19. Community mental health nursing
Matter for discussion submitted by the RCN Essex Branch
That RCN Congress discusses the changing role of community mental health nurses across the UK
Progress reports
Submitted by: North Essex Branch
Council lead and committee assigned: Kevin Bell (until October 2011), Rachel Trencher (from October 2011) Nursing Practice and Policy Committee
Committee decision: No work required
Members involved: Cris Allen, Brighton and Hove Branch and Chair of the RCN Mental Health Forum
Final summary update at May 2012
This debate was a wide-ranging discussion on contemporary practice in community mental health nursing. There was no consensus as to any single particular issue that was a challenge to the membership or indeed the RCN.
However, following Congress it was agreed in conjunction with Cris Allen, the Chair of the Mental Health Nursing Forum, to appoint a Community Mental Health Nurse member to the steering committee of the forum. It is anticipated that the addition of a Community Mental Health Nurse will enable the committee to accurately reflect the composition and concerns of the contemporary mental health nursing workforce.
The recognition of community psychiatric nurses continues to be on the RCN’s agenda through membership of the steering group of the Joint Commissioning Panel for Mental Health, which is establishing guidelines for the commissioning of mental health services by clinical commissioning groups in England.
The RCN has also submitted comments on the proposed Scottish Mental Health Strategy which highlights the role of community psychiatric nurses.
Update at November 2011
Within the RCN a number of pieces of work are underway which focus on the role of health care support workers (HCSW), such as health care assistants and assistant practitioners.
The role of the Assistant Practitioner (AP) is an emerging issue for the RCN and a recent AP scoping project, which looked at the overall climate of AP roles in the UK, including regulation, training and role expectation, identified that the role is growing and that there is great variation in training and role expectations across the UK.
Tanis Hand, RCN HCA Adviser, is leading on a Future Nurse, Future Workforce work stream on health care support workers, one section of which is to clarify the differences between the registered nurse and support workers. Future Nurse Future Workforce is an RCN project which looks at seven key areas of nursing.
A group has been set up to discuss the best ways of providing information around these role and boundary differences, and Tanis Hand has produced a draft briefing paper on this which was shared with members of the RCN Nursing Practice and Policy Committee in early November. Once completed, this paper will be made available to members on the HCA information zone/website.
The RCN has consistently campaigned to introduce a mandatory register for HCSWs including APs and has widely lobbied members of the House of Lords as to the benefits of mandatory registration.
This issue continues to be discussed and debated as the Health and Social Care Bill goes through the House of Lords. The RCN continues to work with the NMC on this important agenda.
Debate report
Idris Adams from Essex branch began this matter for discussion by outlining the evolving role of community mental health nurses (CMHNs), formerly community psychiatric nurses (CPNs). He said in the 1950s there was only one CPN for every 10,300 patients but since then mental health nurses had played a key role in overseeing the movement of patients out into the community. “Mental health nursing has enabled a lot of people to live in their own homes rather than in hospital,” he said.
With some CMHNs likely to adopt the role of approved mental health worker under the Mental Health Act, student Natalie North said in the future she hoped to adopt that role. But Carla Lewington, from Bedfordshire branch, s aid she was a CMHN working with older people, a job she had wanted to do since she was a nursing student, and had no desire to be an approved mental health worker.
Malachy Ujam, Surrey branch, spoke of CMHNs having to work across disciplines – with the police and paramedics, for example. He also described wide variations across the country in terms of the community mental health care people receive. “It all depends where you live,” he said.
Summing up, Idris Adams said there were now far fewer CMHNs working at G grade than there were in the 1990s. “Any of us can be a patient,” he said. “Mental health has no boundaries.”
Community mental health nurses (CMHNs), formerly community psychiatric nurses, have been instrumental in the transition of mental health services from an institutional setting to a community setting. Today they work in both urban and rural settings across the four countries of the UK.
Previously attached to GP surgeries, CMHNs now work in dedicated community mental health teams where they hold caseloads and are predominantly responsible for the care and treatment of people with serious and enduring mental health issues. They operate in a variety of mental health spheres – including children’s services, forensic, elder care, and alcohol and substance misuse.
Recent developments include new services such as assertive outreach, home treatment, crisis resolution and early intervention, which have seen CMHNs expand and transform their role and work in radically different ways.
In addition, legislation changes have facilitated CMHNs becoming secondary and independent prescribers, and in England and Wales they may now adopt the role of approved mental health professional which, under the Mental Health Act (2007) replaced the approved social worker role. The Act also introduced community treatment orders, giving CMHNs a greater supervisory function and the ability to recall clients back to hospital if certain conditions of behaviour are not met.
In its submission to the Department of Health, however, the RCN strongly argued that the changes proposed by the 2007 Mental Health Act (England and Wales) – in particular the introduction of the community treatment order – would potentially harm the essential therapeutic relationship between client and CMHN. But the amended Mental Health Act (Department of Health, 2007) in England and Wales did create the potential for adoption of the approved mental health professional and approved clinician roles by mental health nurses in these countries.
In Scotland, the awaited recommendations of the Modernising Community Nursing Board may impact upon the role and responsibilities of the CMHN and could generate some scope for divergence across the UK. In addition, plans to further integrate health and social care in Scotland and the impending update to mental health nursing-specific policies may also affect the CMHN role.
In Northern Ireland, the RCN is lobbying for mental health nurses to take on the approved mental health professional role under the new single legislation currently being drafted in Northern Ireland. This development in the role was discussed in the recent review (Department of Health, Social Services and Public Safety, 2010) Delivering excellence, achieving recovery: a professional framework for the mental health nursing profession in Northern Ireland 2010-2015 recent review of mental health nursing.
Meanwhile in Wales, the NHS is shifting its focus from acute to community care, and the RCN has contributed substantially to the Community Nursing Strategy which contains specific recommendations to take forward community mental health nursing.
References and further reading
Bamford D (2007) Bamford review of mental health and learning disability (Northern Ireland): a comprehensive legislative framework, Belfast: Department of Health, Social Services and Public Safety. Available at:
www.dhsspsni.gov.uk/legal-issues-executive-summary.pdf
(Accessed 8/2/11) (Web)
Bee P, Playle J, Lovell K, Barnes P, Gray R and Keeley P (2008) Service user views and expectations of UK-registered mental health nurses: a systematic review of empirical research, International Journal of Nursing Studies, 45(3), pp. 442-457.
Department of Health (2007) Mental health act, London: DH. Available at: www.dh.gov.uk/en/Healthcare/Mentalhealth/DH_077352
(Accessed 3/2/11) (Web)