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The crisis in mental health nursing and a nursing response

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On the face of it, Christmas arrived early for those using and working in the increasingly beleaguered world of mental health. Not to mention a few birthdays, Hogmanays, Bar Mitzvahs and baby showers.

All this from the report of an independent taskforce looking at mental health provision in England, The Five Year Forward View for Mental Health. Not the catchiest title, but it does a reasonable job of summarising current service provision and proposing wide reaching change to address some appalling problems.

”Were cancer services described in the way mental health services are in the Report, there would rightly be a national outcry”

Were cancer services described in the way mental health services are in the Report, there would rightly be a national outcry and the health secretary would almost certainly have had to resign.

Having headlined the inadequacies of the nation’s mental health system, the BBC’s Fiona Bruce asked the Prime Minister, “Why have you allowed this to happen?”

His answers were illuminating: “It’s a very powerful report and shows how much more we have to do.”

He didn’t say something like, “We’ve neglected mental health like most governments before us but made things infinitely worse with our ideologically driven ‘austerity’ programme.” When pressed, he commented vaguely about accepting the Report’s recommendations but then added, “Now we have to work out what we can afford to do.”

Mr Cameron and his ministers repeatedly refer to the £1bn ‘extra’ funding they’re making available to what should be a grateful nation (even though it’s our money in the first place), as if saying it often enough stretches it further across the yawning chasm of unmet need. It won’t.

This isn’t new money but what was promised before the election.

”It’s easy to rage at Cameron, George Osbourne and Jeremy Hunt. Too easy.”

It comes against a backdrop of an escalating NHS deficit, which the King’s Fund estimate will reach £2.3bn by April, with NHS England saying the service faces a £30bn annual shortfall by 2021. Moreover, mental healthcare in the NHS needs the support of cash-starved councils, already hit by budget cuts of more than 40% since 2010.

And anyone expecting miracles for mental health should look at the government’s lame promises to reform learning disability services.

It’s easy to rage at Cameron, George Osbourne and Jeremy Hunt. Too easy. They oversaw the scapegoating of nursing post Mid Staffs. By their own admission they distrust public services and are ideologically driven to reduce spending on the State to 36% of GDP, the lowest percentage that will be spent by any government since the 1930s.

”No matter how hard we work, no matter how tough the environment, it is also a question of what we actually do”

Their policies have resulted in the mess that is our commissioning arrangements, ward closures, reduced numbers of beds and massively increased caseloads for CPNs. Yet what of us mental health nurses? Ms Bruce’s question applies equally to us. How did we let this happen? It’s not all about money. No matter how hard we work, no matter how tough the environment, it is also a question of what we actually do.

Ironically, the major weakness in the Report is its lack of focus on nursing, despite the vast majority of mental health care being provided by nurses. Yet it still asks how it could be that, of those adults with severe mental health problems, “Many never have access to key interventions recommended by NICE”.

How is it that 25% of people using secondary mental health services “do not know who is responsible for coordinating their care”, while the same number have not agreed the care they’re receiving and 20% haven’t had a formal CPA review in the previous 12 months?

”How is it that 25% of people using secondary mental health services “do not know who is responsible for coordinating their care”?”

My generation has left a sorry legacy. Funding was better in the New Labour years but we focused endlessly on ‘interventions’, allowing unhelpful targets and ever more convoluted systems to be imposed, creating fragmented teams that have created a maze like system even experienced healthcare professionals find difficult to navigate.

It’s years since we led the debate about the nursing care we should be providing. The CNO review of mental health nursing from 2006 sank without trace. In education we have presided over the demise of ideas, process and genuine values. The curriculum doesn’t meet the needs of mental health students. ‘Genericism’ is the default term for adult bias.

‘Recovery’, ‘compassion’, ‘collaboration’, ‘patient centered care’ and ‘therapeutic relationships’ are just some of the terms parroted by students and qualified staff alike, who rarely explore what lies beneath them or really reflect upon the experience of someone who is psychotic or has lost all hope. Indeed, these words, just like phrases such as ‘valuing the patient/student experience’, have become part of an Orwellian nightmare – the more you hear them said the more you know they are not happening.

”Why did we need an independent taskforce to tell us that staff should show respect for patients?”

Why did we need an independent taskforce to tell us that staff should show respect for patients? We know too many patients are still treated with disrespect. Did we need to be told that too many patients have extraordinary difficulty accessing our services? That our wards are more focused on ‘throughput’ than treatment and care?

Is it a surprise to be told that that it’s unhelpful bringing psychotic patients onto wards where there is scant attention paid to organisation, prioritising or effective systems?

We have no model for inpatient care in the 21st century and don’t even adhere to primary nursing anymore. We treat every area of our work as the same, thinking nothing of having our most specialist areas staffed by nurses who have undergone no specialist training at all. Post graduate training is required for most district nurse’s posts. Imagine an ITU being staffed by nurses, none of whom had a specialist qualification.

Think of the outcry if a cancer patient was sent home midway through their chemotherapy to make space for someone else. Or they were admitted to a hospital more than 100 miles away.

”Imagine an ITU being staffed by nurses, none of whom had a specialist qualification”

We write about the importance of consistency and continuity of care, then subject people to multiple assessments and pass them from one team to another. Crisis and home treatment teams, whose patient group is, by definition, in serious need, usually send out a different nurse for each visit. Then wonder why patients get frustrated.

