Psychiatric and mental health nursing: past, present and future

Recently the Chief Nursing Officer announced a major review of mental health nursing. Much has changed since the last review in 1994; mental health sits near the top of the health care agenda, a National Service Framework set standards for the delivery of care, a Health Care Commission will monitor how services are meeting these standards, Nurse Consultants have appeared so has a mental health tsar, a Mental Health Bill promising sweeping changes to the Mental Health Act and the integration of Health and Social Care. The term Serious Untoward Incident (SUI) has entered the lexicon of mental health. Service users and carers are, in theory, at the heart of care. Mental health nurses are now prescribing medication, working with colleagues who are also service users, and there is finally a drive to address diversity issues in service delivery. The review takes place in the context of work on new roles for new and existing professionals and planned reviews of education by the Nursing and Midwifery Council (NMC). It is tempting to be cynical with the announcement of yet another government review. Reasonable people ask whether these reviews change anything. The evidence following the recommendations made in the 1994 review suggests that they can lead to changes: shifting the focus of mental health services on people with so-called ‘severe and enduring mental illness’, championing new psycho social interventions (PSI) roles for nurses, increasing the number of liaison mental health services in Emergency Rooms, working in partnership with service users and user choice, education and service providers working in partnership in the delivery of nursing education, and the accreditation of prior learning for entry to pre-registration programmes. Whether or not you agreed with these recommendations at the time, these issues are now part of mainstream mental health and seem, 11 years on, almost routine. The current review of mental health nursing involves the formation of a Review Reference Group (RRG) of which we are members. The group also includes service users and carers, students, clinicians, academics, the NMC, managers, representatives from professional organizations, e.g. the Royal College of Nursing, Mental Health Nurses Association, UNISON. This group has advised on the content and focus of the review. In addition to input from the RRG the Review is informed by two specialist subgroups: one considering pre-registration education and one examining practice; consultation with service users, carers, nurses and other interested groups through open forums; meetings with key organizations; and a specially commissioned review of literature examining the evidence for mental health nursing. The results of the review are due in early 2006. Mental Health Nurse Academics UK (MHNAUK) was formed in 2003. We were elected Chair and Vice Chair respectively in 2004. MHNAUK is a group that brings together representatives from all UK Higher Education Institutions engaged in mental health nursing education and research. The group's purpose is to promote mental health nursing education, research and practice development, and influence the national mental health agenda through well-informed debate, discussion and the dissemination of papers that reflect our views on a range of issues. So far, we have issued position papers on career pathways in mental health nursing, research, pre-registration education and working with users and carers. The group is also keen to promote collaboration between mental health nurse educators, service users, carers and clinicians. MHNAUK met in September to discuss the Review and prepare our response. The group welcomed the review and the opportunities it provided to shape the future of mental health nursing. We felt that the review, while welcome, should be independent of the Department of Health in order to enhance its impartiality. Mental health nurses are in the majority of professions providing mental health services. As such they are in a powerful position to exert significant influence over the direction, nature and quality of mental health care. In short, mental health nurses make a difference to the lives of people using mental health services. We welcomed the challenging and provocative issues raised in the consultation document, but overall we felt that the document could have been more visionary. Some of the questions appear rhetorical and leading. There was concern that the context in which mental health nursing occurs was overlooked throughout the document; too many of the issues raised appear to suggest change at the level of the individual without identifying the conditions in which mental health nursing occurs. There is an implicit assumption being made that the values of mental health nursing are clear and shared by all mental health nurses. Little is said about identifying the values, attitudes and beliefs that should underpin mental health nursing, beyond the recovery model, and how to demonstrate these values in practice. We were pleased to note the attention to evidence-based practice. However, a serious oversight is the absence of questions related to the nature and direction of mental health nursing research in developing the evidence base for mental health nursing. While acknowledging the merits of the Recovery Approach in providing a value and evidence-based approach to support good practice, MHNAUK values a user-led approach centred on, and driven by, the needs of the person using services. We believe that values are valid, but become rhetorical if nurses do not demonstrate skills to underpin the values. The group recognize the importance of working in partnership not only with users and their carers but also with the wider communities and agencies with which users and their carers interact. The issue of whether nurses should be trained in psychological therapies is aired frequently. MHNAUK believes that mental health nurses should be trained in evidence-based psychosocial interventions where required, and should use these interventions in circumstances where they are needed, and where evidence indicates that they will improve outcomes for users. At the point of registration, students should demonstrate capabilities in user-centred assessment, interviewing and education, measuring problems and their impact using standard measures, forming and sustaining helpful therapeutic alliances with users, their carers and other agencies, shared decision making, case formulation and working in partnership with users and their carers, families and significant others. It is our view that mental health nurses should contribute to facilitating therapeutic milieux where care is occurring, using evidence-based approaches such as those demonstrated by The Sainsbury Centre's (2005) Acute Solutions Project and by Bowers