A review of three social media events on the work of mental health nurses in the UK and some next steps

Background

It is ten years since a last UK Government review of mental health nursing, however there has never been a review of the work of practising mental health nurses undertaken by the profession itself. With this in mind, mental health nursing as a well found graduate profession is now strong enough take responsibility for itself and undertake a reflective consultation process within and outside the profession, about the work they do. The Foundation of Nursing studies is an active Charity whose work is in large part dedicated to the development of nursing practice, it is appropriate therefore that the Charity should assist mental health nurses in this work.
With significant changes to mental health policy in England and Scotland and Northern Ireland the delivery of mental health services will be transformed in the next decade and mental health nurses must identify where they can make their most telling contribution to the care of people in need.
We have undertaken three social media events and asked questions about the work of mental health nurses within areas of primary, secondary and tertiary prevention.
This paper offers an analysis of, and some commentary on the conversations that took place during the three events. These outputs will inform the basis of eight roundtable conversations that will take place between September and the beginning of November.

The activity
The Foundation undertook three twitter-based conversation events on Monday 9th May, Monday 6th June and Monday 11th July 2016. We used the supportive platforms and expertise of WeMHNurses and the Foundation of Nursing Studies to host the events and informed each of our conversations with three pre-prepared blog papers on mhnurses.wordpress.com. Data on participation numbers shows a range of between 43-75, tweets between 313-428 and a potential reach of between 2,792,162 and 3,503,264 people. We have been expertly helped in our data analysis by Dr Ian Holt who has assisted in thematically organising the outputs from the twitter material. This has been secondarily analysed by Professor Tony Butterworth and is therefore subject to the normal cautions of individual bias. Nonetheless, we believe the material provides interesting and informative views and ideas.

A first step using social media
The reported strengths of social media are that it allows rapid access to a large audience and places debate into a more public domain. It reportedly allows participants to think differently and in safety. Although contributors offered observations with each of the three elements of preventive psychiatry (primary, secondary and tertiary) they wished to support the strength of, and need for continuous and seamless service provision across all services. They were clear that MH nurses had an important role to play in such a system wide approach.

Emerging themes
A number of significant themes have arisen from our social media activity. In summary these are grouped around 1. Education and Training 2. Employment, staffing and capacity to improve 3. Therapeutic environments, engagement with people and building design 4. Care systems – the contribution of MH Nurses 5. Mental health nursing identity
6. The role of mental health nurses 7. Motivations for change 8. Person centred mental health nursing work across services.

