Section 5: Education and development - preparing for the future
Many of the issues explored during the review in relation to education and development are applicable across the whole nursing profession, while some are specific to mental health nursing. The Directorate of Nursing, Midwifery and Allied Health Professions of the Scottish Executive Health Department has developed a range of initiatives to progress some of these issues across the nursing and allied health professions workforce (Appendix I).
Pre-registration preparation
Pre-registration preparation of mental health nurses is designed to meet the statutory requirements determined by the Nursing and Midwifery Council ( NMC, 2004). Generic proficiencies are prescribed in terms of outcomes students must achieve at the end of Year 1 (Common Foundation Programme) and the end of years 2 and 3 (the Mental Health Branch Programme) to become eligible for registration. The NMC started a review of pre-registration programmes across the UK in 2005, and this is ongoing.
Questions were raised during this review about the robustness of the pre-registration programme in preparing students for practice. The generic nature of the NMC framework does not detail specifically the core values and competencies expected of registered mental health nurses. Consequently, there is no nationally agreed or consistent framework for pre-registration preparation of mental health nurses in Scotland.
The overall conclusion was that pre-registration mental health nursing programmes need to be redesigned within a national framework that will ensure consistency of content and standards throughout Scotland. The generic nature of the NMC competencies, which also form the basis for practice assessment in Scotland, need to be urgently revised and a national mental health nursing practice assessment framework developed.
Ten Essential Shared Capabilities ( ESCs) have been developed by the Sainsbury Centre for Mental Health (2004). These detail core capabilities for all mental health workers, taking account of values-based practice, the recovery approach and person-centred care. A range of materials to support teaching, learning and development in relation to the ESCs is now available and must become firmly embedded in pre-registration curricula in Scotland.
The emphasis on holistic care and health and well being in pre-registration programmes should be strengthened, and this should be addressed in the national framework. There should also be a commitment to developing greater awareness of the benefits of caring for older people with mental health problems, highlighting and promoting the many positive aspects and examples of good practice in this area.
Students must have the right practice placements and practical experiences to ensure they have access to appropriate learning experiences, role models and supervision in practice on which to base values and to develop competence and capability. This must also be reflected in the national framework for pre-registration mental health nursing education in Scotland.
The capabilities outlined in Appendix IV should also inform the redesign of pre-registration programmes.
WE NEED TO:
- Redesign the pre-registration mental health nursing programme to ensure a clear and consistent national framework.
The meaningful involvement of service users and carers in programme design and delivery of pre- (and post-) registration mental health nursing education must continue, with existing models of good practice guiding developments nationally.
Positive practice example
Promoting service user and carer involvement in education |
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The Mental Health Team at Napier University has worked with service users and carers to develop a strategy for user and carer involvement in their programmes. This included the appointment of a dedicated development worker. Education is being used as a means to bring about changes in practice that improve experiences and outcomes of care for service users and their families and carers. The value of meaningful service user and carer involvement is a central part of education at Napier and influences all classroom teaching and learning. The strategy has now grown to include working among informal partnerships of lecturers, service user and carer groups, practitioners and students. The 'partnership' is working on two specific projects: - attitudes and responses to self harm workshops for student nurses
- developing service user and carer-defined proficiencies that will be used to assess students during practice.
The partnership approach is also helping all involved to continue to learn about involvement and is bringing about positive change in practice through joining forces to work together. For further information, contact Lynne Edwards, Service User and Carer Involvement Development Worker.
E-mail:l.edwards@napier.ac.uk |
Higher education institutions ( HEIs) should maximise the involvement of practitioners in programme design and delivery. Secondments of clinical staff to higher education institutions to inform particular parts of programme design should be considered. The appointment of part-time or sessional lecturers should continue to be progressed as a means of enabling expert practitioners to contribute to programme design and delivery.
There is also a need for lecturers in higher education to maintain links with clinical practice through clinical work, supervision of practitioners and joint working on particular practice development projects.
WE NEED TO:
- Meaningfully involve service users, carers and practitioners in the design and delivery of pre-registration and post-registration mental health nursing programmes.
- Identify and disseminate examples of good practice in service user and carer involvement in education to inform development on a national basis.
- Enable lecturers in higher education institutions to have direct links with clinical practice.
While there are constant pressures to recruit adequate numbers of students to pre-registration programmes, the focus must be placed on recruiting the right people, with the right values base. People who have personal experience of mental health problems and those who are carers often fit this description.
Service user, carer and practitioner involvement in the selection of candidates for pre-registration mental health nursing programmes is key in ensuring appropriate candidates are selected to enter programmes. Involvement can take a variety of forms, including participation in interviews, forming of interview schedules and questions, and contributing to guidance on selection procedures.
