Working with The Royal College of Nursing we have outlined some relevant advice for staff working on mental health inpatient wards.
Visit the NHS England website for national guidance about assessment, diagnosis and management of suspected and confirmed cases of COVID-19.
How should we keep the ward community together?
Every ward is a community of people – staff and patients. As much as possible, this community should work together to best ensure the safety of everyone. But we cannot expect “business as usual” at this time. Each ward will have to find a way to focus on physical safety and infection control as the main priority. Key to managing this will be ward cohesion, communication and adapting as a community within local services.
- Inpatient wards treat people whose mental health needs cannot be met in less restrictive settings out of hospital. The present situation gives an added dimension to this decision and teams, patients and families will need to work together to best protect the ward from COVID-19 infection.
- Many of the familiar routines associated with ward care will need to be reviewed. All activities that bring people into close contact will need to stop altogether or be adjusted to meet national guidance. Ward groups, ward rounds, mealtimes and visiting times should all be reviewed to allow for as little contact as possible. It is anticipated that much of this routine will be postponed on wards for the foreseeable future.
- However, removing all ward activities is likely to be counterproductive. People who are restricted can become bored and agitated and require restraint or other restrictive practices. Wards should consider adapting communal activities to reduce duration, unnecessary attendance and increase personal space. Activities such as mindfulness/relaxation groups, dancing/exercise, karaoke and 1:1 meetings can all be done whilst maintaining the recommended two metre distance. Any such activity will have benefits in keeping up staff and patient morale and increase ward cohesion.
- Each ward community should work on keeping communication between staff and patients as good as possible through notice boards, written communication, smaller group or individual meetings and even text and digital messaging within the ward. As stated, meetings can still be carried out provided personal contact is avoided and adequate distancing is able to be maintained.
- Latest government and national guidance should be easily available to all and the whole ward encouraged to stay informed of the situation as it develops. Staff should be clear about rules that are being imposed from national advice and that must be followed by all. Staff should always also model this advice.
- Patients are active agents on wards and should be included as much as possible in assisting in the restructuring of activities and ward routines. Many can and should advise on what they need to stay informed and be included in decision making.
- It is anticipated that there will be high levels of anxiety in the present situation. Good mental healthcare staff are highly skilled in the management of anxiety, both their own and other peoples. It is important to remain confident in your ability and ensure that principles of mutual support and team cohesion remain a cornerstone of your care.
How should we deal with visiting and visitors?
Please follow the below visitor guidance as issued by NHS England (pdf)
We are asking the public to limit visiting and to consider other ways of keeping in touch, like phone calls.
Visitors must be immediate family members or carers.
They should not visit any health and care settings, and this applies to all inpatient, diagnostic and outpatient areas, if they are:
- unwell, especially if they have a high temperature or a new, persistent cough
- vulnerable as a result of their medication, a chronic illness or they are over 70 years of age.
Visitors should be limited to one per patient unless:
- the patient is receiving end-of-life care
- the visitor needs to be accompanied – accompanying visitors should not stay in patient, ward or communal areas, and this applies to inpatient and outpatient settings
- they are a partner and birthing partner accompanying a woman in labour.
No children under 12 should be visiting without the ward sister or charge nurse’s prior permission.
Hospitals and other health and care settings will restrict visiting to one hour per day at designated visiting times.
Slightly different rules apply to paediatrics and neonates – two visitors are allowed and this may include a child under 12. Paediatric trusts can use their own discretion on visiting hours.
We ask for the public’s help in respecting these rules.
What about infections on the ward?
Given the nature and spread of the infections, it is highly likely that every ward will have a member of the ward community display symptoms at some point.
At present the most common symptoms are fever and persistent dry cough. Most people will experience mild to moderate symptoms while a smaller number will have symptoms that have to be managed in a general healthcare setting. Managing infection on a ward should mirror the steps taken in the wider community both in trying to prevent spread and the management of any infections.
- Wards should exercise the principles of social distancing across the ward community. This means minimal contact and an advised distance of two meters. The need to limit contact between individuals should be clearly communicated to patients and staff.
- Careful and sensitive management of patients who experience symptoms of the virus while on the ward will be essential in the coming months. While it will not be possible to turn mental health wards into full isolation units, it will be necessary to take appropriate steps to isolate patients with mild symptoms on the ward.
- If symptoms do not resolve after 7 days, or the patient deteriorates, there will need to be a review of their safety on the ward. Each local area will need to develop a local agreement on the management of severe cases which will include transfer to a general healthcare environment. Teams should provide support and advice to general healthcare colleagues in these situations and continue to monitor the patient’s progress with a view to returning them to the ward should they improve.
