The story so far —-

During 2016 The Foundation of Nursing Studies (fons.org.uk) is examining the work of mental health nurses across the UK. With competing demands to respond to national mental health policies, nursing strategies as well as educational and workforce re-deign it is essential that graduate mental health nurses can articulate their own contribution and describe a forward view for mental health nursing and their work with people who use services.

Following an initial scoping meeting in March 2016 and by using a platform of informing blog papers on the site mhnurses.wordpress.org, three Twitter-based conversations were held in May, June and July 2016. When data were exposed to thematic analysis five overarching outputs emerged from these social media conversations
– Education and training
– Employment, staffing and capacity to improve
– Creating and managing therapeutic environments, engagement with people and building design
– Care systems – the contribution of MH nurses
– Mental health nursing identity
A conversation paper was developed and has been used as a basis for 9 roundtable conferences across the UK. These will be complete in December and outputs from all of them can be found on this blog site – please see all the posts from each event on this site.

We have presented our work to a conference of 500 mental health nursing students in October and will meet with the Standing Conference of Nurse Directors in November.
We organised a roundtable event for senior mental health nurse educators and the outputs from that are on this blog site. It was most encouraging to note that a purposeful and evidence- based curriculum can now be quickly developed. Our work will be complete by the end of 2016 and a first draft report will be made available for critical consultation in January 2017.
It is likely that our report will include suggestions for some necessary work to take the profession forward and it is pleasing to note that collaborative work with the Royal college of Nursing and with Mental Health Academics UK is already underway.

Tony Butterworth, Chair, Foundation of Nursing Studies

Playing our part – outputs from a group of expert mental health nurse educators

Background
As part of our work with mental health nurses The Foundation of Nursing Studies (FoNS) hosted a roundtable conference for mental health nurse educators on Monday 31st October at the Kings Fund, London. A group of senior academic teachers from across the UK met to discuss the present and future education of mental health nurses.
The day was informed by a FoNS paper from the blog site – mhnurses.wordpress.com, developed from the thematic analysis of three social media events conducted earlier in 2016. In that paper and in several conferences since, it has become clear that the pre-registration and post-registration education of mental health nurses should be analysed and reframed to best equip nurse to work effectively both today and tomorrow. ‘Generic nurse’ models being promulgated by regulatory and non-regulatory Government bodies particularly in England raise important questions about the nature of mental health nursing and how best to prepare students to work in services being constantly redefined and changed. The work of graduate mental health nurse is common to all countries although the shape of servcies and policies will have differences.

7 significant outputs from the meeting

Participants were in no doubt as to the importance of properly describing mental health undergraduate education and identifying the uniqueness of the work mental health nurses.
1. It was agreed that mental health nursing is very particular, and is different to other more generic nursing activity

They were clear that It is possible to articulate that difference in a way that uses evidence from social and behavioural sciences, from evidence based interventions and from the interpersonal and experiential approaches that are now well enough known and can be described.
2. There Is a well-found evidence base to curriculum content that is specific to specialist mental health nursing activity

In describing the work that mental health nurses do, it is possible to describe their activities within areas of expertise such as skilled and sustained engagement with people in distress or with those resistant to interpersonal exchanges because of their illness.
3. Working with and alongside people on a 24 hour basis who are vulnerable and distressed as a result of their mental illness is a particular and high level skill offered by mental health nurses

Mental health nurses have been in the vanguard of developing services, creating therapeutic environments and offering interventions that are innovative, safe, productive and accessible for example – star wards/safe wards, Thorn PSI training and Admiral nurses.
4. Mental health nurses have created and regularly use evidence-based interventions in their work – students on undergraduate programmes should be introduced to these skilled processes.

Mental health nurses are working productively in primary care in accident and emergency centres and with other agencies such as the police and ambulance services. While calls for ‘more training’ for general practice nurses, prison and police services are frequent, the combination of their own expertise and that of mental health nurses adds new dimensions to multidisciplinary working. There is evidence based output from such work and students must experience it (if possible) or at least understand the benefits to those at risk.
5. The potential for graduate mental health nurses working in a variety of settings closer to those at risk and using their particular expertise collaboratively, must be better understood and utilised.

The group were convinced that the role of critical reflection and clinical supervision has a firm place in the work of mental health nurses and that it is much more than a reflective conversation that can be seen for example in professional re-registration processes. Students must be exposed to dynamic models of supervision throughout their education programmes. There are models that can use a ‘closed group’ social media platform to learn from these valuable insights and experiences.
6. Critical reflection and clinical supervision is part of the everyday work of mental health nurses. Students need to be familiar and comfortable with its processes and practice.
There was extensive discussion on the capability of mental health nurses to create therapeutic environments and the use of psychological therapies in settings in which mental health nurses operate. A tendency to undervalue this demanding and difficult work was concerning.