The social media conversations

  1. Education and Training
    Informing data from our debates ranged across a series of important areas such as the need for all nurses to gain an understanding of mental illness and at what point this becomes more comprehensive and ‘specialist’. A complex (and divided) debate about all nurses being ‘generic’ and then becoming mental health specialists at a post graduate level was aired. This discussion became a little clouded by a need for nurses to understand the physical health of people with mental illness and conversely need for general nurses to understand the mental health of those with physical illness. The proposed ‘generic nurse’ as a solution to this has few advocates. Several people lamented the reducing content of social sciences in undergraduate programmes and indeed it was suggested that some programmes prepared graduates for ‘yesterday’s world’ focussing too much on in-patient care and traditional approaches rather than broader preventative models.
    The need for practice nurses being better prepared to work with those with mental illness and prevention was seen as critical to primary care. Mental health nurses’ understanding of and engagement in prevention and public health work was seen as inadequate and preparation of mental health nurses enabling them to work with children and adolescents was seen as being in need of urgent development.
    Notes
    i) At the time of writing this paper a significant piece of work has been undertaken by Skills for Health in collaboration with Skills for Care and Health Education England to produce a Core Skills Education and Training Framework that offers a guide to the knowledge and skills required of all health professionals. It will be published in full in September 2016.
    ii) We are keen to gain a better understanding of the particular requirements of mental health nurse students and how they might develop an understanding of the unique nature of their work. We have established a reference group of expert nurse educator/academics to explore this further and will publish more later.
    iii) In May 2016 the Department of Health in England produced a report on the importance of mental health nurses understanding the physical health of those with mental illness. It contains helpful guidelines and advice.
  1. Employment, staffing and capacity to improve
    If service innovation is to take place then the nature of who employs mental health nurses may have to change. Commentators suggested that who employs MHNs will determine the nature of their work but that staffing capacity is a continuous headache for service delivery across primary, secondary and tertiary care. Community psychiatric nurses are no longer undertaking work that does not fit with a ‘target driven’ system and so working with prevention in primary care is seen as low priority. The over-complex systems being established to deliver IAPT services have been challenging, however research that describes the effectiveness of nurse-led psychosocial interventions with patients and families is well documented and proven to be effective. It is concerning to see therefore that this evidenced-based work is losing some focus and that MH nurses cannot undertake more. MH nurses are more than willing to innovate new service models but sadly, the almost total absence of opportunities for employer supported continuous professional development for qualified mental nurses is alarming. It is seen by commentators as detrimental for nurses wishing to offer more innovative and different care, as well as being unfair to people who use services. If services are to change focus and offer different models of care, then then continuing education for MH nurses is essential. The absence of funded CPD to develop practice and devise new ways of working becomes self-defeating. The loud debates in general health care about the need for ‘safe nurse staffing’ is less intense in mental health services although the volume is building, and was the subject of several comments in our debates.
    Notes
    i) A shortage of mental health nurses continues to plague the health care system across the UK. As an example data show a fall in numbers of registered nurses England from 40,744 in 2010 to 35,754 in April 2016. Recruiting to posts in children and adolescent psychiatry is particularly hard. An increase in temporary staffing costs of 82% shows the unwanted financial short-term fixes to these problems.
    ii) Work led by Professor John Baker is enabling useful discussions on safe staffing and at the time of writing this script an initiative by the Mental Health Work Stream for Safe and Sustainable Staffing Improvement Resource is developing a consultation process to begin in Autumn of this year. It will be important to focus on this in our work. Its brief is multi-disciplinary and will cover in-patient and community services. 
  2. Therapeutic environments, engagement with people and building design
    We posed questions to feed the twitter debate on our blog site mhnurses.wordpress.com focussing on the therapeutic environment and the role of nurses ‘creating’ positive caring settings. This was based on a belief that the places where people are cared for in the community or in hospital should be able to offer retreat and ‘asylum’ in its truest sense. We believe that MHNurses are the ‘psycho-social architects’ of this environment and through their therapeutic use of self and the creation of a settled and beneficial environment, those in care should benefit positively. It is unclear if this work is sufficiently well addressed in undergraduate curriculum or that the present workforce takes on this professional responsibility with enough energy. Reports suggest that acute in-patient services are intense, hectic and often disturbing environments thus allowing the use of these skills both difficult and challenging.
    Correspondents said that the physical structure of some wards made the creation and delivery of therapy impossible. Poor building design, the need for office space, therapy rooms and quiet areas were referenced as being absent. While physical safety (patients unable to go out) was easy enough to create, the downsides of this system are self-evident. Some debate was had on the need for an office with some suggesting it can become a hiding place or a ‘power base’ for staff, nonetheless some opportunity for safe storage and telephone discussion is essential. Good practice models are available (see notes below).
    Notes
    i) Significant research has taken place to determine what constitutes safe or ‘Star’ wards for in-patient care. The work of Professors Len Bowers and Alan Simpson is considerable and influential. Their work and the ‘push’ of influential individuals such as Marion Janner offers practical advice on what constitutes a more safe and therapeutic ward environment. The benchmarks they offer are so useful there seems little point in re-inventing them.
    ii) If the therapeutic use of self is central to the work of mental health nurses then the need to understand and practice this in an undergraduate curriculum appears self-evident. Time within a curriculum is precious and may be overcrowded with ‘generic’ and unnecessary requirements for nursing practice– we intend to explore this with educational and academic experts.
    iii) The work of Professor Mary Chambers is advancing the necessary skills of therapeutic engagement with people who use services and trying to capture the impact on patient outcomes and experiences using a therapeutic engagement questionnaire. It has been tested and validated for general use in mental health in-patient settings.
  1. Care systems – The contribution of MH Nurses
    If services are to be differently delivered and the emphasis on prevention seen in mental health policies is to be realised, then the contribution of MH Nurses has to be re-drafted such that they can be better used. References to staffing shortfalls have already been mentioned here but the employment and location of expert mental health nurses will need to be different in the future. To use a precious and expert (not to say expensive) resource in areas of most need makes sense and our commentators were loud in their views on this. Many mental health nurses in current practice are working in tertiary care settings and in acute in-patient care facilities. Redeployment to other areas of need and away from tertiary care facilities may be necessary. To ‘drill down’ and capture workforce data that shows the exact setting where MH Nurses presently work is hard and it is inevitable that whilst most of them are employed by mental health organisations this will be the focus of their work and related to the mission and purpose of those organisations. Conversely, there are examples of mental health nurses already working to good effect in general practice, in accident and emergency services and with the police and the prison services. The volume for this work may need to be turned up. Commentators also offered views on the need to develop a career pathway for MH Nurses in primary care and the need to move the agenda away from ‘just recovery’ – which is seen by some as having become more of a buzz word than helpful preventive activity. Mental health Nurses greatly value the role they can play in continuity of care as people move across different parts of the system. A ‘guestimate’ would suggest that less than 15% of mental health nurses are working in Primary Care a more radical redeployment of MH Nurses must be realised and the workore force footprint must look different. It will require a significant willingness on the part of all employers to make it happen.
  1. Mental health nursing identity
    There was a widespread view that MH nurses are concerned about how they can meaningfully contribute to service development and the uncertain future of their own profession. While trades union support for employee rights was seen as sufficient there is felt to be a poor representative voice for MH nurses and their career development and there was criticism of the Royal College of Nursing and other Trades Unions in supporting specialist needs for mental health nurses.
    There exists a view that support for a generic nursing model is going unchallenged and an imbalanced concern for the physical needs of those with mental illness (although very important) was stifling other more important agendas. Commentators did mention the need for a College of Mental Health Nursing to redress the balance. If accreditation was to emerge as means of validating post-registration education, then commentators saw this as a means to funding a new and more useful organisation. There was a view that if the Royal College offered something more purposeful – that would be very helpful (see note i). As there are significant numbers of MH nurses holding RCN membership this appears to be an important issue, there are after all 35,754 registered MH Nurses.
    Notes
    i) The Royal College of Nursing has helpfully agreed to host a ‘summit meeting’ in Autumn with key players to see what necessary changes might be made to better address the particular needs of mental health nursesii) A thriving network of academics exists already – the group Mental Health Academics UK is well connected and making purposeful contributions to policy developments. The group is clearly focussed on education and research.
    iii) There were previously organisations mostly dedicated to the work of MH nurses in practice  – the Community Psychiatric Nurses Association and the Psychiatric Nurses Association. Vestiges remain nested within in other Trades Unions such as Unison and Unite.
  1. The undergraduate and post graduate education of mental health nurses
    There were multiple references to initial and continuing education for MH Nurses. We have established an educators reference group and will address this with more purpose in due course.
  2. Motivations for change
    The main purpose of our work with ‘Playing our part’ was to articulate the views of a graduate workforce that plays a significant part in the delivery of mental health care. There is clear evidence that MH nurses wish to be a part of new patterns of service delivery. Their motivation is in no doubt and the need to change their ways of working is self-evident. It is important to harness that willingness for the benefit of those who use mental health services.

