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Championing 20 years of mental health nursing

From focusing on personality disorders to reviewing drugs for schizophrenia and cognitive behavioural therapy, mental health services have come a long way since Mental Health Practice first rolled off the presses in 1997. And nurses have been a crucial part of this cultural change over the past two decades. But what of the future for the profession?

From focusing on personality disorders to reviewing drugs for schizophrenia and cognitive behavioural therapy, mental health services have come a long way since Mental Health Practice first rolled off the presses in 1997. And nurses have been a crucial part of this cultural change over the past two decades. But what of the future for the profession?


Celebrating Mental Health Practice journal covers from 1997 to the present day

Education and innovation

Mental Health Practice is celebrating a significant milestone this month as it turns 20 years old. For two decades this journal has been informing, celebrating, championing and encouraging the work and innovation of mental health nurses.

When the first issue rolled off the presses in September 1997, Tony Blair was prime minister after his landslide election in May, Harry Potter and the Philosopher’s Stone had just been published, and indie Britpop was filling the (non-digital) airwaves.

In its first issue, Mental Health Practice considered personality disorder, spoke to the new junior minister for mental health and social care, Paul Boateng, and looked at new drugs for schizophrenia.


Mental Health Practice journal first rolled off the presses in 1997 – the year that Tony Blair
was first elected prime minister and people thought things could only get better. Picture: Getty 

There has been lots of change over the past 20 years – but how has mental health nursing and practice faired? And what does the future hold?

11%

reduction in
mental health nurses
between 2010 and 2015

Shift towards recovery model

Mental health nursing leaders say there has been a major shift towards the recovery model, which altered the relationship between service users and nurses. Patients and families are encouraged to be partners in their care planning and their journey towards recovery.


Steven Pryjmachuk

Steven Pryjmachuk, who is professor of mental health nursing education at the University of Manchester and the chair of Mental Health Nurse Academics UK, says: ‘The recovery model has brought with it a steady, yet significant, shift in the power balance between mental health nurses and service users.

‘It’s a shift that that gives more credence to service-user perspectives and one that creates an environment for true co-production and shared decision-making.’

Mental health nurses have been an essential part of this change towards services that empower the service user.

‘It has taken the focus of mental health services away from being largely concerned with responding to people’s presumed deficits’

Cultural change


Ben Hannigan 
Picture: Stuart Fisher

‘It has taken the focus of mental health services away from being largely concerned with responding to people’s presumed deficits,’ says Ben Hannigan, professor of mental health nursing at Cardiff University.

‘Mental health nurses have been a big part of this cultural change, in the same way that they have embraced the idea of working in partnership with people with lived experience of mental health difficulties.’

Part of this change has been the ongoing shift away from long-term institutionalised care, and the physical and medical constraints that this could imply.

While the move away from asylum care started well before 1997, the Winterbourne View learning disabilities hospital scandal in South Gloucestershire in 2011, revealed that problems with long-term residential care have continued.

14%

real terms pay cut
for nurses
since 2010

Mind report


Ian Hulatt
Picture: David Gee

Ian Hulatt, the former RCN professional lead for mental health, says that the move away from restrictive practices has been an important change. The 2014 coalition government programme, Positive and Safe, aimed to end the unnecessary use of restrictive interventions across all health and adult social care. It followed a Mind report which said dangerous face-down restraint was used almost 3,000 times in England in 2012.

Another key change has been the way that mental health nurses, like other nurses, have been educated.

Professor Pryjmachuk says: ‘We’ve seen the successful transfer of pre-registration nurse training into universities and formal acknowledgement that mental health nursing, like the other fields, is a graduate-level profession requiring graduate-level skills and preparation.’

Reducing the stigma of mental health problems has seen significant progress over the last two decades. While there is much more to be done, general awareness around conditions such as depression, post natal depression, anxiety and post traumatic stress disorder has changed, mental health nurses point out.

‘We’ve seen the successful transfer of pre-registration nurse training into universities and formal acknowledgement that mental health nursing is a graduate-level profession requiring graduate-level skills and preparation’

Educate emergency nurses


Karen Wright
Picture: Neil O’Connor

Karen Wright, head of the school of nursing at the University of Central Lancashire says that there was little understanding of conditions such as self harm when she was working on an acute ward 20 years ago.

She took on an early liaison role with an emergency department and says understanding has come a long way since the 1990s. 

‘I created a training package to educate emergency nurses on creating fundamental skills, such as not being judgmental and remembering that [there are reasons why] people deliberately harm themselves,’ she says.

‘People in general practice didn’t understand these basic principles 20 years ago.’

Dr Wright has also seen a major change in the approach to caring for those with personality disorders. The front cover of the first issue of Mental Health Practice was entirely focused on exploring personality disorders, suggesting the journal was part of the movement to improve understanding of those affected by the condition. 