7. There was a view that all nurses and carers should understand and use mental health ‘first aid’ techniques and that should include graduate mental health nurses. Work relating to acute in-patient settings, care in the community, care in people’s homes and with particular groups (elder care as well as children and young people) requires a particular and more advanced skill set.

The shape of the meeting
Following a short introduction on the work of the Foundation of Nursing Studies attendees were asked to think about a series of questions relating to the education of mental health nurses. Participants offered their expert views on each and then rated the outputs as to importance and relevance.
Some questions asked
Questions were crafted around
1. How do you prepare students to uniquely become mental health nurses?
2. How do you teach students to create and manage care settings?
3. Do you think undergraduate students should be exposed to basic psychosocial intervention skills?
4. What core therapeutic skills must undergraduate mental health nurse students acquire?
5. Do you have a view on mental health first aid?
6. How is the acquisition of skills assessed in you programme?
7. Are there particular skills need in dementia care?
Table conversations produced ideas and views that were displayed to the whole meeting and then rated as to value and importance by individuals.

Some other top rated points from each area

Preparation of students
Careful and purposeful recruitment, developing capacity to tolerate uncertainty, being unafraid to challenge, enhancing political awareness, developing professional identity, being sensitive to and using ‘social and emotional intelligence.
Teaching the management of care settings
Being able to resist doing the things that are ‘always done’, challenging conventional perceptions of risk and discussing with service users, being sensitive to organisational cultures, understanding socialisation but maintaining critical companionship, positive role-modelling.
Core therapeutic skills must students acquire
Co-production in care planning, capability to form relationships/alliances but managing boundaries, care based on evidence -based practice, skilled bio-psycho-social assessment skills, critical thinking related to service delivery, understanding supervision and psycho-social intervention skills. MHNurse education aims to understand, use and translate complex medical information and in doing so support shared decision making, safe medication reconciliation or the management of certain behaviours. Experiencing and using these interventions requires the application of biological as well as psycho-social knowledge.
The need for basic PSI skills as part of a therapy toolkit
A need to understand the use of evidence based interventions (PSI, DBT etc) , helps with recovery, stability and understanding complex medication management strategies. It is challenging to fit into a curriculum but there is a need to experience in practice if possible.
Views on mental health ‘first aid’
a positive frame of reference for all health workers, need to understand mental health literacy, important when working with other non-health services, challenging to MH stigma, helpful in building confidence for all public services.
Measuring the acquisition of skills
Formative skills simulation, some assessment involving service users, a need for properly qualified assessors, testing of appropriate behaviour and attitudes, a willingness to fail students.
Particular skills in dementia care?
The group thought that this was a hard question to answer. There are significant strides being made in public awareness of dementia but a need for students to ‘work with purpose’ in dementia is important. This was an area where the physical and mental health needs of people demanded skilled interventions across the board.

Participants were asked about the value of having a standing conference on mental health nurse education. There was considerable support for such a group. It could be ‘nested’ within Mental Health Nurse Academics UK.

Tony Butterworth November 2016

MH nurses ‘Playing our part’: a roundtable debate in Belfast Wednesday 6 November – some headlines from the day

INTRODUCTION

Individuals identified themselves and offered one thing people wouldn’t know about them.

Tony Butterworth outlined the purpose of the event. The only one being conducted in NI.

Series of twitter based conversations, now taking round table discussions across country. Aiming for a report in place by end of calendar year.

Aim is to identify and create work streams with recommendations to continue to raise profile further

Senior people in MH asking what can be done, to inform the future of working effectively as a graduate MH nurse?

Working with independent charity, FONS.
Some asking why doing this? Provides an independent voice.

MHN is a graduate profession therefore want to be/ should be involved and influential in managing our future and how to best contribute to nations health and policy agenda Speaking to other disciplines, recognise need for graduate MH nurses, but not aware how best to employ them . Want to be able to say these are the skills, this is what we can do, and this is where we fit in.

3 social media events. Using #FoNS and #mehmns. All papers based on the web blog site mhnurses.wordpress.org
Key emerging issues: five themes informed the days activities
Education
Employment
Therapeutic environments
Care systems
MH nursing identity

Aim of today, speak openly, critically and discuss what MHN is and how to strengthen skills.

