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Section 2: Context and process
Introduction
The review gathered evidence from a variety of sources to examine the current and future contribution of mental health nurses in Scotland to meeting health policy objectives for the care and support of people with mental health problems. It takes its place as part of a number of initiatives considering the nursing response to the new health policy agenda in Scotland.
The review was driven by a single core purpose: to enhance and develop mental health nursing so that service users and their families and carers gain continual improvements in their experiences and outcomes of care.
It explored issues across the whole mental health nursing profession, taking account of concurrent initiatives impacting on the wider nursing community (Appendix I) and other mental health workforce-specific initiatives. Separate work has been progressed alongside the review, including:
- a forensic mental health workforce planning project (Forensic Network, 2005)
- a framework and workforce planning project for children and young people's mental health services (Scottish Executive, 2005 a and b)
- an exploration of the training needs of community mental health teams.
The objectives of the review were to draw on a range of evidence and adopt an engaging and consultative process with key stakeholders to:
- identify, analyse and disseminate existing strengths and areas of good practice in mental health nursing
- explain the conditions necessary to enable mental health nurses to fully realise their potential in improving the experience and outcomes of care for services users and their families and carers
- identify and analyse gaps in mental health nursing practice
- prioritise areas for development linked to legislative and policy agendas in Scotland to reflect the current and future mental health needs of the Scottish population
- identify the organisational, education and developmental strategies that will support and enable the mental health nursing profession to realise its full potential
- identify priorities for the development of mental health nursing over the next five years.
This report:
- outlines how the review was done
- describes the policy and service drivers that informed the review
- explores the issues, challenges and opportunities facing mental health services and mental health nursing
- looks at how the profession can be supported and developed in future to deliver on this agenda
- sets out an action plan to take mental health nursing in Scotland forward.
While the report focuses on mental health nurses employed by NHS Scotland, many work in other health care sectors. The report and its action plan are also applicable to them and their employing organisations.
The action plan of this report is presented as a separate document.
How the review was conducted
Project Steering and Reference Groups
The following steering and reference groups were established at the outset of the review process:
- Project Steering Group
- Practitioner Reference Group
- Service User and Carer Reference Group
- Expert Reference Group (the existing Scottish Mental Health Nursing Forum).
Details of the groups' remits and membership are outlined in Appendix II.
Review methodology and process
The process of the review was consultative, with the specific focus of key stages determined as the review progressed. A wide range of evidence was accessed to address key questions within the review.
A literature review was undertaken to support Chief Nursing Officers' reviews of mental health nursing in England and Scotland. The literature review was conducted collaboratively by the Institute of Psychiatry in London, Manchester University and Sheffield University. It drew upon UK and international literature to explore:
- the evidence base for interventions delivered by mental health nurses
- service users' and carers' views on mental health nursing
- stress and satisfaction in mental health nursing
- issues relating to recruitment and retention.
A summary and synthesis of the literature review is presented in Appendix III. A full copy of the review can be accessed at: http://www.nursing.manchester.ac.uk/projects/mentalhealthreview
Calls for contributions were made throughout the review process. Written contributions were submitted by members of the Project Steering and Reference Groups at the start of the review, setting out their priorities and aspirations for the future development of mental health nursing and services. A call for submission of examples of positive and innovative practice in existing mental health nursing practice in Scotland yielded in excess of 90 submissions and provided a crucial source of evidence for the review. And a call for contributions on mental health nurses' roles in supporting and promoting recovery was taken forward by the Scottish Recovery Network ( SRN).
Briefing and update papers and interim reports were produced throughout the review process. They were circulated to Steering and Reference Group members for comment and helped to establish key issues and priorities.
The review website was set up to ensure openness in the process and involvement of as wide an audience as possible. Notes from meetings and reports emerging from the review were posted on the site, with publicity about related events and calls for contributions.
Two national conferences were held during the review process, in June 2005 and January 2006. Presentations were also given at a number of conferences and forums.
The Project Officer conducted focus groups throughout NHS Board areas. Twenty-eight groups were conducted, engaging in excess of 400 mental health nurses and other workers in the review process. Members of the Practitioner and Service User and Carer Reference Groups supported discussion about specific questions and issues relating to the review within their own areas and networks.
