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 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.
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
- 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.
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.
- 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.
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.
- 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).
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.
- 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.
- 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.
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.
- 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.
- 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.
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
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?