The ‘outputs’ presented here are brief and in headline format – much more detail underpins them

ACTIVITIES
Use of small groups to identify the top statements (these were rated with each individual using five spots each per theme page)

1.What do we already know about what mental health nurses do ?

1. MHNursing is a transformational relationship rather than a transactional relationship
2. MHNursing offers the chance to be a ‘named nurse’ which is important for continuity of car, it is a ‘constant conduit of care
3. MHNursing can be overburdened with admin and bureaucracy
4. MHNurses approach care holistically based on an understanding of mental ill health and its impact(s)
5. MHnurses have the capacity to intervene therapeutically and with purpose

2: What would you like mental health nurses do differently?
1. MHNurses being ‘around the table’ and influencing the development of care systems
2. A purposeful enhancement of PSI skills
3. Pay more attention to improving physical health outcomes linked to anti-psychotic meds
4. Become more outcome focussed
5. Be more purposeful in formulating care using carefully assembled data

3: What are the new things we should be doing?
1. developing a clinical career pathway
2. enhancing evidence based interventions
3. Earlier interventions with people in need
4. Moving the workforce closer to primary care
5. Changing from directive styles to more coaching/facilitating

4: Education of mental health nurses
1: More Standardisation of curriculum, assessment and outcomes
2.More on medication management and man’ment of side effect
3.Consistency and progression of clinical placements
4. Understanding and recognising the specialness of MH nursing
5. Some emphasis on prevention as well as treatment
6. Educators need to deliver more in the clinical environment
7. Undergraduate progs should provide a ‘toolkit of skills

5: Employment of MHNs
1. GPs should have access to MH Nurses
2. Enhance access to schools and occupational health
3. Enable rotation across different services
4. Develop clinical carer pathways
5. Develop early intervention teams and encourage MH nurses working in A&E and Prisons
6: Professional identity
1. Being able to articulate interventions clearly
2. Develop a language for person centred- holistic engagement
3. Create a structure for advanced practice
4. ‘Regain the edge’ in psychological engagement
5. Restoration of the model of ‘context’
6. Raise the profile of MH nursing with the public
7. Parity of esteem and valuing MH nurse work

Any other issues/matters of interest?
It was very pleasing to see the active establishment of ‘recovery colleges’ in NI – they provide a very positive working model for organisational change, access and recovery

Round table event- Fieldhead, Wakefield November 7th 2016

Attendees:

16 people attended the round table event. Attendees represented an extensive background associated with MHN ranging from professors of mental health research, directors of nursing departments, lecturers and practising specialists. One research associate was present to take notes.

Building upon the previous success of several social media events and other round tables in which evoked a variety pertinent themes associated with mental health nursing (MHN) such as education and training, employment, staffing and capacity to improve (to give a few examples); the current roundtable is dedicated to building upon these issues of concern in a format dedicated to comprehensively discussing these issues. These discussions would be presented as a list of statements on post-it notes. As a group collective, attendees were to dot which statement they felt were most pertinent to the topic. These were ranked.

Question 1: What do we already know about MHN Nursing ?

1. No strong sense any more of professional identity
2. The expansion of the role has led to blurring of the role of the mental
health as we span across the MDT
3. Difficult to articulate to the general public who we are and what we do
4. We are of great value to those we work with and their families and other
care providers
5. Jack of all trades
6. Passive
7. Collaborative decision making
8. Lack confidence in decision making
9. Largest workforce in mental health
10. Brokering of relationships
11. Mental health and its attached stigma can affect the view of people in
mental health including mental health nurses
12. Lack of national leadership
13. 50,000 UK
14. Invisible profession
15. Mental health nurses are flexible and complete practitioner offering a wealth of resources
16. Call self-everything but a nurse
17. Confusing titles
18. It is difficult for us now to articulate who our client groups are, as the whole breadth of emotional distress becomes ‘mental health’ (rather than people who may have been traditionally termed mentally ill’
19. Removal of senior leadership in senior environments
20. Supportive and compassionate
21. Different types of advanced role in different organisations
22. Different ideologies about mental health nurses (sometimes driven through academics) can be driven through pre-registration training to develop the next generation
23. Interchangeable
24. Become more custodial or one hand but patients have much more choice
25. Nurses undertake positive risk-taking but are stopped by others in MD
26. Still entrenched in secondary care and a subsequent lack of focus on wellbeing preventive work

Question 2: What would you like mental health nurses to do differently?