Next steps
Following this series of events using social media we will proceed to 8 ‘roundtable conferences’ that will be held across the UK. Our expert educationalist group will continue to explore issues of concern in undergraduate and continuing education. Initial findings from our work will be offered to two national conferences and a final report will be produced in the early new year.

Emeritus Professor Tony Butterworth – September 2016

Endnote

In order to offer some structure to the informing papers on our blog site we used a Public Health Model of preventive psychiatry (Caplan 1964) and posed questions within each element for our twitter conversations. There were as follows –

Primary care (Stop it happening)
Question 1. Is a model of preventive psychiatry a valid and useful way of thinking about the work of mental health nurses?
Question 2. How can we improve career pathways for mental health nurses in primary care
Question 3. Is this an accurate description of the present work of mental health nurses in primary care?
Question 4. Are we missing something here – what else do you know and can share?
Question 5. What are the likely issues of employment and do good existing and alternative examples exist?
Question 6. How can clinical supervision for mental health nurses be more purposefully and constructively used?
Question 7. What if any continuing professional development might be needed to begin to place mental health nurses in primary care and prevention now?
Question 8. For mental health nurses to properly play their part in co-designing policy and service development do they need a dedicated College of Mental Health Nursing to support them?

Secondary care (Catch it and intervene early)
Question 1 – How can mental health nurses implement evidence based practice more consistently in in-patient care?
Question 2 – How can mental health nurses best create and sustain a therapeutic milieu where care and treatment can take place more purposefully?
Question 3 – How can we ensure that mental health nurses play a full part in the re-design of community health teams?
Question 4 – How can mental health nurses be better enabled to offer continuity of recovery-focused care?
Question 5 – How can work more purposefully in prison services and accident and emergency settings?
Question 6 – The relationship between mental illness and physical ill-health in now well documented, how can mental health nurses dealing with this proactively?
Question 7 – Does the preparation of newly graduating mental health nurses take sufficient account of ‘new science
Question 8 – How can mental health nurses specifically lead on developing professional aspirations?
Tertiary care (restore to full health or maximum capability)
Question 1 – are mental health nurses still offering skills more appropriate to institutional care?
Question 2 – Is the work of community psychiatric nurses becoming differently focused towards active intervention? Is this at the cost of ‘other work’?
Question 3  – Is tertiary care a place where mental health nurses belong?
Question 4  – Are mental health nursing skills necessary in locations where recovery and retreat are on offer
Question 5 – What more general lessons can be learned by all mental health nurses from the creative co-production models being established in dementia care?
Question 6  – Is our analysis of the work of mental health nurses through primary, secondary and tertiary prevention tenable, or should models which embrace continuity of care be used instead?
Question 7 – If not what alternative platforms might we use and can you describe them?

Mental health nurses – working to good effect in tertiary care

What are we trying to do?

Outputs from this third blog will contribute to a report to be produced by the Foundation of Nursing Studies (www.fons.org) at the end of 2016 on the present and future work of mental health nurses. As a graduate profession, mental health nurses must now be confident enough to offer a constructive debate about their work rather than playing a limited part in policy development and service re-design. We hope the approach used in Playing our part will allow us to think differently by asking purposeful questions and sometimes we will allow ourselves to think disruptively! We want to put mental health nurses in a place where they can proactively contribute to service delivery. This third blog is to stimulate early discussion towards developing a contemporary view of the work of mental health nurses in tertiary care. We wish to explore existing and further potential for mental health nurses working in tertiary care and ask some questions about their present engagement and future work. The paper and your responses will help to stimulate a twitter conversation on Monday 11th July at 8pm. Please join us at #WeMHnurses.