- Wards that provide single rooms with en-suite facilities for patients should encourage patients to remain in their rooms as much as possible. We are aware that this is contrary to the normal running of a ward and staff and patients are encouraged to find creative ways to adjust to this. As with mobile phones, this may require rules and restrictions to be relaxed, such as allowing patients to eat, make phone calls or watch television in their rooms.
- Wards that have single rooms without toilet or showering facilities will need to proactively plan to manage personal hygiene. While this may require the use of commodes or planned bath and showers, these plans should consider the routine cleaning of the equipment that is needed and may require supervision. All such plans should be clearly communicated to patients.
- Wards that have dormitory accommodation should make specific plans for the management of infection control in these areas. If a patient in these areas were to display symptoms, they will need to be moved to a private area. Local services should identify provisional plans for this eventuality.
- When a patient does display symptoms, they should be managed in a private room under local infection control guidance. If this is not possible for any reason, this should be reported immediately to senior management and this should be treated as an emergency.
- Family and carers should be informed as soon as possible if any patient display symptoms and is placed in isolation on the ward. Any person who has visited the patient 7 days prior to the onset of symptoms should also be informed and advised to self-isolate in keeping with national guidance.
More detailed information can be found on the RCN website.
What about routine mental healthcare?
There is no doubt that providing even basic treatment for patient’s mental health needs is compromised in the present crisis. The provision of specialist services such as occupational therapy, psychology or pharmacology is secondary to maintaining their physical health in the present situation. However, given the nature of wards, patients will still require basic mental healthcare.
- The basic principles of care should be to provide at least minimum care to each patient according to their needs.
- For many patients this will mean being given the same information as the general public and assisted in following the advice given. Much of what has been discussed re communication and access to networks is to alleviate any deterioration in mental health. We cannot shield patients from the anxiety presently experienced in society, but we can make every effort to include them in planning and management of the situation.
- Patient ongoing mental healthcare will need to be reassessed. Again, wards should consider carrying out some care meetings via phone or video depending on the resources available. This should includer any ongoing 1:1 psychological therapy.
- If a patient displays COVID-19 symptoms, their physical healthcare takes priority. This may require a postponement of any therapies and a revaluation of any medications in line with advice from Pharmacy departments. As far as possible therapy should be continued via phone when patients are in isolation.
- It is not possible to provide guidance for every complication in individual treatment, but ward staff should be assisted by the wider MDT in the management of issues as they arise. Each patient should have a minimum of a weekly MDT review. If they display symptoms there should be a daily review of their care.
- As mentioned above, wards should try and maintain some group activities with adjustments to maintain morale, communication and provide reassurance to patients.
- One area that staff and patients will need to be clear about is smoking. In the present situation staff and visitors will not be able to escort patients for smoking or so called “fresh air breaks”. This will need sensitive communication to patients and should be backed up with written information or posters. As COVID-19 attacks the lungs, patients who smoke should be encouraged to give up smoking as a priority at this time –please see further information on COVID-19 and smoking.
Any decisions about leave will need to be taken based on latest government advice at the time and analysis of benefits and risks for that individual patient’s recover
Patient leave from the ward, either escorted or unescorted, will require additional risk assessment depending on patients’ exposure to symptoms.
Where possible, leave and time off the ward should be maintained. If it is not possible this should be clearly communicated to the patient including the process for review.
S.17 escorted leave arrangements will depend upon the location of the hospital and a localised risk assessment. Escorted leave should be individual and follow the guidelines of social distancing i.e. staff are advised to only escort 1 patient at a time and to maintain a two metre distance.Some hospitals may want to limit all leave to 30 minutes to the local area only so that patients can get fresh air and time off the ward, but with limited chance of social interactions.
What can I expect from services around me?
- Ward staff, organisations and national bodies are facing unprecedented challenges. It will be important in the coming months for organisations to work to assist those staff and patients on the front line by anticipating and planning for issues and being responsive to issues as they arise.
- All organizations should create specialist clinical committees to assist wards to manage the current challenges. Those committees should be chaired by senior clinicians and should have a direct line of communication to and from all ward managers and frontline staff and patients.
- These committees should be available to problem solve issues that teams face as the pandemic progresses and should be the central point of communication for national guidance and contingency planning. The chair of these committees should be identified as the central point of communication for all national bodies providing guidance to ward.
- The committees should either have a subgroup to consider any ethical dilemmas individual patient care or have this as a standing item of business and follow national ethical guidance (due to be issued soon - this page will be updated as soon as possible) ward should be clear on how to seek advice about patient care through this route.
- Organisations should cancel all non-essential meetings or release front line staff from attendance at such meetings.