Mental health nursing comment

It's time the giant of mental health nursing woke up

May 16, 2005

The views of mental health nurses are markedly absent from clinical guidelines produced by The National Institute for Clinical Excellence, say Phil Barker and Poppy Buchanan-Barker. Mental health nurses, it seems, just don't count. So, argue Barker and Buchanan-Barker, it's time mental health nurses had their own representative body to stand up for them.

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A lot has happened in nursing over the past 35 years that we have been in the mental health field. At the end of the 1960s nurses were 'trained' in a highly institutional fashion. As Steve Wright has observed, then there were a couple of weekly nursing journals and "not enough nursing books by nurses to fill a shoebox" (Wright, 2004). If anyone had told us that 35 years later, huge numbers of mental health nurses would be graduates - many with Master's degrees and even some staff nurses with doctorates - we would have laughed. In those days, nurse tutors recycled, uncritically, the medical wisdom of the day and practising nurses focused on 'fitting in' - avoiding rocking the institutional boat, at all costs. By the early 1970's this changed dramatically as nursing was redefined as a 'research-based profession' and the 'training' of nurses turned slowly into proper 'education'.

Today, mental health nursing is a remarkably diverse discipline, led by an increasingly well-qualified group of teachers, many of whom also conduct research and a few of whom also find time to practice. Mental health nurses now fulfill a wider range of responsibilities than ever before. Nursing is more important than ever, and those who are being prepared to practice nursing are - at least in principle - better prepared than ever (Wilshaw, 2004).

However, when was the last time a mental health nurse appeared on radio or television, discussing the importance of caring (Barker, 2000)? When was the last time a newspaper or popular magazine described how nurses rise to the challenge of caring for people across the psychiatric lifespan? However nurses do make media appearances whenever someone wants to blame them for some failing in service delivery. By contrast, radio programmes like 'All in the Mind' or 'In the Psychiatrist's Chair' perpetuate the myth of the highly-accessible, all-seeing, all-knowing, psychiatrist. Nurses - who are the font-line of almost every aspect of psychiatric practice - remain largely invisible.

We are surprised that nurses are not incensed by this state of affairs, especially since the public face of any professional discipline is the key to recruitment. We suspect, however, that mental health nursing has something of a professional esteem problem.

Nurses find it hard to believe that they are that important. In a sense, they remain the children of the psychiatric family, allowing their parents - psychiatric medicine and psychology - to do most of the talking.

A concrete example of this low professional esteem is provided by the National Institute for Clinical Excellence (NICE). This important body was established by the government to make recommendations on treatments and care using the best available evidence.

Given its brief, one would have expected that NICE would recognise the central role of nursing in mental health service delivery, and nurses would be fully represented in the various NICE Guideline Development Groups or Review Panels.

However, compared to the prominent positions adopted by psychiatric medicine, psychology, social work and even the voluntary sector groups - like Mind or Rethink - mental health nursing is pitifully represented, if not absent altogether.

For each mental health guideline published to date, the Guideline Development Groups (GDG) and Guideline Review Panels (GRP) have included several high-ranking professorial and research psychiatrists, GPs, psychologists and social workers.

The GDG for the schizophrenia guidelines (NICE, 2002) included no less than five doctors - one consultant psychiatrist from practice, two professors of psychiatry, one professor of primary care and the deputy director of the Royal College of Psychiatrists Research Unit. The GDG also included two psychologists. One was a professor of clinical psychology and the other the director of the Centre for Outcomes Research and Effectiveness. Despite the fact that the care and ongoing management of people with a diagnosis of schizophrenia almost always is a nursing responsibility, NICE chose not to enlist any distinguished or high ranking mental health nurses, as they had done with medicine and psychology. Instead, a solitary nursing lecturer-practitioner was included in the GDG, but seemed unable to convince the elite forces of psychiatry and psychology, of the importance of nursing for the care of this vulnerable group. The resulting guidelines - most of which were based on nothing more than the evidence of 'expert opinion'- focused exclusively on medical and psychological issues.

In our view, the guidelines marginalised the nursing voice (Barker and Buchanan-Barker, 2003), illustrating the highly political nature of the power games in health care (Hart, 2003).

This year NICE published its self-harm guidelines, focused on a clinical population that presents considerable challenges for mental health nurses working with younger people, adults and the prison population. Once again, distinguished professors of psychiatry and psychology were prominently represented at both guideline development and guideline review level, supported by other senior medical and psychology clinical and research staff.

A solitary charge nurse from accident and emergency was included, who doubtless provided a vital view from A&E.

However, the guideline was focused on primary and secondary care, acknowledging that the problem of self-harm extends way beyond the beleaguered confines of emergency room.

If a bevy of highly experienced doctors and psychologists, was needed to join with GPs, representatives of the Samaritans and a local Mind group, and various 'research assistants', surely the inclusion of one highly experienced mental health nurse could have been justified?