Visits were made to sites of practice innovation and service users' forums to discuss the review. Specific forums were held with educationalists and student mental health nurses, and a focus group was held with mental health nurses who had selected to leave NHS employment to work in the voluntary sector.
Sub-groups involving cross-working between members of the Project Seering and Reference Groups developed specific work in the following areas:
- the vision and values base for mental health nursing in Scotland
- the future role focus for mental health nursing and matching mental health nurses' contribution to service development, service tiers and population need
- models for career progression and development
- issues specific to developing the role of mental health nursing in acute inpatient care.
In addition, a sub-group of the Expert Reference Group examined how to enhance and develop nurse prescribing in mental health.
National and international links were made with people involved in both the CNO Review of Mental Health Nursing in England and the Mental Health Nursing Review in New Zealand. Additional links were made with senior nurses in New Zealand, who generously shared information about progressing recovery-focused practice in mental health nursing and services.
The context of the review
Mental health nursing in Scotland
Mental health nurses represent the largest paid workforce of direct care deliverers to people with mental health problems in Scotland.
As of September 2005, there were approximately 6708 whole-time equivalent registered mental health nurses employed in NHS Scotland, working in a diverse range of hospital and community-based services. In common with the total health care workforce, the age profile indicates a significant number of the profession are 45 years and older.
Nine universities across Scotland provide the three-year pre-registration programme that leads to registration as a mental health nurse. The Scottish Executive contracts approximately 580 new students each year, with a total of 1500 students undertaking pre-registration programmes in any given year. There is, however, approximately 10% under-recruitment to courses annually and attrition rates from mental health nursing programmes average 25%.
The review had to consider:
- how we can continue to attract a diverse range of people to, and retain them within, the profession
- how we can best match the skills of mental health nurses to the needs of Scotland's population
- how we can continue to support and develop an increasingly scarce and valuable mental health nursing resource to realise a new vision for mental health services in the future.
The mental health policy context
The Mental Health (Care and Treatment) (Scotland) Act 2003 came into effect in October 2005.
The Act contains much more than simply legislation for new forms of compulsory power and safeguards. Its underpinning principles herald a new era of rights-based care for people who use mental health services.
The Act also has profound implications for service delivery. As well as providing care and treatment, services are now required to promote social inclusion and a wider citizenship agenda. The requirements of the Act are influencing new models of service delivery and the practice of mental health nurses, including:
- a variety of models of service delivery within the community to act as alternatives to inpatient care, such as crisis care and intensive home treatment services
- new inpatient facilities for children and young people and for mothers with perinatal illness and their babies
- the provision of least-restrictive environments for people with mental health problems who have committed criminal offences
- the rights of people to be able to access a range of therapies including psychosocial interventions and psychological therapies, meaningful activity, employment and support for recovery
- the provision of evidence-based services and treatment for people with a diagnosis of borderline personality disorder.
The National Programme for Mental Health and Well Being in Scotland has placed an important focus on the public mental health agenda, with programmes of work aimed at:
- raising awareness and promoting good mental health and well being
- eliminating stigma and discrimination
- preventing suicide
- promoting and supporting recovery from long-term mental health problems.
These had particular relevance for the review of mental health nursing in Scotland.
The Framework for Mental Health Services in Scotland was published in 1997 ( SODoH, 1997). It subsequently has been extended in response to the need for service development, with additional guidance issued on postnatal depression, psychological therapies, eating disorders, services for adult survivors of childhood sexual abuse, services for people with dementia and access to mainstream services for people with sensory loss and a mental health problem.
Delivering for Health (Scottish Executive, 2005c), the new policy for NHS Scotland, was published in October 2005. It sets out a new vision for delivering services based on:
- a fundamental shift in the way the NHS works, from an acute, hospital-driven service to one that is community based
- a focus on meeting the twin challenges of an ageing population and the rising incidence of long-term conditions
- a concentration on preventing ill-health and treating people faster and closer to home
- a determination to develop responses that are proactive, modern, safe and embedded in communities.
