What are we trying to do?
Outputs from this second blog will contribute to a report to be produced by the Foundation of Nursing Studies (www.fons.org) at the end of 2016 on the present and future work of mental health nurses. As a graduate profession, mental health nurses must now be confident enough to offer a constructive debate about their work rather than playing a limited part in policy development and service re-design. We hope the approach used in Playing our part will allow us to think differently by asking purposeful questions and sometimes we will allow ourselves to think disruptively! We want to put mental health nurses in a place where they can proactively contribute to service delivery.
This second blog is to stimulate early discussion towards developing a contemporary view of the work of mental health nurses. We wish to explore existing and further potential for working in secondary care and asking some questions about it. Tertiary care will be considered in a later blog and all outputs will be used to inform roundtable conferences from July onwards. Please help us to develop Playing our Part.
The paper and your responses will help to stimulate a twitter conversation on Monday 6th June at 8pm. Please join us at #WeMHnurses.
A Definition for SECONDARY care and prevention
Working within a public health and preventive model of psychiatry (Caplan 1964) allows us to test the actual and potential work of mental health nurses. Having considered PRIMARY PREVENTION in an earlier Twitter debate we now turn our attention to SECONDARY PREVENTION and must not only consider where mental health nurses are already working to good effect, but how they can work differently and better. For the purposes of this blog, secondary care is defined as minimising the effects of mental disorders through early detection, purposeful treatment and care. Early detection and interventional work with people thus requires an ability to expand work across traditional service boundaries but this might possibly be constrained by employer requirements. Offering care across boundaries requires new ways of working and different models of employment.
Mental health nurses continue to work successfully in in-patient settings, early intervention services and recovery. Evidence as to the effectiveness of mental health nurses has already been reported in such areas as psychosocial intervention and creating ‘safe’ wards but benchmarked and evidenced work such as this is still not USUAL practice. Why are mental health nurses not using evidence based practice in their everyday work?
Question 1 – How can mental health nurses implement evidence based practice more consistently in in-patient care?
Mental health nurses working in secondary prevention and care in in-patient settings.
The core skills of mental health nurses are mostly learned and then expressed in secondary care and in-patient settings. It is useful to think of the application of these skills through an organisational design and ‘climate’ that allows the creation of a therapeutic milieu, person centred interventions through individual and group work, an understanding the important dynamic of physical and mental health and the essential value in continuity of supported care. Although the backcloth to secondary care is coloured by a recent decline of numbers in the mental health nurse workforce and a shortage of more traditional in-patient care facilities, it is also where innovative service provision and creative service delivery is already taking place.
It is also important to note present conditions that characterise some in-patient care. Reports continue to show that in-patient care is seen by nurses and by patients and families as unsafe and not therapeutic. Some in-patient beds are still sourced many miles from home and waiting times are often unacceptable. Although national strategies are being designed through forward focussed planning, the present reality is still one of continuing difficulties. Is it possible to create a therapeutic and helpful environment where care can take place in difficult ‘real life’ circumstances? Meeting the challenges of care planning, containment, support, daily structure, active involvement and individual validation lie at the heart of the day to day work of mental health nurses in in-patient settings and is VERY challenging!
Question 2 – How can mental health nurses best create and sustain a therapeutic milieu where care and treatment can take place more purposefully?
Continuity of care and working across traditional boundaries
Evidence suggests that the numbers of people with mental ill-health continues to cause challenges to the health and social care system. There are increasing numbers of people in the prison system who display significant signs of mental illness and are being treated inappropriately as a consequence. The well reported problems of alcohol misuse by adults as well as the young and vulnerable are challenging. This, compounded by increases in suicide by both men and women place huge demands on health, social care and law enforcement. There are good examples of nurses working differently with police services, prison services and accident and emergency departments to try and mitigate delays in referral and inappropriate placement. Community psychiatric nurses continue to bridge between services in primary care and in-patient care but are increasingly distracted by demands for access to psychological therapy services and mandated ‘waiting times’. Secondary care also requires that care planning is both efficient and timely and should be recovery focussed. Recent evaluative work has suggested variations of experience in care planning by those for whom it is intended and the reported ‘burdensome nature’ of care plans which are then rarely consulted. This suggests that change is necessary. Interestingly however, people who use services appear to value their therapeutic relationship with care co-ordinators so this approach appears to have value. In order that care planning has greater purpose and value then the bureaucracy that surrounds it must be mitigated and information systems made more useable.
There is work underway to re-design and reconstitute community mental health teams, mental health nurses must be able and willing to play their part from the start and not as afterthought! Attention to the particular needs of children and young people as well as older people with dementia require particular focus. Although significant recent attention has been given to people with dementia, those in need of in-patient care are likely to be offered a care home facility or a bed at distance from home. This is unhelpful to both people with dementia and their families – early expert care from mental health nurses is essential across the whole age range.
Question 3 – How can we ensure that mental health nurses play a full part in the re-design of community health teams?
Question 4 – How can mental health nurses be better enabled to offer continuity of recovery-focussed care?
Question 5 – How can work more purposefully in prison services and accident and emergency settings?
The challenges of ‘new science’ and professional development
Revolutionary thinking that brought about models in psychodynamic and behavioural therapy as well as significant changes in the use of psychopharmacology forced radical change into the care and treatment of people with mental ill health. In using models from the social and organisational sciences there will be inevitable re- shaping of service delivery. Innovation and organisational science must be recognised and used to effect continuous development, although this is always dependent upon the nature of employer organisations and their willingness to change. We will be obliged to think differently and purposefully about the relationship between physical health and mental health and work being undertaken by research based in post-genomic specialist research centres will impact significantly on the work that all nurses do.
In seeking to develop the work of nurses a series of ‘nursing strategies’ have obliged the profession to look again at the work they do and the behaviours they display. Most recently in England, nurses have been urged to lead on a new strategy that embraces 10 aspirational commitments focussing on cultural change, reductions in variability and leadership and in research. Sadly, continuing professional development is increasingly underfunded and unavailable which is lamentable and so realizing these worthy ambitions may prove difficult.
Question 6 – The relationship between mental illness and physical ill-health in now well documented, how can mental health nurses dealing with this proactively?
Question 7 – Does the preparation of newly graduating mental health nurses taking sufficient account of ‘new science?
Question 8 – How can mental health nurses specifically lead on developing professional aspirations?
How you can help?
When you have read this blog please offer your views and comments in the box at the bottom of the blog page. You do not need to answer just the questions posed here. Any comments are useful! We will also be holding a twitter chat on Monday 6th June at 8pm and to join in please use and add #WeMHnurses to your Twitter favourites!
Tony Butterworth June 2016