A Definition for TERTIARY care and prevention

Working within a public health and preventive model of psychiatry (Caplan 1964) allows us to test the actual and potential work of mental health nurses. Having considered primary and secondary prevention in earlier Twitter debates we now finally turn our attention to tertiary prevention and must not only consider where mental health nurses are already working to good effect, but how they can work differently and better. For the purposes of this blog, tertiary care is defined as –‘mitigating the residual effects of mental disorder and the effects it may leave on individuals and families’.

Where does Tertiary care take place?

Health care professionals, social care agencies and the charity and voluntary sector can and should play an equal part in supporting and working with people and families who live with the residual effects of mental ill health. In previous times, tertiary care was in large part where many mental health nurses learned to work and offer support and help but the settings for tertiary care have now changed significantly. The closure of large institutions has meant that those in recovery or in need of long term support now go to very different destinations. Many have returned to live in their communities, some have gone to safe sheltered care, others re-emerge in the prison system and some are lost altogether and appear in the statistics of the homeless and rootless populations that can be found in most UK cities. Persistent system reorganisations created by services looking to work more efficiently have meant that vulnerable people in greatest need of long term care have likely suffered the most and the notion of ‘asylum’ in its best sense as a place of retreat and security has somehow become out of date as services implement models of ‘recovery’ which claim to be more active and purposeful. Several services have now established centres or ‘recovery houses’ in which both the realising of a persons’ full potential as well as the offer of asylum hold equal weight.

Question one – are mental health nurses still offering skills more appropriate to institutional care?

What is happening in tertiary care?

If, as we discussed in our blog on secondary care acute in-patient settings are highly charged environments for those in acute distress, than it must follow they are unsuitable for respite and sheltered recovery. In the search for alternatives such as the training available through ‘recovery based training’ programmes, day care and residential settings being created in ‘recovery houses’ and patient empowerment through ‘victim to victor’ approaches exciting new possibilities are emerging. If mental health nurses are to engage with the tertiary care revolution, then some questions are necessary. The first is a difficult one – is this mental health nurses work? The second is equally difficult – are tomorrows graduates being properly prepared for the new work landscape and is the University teaching faculty up to the job? The third question asks us to bite a very hard bullet – should mental health nurses ‘move aside’ and leave tertiary care to more expert non-statutory agencies? In doing this they can concentrate on using their skills in secondary acute care settings? The role of community psychiatric nurses (CPN’s) has continued to evolve and still provides essential support for those who have returned to their communities to live. Continuity of care for those requiring sustained contact is vital. Much of the work undertaken by CPNs has been drawn into active recovery and outreach programmes and is often measured in ‘sessions’ and defined programmes of intervention. Has this subverted the important work of sustained contact with people who need minimal but skilled support?

Question two – Is the work of community psychiatric nurses becoming differently focussed towards active intervention? Is this at the cost of ‘other work’?

Question three – Is tertiary care a place where mental health nurses belong?

Question four – are mental health nursing skills necessary in locations where recovery and retreat are on offer?

Do models of care developed in dementia service provide some answers?

Those individuals and families living with a diagnosis of dementia require particular support and service responses. There is ample evidence that mental health nurses can play a vital role. Models such as those on offer from Admiral nurses and their co-production systems offer a different way of working with families. The powerful lobbies created by partners and families of people with dementia offer good examples for professionals and families working together and the demand for skilled mental health nursing support is loud and clear as they move across the boundaries of primary, secondary and tertiary care.

Question five – What more general lessons can be learned by all mental health nurses from the creative co-production models being established in dementia care?

Two final big Questions

This is the last of our three blogs. We will now take the outputs from these blog papers and the twitter events that have followed and develop a paper and a series of questions for some ‘roundtable conferences’ in which we will further develop out thinking

Question six – Is our analysis of the work of mental health nurses through primary, secondary and tertiary prevention tenable, or should models which embrace continuity of care be used instead?

Question seven – If not what alternative platforms might we use and can you describe them ?

We will be holding a twitter chat on Monday 11th July at 8pm on mental health nurses working in tertiary care. To join in please use and add #WeMHnurses to your Twitter favourites!

What next?

We have a large amount of rich and informative data from our twitter events.
During September and October we will be holding a series of roundtable conferences with participants from the professions, people who use services and other invited guests. Outputs from theses will again contribute to our final paper to be completed by the end of 2016.