As noted, The Report doesn’t get into the specifics of nursing. Specifically, however, we know there are still alarming deficiencies in many of the more ‘technical’ areas of mental health nursing, such as writing care plans (let alone negotiating collaborative plans).

Medication management is often reduced to ensuring compliance. Many nurses struggle with risk assessment and risk management while the frequency and similarity of serious incidents tells us it’s no exaggeration to suggest too many services still take a ‘hope-and-see-how-it-turns-out’ attitude to risk. I could go on.

Why did we need this Report in the first place? Most of us know we have fallen back into the dark ages.

A respected academic once described the 1982 syllabus as lunatics taking over the asylum. I fear we have been taken over by automatons. Both in the NHS and now education, mechanistic systems over which no individual seems to have any control govern our work. It’s as if many nurses and those managing them don’t really believe in the power of the therapeutic relationship or even the genuine capacity for change.

”A respected academic once described the 1982 syllabus as lunatics taking over the asylum”

Success and quality is measured in stage managing visits for external inspectors. In the midst of all this the expectation of our patients, our services and ourselves has fallen so low.

Is everything awful? Of course not. There are many, many excellent clinicians, educators, managers and teams. But they usually excel despite, rather than because of, the overall system, often escaping the watchful eye of managers because there are now so many targets and unnecessary bureaucratic mechanisms they can’t watch over it all.

Can anything change? We have to believe it can. That belief is the essence of mental health nursing but may be the hardest thing to restore. Perhaps we have to start with smaller things, such as a much greater focus on the use of emotional intelligence rather than self awareness and developing an understanding of the real meaning of emotional labour, how to do it and the resilience it requires. Nurses have to be given time to develop their knowledge and skills, both general and specific.

Mental health nursi is tough work and those undertaking it need tools such as these to be able to look after themselves. That has to be the starting point. Nurses must be supported by the employer but unless they can care for themselves how can they be expected to care for anyone else?

The next level is establishing robust, proven systems to support nurses, as doctors and other disciplines already have, like clinical supervision and reflective practice groups, re-introducing nurse consultants routinely into areas where they can provide nursing leadership.

Management has to change, providing structures and systems that facilitate clinical stablility, enhance organisation and involve nurses and other staff in decisions that affect them, allowing them to shape the services they provide.

”Management has to change, providing structures and systems that facilitate clinical stablility”

With these in place we are in a genuine position to empower patients, bringing them into the creative process as we reshape mental health services for the future, developing a coherent model for inpatient care and community services that are accessible, integrated and provide consistent care for the individual through all phases of their treatment.

This should be one of the most exciting eras in which to be a mental health nurse as science tells us more and more about brain function and how it relates so directly to the experiences people describe and behaviours we see. Combining that with the art of nursing will take us to another level.

Education and practice need to come together far more effectively, with a curriculum that places much greater emphasis on the clinical skills needed, underpinned by theory but placed in a wider philosophical, political and sociological context.

Person centered care requires really getting to the bottom of what it means to be a person in 21st century Britain.

It sounds like a no brainer but is incredibly complex and, in many cases, we are not even close to getting it. But once we are, we can meaningfully communicate with that person about what is important for them, in their world. We can then begin helping them think about negotiating the social systems in which they find themselves, rebuild the social capital many of us take for granted and integrating into their community. We can help people manage themselves rather than attempting to ‘manage’ them, understand what has happened to them and how to change in ways that are helpful to them.

This is all about giving people a sense of agency, the sense that they can act or intervene with a decisive result.

Before we can help people discover that in themselves, we need to develop it in ourselves – and, in so doing, rediscover the belief that change truly is possible.

”Largely, it is about mental health nurses taking control of their own destiny and taking the discipline forward”

Partly, that means holding Mr Cameron and his government to account – not just for their half promises to make mental health a real priority for this nation but to go on and put mental health nursing at the heart of that.

Largely, it is about mental health nurses taking control of their own destiny and taking the discipline forward, building the structures, relationships and alliances that create a framework for us to work effectively. For mental health nursing is essentially helping people with what it means to be human.

And there is no greater task than that.

Chris Hart is a Senior Lecturer at Kingston University and St George’s University of London, and Independent Nurse Consultant

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Readers' comments (1)

  • I took part in the CNO review of MH nursing and found it to be a waste of time: too much listening to people who were well out of clinical practice (Directors of Nursing and their deputies and such like folk) with minimal attention paid to actual sharp end nurses - at the event I attended out of around 100 people barely half a dozen of us were still in clinical practice...

    Many of the problems so well described come down to managers and commissioners and have been well known for decades in my experience. However, those folk have a long history of ignoring and victimising clinicians who speak out (I know from bitter experience).

    I have addressed some of these points on the currently inactive Grumbling Appendix blog, should anyone be interested:

    https://grumblingappendix.wordpress.com/2015/02/24/something-rotten-in-the-state-of-denmark/

    https://grumblingappendix.wordpress.com/2015/02/05/does-no-one-ever-listen-to-me/

    https://grumblingappendix.wordpress.com/2015/01/15/squaring-the-circle/

    https://grumblingappendix.wordpress.com/2015/01/08/do-as-you-would-be-done-by/

    https://grumblingappendix.wordpress.com/2014/12/11/plausible-deniability/

    https://grumblingappendix.wordpress.com/2014/12/02/nick-clegg-discovers-mental-health-again/

    Apologies for the shameless blog pimping, but I feel the need to point out that some of us did try to change things but got abvsolutely nowhere other than out of a job...

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