et al.'s (2005) work on acute psychiatric wards in east London. We felt it important that mental health nurses should have adequate support in using evidence-based psychosocial interventions and that such support will include clinical supervision – which we believe should be mandatory – and education and training in these interventions. Strong leadership at the level of practice, policy, research and education is needed to support mental health nurses. The links between leadership and practice must be coherent and strengthened. There needs to be synergy between leaders in practice, education, research and policy. It is our view that effective leadership can best be developed by leaders who role model their skills close to the point of delivery of care, sound education and training and effective supervision. Question 18 of the Review consultation document addresses key mental health-related competencies (including skills, attitudes and knowledge) that all mental health nurses should have at the point of qualification, and changes that could improve the pre-registration training provided in academic and practice settings. The Ten Essential Shared Capabilities framework (Hope 2004) provides a set of key skills that mental health nurses should have at the point of qualification. We believe that those involved in the education of mental health nurses should develop a skill's schedule identifying the specific behaviours within each capability that mental health nursing students should demonstrate at different stages of their programme. There needs to be a national curriculum for mental health nursing education and the four countries of the UK should move towards ensuring standards of care and education are benchmarked. The minimum exit qualification for mental health nursing education and subsequent registration should become a degree. The profession needs to consider alternatives to the present system of providing nursing students with practice experience; Client Attachment where students are attached to clients instead of wards offers a promising alternative (Turner et al. 2004). There should be an increase in the number of roles linking education and practice where mental health nurse education is delivered. The Values-based Practice model (Woodbridge & Fulford 2004) provides a set of key values that all mental health nurses should demonstrate. Recruitment and selection procedures for entry to mental health nursing education programmes should assess the extent to which people demonstrate these values. Nursing education programmes at the pre-registration level for mental health nursing must focus largely on mental health nursing and should not be generic. The demonstration of these values should be a prerequisite for entry to education programmes. We recognize that there needs to be a strong practice infrastructure to support the 50% of the curriculum that is delivered in practice. Strong partnerships between Universities, Strategic Health Authorities and service providers are needed to deliver effective mental health nursing education. In relation to the issue of what systems need to be in place to support mental health nurses to develop their knowledge and skills after initial qualification, MHNAUK recommends that there should be an internship period of at least one year following qualification. During this year newly qualified nurses will have provisional registration. Once they have demonstrated further capabilities through formative assessment, while working under supervision, they can achieve full registration status. We felt it was important that all mental health nurses have one day per week dedicated to research and development. Again, strong partnerships between Universities, Strategic Health Authorities and service providers are needed to deliver the systems needed to support mental health nurses to develop their knowledge and skills after initial qualification. The notion of providing holistic care features strongly in the Review consultation document. Mental health nursing care must be driven by the needs of service users. A holistic approach should be used only where it is indicated by users’ needs. We believe strongly that the enforcement of a holistic approach against the wishes of service users could be counter-productive. That there can be little doubt being mentally ill is often a condition of social exclusion. Getting to the bottom of what includes or excludes people socially can be a daunting task. Mental health nurses can help to promote social inclusion by enabling people to work or engage in productive occupation and use and maintain supportive social contacts. However, not all people wish to be socially included; we caution against using social inclusion activities as a mask for intrusive social surveillance. Considering how mental health nurses can contribute to delivering a service that acknowledges and respects the differences between differing needs of service users is an important objective at the heart of the Review. Mental health nurses can best contribute to equality through demonstrating capabilities in providing care that does not discriminate on the grounds of race, gender, sexuality, age, ability and personal status. We believe that using the Values-based Practice model and demonstrating the Ten Essential Shared Capabilities are good starting points that should help facilitate the provision of such care. The issue of patient choice is high up in the government's priorities for the National Health Service (NHS). It is arguably the most challenging part of its agenda. MHNAUK believes that mental health nurses can best promote service user choice by helping people to access information to enable them to make decisions that will inform them about what services to choose. MHNAUK hopes for a future in which services users and carers report a high level of satisfaction with mental health nursing care; service users report that mental health nursing care meets their expectations; there is a national mental health nursing curriculum; the values, attitudes and beliefs of mental health nurses lead to mental health nursing practice that promotes people's health and well-being through clear teaching and demonstration of skills; mental health nurses are able to demonstrate the 10 essential shared capabilities in practice and the public image of mental health nursing is positive. It strikes us that the goals to which most of us aspire, and which are fundamental to our own quality of life: health, paid, productive occupation, social support, safe, secure shelter and freedom from fear, discrimination and prejudice are central to the lives of people with mental health problems. The task of mental health nursing is to enable people living with mental illness achieve these goals. The review of mental health nursing will succeed if it provides direction on how this is best achieved.