1. National leadership must improve the identity of MHN, MDT leaders
2. Commonality and consistency. Need core role defined then specialise
3. Be less defensive
4. Treating ourselves as equal amongst other professional groups
5. Promoting and reinforcing the role
6. Have specialisms and occupy these roles. Have accreditation for what is done by MHN.
7. Have more of a collective voice
8. Look after the MHN rather than others
9. Have increased training for higher severity clients rather than lacking compassion (i.e.: personality disorder)
10. Develop skills to meet higher acuity and increasing complex cases
11. Ability to work across roles flexibility
12. Protect people
13. Value MHN and make sure our needs are met
14. Understand the need to deliver service with flexible practitioners whilst at the same time enabling nurses to have specialist interest and develop their careers along a pathway
15. Increase awareness of sub-specialism
16. Be innovative – take more (not clinically) risks and be brave professionally with regard to service development and research
17. Be more politically active
18. Increased national presence
19. Ask for job plans and CPD parity with medical colleagues
20. More cohesion
21. Higher profile
22. Manage our boundaries: spanning roles better
23. Invest in new staff (emotional and time)
24. Demand appropriate resources

3. Question 3: What are the new things we should be doing?

1. Know where we came from: what our legacy is going to be. Appreciate the history and cultural context from which MHN profession has come from
2. Be more politically astute and business minded
3. Be in senior nursing posts (RCN and NMC)
4. Preventive as still embedded in medical model
5. Physical health to be an absolute not an option
6. Do more to work on public perception
7. Say ‘no’ in order to define the MHN role
8. Primary care should be needs based
9. Not enough learning from when things go right; focus to much on negativity as they prompt enquiry
10. To make every contact count as a profession
11. Louder voice STPs
12. Network on a national scale
13. Recognise and value one treatment they are already delivering
14. Need to better respond to psycho-social needs
15. Louder voice at CCG meetings
16. Actively engage with families (rather than devolve)
17. Challenge the MHA + MCA
18. To join properly with the nursing family
19. More deprescribing
20. More R/Cs and A/Cs as MH nurses
21. Work in wellbeing and preventative services (especially with children and young people) when they are not unwell
22. Define generic
23. Inreach as clinical leads in care homes
24. Be more entrepreneurial
25. identify gaps in provision and services
26. suggest ways nurses could provide help with gaps in nurses
27. Train GPs
28. Work in other areas such as cancer services

4. Question 4: The education of mental health nurses.

1. CPD to fulfil role requirements and how it enhances care
2. Keep nurse education free
3. Need to bring the real world of clinical practice into the HEI
4. Skill people up to recognise opportunities for their career
5. First and foremost, individuals are students of nursing
6. Critically examine other modules of healthcare education seeking to take the best of the HEI’s and practice experience and keep them
7. Should there be adult mental health dual registration – would the need to be a 4-year course.
8. Culture is very powerful ad how people fit in. Newly registered staff should be encouraged to challenge and innovate rather than become side-lined and unpopular
9. Pre-registration standards should have core mental health competencies for all pre-registration nurses
10. Undergraduate courses are regulated while advances practice is open to interpretation
11. The involvement of clinical mentorship would increase the credibility of MHN education
12. Career pathways for research active clinicians must be improved with increased flexibility
13. Address deficits in clinical practice by partnerships with clinics for real world experience
14. Tutors in practice

Question 5: The employment of mental health nurses

1. NHS image and reputation has been tarnished
2. Need to make role of MHN more attractive
3. When thinking about employing you also need to think about retention
4. Look at non-nursery tasks – devolve to others (such as admin) then would enhance the identity of MHN
5. Primary care is associated with isolation and demand likely to be in response to crisis
6. Increased visibility of MHN employed in GP practices
7. Address remedies for potential burnout
8. Allow and potentially encourage career stoicism; advanced training may not always be wanted or desired.

Question 6: The professional identity of mental health nurses

1. MHN are the therapeutic tool rather than specific skills (ability to set up a drip)
2. There should be an increase in comprehensively understanding who is coming to the profession and understand what they are bringing and how they will apply it to shape the future of the profession
3. We are defined by the most negative (and arguably the smallest part of what we do) this needs to be readdressed
4. Need to articulate own MHN contribution to care delivery
5. Opinions about MHN and the image of this should be managed
6. Problems of perceived identity
7. Collective identity conflates MHN identity issues
8. A champion to help coalesce MHN identity
9. Format and create cohesion within MHN identity and address this with new nurses
10. Wounded healer and lived experiences

Playing our Part – Roundtable event, outputs from Camden and Islington October 19th 2016

