The Scope of Mental Health Practice - Historical and Current Views of What Constitutes Advanced Practice in Mental Health Nursing Set Against New Zealand Nursing Council Guidelines

The Scope of Mental Health Practice - Historical and Current Views of What Constitutes Advanced Practice in Mental Health Nursing Set Against New Zealand Nursing Council Guidelines

In the following discourse the scope of mental health practice will be explored. This will be set against historical and current views of what constitutes advanced practice in mental health nursing as set against New Zealand Nursing Council Guidelines.

In doing this it must be recognised that outlining these areas is a large subject and therefore not all will be discussed in depth. Throughout this essay definitions of nursing roles and what separates the novice practitioner from the expert will be explored. Once these have been established the remainder of the essay will reflect on the findings of an actual case dealt with in practice. Through this process it is hoped that the continued advancement of nursing practice can be demonstrated by the generation of new approaches to specific situations.

The scope of mental health practice has changed significantly over the years. Boling (2003) traces the history of the care of psychiatric patients. This finds the nurse in little more than a prison warders role, entreated to maintain order, prevent escape, and guarding patients from sharp objects (Davis (1980) cited in Boling (2003)). This persisted throughout the asylum era; in some cases the similarity to prisons continued with patients being placed according to their behaviours, rather than their needs (Rothman (2002) cited in Boling (2003)).

Further to this, nursing in mental health was seen as inferior to that of general nursing. Peplau (1982) believed that this was in part due to the stigma of mental illness, which still persists today. She went on to extrapolate that this lack of respect for mental health nursing was a result of institutions being, for the most part, built in remote areas. Adding to the stigmatisation was the idea that those who cared for the mentally ill were themselves peculiar (Peplau 1982).

It was Peplau’s work that described a change from the custodial care previously noted. She conceptualised nursing as psychodynamic and holistic with emphasis on the therapeutic nature of the nurse-patient relationship (Boling 2003). Through her work, the first graduate programmes in psychiatric nursing were introduced in 1954. The aim being to establish advanced nursing practice and produce the first clinical nurse specialists (Boling 2003).

In recent decades (Wheeler and Haber 2004) de-institutionalisation has been the most important driver for change in the advancement of nursing practice. This push for community care, or emphasis on primary care, has lead nursing into many new areas. Continued development of community health settings has given rise to many and varied employment possibilities for psychiatric nurses (Boling 2003); for example, court liaison nursing and assertive outreach teams (Wheeler and Haber 2004).

This in itself has caused problems. With the diversification of psychiatric nursing and the various conceptualisations of these roles has come the concern that the advanced practitioner role is in danger of being eroded (Delaney et al (1999) cited in Wheeler and Haber (2004)). This fragmentation and lack of definition was criticised as possibly undermining the advanced practitioners’ position; perhaps even resulting in it’s extinction.

So what is seen as advanced practice? Benner (1982), feels that the increased acuity of patients, the push for community-care and the resulting decreases in hospitalisation have increased the need for more highly qualified and experienced nurses. The proliferation of health-care and specialization needed today requires long-term and ongoing career development (Banner 1982). This, she states, requires practitioners to understand the difference between the expert and novice.

Benner (1982) notes that the transition from novice to expert reflects changes in all aspects of skilled performance. In her eyes this is as a result of change from reliance on abstract principles and models of care, to the use of past concrete experience as a paradigm. This change allows a nurse to see a situation as a complete whole and identify which parts are of greater relevance to the current problems faced (Benner 1982).

The expert nurse has a large amount of background experience on which to draw. This can give an intuitive grasp of situations and the ability to focus in on the areas to which care should be first directed. In this way the consideration of a large range of unfruitful possible problem situations is eliminated.

Benner (1982) recognises the difficulty of verbalising this into a concise description of advanced practice. This is, she states, because the advanced practitioner operates from a “deep understanding of the situation much like a chess master who when asked why he made a particularly masterful move will say, because it felt right” (p405 Benner 1982).

What is also emphasised is that experience alone cannot lead to expert practice; rather, experience must go hand-in-hand with formal education in order to develop competency. The difficulty in definition and confusion in the international health-service community is apparent in much of the literature available on the subject. The advanced practice nurse role is the subject of much discussion. The changing patterns of health-care previously outlined calls for nursing to examine new service delivery models (Gardener et al 2006). As a result there is a clear need for expanded levels of autonomy, skill and decision making in the nursing role.