Tony Butterworth July 2016

Headlines from our twitter event on secondary care

  • Questions and themes

  • Is in-patient care a therapeutic setting?
  • How do we tackle continuity of care?
  • Safe staffing as a key requirement
  • The nature of ‘recovery’ as a descriptor of service provision/experience
  • Emerging discussions that followed

  • Service design obliges patients to be in and out as fast as possible
  • Staffing levels make an obvious and critical difference
  • ‘Recovery’ is an unhelpful descriptor but no agreement on what else to call it
  •  Access to education and knowledge is empowering
  • Acute in-patient care requires the right staff, it has to do with leading meaningful lives,
  • A ‘healthy’ environment and quiet areas for residents are critical for therapeutic in-patient care
  • From a patients point of view the ‘boundaries of primary, secondary and tertiary care are blurred.
  • Continuity of care is a useful concept to guide the work of mental health nurses and service design.

Mental Health Nurses – developing purposeful work in secondary care

What are we trying to do?

Outputs from this second blog will contribute to a report to be produced by the Foundation of Nursing Studies (www.fons.org) at the end of 2016 on the present and future work of mental health nurses. As a graduate profession, mental health nurses must now be confident enough to offer a constructive debate about their work rather than playing a limited part in policy development and service re-design. We hope the approach used in Playing our part will allow us to think differently by asking purposeful questions and sometimes we will allow ourselves to think disruptively! We want to put mental health nurses in a place where they can proactively contribute to service delivery.
This second blog is to stimulate early discussion towards developing a contemporary view of the work of mental health nurses. We wish to explore existing and further potential for working in secondary care and asking some questions about it. Tertiary care will be considered in a later blog and all outputs will be used to inform roundtable conferences from July onwards. Please help us to develop Playing our Part.
The paper and your responses will help to stimulate a twitter conversation on Monday 6th June at 8pm. Please join us at #WeMHnurses.

A Definition for SECONDARY care and prevention

Working within a public health and preventive model of psychiatry (Caplan 1964) allows us to test the actual and potential work of mental health nurses. Having considered PRIMARY PREVENTION in an earlier Twitter debate we now turn our attention to SECONDARY PREVENTION and must not only consider where mental health nurses are already working to good effect, but how they can work differently and better. For the purposes of this blog, secondary care is defined as minimising the effects of mental disorders through early detection, purposeful treatment and care. Early detection and interventional work with people thus requires an ability to expand work across traditional service boundaries but this might possibly be constrained by employer requirements. Offering care across boundaries requires new ways of working and different models of employment.
Mental health nurses continue to work successfully in in-patient settings, early intervention services and recovery. Evidence as to the effectiveness of mental health nurses has already been reported in such areas as psychosocial intervention and creating ‘safe’ wards but benchmarked and evidenced work such as this is still not USUAL practice. Why are mental health nurses not using evidence based practice in their everyday work?

Question 1 – How can mental health nurses implement evidence based practice more consistently in in-patient care?

Mental health nurses working in secondary prevention and care in in-patient settings.

The core skills of mental health nurses are mostly learned and then expressed in secondary care and in-patient settings. It is useful to think of the application of these skills through an organisational design and ‘climate’ that allows the creation of a therapeutic milieu, person centred interventions through individual and group work, an understanding the important dynamic of physical and mental health and the essential value in continuity of supported care. Although the backcloth to secondary care is coloured by a recent decline of numbers in the mental health nurse workforce and a shortage of more traditional in-patient care facilities, it is also where innovative service provision and creative service delivery is already taking place.
It is also important to note present conditions that characterise some in-patient care. Reports continue to show that in-patient care is seen by nurses and by patients and families as unsafe and not therapeutic. Some in-patient beds are still sourced many miles from home and waiting times are often unacceptable. Although national strategies are being designed through forward focussed planning, the present reality is still one of continuing difficulties. Is it possible to create a therapeutic and helpful environment where care can take place in difficult ‘real life’ circumstances? Meeting the challenges of care planning, containment, support, daily structure, active involvement and individual validation lie at the heart of the day to day work of mental health nurses in in-patient settings and is VERY challenging!

Question 2 – How can mental health nurses best create and sustain a therapeutic milieu where care and treatment can take place more purposefully?

Continuity of care and working across traditional boundaries

Evidence suggests that the numbers of people with mental ill-health continues to cause challenges to the health and social care system. There are increasing numbers of people in the prison system who display significant signs of mental illness and are being treated inappropriately as a consequence. The well reported problems of alcohol misuse by adults as well as the young and vulnerable are challenging. This, compounded by increases in suicide by both men and women place huge demands on health, social care and law enforcement. There are good examples of nurses working differently with police services, prison services and accident and emergency departments to try and mitigate delays in referral and inappropriate placement. Community psychiatric nurses continue to bridge between services in primary care and in-patient care but are increasingly distracted by demands for access to psychological therapy services and mandated ‘waiting times’. Secondary care also requires that care planning is both efficient and timely and should be recovery focussed. Recent evaluative work has suggested variations of experience in care planning by those for whom it is intended and the reported ‘burdensome nature’ of care plans which are then rarely consulted. This suggests that change is necessary. Interestingly however, people who use services appear to value their therapeutic relationship with care co-ordinators so this approach appears to have value. In order that care planning has greater purpose and value then the bureaucracy that surrounds it must be mitigated and information systems made more useable.
There is work underway to re-design and reconstitute community mental health teams, mental health nurses must be able and willing to play their part from the start and not as afterthought! Attention to the particular needs of children and young people as well as older people with dementia require particular focus. Although significant recent attention has been given to people with dementia, those in need of in-patient care are likely to be offered a care home facility or a bed at distance from home. This is unhelpful to both people with dementia and their families – early expert care from mental health nurses is essential across the whole age range.

