In-patient mental health care is in crisis. A report by the Kings Fund (2024) showed that the pressure on services is continuing to increase. There were more admissions, longer hospital stays, fewer beds and a staff vacancy rate higher than any other sector of NHS provision. Furthermore, they reported that the expansion of the workforce has not been sufficient to meet the increase in demand.

These findings suggest a service in deep trouble, and clearly impact the work undertaken by Mental Health Nurses – the most numerous group of registered clinicians in inpatient settings. In the context of a system under extreme pressure, Mental Health Nurses are too often caught in the increasingly precarious position of trying to maintain safety, while attempting to provide compassionate care. While some high-level solutions have been proposed, such as an increase in the retention and recruitment of staff, and a long-term workforce plan, these are unlikely to ease the pressure in the short to medium term.

Faced with these challenges, I feel the balance between a therapeutic versus a custodial model of care for Mental Health Nursing has shifted towards the latter. Patient and staff safety is the priority and rightly so, but I have lost sight of what the role of the Mental Health Nurse in acute in-patient settings is anymore. There are plenty of things for me to do such as safeguarding practices, minimizing risk to self and others, ensuring legislative procedures are followed, and working with least restrictive practice. Yet, these are the frameworks within which I am expected to operate to ensure environmental protectors for service users and staff, not direct guidance for building a therapeutic milieu.

There were moments in my career when the philosophy of mental health nursing could be shaped by theoretical principles; the humanistic conditions proposed by Rogers and Egan would inform me of my practice, the conceptual framework of Peplau might shape the way in which I would work with service users, I could challenge myself by recourse to the anti-psychiatry movements of the 1960’s and 1970’s. Now, I feel like I am operating in a vacuum with an absence of theoretical guidance to base my practice on. My training and experience occurred during periods where new therapeutic models were being introduced and integrated into mental health nursing. The impetus was driven by the difference nursing could make to the recovery of people by thoughtful and purposeful engagement and interventions. Now the paradigm appears to have shifted and it is a struggle to make sense of what I am supposed to be doing in relation to this. 

I know I can still be a supportive influence, but the goals of therapeutic change seem to have been invested more in other professions such as Doctors, Occupational Therapists and Psychologists. The perception of inpatient Mental Health Nurses seems to have become that of guardians, providing protection and safety. Perhaps it is within this role of creating conditions for safe practice that the future will unfold.

What I experience in everyday practice is chaos, with crisis management and firefighting now essential elements for most shifts. The custodial nature of the work takes precedence, with any meaningful engagement taking secondary place. The doors to the unit are secure and what was once termed ‘observation’ now feels more akin to ‘surveillance.’ If I struggle to make sense of what is going on, then how are service users doing so?

The teams I work within are supportive and we endeavour to construct philosophies of care which are well-intentioned, yet we are given little direction. From some other health professionals, I notice an occasional bout of snobbery with the implication being “you are just a nurse.” I am not intentionally critical of the profession of Mental Health Nursing which has served me well for many years. Believe it not, I enjoy my work, yet I struggle with the current nature of it and feel I need help in understanding my role in the acute in-patient setting. Perhaps I am alone in my views and a dinosaur whose time has passed.