Attendees: 17 people attended including nurses at band 6, 7, 8a, 8b, two directors of nursing, one associate professor from a HEI, a representative from Healthy London Partnership, one student nurse, one service user representative. Two research associates were present to take notes.
Introduction:
Professor Butterworth provided a presentation outlining the background to the roundtable events. The Foundation of Nursing Studies (FoNS) in collaboration with the WeMHNurses group hosted three twitter based conversations discussing the work of mental health nurses in primary, secondary and tertiary care. A thematic analysis of three twitter based conversations was conducted by Dr. Ian Holt and eight emerging themes arose. These themes were then used to guide the discussions and topics for the roundtable events.
This is the second of eight planned events taking place during October and November across the country. These events are aimed at providing a platform for key mental health nursing stakeholders to discuss key issues within the profession. Initial findings from the events will be presented at two conferences. A final report based on the overall findings, recommendations and future directions will be produced early next year.
The layout of the meeting was then outlined to attendees and group discussions began.
Group discussions
The groups were asked to discuss the main themes which resulted from the twitter analysis. The discussions lasted between 10-20 minutes. Researchers were seated at 2 of the 4 groups and their purpose was to take notes of the discussion to contextualise some of the statements and key themes.
A list of statements were produced by each group and written on post-it notes. These were then collated, and placed under the relevant theme heading. Each participant then placed a dot on the statements they felt were most pertinent to the topic (see pg. 5-10) and the top ranked statements are listed on pages 10-11.

What do we already know about mental health nurses?
• Nurses are comfortable with illness and challenging behaviours
• Nurses are resilient
Two of the most popular statements related to the personal qualities of mental health nurses. People who choose to be nurses appear to be comfortable with human distress and have the capacity for compassion and are caring by nature. Mental health nursing was also viewed as more than just a job; it was perceived as a vocation and different to your average job.
• Containment
• Assessing risks and keeping people safe
The next most popular statements seemed to reflect the specific skills that nurses use in their roles. These included very practical skills, such as; administering medication, knowledge of mental illness, assessing risks as well as the personal skills used to manage distress, for example, de-escalation and talking therapies.

What would you like mental health nurses to do differently?
• Mental health nurses to do more nursing related research as part of their role
• Be more vocal and articulate when describing what they do
• Occupy more leadership positions
The most popular statements within this discussion related to the desire to improve the status of mental health nursing and mental health nurses. There was a wish to take on roles which have traditionally been seen as the remit of psychiatrists and psychologists, such as; non-medical prescribing and positioning themselves as therapists.
It was felt that nurses needed to occupy and create more leadership roles within the profession at both a local and national level.
Research was seen as very important to provide an evidence base for the profession, thus increasing their status and aiding in articulating what they do to other medical professionals.

What are the new things we should be doing?
• Branching out into non-traditional roles and settings e.g. police cells, primary care
• Desire to modernise mental health nursing e.g. to use innovative technology within their roles.
• Move to co-production and working alongside service users in training and in practice.
There was some repetition from the previous session pertaining to leadership roles, being more vocal and taking on greater responsibilities, such as prescribing. With regards to new directions for mental health nursing there was an emphasis on the need to branch out of mental health services and occupy a space within primary care and police services with more focus on prevention. However, there was a concern about inpatient nursing and how this was an area requiring improvement.
It was acknowledged that co-production is going to become a necessary part of mental health nursing from training to working alongside service users.
There was an interest in working with new technologies which improves the service which can be provided, for example, skype consultations, use of video conferencing for CPA meetings to allow family members to attend etc.

The employment of mental health nurses.
• Pathways and career progression
• Potential for STPs to trial a model of flexible practitioners
• Cost of living in London and providing financial incentives
• More rigorous revalidation threshold
There was lots of discussion relating to the need for more clarity in the available career paths for mental health nurses and the need for more senior clinical roles (not managerial).
The concept of flexible practitioners was raised in various different ways, in particular the desire for rotational models of employment was highlighted which would allow nurses to move between different settings, specialities and roles.
It was mentioned that nursing pay scales should be higher to attract people to the profession and also to high-cost areas by providing further financial incentives.
A discussion surrounding the quality of the workforce came up in numerous ways, including the need for a more rigorous revalidation process.

The education of mental health nurses.
• Joint clinical/academic posts
• More consistency in training and core competencies
• More service user involvement in education and development of training
• Preparing mental health nurses to work in specialist roles e.g. CAMHS, forensics
Increasing the number of roles available to nurses to allow time and recognition to academic and research activity within the profession.
The topic of the content of the training was highly contentious. There was little agreement on whether the courses should be standardised, whether the course provider should have the flexibility to choose the structure and content of the course and whether a common foundation model should be used, with further specialisation in mental health. It was also mentioned that there is a lack of placements within specialist settings, for example, it was noted that newly qualified nurses may not feel competent to work in CAMHS.