It has been our privilege to work with, teach or supervise, nurses with an enviable knowledge of self-harm. Some of these nurses have written dissertations at Master's and even doctoral level, thereby breaking new academic and clinical ground. Why were some of these nurses not represented on both the Guideline Development and Guideline Review Panel's? Again, Chris Hart's (2004) recent book appears to offer the unspoken answer is - nurses don't count.

We had hoped that mental health nurses would create some kind of a fuss about their exclusion from core membership of this important body (Barker and Buchanan-Barker, 2004), but again, the silence has been deafening.

As if to add insult to injury, NICE excluded mental health nursing entirely from the Guideline Development and Guideline Review Groups for its work on depression. We were astonished that NICE could so casually ignore nursing, which is patently a vital part of the therapeutic process for people with depression. Again, we know many clinical and academic nurses who could have brought their expertise from research and practice to bear on the NICE considerations.

Our observation of the nursing journals and nursing internet sites suggests that there has been virtually no protest from mental health nursing over its marginalisation from NICE. We would have thought that groups like the Mental Health Nurses Association and the Royal College of Nursing's mental health nursing forum, would have vigorously challenged this state of affairs. However - at least so far - nothing.

Perhaps mental health nursing needs is a dedicated organisation to represent its interests; to provide leadership; and to ensure that its voice is heard alongside the other key players in the field.

Psychiatrists have the Royal College of Psychiatrists. Psychologists have their specific branches of the British Psychological Society. Social Workers have BASW. In other countries, like Australia and New Zealand, mental health nursing has dedicated leadership and a dedicated 'college'. Although the existence of such a college would not resolve all the problems that nursing faces, it might at least help provide some sorely-needed public profile.

In the UK, there exist a number of competing organisations - the Mental Health Nurses Association, the Forensic Nurses Association, the Royal College of Nursing and Unison - which risk spreading the power base of the discipline too widely. The Royal College of Nursing (RCN) is led by an American former psychiatric nurse, but her brief as general secretary means that her influence in mental health nursing is virtually non-existent.

We have met thousands of mental health nurses who are rightly proud of the work that they do. Invariably, this is a private expression of pride. These nurses have precious little in the way of organisational means to bring their understanding of nursing's importance to a wider, public audience. Presently, mental health nursing is like a sleeping giant - awaiting some magical event to rouse it from its slumbers. If the awful sound of 'exclusion' and 'marginalisation' made by NICE is not enough to waken it, one wonders what actually will.

References
* Barker P (2000) The virtue of caring. International Journal of Nursing Studies 37, 329-336

* Barker P and Buchanan-Barker P (2003) NICE: Does the gold standard have feet of clay? Mental Health Nursing 23, 9-11

* Barker P and Buchanan-Barker P (2004) Experts without a voice Nursing Standard 18(50) 22-23

* Hart C (2004) Nurses and Politics: The impact of power and practice. Basingstoke, Palgrave Macmillan.

* National Institute for Clinical Excellence (2002) Schizophrenia: Core interventions in the treatment and management of schizophrenia in primary and secondary care. NICE, London

* National Institute for Clinical Excellence (2004) Self Harm: The short-term physical and psychological management and secondary prevention of self-harm in primary and secondary care. (Clinical Guideline 16). London: National Collaborating Centre for Mental Health, July 2004

* Wilshaw G (2004) Consultant Nursing in Mental Health Chichester: Kingsham

* Wright S (2004) The value of values. Nursing Standard 19(9) 15-16

* Phil Barker is a psychotherapist in private practice and honorary professor at the University of Dundee. He was a nurse for more than 35 years and the UK's first professor of psychiatric nursing practice. He is also professor of health science, Trinity College, Dublin, Ireland

* Poppy Buchanan-Barker is a counsellor, advocate and director of Clan Unity International, Scotland.

They have, between them, authored a number of books, including The Tidal Model: A guide for mental health professionals and Spirituality and Mental Health: Breakthrough

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Nurses have little power

Comment from: Jane Sedgewick, Child and Adolescent Mental Health Service Regional Development Worker, Yorkshire and Humber.
Date: January 16, 2006

I do wonder why mental health nurses are so quiet, and what we can do to raise the profile of their work.

I wonder if the professional self-esteem problem is replicated in general nursing? I believe that partly it could come from the perception that nurses follow the 'medical model' (a left over from the 'training' days outlined above) by those outside of ther profession. I also feel nurses keep quiet because they don't have the power of the medics if they want to challenge something.

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See also:
Feb 15, 2005: Mental health nursing to be overhauled by end of the year - time for the country's 45,000 mental health nurses to adapt to change in the NHS, says chief nursing officer Chris Beasley.
Book extract: Jan 24, 2005: Psychiatric disorder or spiritual misery? - People who've experienced madness have later appreciated the spiritual insights of their distress. We should do more to acknowledge this, argue Phil Barker and Poppy Buchanan-Barker
August 16, 2003: Pushing for compassionate and ethical psychiatric nursing - Name an eminent thinker from 20th century psychiatry and mental health, and a psychologist, psychiatrist or philosopher might spring to mind. It's unlikely to be a psychiatric nurse. But if it was, it might be Phil Barker.

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