Question 3 – How can we ensure that mental health nurses play a full part in the re-design of community health teams?

Question 4 – How can mental health nurses be better enabled to offer continuity of recovery-focussed care?

Question 5 – How can work more purposefully in prison services and accident and emergency settings?

The challenges of ‘new science’ and professional development

Revolutionary thinking that brought about models in psychodynamic and behavioural therapy as well as significant changes in the use of psychopharmacology forced radical change into the care and treatment of people with mental ill health. In using models from the social and organisational sciences there will be inevitable re- shaping of service delivery. Innovation and organisational science must be recognised and used to effect continuous development, although this is always dependent upon the nature of employer organisations and their willingness to change. We will be obliged to think differently and purposefully about the relationship between physical health and mental health and work being undertaken by research based in post-genomic specialist research centres will impact significantly on the work that all nurses do.
In seeking to develop the work of nurses a series of ‘nursing strategies’ have obliged the profession to look again at the work they do and the behaviours they display. Most recently in England, nurses have been urged to lead on a new strategy that embraces 10 aspirational commitments focussing on cultural change, reductions in variability and leadership and in research. Sadly, continuing professional development is increasingly underfunded and unavailable which is lamentable and so realizing these worthy ambitions may prove difficult.

Question 6 – The relationship between mental illness and physical ill-health in now well documented, how can mental health nurses dealing with this proactively?

Question 7 – Does the preparation of newly graduating mental health nurses taking sufficient account of ‘new science?

Question 8 – How can mental health nurses specifically lead on developing professional aspirations?

How you can help?

When you have read this blog please offer your views and comments in the box at the bottom of the blog page. You do not need to answer just the questions posed here. Any comments are useful! We will also be holding a twitter chat on Monday 6th June at 8pm and to join in please use and add #WeMHnurses to your Twitter favourites!

Tony Butterworth June 2016

Our first Twitter event

 

Our first Twitter event took place on Monday, many thanks to @WeMHNurses and @FoNSCharity for holding our hands!  Interesting things emerged from the twitter event.
One of them related to the initial and continuing education of mental health nurses – if they are to be employed and then work in primary care are they well enough prepared? If they wish to move out from in-patient care is there CPD to help them do this? Who should employ them in primary care and who will commission a primary care workforce to include mental health nurses? Does their education prepare them sufficiently well to assess physical health needs and problems but equally a concern that they should not dilute their specialist skills. There was some small debate about the representation of the interests of mental health nurses and how they can best offer a voice to policy and service development.

 

 

 

Mental health nurses – working with purpose in primary care

What are we trying to do?

Outputs from this blog will contribute to a report to be produced by the Foundation of Nursing Studies (www.fons.org) at the end of 2016 on the present and future work of mental health nurses. As a graduate profession, mental health nurses must now be confident enough to offer a constructive debate about their work rather than playing a limited role in policy development and service re-design. We hope the approach used in Playing our part will allow us to think differently by asking purposeful questions and sometimes we will allow ourselves to think disruptively! We want to put mental health nurses in a place where they can proactively contribute to service delivery.
This first blog is to stimulate early discussion towards developing a contemporary view of the work of mental health nurses and their potential for working in primary care. Secondary and tertiary care will be considered in later blogs and all outputs will be used to inform roundtable conferences from July onwards.
The paper and your responses will help to stimulate a twitter conversation on Monday 9th May. Please join us at #WeMHnurses at 8pm, Watch out for more information!

What’s our approach?

Working within a public health and preventive model of psychiatry allows us to test the actual and potential work of mental health nurses. Traditionally they are thought of as working in in-patient settings, early intervention services and recovery, it could be argued that this focus is limited. There should be a shift of view in which mental health nurses become more purposefully involved in PRIMARY PREVENTION (stop it happening) and SECONDARY PREVENTION (catch it early) rather than just TERTIARY PREVENTION (intervention, treatment and recovery). If this is the case, are education providers and commissioners willing to re-examine their curriculum? Who might employ them and what will their career pathway look like? Will the Nursing and Midwifery Council have a view on this?

Question 1. Is this a valid and useful way of thinking about the work of mental health nurses?
Question 2. How can we improve career pathways for mental health nurses in primary care?

The demand for mental health nurses working in primary care and primary prevention.