The professional identity of mental health nurses.
• Specialist roles: would that create a stronger or weaker identity?
• Need for senior clinical posts
• General uncertainty of what the identity of mental health nurses is
There was general agreement that nurses need to be more confident in their professional identities, clarify exactly what is unique about their profession and to articulate this within the mental health field.
It was questioned as to whether specialist roles would create a stronger or weaker professional identity. It was clear that there was a desire and a need for clinical leadership roles to mentor and inspire newer nurses.

General discussion and closing statement
Several people raised the issue that there should be a more positive approach to developing the profession rather than focusing on the failings. It was mentioned that there should be a focus on learning from what others in the profession do well and how this can be used to strengthen the field.
The top ranked statements were as follows:
Statement
More research (nursing research) and study as part of our role
Be more vocal and articulate/describe what they do
Containment
Being comfortable with illness and challenging behaviours.
Pathways and career progression.
Joint clinical academic posts and clinical academic career pathways.
Specialist roles – stronger or weaker identity?
Senior voice- clinically relevant- dissemination and feedback.
More service users involved at designing and developing training at every stage.
At risk of loss of identity due to so many different roles.
Unique selling point? What do we do that others don’t?
Highly banded clinical posts have been reduced should be increased e.g. practice development/ nurse consultant.
Prescribe medication.
Potential for STPs to trial a model of flexible practitioners.
Preparing RMNs to work in other areas, such as; CAMHS, dual diagnosis, D&A, L.D, forensic etc.
Introduce flexible and innovative degrees e.g. psychology & nursing, MH nursing & social work to change branding of nursing.
Assessing risks and keeping people safe.
25% are over 50. Ageing population.
We are resilient.
Occupy more leadership positions e.g. Health Secretary, Chief Executive.
Positioned in police cells, on the beat, British Transport Police, MH awareness training.
More technology that works and improves efficiency.
How to manage under-performing staff.
Content of pre-registration training should be standardised up to 80%.
Seniors should work clinical hours as part of their regular hours to stay relevant/mentor junior staff and motivate.
Are we seen as a profession with good career pathways and options?
Talking & therapies.
Better recruitment – trial of job first.
More co-production with service users.
Inpatient specific training and career pathway to make working on wards more attractive
Cost of living in London- financial incentives.
Improved feedback from universities & service providers.
Caring.
Diverse careers, roles and practice.
Unclear identity.
Challenge: system, perceptions, status and others.
Head services and teams.
More evidenced based and research (with direct engagement of the profession).
Confidence in decision-making (and authority).
New roles: non-medical prescribing, primary care, talking therapies, schools/universities.
New models of working.
Innovation should be incentivised e.g. flexibility within roles.
More rigorous revalidation threshold.
Creative partnerships between sectors and agencies.
Rotations across sectors; social care, police, private sector.
Education needs more uniformity and consistency of core skills, but still keeps flexibility to create more specific/unique training.
Confidence in our identity and greater clarity about our identity professionally.
Positive media campaigns – MH nurses are here to help.
Academic identity and status: where would we position BSc, PG Dip., MSc, and Doctorate/PhD?
Interest in people.
Struggle to articulate role.
MH nurses are often frustrated by having to deal with heavy workload of paperwork to the detriment of therapeutic activity.
MH nurses work with only 5% of people with serious mental illness.
Hope.
Prioritising and valuing the core of the patient- knowing the patient’s story.
Less office based.
More solution focused (less orientated to problems).
Use a model of health promotion throughout life span.
Positioning ourselves as experts and therapists.
Remembering we are a graduate profession.
Nurse prescribers.
Better management, training & development and clinical leadership.
MH nurses should be accountable for care – use responsible clinician role.
More therapeutic education, delivery and use in practice.
Rotations across different employers – how to make this happen?
Trial in job before signing contract.
Articulate clearly the role of MH nurses in primary care.
Understanding what students want from employment? Expectations?
New role -How does that happen-How do we sell ourselves.
More structural pathways and management of careers.
Discrepancy in banding – lower paid than therapists for the same job.
Loss of bursary.

Playing our part-some feedback on our Roundtable event at the ‘Curve’ centre Greater Manchester on Monday October 24th.

Introduction

We are well underway with our nine ‘Roundatable events’ that we promised to undertake following the twitter activity previously reported here.

