards address environment and facilities; staffing and training; access, admission and discharge; care and treatment; information, consent and confidentiality; young people’s rights and safeguarding; and clinical governance. The QNIC standards are well regarded both by service providers and commissioners and the CQC and are used within 95% of inpatient units.
In their review of standards of care in CAMHS, the CQC (2017) highlighted safety as their single biggest concern. This included the use of restraint, seclusion and long-term segregation as well as sexual safety and the poor physical environment of many wards. This is interesting since the very fabric of inpatient CAMHS wards is linked to the concept of the therapeutic milieu which is seen as integral to the success of inpatient care. Milieu therapy has been used with children since the late 1800s, when the so-called moral treatment and therapeutic communities were the key approaches in the treatment of choice for psychiatric problems and disorders (Sergeant 2009).
4.4 Nursing Staff and Skill Mix in Inpatient Settings
It is not just the perceived lack of beds and the quality and safety of inpatient care that has been in the media spotlight. The staffing, skill mix and quality of care provided in inpatient child and adolescent mental health services have also been called into question. Nurse recruitment, retention and training have increasingly become significant areas of challenge over the years, and this is just as evident in the CAMHS inpatient setting as it is more generally (NHS England 2014). Multiple high profile reports have confirmed that the number and skill mix of nurses makes a difference to quality of care, patient experience and clinical outcomes (Francis 2013). Care Quality Commission (CQC) standards state that to safeguard people’s health, safety and welfare there must be sufficient numbers of suitably qualified, skilled and experienced staff (CQC 2012). This has also been illustrated in various high profile reports of nursing and care staff including the Cavendish Review (Department of Health 2013a, b, c), the Berwick Review (Department of Health 2013a, b, c) and the Keough Review (Department of Health 2013a, b, c).
Nursing care and treatment within inpatient CAMHS settings is poorly defined. Registered nurses in adolescent inpatient settings most often come from a mental health background, and those working in Children’s Units may include Registered Sick Children’s Nurses (RSCNs). Some inpatient settings also include both learning disability and adult nurses. Unlike in many health specialties this is not the result of strategic workforce design, rather it is the culmination of custom and practice, historical variation in commissioning and attempts to fill vacant posts. This lack of a strategic approach to planning is of concern given that nurses comprise approximately three-quarters of the inpatient CAMHS workforce (NHS Benchmarking Network 2013). As Hadland and Ehresmann (2017) comment, there has been a serious lack of attention paid to workforce development in mental health and more specifically in CAMHS. The Foundation for Professionals in Services to Adolescents (2011) reported that it was common for nurses and care staff who are working directly with young people to have received little or no CAMHS specific training.
It seems unthinkable that a similar such situation could occur in say maternity services or paediatric oncology, which illustrates the lack of parity that children’s mental health has when compared to physical health care and provision. Indeed, the Bristol Royal Infirmary inquiry report (Kennedy 2001) recommended that children and young people should always be cared for by health care professionals who hold a recognised qualification in caring for children. It is 15 years since the Royal College of Nursing published a report on the post-registration education and training needs of nurses working with children and young people with mental health problems which included a specific focus on what were identified as the most important training needs for nurses working in CAMHS inpatient settings (RCN 2004). However, no such specialist qualification currently exists for the inpatient CAMHS nurse. The English National Board course number 603, once regarded as the gold standard training for inpatient CAMHS, was decommissioned in the 1990s and there has been no appetite to replace it with a specific nursing award. The adaptation and introduction of IAPT (Increasing Access to Psychological Therapies) into CAMHS inpatient wards is positive, welcome and long overdue. Amongst other skills and competencies, this includes a focus on issues of consent, capacity, confidentiality and the legal framework for children and young people; multidisciplinary assessment and formulation; group processes and team working; and trauma informed care which is fast gathering momentum in mental health care in general.