Good practice guidelines about involving service users and carers in mental health education and student recruitment and selection have been produced by the Social Care Institute for Excellence (2004) and Tew et al (2004).
WE NEED TO:
- Maximise service user, carer and practitioner involvement in selection procedures for student nurses.
Pre-registration preparation needs to reflect the multi-disciplinary, multi-agency context of mental health services by maximising opportunities for learning with other disciplines and agencies involved in mental health care. This should be reflected in the redesign of the pre-registration programmes in Scotland, including the Common Foundation Programme, which comprises a third of the preparation programme for mental health nurses.
Health care support worker staff development
Health care support workers make a significant contribution to the work of NHS Scotland. Natural, flexible and employer-supported pathways towards registration have been developed via a Facing the Future initiative that encourages support workers, with employer support, to access the NHS Education for Scotland-endorsed Higher National Certificate ( HNC) in Health Care. Successful completion of the programme enables direct entry into Year 2 of pre-registration nursing programmes.
Uptake of this initiative has, however, been variable. There is a need for all NHS Boards to develop a structured education programme for support workers through Scottish Vocational Qualification ( SVQ) levels 1, 2 and 3, followed by HNC-level study if appropriate.
The potential to enable part-time study of the Mental Health Branch Programme while retaining employment in NHS Scotland should also be further explored and developed. For example, the Open University pre-registration work-based programme has been established in both adult and mental health nursing in remote and rural areas, enabling NHS-employed support workers to complete a four-year diploma programme while retaining employment throughout the duration of their studies.
The creation of an 'associate practitioner role' in mental health nursing has been suggested, and will be further explored though work undertaken by the Facing the Future group. While having a less academic focus than nursing, the role could be a 'stepping stone' leading to the post holder accessing pre-registration nursing programmes at an appropriate level. The NHS Modernising Clinical Careers framework supports the progression of non-registered staff and outlines a framework that enables the progression of staff from support worker grade to senior health care assistant and assistant/associate practitioner. This enables NHS Boards to develop careers within the context of 'capable teams' built to meet the needs of local communities.
WE NEED TO:
- Maximise and develop the role of the support worker in mental health services.
Activity on developing support workers should be informed by the significant contribution people who have experienced mental health problems could make to mental health teams in both inpatient and community-based settings. The employment of peer support workers is well established in services in the USA that have embraced recovery and strengths-based service and practice models. Maximising peer support, self help and the key role of 'expert patients' are central messages in Delivering for Health and should be progressed as part of the Mental Health Delivery Plan.
Development of newly qualified nurses
Many newly qualified nurses start their career in inpatient care (often the most challenging area of practice). Consequently, the least experienced nurses are often providing care for people with the most complex needs.
NHS Education for Scotland has developed the 'Flying Start' one-year national development programme for newly qualified nurses, and will support NHS Boards in its implementation. Findings from the review suggest that Flying Start should include a planned rotation for mental health nurses through various areas, including community, to ensure consolidation of skills and knowledge.
WE NEED TO:
- Support newly qualified mental health nurses through the 'Flying Start' programme and provide a planned rotational development and consolidation experience.
Leadership in mental health nursing
While there are variations across NHS Board areas, the perception of a gradual but significant erosion of frameworks, roles and systems that provide clear professional leadership and a strong professional voice for mental health nursing emerged as a theme within the review process.
The landscape of health care in Scotland is evolving towards integrated models. In the future, leadership frameworks in the NHS will become less dependent on formal management structures and more dependent on the capabilities of individuals at all levels. Findings from the review show that strategically placed and robust professional leadership structures are essential for driving clinical practice development in parallel with, and in support of, wider service and organisational developments.
WE NEED TO:
- Strengthen and enhance leadership capacity and capability in mental health nursing.
The Scottish Executive leadership development plan set out in Delivery through Leadership (Scottish Executive, 2005f) provides a practical action plan for implementing leadership development in NHS Scotland at national and local level. It also details descriptors of leadership qualities and behaviours.
The plan notes that leaders and managers often emerge through clinical routes and in the past have had to 'pick up' leadership and management skills and behaviours on an 'ad hoc' and 'do it yourself' basis. It emphasises the need to change this with the provision of comprehensive leadership development opportunities and attention to succession planning and growing people into leadership posts. As part of this aim, NHS Education for Scotland will commission clinical leadership development packages for all front-line NHS staff.
NHS Board Nurse Directors have had a responsibility since 2001 to ensure that all ward sisters/charge nurses have access to a leadership development opportunity (Scottish Executive, 2001). Access to leadership development in mental health should also be extended to staff nurses to ensure succession planning for more senior clinical, managerial, academic and research posts.