Our Manchester event took place on October 24th at the ‘Curve’ Prestwich Hospital . Sincere thanks for hosting and organisation must go to Celeste Foster, Tim McDougall and Steven Pyjmachuk. Big thanks are also due to the attendees who gave so generously of their time. I have received a detailed feedback from Steven and it will go towards an analysis of all our roundtable activity and outputs taking place over the next 8 weeks. Some key messages are listed at the end of this blog but clearly there will be much more to say later.

Structure of the event

We followed our usual half day programme in order to have consistency in all our events.

  • Introductions and Welcome – Tony Butterworth
  • Small group discussions and debate in 3 areas – things we already know about mental health nurses – some things we would like mental health nurses to do differently – some ‘new things’ we would like mental health nurses to do
  • Feedback and agreement on a ‘list’
  • Small group discussion and debate in 3 further areas – Education of mental health nurses – Employment and mental health nurses – Professional identity and mental health nurses
  • Final round up discussion and agreeing key mesages

Some key outputs and messages

  • We aspire to be nurses who spend time with services users but struggle with the demands of ‘defensible practice’.
  • Frustrations with the quality and quantity of pre-reg education.
  • Get better at naming, explaining and feeling proud of the craft of MH Nursing
  • A need to move around different clinical specialities (eg adult to CAMS)
  • Undergraduate education is only the first part of being competent
  • Needs and issues must be reflected in pre-reg educaton – walking in the shoes of others – ie people who use services
  • Pride in being a mental health nurse
  • A need to stregthen the voice of MHNurses
  • Work opportunites should be further created in primary care, schools and General Practice
  • Some clarity/research needed that graduate nurses lead to better patient outcomes
  • Retain a specialist route for mental health nursing
  • Greater involvement of service users in pre-reg education
  • Can we create a more up to date ‘school of nursing’ model linked and joined to Univestities?
  • Practitioner burnout must be taken seriously
  • An urgent need for MHNurses to be more actively engaged in policy development
  • Do we need a ‘College of Mental Health Nursing’.
  • This is a very abriged version of events and there is much more to come – watch this space.Tony Buterworth October 2016

Playing our part – LSBU event October 3rd 2016

15 people present: Students, preceptors, nurse educators, researchers, Peoples Academy (lived experience), practitioners and consultant Psychiatrist,

INTRODUCTION

Individuals identified themselves and offered one thing people wouldn’t know about them.

Tony Butterworth outlined the purpose of the event.

First of eight round tables across country

Series of twitter based conversations, now taking round table discussions across country. Aiming for a report in place by end of calendar year.

No other profession would allow others to tell the profession what should be doing.

Aim is to identify and create work streams with recommendations to continue to raise profile further

Senior people in mh asking what can be done, to inform the future of working effectively as a mh nurse?

Working with independent charity, FONS.
Some asking why doing this? Provides an independent voice.

MHN as a graduate profession therefore want to be involved and influential in managing our future and how to best contribute to nations health and policy agenda

Speaking to other disciplines, recognise need for MH nurses, but not aware how best to employ them . Want to be able to say these are the skills, this is what we can do, and this is where we fit in.

3 social media events #wemhnurses, blog site.
Thematically analysing this
Key issues: five themes informed todays activities

Aim of today, speak openly, critically and discuss what MHN is and how to strengthen skills.

Who looks after the interests of the MH Nursing? RCN president summit meeting, to look at how this can be achieved with greater emphasis. Any specific MHN association has all now gone

ACTIVITIES

Use of group identifying the top five statements (with five spots each per page)

1; What we already know about what mental health nurses do?

1. Re-emphasising the notion of mental health nursing being a vocation
2: Enablement: cannot measure like Psych and Psychiatry, but skill to enable others
Being human, is part of this
Giving of self , (giving away of gifts) not just science and measurement,

3: Concentrate on cause rather than just treat or work with symptoms, see the person as a whole person. Working with their whole network. Empowering and enabling others

4: Interventions: interpersonal, biological, therapeutic, assessment, social, care co-ordination, medications, advocacy,

Look at resources such as:
Marian Jenner’s narration in RCN resource, Keep it in mind..
Ben Thomas’s chapter : What is Mental Health Nursing – as Sensitive attachment of other. An emotional anchor.

2: What would you like mental health nurses do differently?

1: Like to know more about understanding people’s physical wellbeing better.
2: Engagement with people who use service s – continuing emphasis on those who are our partners, bottom up change/activism
3: Looking after ourselves and each other – through clinical supervision
4: Nurses shy about speaking up – contribution is often not well articulated to others
Take to other round tables – speaking out for clients I know what is right..
Thorn course, talking to people properly… not happening in acute settings
5: Nursing language –
Evolution, revolution in terms of what is and what needs to be
Students enthusiasm, being eroded, by current regimes..