‘It was generally totally misunderstood. There was little written about it in this country that wasn’t pejorative.’

‘I created a training package to educate emergency nurses on creating fundamental skills such as not being judgmental’

Tough workloads

When it comes to workloads, it is hard to know if things are getting tougher for mental health nurses. While all NHS services are under strain, and budget cuts mean services are struggling to cope with demand, Dr Wright points out she had a high workload in the late 1990s too. As a community psychiatric nurse in 1999, she had 54 people on her case load, the majority of whom had personality disorders. A nurse would not have such a case load now, she says.

The move to having more care closer to home means that people in the past who may have been in hospital are now being supported by community teams. This also means that a larger cohort of people considered to have less intensive needs are supported by primary care. Many people with anxiety disorders and depression can now access therapies that were not widely available two decades ago.

The Improving Access to Psychological Therapies programme, which began in 2008, has helped more than 900,000 people a year in England access cognitive behaviour therapy.

900,000

people a year access care through the
Improving Access to Psychological Therapies programme

Fewer mental health nurses

But despite there clearly being great demand for mental health services, the number of mental health nurses has diminished over the past 20 years, and many of those still working are approaching retirement age.

Figures from the NHS’s health and social care information centre, obtained through a parliamentary question in 2016, showed that the number of qualified nurses working in psychiatry dropped by almost 11% from 41,320 in 2010 to 36,870 in 2015.

Mental health nurses, like other NHS staff, are also suffering from the impact of the nursing pay cap that the RCN says has led to a 14% drop in real terms pay since 2010.


Alan Simpson

Alan Simpson, professor of collaborative mental health nursing at City, University of London, says: ‘Over the last eight years the workforce has been decimated. Numbers of mental health nursing posts - the bedrock of care and treatment - have fallen more than in any area of nursing since 2009 and more than the rest of the psychiatric workforce.

‘Attrition rates in mental health staff are almost 14% and much higher than in other parts of the health service.’

Funding disparity

Mr Hulatt says: ‘Sometimes I wonder what it will take before people get concerned about that state of mental health services. We have got "out of area treatments" and people travelling hundreds of miles, the lowest bed numbers we have ever had and people saying services are in crisis. And with the disparity of funding between physical and mental health, there still seems to be an institutional bias.’

He expects there to be a greater diversity of roles within mental health services, such as the new nursing associate, over the next 20 years, to help cope with demand and falling numbers of nurses.


Tony Butterworth

Tony Butterworth, a leading mental health academic and chair of the Foundation of Nursing Studies , says he would have liked to see greater improvements in research over the past two decades.

While there are honourable exceptions, more progress is needed, he says. ‘I would like to say we have produced some cutting edge research, but I am not so sure we have,’ says Professor Butterworth.

‘We struggle to get a firm foothold in research driven by mental health nurses.’

Generic nurse for the future?

When it comes to the future, mental health nursing leaders speak of their hopes that the profession will continue to grow in stature. But they are also fearful, partly due to the growing squeeze on budgets as demand for services continues to grow, and partly because of what is seen as a push towards producing a more generic nurse for the future. This has created concerns that courses that give direct entry to branches of practice might not have a secure future, and may eventually be replaced by a single generic nursing qualification.

There is also a need for greater parity between mental and physical health services, Mr Hulatt says. Despite announcements by various governements to close this gap, it still persists.

Senior figures are urging mental health nurses to speak out to help shape the future of services and the workforce.

‘We are the largest professional group of mental health workers, yet our influence on policy and practice has been relatively weak compared to other professional groups,’ says Professor Pryjmachuk.

‘Assertive and politically active’ 

‘I’d like to see mental health nurses active, visible and in demand in a wide range of settings.’

Professor Simpson also makes a rallying call to the profession.

‘Mental health nurses really need to articulate and evidence what we do and do well. We have no divine right to exist and need to be more assertive, informed and politically active.’

Mental health nurses valued by patients

Recent research has reinforced the value of mental health nurses to their patients.The Foundation of Nursing Studies review of mental health nursing (Playing our Part) published in February, found that support from services users for nurses is high. But the study, which used social media, round table events and conferences to gather the views of about 600 nurses and service users, found that nurses were concerned about diminishing opportunities to sustain long-term supportive relationships with vulnerable people.

‘Our work has confirmed that people who use mental health care services greatly value the sustained contact nurses offer,’ the report says.

‘However, the rush to provide session-based psychological intervention services has placed this subtle, but valued relationship under threat.’

The report also called for all nurses to have physical and mental health assessment skills, a change that could make services over the next 20 years even more person-centred and successful - provided the long-term funding problems are adequately addressed.


Erin Dean is a freelance health journalist


References

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