The Clinical Nurse Specialist would seem competent to fulfil this need and has been in existence for many years (Boling 2003), but despite this, central roles and scope of practice for advanced nursing practice remain unclear. Furthermore, health-care has seen the emergence of many different nurse practitioner roles. There is a need to establish core competencies that differentiate these roles from the Clinical Nurse Specialist.

The abundance of titles alone used to describe advanced roles for nurses causes confusion. According to Daly and Carnwell (2002) in the UK these include:

1. Clinical Nurse Specialist
2. Nurse Practitioner
3. Specialist Practitioner
4. Advanced Practitioner
5. Nurse Therapist
6. Physicians Assistant
7. Higher Level Practitioner (UKCC 1999a)
8. Nurse Consultant

All these with come with little consensus as to the differentiating features of each. Many of the concerns raised by the nursing profession about these new roles is the need to remain true to the elementary nursing core competences or essence of nursing (Daly and Carnwell 2002).

As this essay concentrates on advanced nursing practice in mental health it will use Gardener et al for guidance. They describe the term advanced nursing practice as: “those nursing roles that involve higher level knowledge and skills that enable clinicians to practice with autonomy and initiate nursing actions but do not include diagnostic and treatment decision making” (p383). This does not include the nurse practitioner who does have this decision-making autonomy.

Peplau ((1965) cited in Wheeler and Haber (2004)), encapsulated the reasons for the proliferation of new advanced roles. This is due to the aforementioned social forces of change that drive and necessitate technological advances. This gave rise to areas of specialization in nursing in response to these public and societal needs.

The New Zealand Nursing Council has addressed this by defining a core competency framework to develop nurses’ progression from novice to advanced practitioner. These are laid out in the form of eleven competences for nursing. The definitions for the competencies remain the same, however, the criteria for performance is greater as nurses’ progress towards expert practitioner.

The professional development recognition programme has been based on these competencies and is aiming for a standard level of practice. The eleven competencies are:

1. Communication
2. Cultural safety
3. Professional judgement
4. Management of nursing care
5. Management of environment
6. Legal responsibility
7. Ethical accountability
8. Health education
9. Inter-professional health care
10. Quality Improvement
11. Professional development

Again, although the competencies remain the same for all levels of nursing practice, therefore ensuring consistency of role and expectation of practice, the performance criteria change to reflect the level of expertise.

For example, in the first competency (Domain 1) ‘Communication’, at the ‘advanced level’ of assessment the performance criteria are set out thus:

• Actively facilitates/ participates in team meetings, organisational committees and or groups.
• Is a skilled communicator and problem solver and facilitates collaborative practice.
• Nursing documentation consistently reflects practice and patient outcomes.

Whereas, at the ‘competent level’:

• Demonstrates effective verbal and non-verbal skill in clarification, reflection, affirmation and eliciting within a therapeutic partnership.
• Ensures information is presented in an appropriate and meaningful manner
• Responds appropriately to patients/ clients’ questions, requests and needs.
• Contributes to interdisciplinary and team meetings.

This difference in focus and level of experience and knowledge necessary to function at an advanced level is mirrored throughout all 11 domains.

These domains are the nursing council’s attempt to unify what is central to the nursing role and reflect the need for clarification noted earlier. As Wheeler and Haber (2004) have identified by looking at 73 educational courses aimed at training nurses to advanced level, a consistent competency is patient contact.

Patient contact provides clinical examples that reveal the true core components of advanced practice, knowledge and experience. For this purpose a case study will be used and relevant aspects explored with direct reference to the competencies outlined previously.

Case Study
Initial contact was made with Client Mabel in January 1986, with treatment for depression at 3 years previously. Mabel was 30 years old at this point. Acute admission characterised by minor overdose attempts, superficial cutting of wrists, and the fact that she maintained she had been raped. This alongside self reported auditory hallucinations telling her that the Russians were coming. At this stage Mabel was still working as an enrolled nurse in a general hospital.

