Dear Chris Connell, Emma Jones, Michael Haslam, Jayne Firestone, Gill Pope and Christine Thompson,
We are class of mental health nursing students in the UK, a mixture of BSc nursing students and some ‘RNDA’ students (also degree-level nursing students but completing pre-qualification education as apprentices). Most of us are doing the standard Future Nurse Curriculum and are now having our first mental health field-specific module of the course, this being the beginning of our third and final year of study. Owing to cohort timetabling complexities, for some of us this is our final module at the end of our third year. This class is made of students who are the subject of your article, Mental health nursing identity: a critical analysis of the UK’s Nursing and Midwifery Council’s pre-registration syllabus change and subsequent move towards genericism, published in August of this year in the Mental Health Review Journal. There was a discussion centred on your article in class today, Friday 11th November, and this is a report of the conversation, written up by the class tutor.
The class found your article very provocative and took time to consider some of its strident claims. For example, you describe the different fields (you particularly address the differences between the Adult and Mental Health fields) as “unrecognisable as the same profession”, describing “seminal differences”. Your view is that mental health nurses need “an altogether different skillset”, that mental health nursing is “conceptually very different”. You question the view that mental health and physical health are as wholly linked as some have claimed, calling that view “somewhat rash”. You argue that the Future Nurse Curriculum has been “reviewed, consulted and designed without the assiduousness that the mental health nursing profession warrants.”
The consequences of these things, you say, are serious. Firstly, you see that a failure to appreciate the role of mental health nurse will have a detrimental effect on our service-users. Secondly, that damage is being made to mental health nursing identity. Thirdly, that aspects of the skills and competency-based course will drive the profession closer to the profession of psychiatry, something that we found we needed to discuss at length. You feel that the Willis Shape of Caring Review and the Future Nurse Curriculum misunderstand mental health nursing.
In the class, time was spent trying to characterise mental health nursing identity. The discussion quickly ran into the problem that you describe; each skill that might be identified as core to mental health nurses is not unique but also found in other fields. To say things such as a mental health nurse tries to see the whole person, or a mental health nurse requires excellent communication skills would provoke nothing more than confused shrugs from Adult nursing colleagues who, of course, also value those things. However, within your article is a feeling that whereas good nursing in any field takes the given diagnosis and then tries to see the whole person in order to provide individual care in context, there is something about mental health nursing that does come from the other direction; we aspire to not form an understanding of health and ill-health, or a plan of care, until the whole person has been met. The class has seen how approaches to mental health that consciously try to include sociological critique of mental health and mental health services can lead to trauma-informed, re-contextualised and re-politicised understandings of mental distress that not only are essential for diagnosis but also undermine the necessity and validity of diagnosis itself. In your article, this makes the therapeutic relationship and its role to help to explore the whole biopsychosocial experience of a person into the core business of a mental health nurse, making other skills peripheral.
Yet you also go further. The “we relationship”, the “being with” of mental health nursing, would not be so radical if it were not for the predicament in which our service-users find themselves. Your descriptions of this predicament include that a mental health service-user may find “their handle on reality, their sense of self and their most deeply held values are challenged by psychiatry and foregrounded by paternalism”. Some students really identified with this; it is the predicament that our service-users are in that defines us as mental health nurses, that gives us our unique identity, the one that requires ‘an altogether different skillset’! Your view is that this is what makes us who we are first, and our connection to ‘nursing’ more generally is second. Our “unique selling point” as mental health nurses is their unique experience.
Students agreed that the easy talk of ‘everyone can have mental health problems’ within the integrated parts of the Future Nurse Curriculum is most strongly countered by the accusation that actually, other fields of nurses do not choose to go where mental health nurses go. They may talk about mental health but do they want to spend time with actual mental health service-users and meet them inside the world of mental health services? The special role of the mental health nurse is a political one, something that within the article is repeatedly described as advocacy… and whenever that is stated, it is clear that this advocacy is not just to get service-users’ needs and rights met within society, but to get their needs and rights – their individuality and autonomy – properly considered within mental health services! Perhaps central to our identity is the inherent paternalism of psychiatry and what mental health nurses must be like if they are to ‘share a horizon’ with their service users in the face of it.