3: What are the new things we should be doing?

1: Clinical academic careers- lack of pathways to match requirements of people wanting to remain clinical and do research or management etc
Need to revisit and emphasise this as important.
2: Like to challenge current practices, why are we doing it this way
3: More CPD opportunities – life long learning and professional development
Eg Thorn programme and how it informed contemporary practice

4: Education of mental health nurses

1: Placements – are we sending students to the right places? Placements that inform a students development – rather than slotting, mentors also need more attention and help as burnt out.
2: Placement based assessment – need to link closer to what learning
3: Whole team involved in teaching – working in a learning organisation: take to Directors of Nursing/Council of Dean

5: Employment of MHN

1: Bring back nurse development units, practice development units
2: Opportunity for providing reflective practice – in workplace
Reflective practice – supervision
3: National funding – for roles working outside public sector organisations
4: Rotational posts – so that people don’t stagnate and burnout

6: Professional identity

1: Connecting far afield: transition between students and qualifying – when students felt aware of national agenda, when working then become isolated and inward looking. Wanting to be worldly wise – as students are able to access and read widely, when take up employment become localised
2: Celebrating MH achievements – writing up what goes well etc
3: Stronger MH voice at RCN
4: Being proud advocates; for the profession

Do we see ourselves in MHN aligned with who we look after, or are we slipping to medical/psychiatry dominance again??Ministers disappointed recovery approach is not more embedded?

Any other issues?

• Want this work to go somewhere – lack of leadership in MHN
• Role modelling – wellbeing side of things – nurse consultant leads on health prevention (smoking cessation) – new roles are out there – how they come about I don’t know
• For us to stay well, nurses need to stay well
• Always nice to sit with different people, be able to have honest conversations – very important
• Running a trust based clinical supervision project, so needed in practice
• Really useful to have time to listen to those with more experience and reflect on own early career
• Made me proud to be a mental health nurse

Next steps

1: Start to identify some workstreams

• POLITICAL Working with the RCN
• EDUCATIONAL Taking feedback to nurse educations (Son of Thorn)
• CLINICAL-PLACEMENTS : employers – and educators working together with social care and CCG/GPs etc.. other disciplines/ judicial system etc.
• ARTICULATING MENTAL HEALTH NURSING PRACTICE EXPERTISE: how to read the room/risk –the giving our gifts away/lacking a voice, 14 steps /safe wards/ starwards

Top ranked statements are:

Challenge current practices- asking why? (13)
General mental health rotation across whole organisation (11)
Connecting with wider colleagues from further afield (11)
Stronger MH voice at the RCN (10)
Celebrating MHN achievements how can we do better at this? (10)

How do we see ourselves, who, what do we identify with? (8)
More CPD opportunities (8)
More CPPD opportunities, training in psychological techniques and models for supervision (8)
Looking after ourselves and each other (8)
Define therapeutic language and engagement with service users as co-partners (8)

Reflective practice: action learning sets (7)
Whole team teaching (7)
Value of placements – length and variety (7)
Placement based assessments, bridge theory with practice (7)
A job not a vocation (7)

Are we sending students to the right placements? (6)
Nurse lecturers spending more time in practice (6)
Training psychological techniques and models for supervision (6)
Concentrate on cause not just symptoms (6)
Family work, Thorn Course, Psychosocial interventions (6)
MHNs in every GP practice across the country (6)

Clear development pathways and updated knowledge (5)
Mental health nurses in schools (5)
MH nurses in GP practices and schools (5)
Being human – more human (5)
Putting our knowledge through our clients (5)

Power of observation – able to read a room, able to recognise rick, able to communicate (4)
Being advocates for the profession being proud of what we do (4)
I haven’t been taught to be confident to stand up for myself (4)
Opportunity to create clinical excellence (4)
Quality of students needs to be improved (4)
Assessment skills, mental health, physical, social needs (4)
I know the patient – ask my opinion (4)

Participate more in design of services environment, education (3)
Working far more in primary care (3)
Linking with other services and professionals (3)
Much more emphasis as recovery approach (3)
Partnership working with service users, teaching, role modelling, and co-regulating (3)
Custodial, authoritarian, dictatorial? (3)
Open and honest conversations in the workplace (3)
People staying in same job too long, lack of wider experience (3)
Spend most of our time with clients, so are responsible clinicians (3)
Open and honest conversations in the workplace (3)
How to tackle institutionalisation (3)
Pride in our profession – sharing what we love about our careers (3)
Needs to stay as a graduate profession (3)
Political awareness and activism (3)
Reflective space and regular updates (3)

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.