Last Wednesday (May 14th 2014 ) I had the chance to speak at the 4th National Association of Lead Nurses in ECT (NALNECT) conference. ECT (electro-convulsive therapy) has been around since the 1930s. It’s sparingly used, typically as a treatment for severe depression and only after other interventions have been tried and found wanting. The procedure involves the use of electricity to induce a seizure, and is conducted under anaesthesia. In the UK there are standards for ECT clinics, which place particular emphasis on quality and safety.
I’m no expert in ECT as a treatment, but I do know something about work and roles and it was this that I spoke about at the NALNECT event. I suggested that, rather like the physical holding of patients and other restrictive practices, ECT might be thought of as an example of the mental health system’s ‘dirty work’. It arouses strong views, and may well be an area about which there is more heat than light. A quick pre-conference search on Scopus turned up just 100 articles at the intersection of ‘ECT’ and ‘nursing’, with only 12 citations attributed to authors in the UK. Amongst these I found this paper investigating nurses’ attitudes, and this paper reporting findings from an observational study of the ECT workplace.
At Wednesday’s event I also talked about the ECT clinic’s unusually complex division of labour. Where else do mental health nurses, psychiatrists, anaesthetists, operating department practitioners and health care assistants routinely work together? The main item at the NALNECT conference was a debate on nurse-led clinics, though there seemed to be a number of different versions of what this might actually look like. Large parts of the discussion centred on the technical: who might apply which bit of the machinery, and who might press which button. I pointed out that tasks have forever moved around in the mental health system, and that a bigger question may not be the physical handling and usage of the ECT kit but nursing’s possession of sufficient knowledge to sustain claims to jurisdiction.
Yesterday the national mental health charity Mind released information on the use of face-down restraint in mental health services. It says:
Mind is today calling for the government and NHS England to put an end to life-threatening face down restraint of people with mental health problems in healthcare settings. Data secured by Mind under the Freedom of Information Act reveals that at least 3,439 patients in England were restrained in a face down position in 2011-12, despite the increased risk of death from this kind of restraint.
Restraining people is part of mental health nursing’s ‘dirty work’. This is a phrase which originally comes from the American sociologist Everett Hughes. Robert Emerson and Melvin Pollner picked it up in a paper titled, Dirty work designations: their features and consequences in a psychiatric setting, and more recently Paul Godin wrote about A dirty business: caring for people who are a nuisance or a danger. There are plenty of other ‘dirty work’ articles out there, too, for those interested in finding them.
‘Dirty work’ involves doings things which are in some way tainted or shameful, but which might still have to be done. A professional group’s dirty work is not the first thing its members typically like to talk about when asked to describe what they do. When mental health nurses present themselves to others it is the helping relationships they build, the listening they do and the recovery they promote that are more likely to feature. My guess is that experiences of holding, secluding and forcibly medicating people are not things that nurses immediately volunteer.
Because dirty work can sometimes feel degrading and morally suspect it can feel easier not to talk about it at all. The good news in mental health nursing is that there are plenty of people interested in describing, researching and questioning the more coercive and controlling aspects of what we collectively do. Len Bowers and Joy Duxbury are examples. In addition to calling for a ban on face-down restraint, in its news release yesterday Mind pressed for the implementation of national standards and accredited training in this area. Nurses have a big part to play in the debates which are to follow and in developing new practices, and I’ll be watching with interest.