The implementation of Section 5(4) of the Mental Health Act 1983.

Section 5(4) (nurse's holding power) of the Mental Health Act 1983 empowers mental health nurses to legally prevent an informal in-patient from leaving hospital for up to six hours. The section may be applied for the patient's health or safety or the protection of others. Since its introduction in September 1983 there have been 34,000 applications of the section, an average of 1460 per annum. The application of Section 5(4) is likely to: lead to further detention under the Act; have implications for the practice of nurses; and affect the care received by patients in the aftermath of its use. However, the literature review revealed a paucity of research on the subject. The existing research has focused on three main areas: nurses' opinions of their holding power; their knowledge of Section 5(4); and trends associated with the implementation of the section. However, no attempts have been made to examine the events before, during and after the implementation of Section 5(4). This qualitative study sought to address this deficit by examining why and how Section 5(4) was implemented from the perspective of the nurses and patients involved in the process.A collective case study approach was utilised to generate data from one mental health NHS Trust over a period of one year. Data were generated from three sources: archival (statistical) records on 803 applications of the section; documentary accounts of the detention process, for example nursing notes; and interviews with 30 nurses and four patients. Within- and cross-case narrative analysis was undertaken on the data set. The method of narrative analysis employed was developed specifically for this study.The analysis produced a six-part typology of nurses' stories that explained why Section 5(4) was implemented. The six types were: 'health, safety or protection'; Tack of knowledge'; 'catalyst'; 'medical inaction'; 'self-protection'; and 'last resort'. The analysis also constructed a collective story of nurses' experiences that identified the key stages in the detention process. Stories were also constructed from patients' experiences of being detained. These stories generated in-depth accounts of patients' admission to hospital, the events leading up to their detention, the implementation of Section 5(4), and the aftermath of their experiences.The implications of the study's findings are considered for education, policy, practice and research and focus on four main areas: informal admission to hospital; information giving; reasons for implementing Section 5(4); and the consequences of the detention for both nurses and patients.