There are growing pressures to think purposefully about mental health and primary prevention. Discussions generated through Playing our part should help us determine the place of mental health nurses in such work. It is certainly at the top of policy makers and service designer agendas. Both left and right of the political spectrum have offered recent views on the importance of primary care. The Reform think tank has suggested that General Practice is overwhelmed with people who might well be better managed by ‘non-doctor clinicians’. The Government has promised to put additional investment into General Practice in England and part of this investment is likely to be put towards the better management of primary prevention and mental health. Interestingly there is talk of employing more mental health ‘therapists’ in primary care, yet previous attempts to use graduate mental health workers had only limited success and there are very few now in practice. Equally, initiatives using IAPT and Psychological well-being practitioners have been uneven with mental health nurses now picking up some of that work. Surely, this is where mental health nurses can play an important and increasing role? Although not asked for by name, mental health nurses might well offer an answer to pressures in primary care others have yet to consider.

What do they already do and what more might they do?

While it might be useful to relieve work pressures on General Practitioners and primary care services but it is also important to purposefully engage mental health nurses in integrated health prevention through early detection of potential self-harm, peri-natal care, alcohol misuse as well as diet and exercise. Active community engagement in developing recovery assets offers a fascinating opportunity for co-production and mental health nurses might lead on this. There are examples of them already working in primary care as liaison nurses, undertaking street triage, working with emergency services and the police as well as running community -based medication clinics. This is good work that can be further extended.
Large numbers of people attending general practices have psychological as well as physical illness. Anxiety, depression and more general somatic disorders can be expertly managed by mental health nurses and locating them in community and primary care settings allows early intervention with these difficult disorders. Research would suggest that working with individuals showing early signs of dementia is much more productive than waiting for increased problems of daily living and behaviour. Many people who have had previous episodes of mental ill-health attend general practice. Primary care and thus primary prevention is a proper place for on-going support from mental health nurses for those with continuing mental ill-health and chronic conditions.

Question 3. Is this an accurate description of the present work of mental health nurses in primary care?
Question 4. Are we missing something here – what else do you know and can share?

Who will employ them?

This is difficult and will depend in which country mental health nurses work. Given that general practice is largely a small business enterprise then would they want to employ mental health nurses? If, as in England there are commissioners then what help can they bring and what persuasions can they bring to bear? It might not be helpful for them to hold contracts with mental health trusts but if not them, then who? General practice nurses, health visitors and community nurses are good practice partners for mental health nurses but their own employment arrangements do not always offer useful examples. New arrangements may be needed.
What models of practice supervision might be necessary?
Clinical supervision is critically important for mental health nurses working in primary care and primary prevention. A recent editorial in the JAN laments the poor implementation and spread of clinical supervision by nurses and renewed efforts to use it are necessary for those undertaking new ways of working. Their more independent practice requires closer scrutiny and support. We would hope that Playing our part will help to re-stimulate the wider use of clinical supervision.

Question 5. What are the likely issues of employment and do good existing and alternative examples exist?
Question 6. How can clinical supervision for mental health nurses be more purposefully and constructively used?
Question 7. What if any continuing professional development might be needed to begin to place mental health nurses in primary care and prevention now?

And finally –

Question 8. For mental health nurses to properly play their part in co-designing policy and service development do they need a dedicated College of Mental Health Nursing to support them?

How you can help

When you have read this blog please offer your views and comments in the box at the bottom of the blog page. You do not need to answer just the questions posed here. Any comments are useful !
We will also be holding a twitter chat on Monday 9th May from 8pm and to join in please add #WeMHnurses to your Twitter favourites!

Twitter dates and blogs

We have organised 3 twitter discussion dates.

The first on May 9th will be about mental health nurses working in primary care, the second on secondary care will be on June 6th and the third on tertiary care will be on July 9th.

Instructions on how to join in and participate will be on this site and will also be posted by @cabutty and @FONScharity.

 

PLEASE JOIN US!

Mental Health Nursing Playing our Part -We are underway and have a plan!

What are we trying to do?
As services are continuously evolving and changing, our ambition is to describe how mental health nurses can play their fullest part in mental health care service delivery in primary, secondary and tertiary care.

How are we going to do it?
Through the Foundation of Nursing Studies, using traditional methods and social media we will
consult with people and families who use services, the nursing profession, other health and social care professions, statutory bodies, people of influence and policy developers. A first paper will be complete by August 2016 and following consultative conferences during September and October a final document produced by December 2016

How long will it take?
We anticipate that this work will be complete by December 2016

How can you be involved?
At the bottom of this page you will find a commentary section (or tweet to @cbutty or email to cabutty@icloud.com) . Please offer us your views, agreements and disagreements 

We will take notice!