WE NEED TO:
- Continue to ensure that all senior mental health nurses have access to leadership development opportunities, and extend access to staff nurses.
Nurse consultants fulfil key leadership roles, shaping and influencing care delivery, service strategy and professional development. There are, however, limited opportunities for mental health nurses who wish to progress their clinical careers to acquire the leadership, education, practice development and research skills necessary for consultant-level posts. NHS Education for Scotland has designed a nurse consultant development programme that will prepare people for consultant posts and enable succession planning.
While this report and its action plan call for specific actions to develop nurse consultant posts in priority areas, they recognise and emphasise the urgent need generally to expand the number of nurse consultant posts in mental health throughout NHS Scotland.
There are very few mental health nurses occupying specialist roles in Scotland, with inconsistency in the grade and nature of such posts signalling a need to harmonise roles and titles across Scotland. The NHS Modernisation Career Framework provides a vehicle for charting role development from senior/specialist practitioner, through advanced practitioner, to consultant practitioner and beyond.
Positive practice example
Nurse consultants making a difference |
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Nurse consultants are central to practice and service development. The nurse consultant for perinatal mental health in NHS Greater Glasgow has played a key role in the design, commissioning and development of comprehensive specialist secondary and tertiary care services for perinatal mental illness, including a West of Scotland Regional Mother and Baby Mental Health Unit, a Community Outreach Team, a Maternity Liaison service and an Integrated Care Pathway. She is also consulted by NHS Boards and other agencies in relation to service development and clinical practice issues. The direct impact of the post on practice includes implementing evidence-based clinical practice across disciplines and introducing a whole-systems nursing model to service delivery, involving nursing staff working across community and inpatient services to facilitate continuity of care. Professional leadership and consultancy activities at local, regional and national levels have included: - providing nursing leadership across maternity, health visiting and mental health nursing within NHS Greater Glasgow
- chairing a short-life working group on perinatal mental illness and joint mother-infant admissions, which produced a service profile addition to the Mental Health Framework for Scotland
- chairing the Practitioner Reference Group that played a central role in shaping the outcomes of the National Review for Mental Health Nursing in Scotland.
Excellence in clinical practice is central to the nurse consultant role. Fifty per cent of the post is devoted to delivering direct evidence-based care to women affected by perinatal mental health problems in the community and maternity liaison service, while also providing clinical support and supervision to mental health nurses, midwives and health visitors. Research and education activities include delivering in-house education and training across professional and organisational boundaries, lecturing on undergraduate and post-graduate nursing, midwifery and public health nursing courses, and acting as grant holder for a 3-year Chief Scientist Office-funded national audit of postnatal depression. For further information, contact Karen Robertson, Nurse Consultant - Perinatal Mental Health.
E-mail:Karen.Robertson@glacomen.scot.nhs.uk |
Continuing professional development ( CPD)
All nurses should have access to CPD activities and the opportunities to extend knowledge and skills vertically (enabling role extension and progression) and horizontally (supporting practitioners to develop within their existing roles).
CPD opportunities are not just about formal accredited courses, but also involve a range of activities such as secondments, visits to clinical areas, and skills-based programmes delivered within service settings. Personal development gained via individual study and peer supervision is also significant.
As services integrate, CPD activity will most meaningfully be delivered in multi-disciplinary, multi-agency contexts involving teams of workers, and with the active and meaningful involvement of service users and carers.
The action plan sets out several items that will lead to increased provision of CPD opportunities, particularly in relation to acute inpatient care, intensive home treatment and crisis care, older people's mental health and psychosocial interventions and psychological therapies. Nationally developed programmes will need to be tendered and developed in key areas. There is also a need for greater joint working among higher education institutions and NHS Boards and across professional groups to share existing expertise and collaborate on new programme developments.
Regular clinical supervision is important for all nurses and midwives, but is considered particularly important in mental health nursing, which is reported to have higher levels of occupational stress and 'burnout' than other branches of nursing and, indeed, other mental health professions. Any role progression in psychosocial interventions and psychological therapies is dependent on practitioners being able to receive high-quality clinical supervision, as is the maintenance of skills in forming and sustaining helpful relationships. Clinical supervision is also essential in promoting values and strengths-based practice.
WE NEED TO:
- Ensure regular clinical supervision opportunities are provided for mental health nurses.
