The Five-Year Forward View For Mental Health1 highlights that ‘nine out of 10 adults with mental health problems are supported in primary care’.1 Although there are increasing numbers of mental health nurses working in primary care, there is still a huge deficit. This article aims to develop awareness of the mental health nurse role and highlight areas for practice development. Mental health problems are the largest single cause of disability in the UK,1 and there is a need to ensure that the needs of both the mind and body are met simultaneously, with mental health given equal status in terms of resources. Creating a greater shift towards primary care settings is essential, focussing on prevention and health promotion. It is also vitally important that primary care nurses develop further skills in recognising and supporting mental health needs, especially in long-term conditions where mental health problems may co-exist or develop. Physical comorbidities and premature death are highly prevalent in those with enduring mental health conditions, with higher rates of respiratory and cardiovascular disease, obesity, and diabetes.2 Holistic person-centred care will contribute to a better patient experience and improved health outcomes. Strengthening the relationship between primary care and secondary mental health services is also paramount.
Mental health nursing
Mental health nursing has developed significantly over the years and has moved away from the title of ‘psychiatric’ nursing. The change of name indicates a trend towards reducing stigma in a population that has long been marginalised. Although the term ‘patient’ has been used in this article, the term ’service user’ or ‘client’ tends to be used in mental health care. An agreement is yet to be reached as to whether this is an acceptable term to all. Terminology has become important in challenging stigma and redefining public perception of mental illness. Psychiatric nursing was historically seen as largely custodial, but is now focused on supporting patients towards recovery, helping them become empowered, autonomous and as independent as possible. Mental health nurses require skillful communication, observation and assessment of complex presentations and will deliver interventions that may be psychological, physical or social. They work in a wide variety of settings such as inpatient, community, prisons, acute hospitals, forensic secure establishments, substance use services, courts and also in primary care. The role is therefore diverse and a varied skill set is required in addition to the core fundamental skills and competencies of mental health nursing.
The cornerstone of mental health nursing is the therapeutic relationship. Establishing a rapport and demonstrating empathy are key and can be a complex process. Therapeutic relationships may need to be developed very quickly in acute settings, or they may evolve more slowly over time. Feeling understood, listened to and truly heard are critical to achieving successful outcomes. Mental health nurses must also be advocates and must consider patient choice and preference, providing the least restrictive options and settings for care delivery. This can often lead to challenging ethical and moral dilemmas regarding the need to balance choice and independence with safety and risk.
The assessment and management of risk is a fundamental aspect of mental health nursing and must always be prioritised. The risk may be to yourself or to others and may be actual or potential. Risk categories include suicide, self-harm, violence and aggression, neglect, vulnerability, safeguarding and hazards. Risk assessment is complex and cannot be quantified using measurement tools alone. Historical factors and incidents are considered in addition to fixed factors, such as gender and age, and ‘fluid factors’, which can change and fluctuate, sometimes rapidly or over longer periods. Interventions to minimise risk vary and require different levels of care provision, depending on the urgency, severity and unpredictability of the clinical presentation. Developing risk management plans is a key nursing skill involving consideration of patterns of thoughts, feelings or behaviours, identifying signs and symptoms of relapse and trigger factors for potential deterioration. Mental health nurses support patients to develop their safety and crisis plans. Risk cannot be eliminated entirely but strong therapeutic relationships and quality collaborative nursing care are essential for reducing harm.
Community mental health nurses work in multidisciplinary teams, fulfilling multiple roles in addition to carrying out traditional nursing tasks and interventions. Nurses may also commission social care, historically a role only undertaken by social workers. This means a more consistent approach for patients, minimising the numbers of professionals involved and allowing the mental health nurse to work within a wider scope. However, many mental health nurses feel their role has been diluted by this and that they have lost their ‘nursing identity’. Services are stretched with increasing demand. Significant underfunding has meant that nurses in secondary care are often seeing only the severest of cases. But working in multidisciplinary teams means that nurses have been able to learn from other professionals to diversify their skill set, and to offer an improved patient experience. The care programme approach (CPA) is a national framework that has been used in mental health services since the early 1990s. It was designed to deliver more coordinated and cohesive care. There are four key components: assessment, care planning, care coordination and review. Patients with complex, severe and enduring problems should have a comprehensive CPA plan and a CPA coordinator, who is very often a community mental health nurse. The care plan should involve other professionals and should cover physical, social and mental health needs and a robust risk management plan.
The CPA care plan has moved towards a ‘recovery-based approach’ in recent years. It aims to enable people to take ownership of their situation by offering choice where possible, encouraging and supporting self-management, promoting social inclusion, and supporting people to have a purposeful and fulfilled role in society and their community.
Primary care nurses can support patients by developing awareness of available resources and by gaining insight into recovery principles (see Box 1). There is a wealth of self-help resources available (see Box 2) and opportunities for primary care nurses to develop further skills and knowledge to support the provision of holistic mental healthcare. A bright future for the promotion of mental wellbeing would mean a greater focus on prevention, where mental health nurses and primary care nurses could work collaboratively. This should become the norm rather than the exception.
Mental Health Taskforce. The Five Year Forward View for Mental Health, 2016. england.nhs.uk/wp-content/uploads/2016/02/Mental-Health-Taskforce-FYFV-final.pdf. (accessed 16 August 2016). 2. Department of Health. No Health Without Mental Health: A Cross-Government Mental Health Outcomes Strategy for People of All Ages.gov.uk/government/uploads/system/uploads/attachment_data/file/213761/dh_124058.pdf (accessed 16 August 2016).
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Video explaining how staff and patients/service user’s can set up ‘The Care Programme Approach’ (CPA) is a way that services are assessed, planned, co-ordinated and reviewed for someone with mental health problems or a range of related complex needs. You might be offered CPA support if you: are diagnosed as having a severe mental disorder.