Perhaps not surprisingly, one of the key challenges facing inpatient CAMHS teams is being able to attract and retain skilled, competent and experienced nursing staff and it is easy to see how this circularity has arisen. There has been concern about the lack of seniority of nurses and the range of therapeutic staff compared to community CAMHS (NHS Benchmarking 2013). In recent years, there has been a gradual workforce shift of nurses from inpatient to community services. This has only added to a challenging situation where the care of children and young people with the most complex and serious difficulties and risks are being cared for and managed by the most inexperienced and poorly prepared staff. In observing this trend, the Quality Network for Inpatient CAMHS (2017) has been concerned about the negative impact on staff morale, team effectiveness and the safety and quality of care. Many stakeholder groups have been concerned about the erosion of skilled inpatient CAMHS nurses in recent years (McDougall 2016). However, this is not a new phenomenon and the gradual decrease in specialist inpatient nursing skills was noted as far back as 1999 as part of the National Inpatient Child and Adolescent Psychiatry (NICAPS) Survey published by the Royal College of Psychiatrists (O’Herlihy et al. 2001).
There has been much debate about the particular skills that inpatient mental health nurses should possess. In 2009, Angela Sergeant (ibid) developed the practitioner’s handbook for staff working with child and adolescent. Although this handbook is now 10 years old, the skills and competencies arguably remain current and just as important today. This includes a focus on child and adolescent development, practical interventional skills, risk assessment and self-care for staff. Many aspects of the handbook apply directly to support workers but its use in practice is not widespread. The strategic support of managers is required to release nursing staff to focus on their continuing professional development (CPD), which is now linked to revalidation and recognised as being integral to the overall quality and safety of care (McDougall 2016).
As we look back over time, we may conclude that the development of inpatient services for children and young people with mental health problems has not been a strategic process. Rather than being based on evidence of what works and the needs of people who use them, inpatient CAMHS care has evolved and has not always been distinct from residential or custodial care for children and young people.
CAMHS in the UK has its roots in the history of children’s welfare services and adult mental health care. There have been many dark periods during this history, and negative aspects of practice intended to rehabilitate delinquent, disruptive or emotionally troubled young people remain in practice in modern CAMHS today. Most notably, these include a culture of restriction and paternalism which is only just starting to transform.
Media reports have been critical of scandals in care but have at the same time called for more beds to be opened for children in crisis. However, inpatient CAMHS admission is not without risk. Whilst hospital admission may be beneficial for some, it can be ineffective or even harmful for others as contagion behaviours associated with self-harm or suicidality can increase. Children and young people who are admitted to CAMHS inpatient units often have backgrounds characterised by high levels of psychosocial adversity. Many have suffered substantial trauma, abuse and loss, which has contributed to their mental health difficulties and risk taking behaviours. They have poor attachments and complex needs, their severe and persistent behaviour problems are difficult to manage in community services and they engage in serious self-harming or suicidal behaviour when faced with perceived threat. Aggressive, threatening or violent behaviour may be placing other people at risk. In this context, it is difficult to see what a time limited inpatient admission can offer beyond physical containment and it is easy to understand why staff may struggle to know what to do to help and resort to control measures, particularly when the necessary staff training and supervision may be lacking.
Inpatient CAMHS wards can be challenging care settings to work in. Supporting children and young people who may use aggression and violence, self-harm or suicidal behaviour to communicate distress, resolve conflict or compete for adult attention is no easy task. Nurses working in inpatient CAMHS must be supported to understand why children or young people behave in particular ways and strive towards enabling a careful balance of authority, responsibility and positive risk taking in helping them to recover. The introduction of trauma informed mental health care is an exciting development and it is vitally important that this is embraced in the CAMHS setting. The education, training and continuing professional development needs of nurses working in CAMHS inpatient care have been neglected during the last 20 years. Most national reviews of CAMHS have highlighted nursing workforce development as a key strategic priority for attention and this is writ large in Future in Mind. It remains to be seen if this latest policy brings further clarity to what CAMHS inpatients units are, why they exist and who they are for.