Support for nurses in remote and rural areas and isolated situations
The challenges of staffing and providing training for NHS services in remote and rural areas are addressed by Delivering for Health. It commits to establishing a 'virtual' School of Rural Health Care to build on existing initiatives and develop world class approaches to the development and training of the rural workforce. It also pledges to bring together a group involving NHS Education for Scotland, Scottish Medical Royal Colleges, NHS Boards and other partners to:
- consider the evidence around standards of care in remote and rural areas
- consider operational issues associated with the delivery of health care in remote and rural areas, including how staffing can be assured and clinicians' skills maintained in low-volume procedures
- develop appropriate training for remote and rural practitioners
- consider how training can best be incorporated into posts in these areas.
These initiatives are likely to have significant positive impacts on mental health nurses working in remote and rural areas of Scotland.
Research culture and capability in mental health nursing
Mental health nurses have a significant role to play not only in delivering evidence-based care and interventions focusing on values, rights and recovery, but also in generating the evidence that will contribute to the continual development of mental health services in Scotland.
While the evidence base that helps to inform mental health nursing practice has grown significantly over the last few years, it needs to continue to grow.
The literature review supporting the mental health nursing reviews in England and Scotland has made several suggestions for programmes of research that could add to the knowledge base of mental health nursing (see Appendix III) including:
- further large scale, user and carer-led research projects examining user and carer views of mental health nurses, in particular focused on children and young people, older people and people from Black and minority ethnic communities
- more high-quality clinical trials to establish the efficacy of interventions delivered by mental health nurses
- research that establishes the efficacy of interventions for deliberate self harm and the prevention and management of violence.
Future clinical trials will best be progressed if they:
- are truly embedded in the context of the 'real world' of mental health services and service developments in NHS Scotland
- progress with multi-disciplinary and multi-agency involvement
- reflect the diversity of people who access mental health services.
Approaches to generating evidence need to be based on the best evidence-gathering methods. Research into recovery in Scotland must progress with the aim of developing a national evidence base, to which mental health nurses should make a significant contribution. Berzins (in press), in a review of the literature on implementing a recovery approach in policy and practice (funded by the National Programme for Improving Mental Health and Well Being), notes that:
- research methods traditionally viewed as 'strong' in the field of evidence-based practice are not easily applied to values and recovery-focused practice
- traditional outcome measures may not necessarily reflect what helps progress towards recovery - we need to re-think these to best capture the meaning of recovery, as defined by people who have made this journey.
The review has shown that many initiatives are already progressing values, rights, recovery-focused and evidence-based care and interventions. The elements of mental health nursing practice that enable this need to be captured, along with indicators of how organisations can support the effort.
As a starting point, mental health nurses must be supported to undertake evaluations of new initiatives, an activity that is not common at the present time. Involvement in evaluation often introduces practitioners to the knowledge and skills they need to enable fuller engagement in research activity. Learning from evaluations can be shared on a national basis as new initiatives and services evolve. Higher education institutions should play a key role in supporting mental health services and mental health nurses in developing this.
The national strategy for research and development in nursing and midwifery, Choices and Challenges (Scottish Executive 2002b), supported by significant funding from the Scottish Executive, has driven the creation of three regional consortia in Scotland to oversee and develop nursing and midwifery research within a multi-disciplinary context. Priorities for developing the research and evidence base supporting mental health nursing practice should inform research programmes undertaken by the consortia.
The Scottish Mental Nursing Forum was established in 2004. The Forum consists of senior mental health personnel from all NHS Board areas, academic institutions and other key organisations concerned with progressing mental health nursing practice, research, education and service development. It should play a key role in shaping and influencing the research agenda for mental health nursing in Scotland, and in promoting collaboration across NHS Board areas and higher education institutions.
WE NEED TO:
- Ensure mental health nurses:
- are involved in evaluations of new initiatives and services
- can continue to build capacity and capability in developing the evidence base for mental health nursing interventions
- are involved in contributing to research into recovery in Scotland
- can influence the research agenda via the Scottish Mental Health Nursing Forum.
Enhancing the mental health nursing learning climate
One of the review objectives was to identify, analyse and disseminate existing strengths and areas of good practice in mental health nursing in Scotland. The examples of positive and innovative practice gathered as part of the review process show that many initiatives are already developing mental health nursing in the direction proposed in this report and action plan.
The mental health nursing community in Scotland is relatively small. It should be able to, and must, share and build on existing innovation on a national basis to inform developments. More robust mechanisms are needed to enable networking, sharing innovation and learning, and disseminating learning about the conditions necessary to support, enable and maintain positive and innovative practice.
The Scottish Mental Nursing Forum has similar aims to the mental health nursing review, and importantly provides a key platform to bring the community of mental health nurses in Scotland together to share learning and progress developments on a national basis. It should be active in supporting and progressing the actions arising from the review.
WE NEED TO:
- Create a more robust climate of learning, development, evaluation and research across the mental health nursing community in NHS Scotland.