The next of these value-battles the class discussed from your article was task vs relationship. Your article helped students to consider the ways in which when they are measured against skills and competencies that the key relationship is somehow missing or turned into an optional extra. This is the basis of your argument that the Willis report and the new curriculum misrepresents us and grossly undervalues the therapeutic relationship, and members of the class agreed that the formation of a therapeutic relationship is not given the respect it deserves. The students want to tell you that they are so stressed about these tasks and skills! The module has also included the 2016 NHS England document, ‘Improving the physical health of people with mental health problems: actions for mental health nurses’. It describes eight massive areas of priority for the physical health promotion of mental health service users, set against the shocking statistic that they live lives that are cut short by 10 – 20 years. With heavy irony the class noted that none of the skills students have been struggling to get signed off by mystified placement mentors, such as venepuncture, catheterisation and canulisation, appear to be likely to improve that life expectancy by even five minutes! And students also feel strongly that if, perhaps a year post-qualification, they actually do find that one of those skills could be of use (although there seems to be no commitment from mental health trusts to change in ways that would make them relevant), their only suitable action will be to refuse to do them, on the grounds that it has been too long since they practised them and no longer feel competent. Far from the next generation of mental health nurses bringing a new focus on the physical health of our service users, there is a risk that they will just feel less prepared for the real job of mental health nursing. Practice mentors do not seem to be seeing the new student competencies as a brighter future for the profession, but as a bizarre set of priorities they do not need. There was wide agreement in the class discussion with a question from one student about why practice mentors have not been trained in these new skills! In fact, one student revealed that their NHS Trust does not actually recognise these competences as sufficient training for qualified practice.
Students reported that when they have been sitting in the integrated lectures (the word “generic”, which you use, has been very strongly discouraged in our institution) there is an implied message that since they need to be upskilled with competencies hitherto the preserve of Adult field, mental health nurses are below par and ‘not real nurses’. Members of the class have also had experiences in which this implied superiority of Adult nursing is far from subtle, with one member of the class saying that they had only recently had a conversation with an Adult student nurse colleague who openly expressed the opinion that the Adult role was more important. Another member said that they had heard the view that it is the technical aspects and skills that make Adult nursing worthy of degree status, but mental health nursing should not be a degree course because it is mostly just talking. A number of class members felt that mental health nursing is viewed and treated as a sub-group by the Future Nurse Curriculum.
Students also want to add that they find short resources – particularly understaffing – to be a massive problem. The class noted that when nurses feel they don’t have time to put the relationship centrally, then they just become the service’s dogsbody – or as you put it, a ‘Jack of all trades’. At other points in the module we have found ways in which it can be hard to even remember that we mental health nurses have an agenda of our own for our service-users. A theme of the module has been that within a field in which paternalism forms such a backdrop, if we mental health nurses just do as we are told, we cannot be at all confident that mental health service-users will get the service they need and deserve. Dealing with opposing and complex values are not occasionally relevant, but often crucial. Maybe Adult nurses will do their best work when they are smoothly and competently following policy within a positive culture of efficient care, perhaps with a wonderful human touch. That would be nice, but it is not true for mental health nurses in a contested field. Perhaps that is another way of describing what the article views as “seminal differences” between mental health and Adult nurses. One of the students posed the question of which stakeholders benefit from the changes that the Future Nurse Curriculum involves. They found it hard to see how it can be argued that it is student mental health nurses, qualified mental health nurses or our service-users. Members of the class identified that the statements in the article about hierarchy, managerialism and capitalism seem very important here. Upon reading your article, there was concern that there might be a case to be made that forces unknown are trying to prevent mental health nurses from critical thinking.
Then the class spent some time talking about ‘taking abuse’ from our patients. This subject came up as we were thinking about the ways in which your article implies an inevitable difference of values at play within mental health services. This feels like something to discuss further. It seemed that the students are caught between the logic of ‘zero tolerance’ and the understanding value-conflict you describe, which makes the idea of ‘zero tolerance’ suspect. Is this something else that demonstrates a fundamental difference between us and our Adult nursing colleagues? Or is that too contentious?