What has happened so far?
A first meeting was held at the Foundation of Nursing Studies (www.fons.org) on Tuesday 29th March. A very non-representative  but nonetheless expert group met to fashion a practical way forward.  The group was Theresa Shaw CEO of FoNS, Tony Butterworth, Liz Hughes, Karen Harrison-Denning, John Baker, Alan Simpson, Ben Thomas, Mike Shaw and Ian McGonagle.
Tony introduced the purpose of the meeting and suggested that a likely timetable for work during 2016 would be that an initial consultation paper would be prepared by August 2016 based on discussions with key informants and twitter debates.
A final paper should be ready for circulation in December.The purpose of this initial meeting was to take advice and views about those who should be engaged and consulted, and what they might and should be asked about mental health nurses and their work.
Theresa explained how the Foundation of Nursing Studies offered a safe and positive  vehicle to locate this work given its Charitable objects to develop the work of practicing nurses. She briefly described some of the previous work  of  FoNS and then expressed her own commitment to this work.
Ben gave a broad overview of the policy setting into which the work might be set and explained the present activity being undertaken in the 4 counties that would need to be taken into account during the consultative process. This stimulated further discussion and intelligence sharing from all attendees. Discussions were helpful not to say exciting!
All the CNO’s from the four countries have been contacted. Further discussions are anticipated. A blog site was established 2 weeks ago and a first blog posted.
A commitment to electronic information and consultation as well as more traditional methods is taken as a given.
Tony asked  a few opening questions. Is work such as this necessary and important and should it continue? The view was yes it should, but there was extensive discussion as to how work should proceed. Tony said that there would be very few meetings and energy would be spent on consulting and engaging with key stakeholders. There was a general contentment that this was the right approach.
Mental Health Academics UK, the RCN, MHNA (Unite) as well as employers and individual Universities have an interest in the work of Mental Health Nurses. There was some discussion as who had the strongest ‘voice’ and it became clear that the fragmentation of interest although honestly found, did not lend itself to a strong central voice for mental health nurses. The dearth of continuing educational/professional development is alarming as is a lack of the presence of mental health nursing expertise in policy development and senior leadership of the speciality is poor.
So then, who should be consulted for an expert view on the work of mental health nurses. A first list of consultees was developed. And although by no means complete the entities listed below were offered as our ‘starter’.
RCN, MHNA, MHAUK, – MIND, Rethink, Mental Health Concern, Carers UK, UNISON – Country Chief Nurses Specialist Advisors, Directors of Nursing, NHS Employers/NHS Confederation, Royal College of Psychiatrists, Royal College of General Practitioners, leaders in Social Work and Psychology, Commissioners and Vanguard Leads, Mental Health in higher Education and Council of Deans. We would welcome more suggestions.
Tony will write to all those listed and ask for a principal contact for the purposes of our work.
We must prepare a first consultative paper by August in time for a series of consultative conferences. The paper will be informed by views from our own professional organisations and ‘expert others’. An active social media conversation will be launched and fed into the process. During September and October Conferences will be organised and held in 4 English locations and hopefully in the other 3 countries.

We would welcome your comments and opinions PLEASE
offer a view and any ideas you may wish to see expressed. There is a comments page here or tweet to @cabutty or write to cabutty@icloud.com.

Thank you
Tony Butterworth

Emeritus Professor Tony Butterworth CBE April 2016

Playing our part – the work of mental health nurses

There is little doubt that mental health services are in serious difficulty in the UK and well reported reviews of service delivery have described shortcomings and poor responses to vulnerable people who need professional help and supported interventions. Service redesign and restructuring are attempting to alleviate the situation and further funding has been promised to make a difference. Nonetheless, the professions working within mental health services also have an obligation to clearly describe their work and look again at their contribution to service delivery. Mental health nurses area key part of service delivery.
The Foundation of Nursing Studies (fons.org.uk) will be examining the work of mental health nurses during 2016. It is important that this largely graduate profession can clearly articulate its expertise and identify key places in the delivery of mental health services where it can best serve the public. The Foundation will be working with the profession to make this happen.
A first scoping meeting will be held in London on Tuesday 29th of March and of course all views and ideas are welcome. Following a press announcement that the
Foundation of Nursing Studies would undertake this work there have been multiple suggestions as to who should be consulted, what specialities should be considered and how the work should progress. Scope and focus will become more clear following our first March meeting and we will use this blog site to communicate more publically, report on progress and ask questions. It would be easy for the Foundation to be pulled towards an attempt to solve all the ills of mental health services, the complexities of safe staffing, the obvious need for more money and the endless demands of questionable service reorganisation but our focus at this point in time must be on the profession. It is likely that we will focus INITIALLY on :-
1. Is the educational preparation of graduating mental health nurses ‘fit for purpose’ and are the teaching and supervising workforce (in Universities and in practice) capable and able and is it available?
2. What elements(s) of educational preparation should be ‘generic’ for all nurses and ‘particular’ to mental health nurses.
3. Does mental health nursing offer value to people who uses services in primary, secondary and tertiary settings?
4. Is this value seen and understood by people who use services and their families?
5. Are commissioners and employers aware of and persuaded by the outcomes of the work of mental health nurses?
6. Is a clinical career pathway well enough defined for mental health nurses and are they taking sufficient advantage of clinical academic career development opportunities?
7. Is continuing professional development sufficiently contemporary and is it available?

ALL COMMENTS AND SUGGESTIONS ARE OF COURSE WELCOME!

Tony Butterworth