Delivering for Health also identifies the main issues that will inform the development of a new mental health delivery plan, due to be published in December 2006.
The review process explored and reported stakeholders' aspirations for the future vision of mental health services and mental health nursing. These articulate well with the vision for services set out in Delivering for Health (see Table 1).
Other professional reviews - common messages and shared opportunities
Mental health services rely on the contributions of many professions from the health, social and voluntary sectors. Mental health nurses do not work in isolation. They operate as part of multi-disciplinary, multi-agency teams, and the progression of mental health services depends upon whole-team approaches to development. Several other professional reviews and initiatives have progressed alongside the review of mental health nursing in Scotland, including:
- Changing Lives: the report of the 21st Century Social Work Review Group (Scottish Executive, 2006)
- New Ways of Working for Psychiatrists - enhancing effective person-centred services through new ways of working in multi-disciplinary and multi-agency contexts (National Institute for Mental Health in England and the Royal College of Psychiatrists, 2005)
- the development of an action framework for psychology in Scotland ( NHS Education for Scotland) and a review of new ways of working for psychologists (National Institute for Mental Health in England) are in progress.
Table 1. Future visions for mental health services in NHS Scotland expressed during the review of mental health nursing. 1
Past model | Evolving model | Mental health nursing response |
|---|
Most resources geared towards episodic treatment of acute episodes of ill health/distress. | Geared towards supporting recovery from long-term problems. | - Continuing to develop key roles in the support of people with complex and long-standing mental health problems and for older people.
- Adopting strengths and recovery-focused models, maximising self management and peer support.
- Adopting frameworks for practice that promote values-based practice, maximising therapeutic contact time and the therapeutic management of individual risk.
- Recognising and valuing diversity and delivering culturally competent care.
- Continuing to build capability to increase access to psychosocial interventions and psychological therapies.
- Continuing to develop and maximise roles and capability in anticipatory care and early intervention.
- Continuing to develop and maximise roles in health improvement, health promotion and tackling health inequalities.
- Playing key and extended roles across the spectrum of acute inpatient, crisis care and intensive home treatment services (hospital and community based), incorporating new whole-systems ways of working.
- Recognising carers as partners and supporting them in their caring role.
|
Hospital centred. | Embedded in local communities, based on local community need with increasing alternatives to hospital care and enhanced quality of inpatient care provision. |
Lack of choice in alternatives to pharmacological therapies; focused on illness and deficits, and risk averse. | Enabling, person-centred recovery and strengths-based focus with a move towards positive management of individual risk. Maximising choice and access to evidence-based interventions. |
Disjointed care. | Continuous whole-systems care. |
Reactive care. | Preventive care and focus on early intervention. |
Service user as passive recipient. | Service user as active partner and expert in his or her experience and recovery. |
Low emphasis on self care/management. | Emphasis on facilitating self management and peer support. |
Carers undervalued. | Carers supported as partners. |
Low tech. With recognised problems with information systems. | Improved technology with the potential for innovative use of technology to support access to care. |
Box 1. Common and shared messages from professional reviews. |
|---|
- The need for organisational and systems change and for strengthening the infrastructure to support and develop the professions in the context of, and closely matched to, service development.
- The need for new ways of working across all professional groups to enable an organisational cultural change to drive service improvement towards person-centred care and services.
- While each professional group seeks to find certainty in its own distinctive contribution, much is shared across different practitioner groups, particularly in relation to aspirations to adopt person-centred approaches.
- The need to develop treatment, care and responses to maximise choice for people by increasing access to psychosocial interventions and psychological therapies, recognising the contribution that all professional groups can make to delivering on this agenda.
- The need to challenge traditional professional boundaries, power bases and tribalism and work together in alliance to develop capable teams, matching different team members' skills and contributions to people's particular needs and journeys through care and treatment.
- The need to develop new roles and new ways of working, taking into account the diverse needs and backgrounds of service users, families and carers.
|
Similar messages on the future direction for professionals and services are emerging from these reviews (Box 1). There is a need to consider the key messages from each review and 'join up' findings to address key challenges and opportunities for progression across disciplines to deliver the future vision for mental health services in Scotland.
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