However, in contrast to the main thrust of your article students did find that there are things that they feel perhaps imply that they can draw closer to Adult nursing, if the relationship were to be more reciprocal. Some in the class would probably not have been sure about your phrase “wholly unrecognisable as the same profession”. For example, students noted that the skills such as Motivational Interviewing and Solution Focussed Practice, that we have been workshopping in our module (and that many felt should have been practiced much earlier in the course) are not given equal parity but could be, and that that these would benefit everyone, in all other fields, if they were given more emphasis. What about having 1:1 skills observed and ‘signed off’ in a more structured way? Likewise, members of the class had examples in which their communication skills definitely made all the difference when dealing with situations within general hospitals (for example, psychiatric liaison services) in which Adult colleagues were not coping well, or when their preconceptions about mental health problems were hindering their ability to care for someone well; it would not be true to say that the class could see no benefits, or potential benefits, to the integrated parts of the course (although no one felt that the balance was right). The physical health of our service users is of huge concern. Students have made friends with Adult student nurses in the first and second year and heard them express a desire to understand mental health nursing better in order to meet the needs of their own patients. They did not blame Adult nurses for their lack of confidence with our service-user group but felt that they would benefit from – well – from more integrated education! The class began to wonder more and more about the processes of consultation and design-decisions that went into the creation of the Future Nurse Curriculum.
There were views expressed that, whatever the mental health nursing identity is, it is not being given new energy and clarity from the Future Nurse Curriculum but the reverse. The discussion finished with the expressed view that your statement, “[t]he NMC syllabus has undermined the unique work of mental health nursing and placed far too much emphasis on a course that is littered with redundant procedural based competencies and proficiencies” is an accurate summary of the feelings in the class.
Thank you once again,
A variety of well made and very important points! I am currently seeking to publish a cut down version of my ma education dissertation in which I touch on many of these same points from the perspective of a lecturer (formerly seeking to contribute to mental health nursing students in particular). I think that one of the difficulties which drives the medical model but also the curriculum issues which are touched upon here relates to the pill popping easy fix culture that is certainly a feature of American society and a product of neoliberal thinking which despite dominating much western discourse for my lifetime appears to be falling apart around us at least in terms economic realities. My fear is that the dumbing down of Mental health nursing as a unique and vital discipline is inclined towards making us part of the problem rather than part of the solution. My rejection of keyholder culture (filer’s language not my own) was largely due to an internal value system which should have had everything due to my training but came much more from within. I fear that just as the Stamford prison experiment (zimbardo) illustrated power dynamics and specifically having power very easily corrupts even the best of us. There is need to recognise that in a quite unique way mental health nurses hold power and the recent panorama program for all its criticism of management/leadership and staffing levels (all completely valid!) The key issue for me is one of character. How many of us as practitioners have such a sense of character that we can maintain the energy and determination to challenge the many and various structural injustice, legal injustices and power imbalances that impact the people we are trained to serve alongside being a support to them in day to day struggles. I worry that the failure to recognise the distinct character and needs of Mental health nursing we are not just failing service users but contributing to their misery!
These are big challenges and there is at least some encouragement to be had from the awareness that such dialogue is occurring!
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Here is Australia there has been a completely successful push by the Nurses and Midwifery Council and the Australian Nurses and Midwifery Accreditation Council supported by the College of Deans to make generic the Bachelor of Nursing. Registered Nurses are now practicing in mental health facilities with a total of 80 hours of placement experience and 16 hours of lectures.
The number of experienced and skilled mental health nurses is decreasing rapidly, particularly over the last two years. and we are seeing the impacts of this through the average lengths of seclusion doubling to 23 hours in NSW, for example. We now have far more psychologists working in mental health than we do nurses. There is only 1000 mental health nurses in this country – these are nurses who have qualifications and sufficient experience to be credentialed by the Australian College of Mental Health Nurses.
Fortunately there has been an increase in the use of peer-support workers in inpatient settings who are prepared to engage in therapeutic relationships with patients, leaving the Registered Nurses able to focus on the important clinical things such as observations and medication.
Midwives in Australia acted politically and were able to have their discipline formally recognised.
I am concerned that the nursing bodies here in Australia, including the Chief Nursing Office, hold prejudice to mental health nursing, possibly from stigma or from the trauma of their mental health nursing placements many decades ago. They appear comfortable with the hierarchical structures inherent (and appropriate) to biomedical nursing especially now that they are in charge.
Biomedical nursing (I think this is a more appropriate descriptor than ‘Adult’ or ‘General’) is harmful to mental health consumers. Our education system and nursing discipline structures need to consider the strong and growing evidence for this – but they will not do so without a strong political campaign. Its too late here in Australia…
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