During following admissions through the early 90s her presenting problems were similar. Overdose attempts, superficial cuts to wrists, depressive symptoms. Mabel commenced a community based day programme in 1991 but the persisting presenting factors, and the additional thoughts that Mabel may have molested children (specifically young boys), led to acute admission in the October. Frequent admissions continued through to 1994, then after a typical 3 day admission and usual follow up Mabel remained out of hospital until early March 2003. During this time she was on IMI Depixol, and lived at home in highly dysfunctional relationship. This involved Mabel sharing her mother’s bed, with father using the spare room.

Community staff reported that although admissions did not happen, Mabel continued with many maladaptive coping strategies. These included becoming hysterical in the family home when a stressor occurred, throwing furniture, and household objects. Mabel’s mother appeared to deal with these in two ways- hiding behind the couch, or slapping her across the face in an attempt to break the episode. Her father died in 2000 from diabetic complications brought on by heavy drinking.

The over dependent relationship with her mother continued until she developed Alzheimer’s and was placed in care in September 2002. Mabel did cope with support, however, in a caring role for her mother from early 2001.

From early 2003 Mabel has been in inpatient care, for most part in S. Clinic (locked rehab facility). There have been short periods of time in Acute service, absconding from an open ward (attempting to throw herself under cars) leading to transfer to a locked ward, then back to S. Clinic. Escalation in behaviours, including many assaults on staff with weapons such as cutlery, throwing objects, punching-and others, linked with threats to kill, lead to Mabel being charged, and a 6 month period in a forensic inpatient unit. During this time Mabel was placed on a behaviourally structured programme of care. This saw her regress to stripping off her clothing in open areas of the ward, and urinating. Much of her time was spent in seclusion, where she again urinated on the floor, and smeared faeces on the walls. During time out of seclusion Mabel was noted to need 3-1 staffing, as this was seen necessary to maintain safety of staff.

On return to S. Clinic Mabel continued to be placed in seclusion for the majority of the day. This lead to human right issues, so Mabel was thereafter managed on a locked ward environment with a constant 2-1 staffing ratio.

In my first contact with Mabel and Mabel’s diagnosis of B.P.D. I noted two things, that B.P.D. engenders many negative stereotypical beliefs about her, as identified by Conklin and Weston (2005) and that Mabel’s nursing team were largely burnt out by her habitual destructive and violent behaviours. Initially I was influenced by these negative factors and the pre-conceived ideas I had about B.P.D diagnosis. This situation is recognised by Stiles et al (cited in Hill (2005)) as: “…having a profound effect on the therapist’s judgement towards the patient and their empathic communications with the patient” (p434. Hill 2005).

Once there was realization that the staff were transferring their anger and disempowerment toward the situation, a place for change in the management of nursing care presented itself.

As laid out in one aspect of the competency framework (Domain 4) of the Personal Development Recognition Programme (PDRP), ‘management of nursing care’, the ability to articulate your own philosophy and incorporate this into delivery of care is critical. In this situation I engendered change by educating the team concerned.

Mahoney (2001) highlighted the importance of moving a group through influence and activity towards a more positive outcome. In leading by example through the use of non-judgemental positive regard, mentorship and innovative care-planning this process began (Mahoney 2001). This role, seen as an area of advanced practice, is discussed by Donaldson and Carter (2005). They stress the importance that good role modelling can have in clinical settings. The value emphasised is on observational learning and facilitating constructive feedback on observed behaviours / skills into an individuals own competency set.

As with Mabel where situations are complex, modelled behaviour was repeated on many occasions. This was done through developing the therapeutic relationship with Mabel. In working towards a trusting, honest and non-judgemental therapeutic relationship with Mabel it gave an opportunity for the team to focus on more positive aspects of Mabel’s personality and allow for deeper engagement on both sides. By changing focus from presenting behaviours and placing Mabel at the centre of the care process it allowed staff to interact more openly with Mabel and avoid the negative transference noted earlier.

Through this process where practitioners were able to evaluate, monitor and adjust their performance, learning was observed. This capacity to improve skills such as personal reflection, appraising evidence and clinical decision-making enabled patient centred care (Kitson 2002).

This is underlined by Peplau, ((1988) cited in Gastmans (1998)) in which a client-centred approach based on the therapeutic relationship leads both client and clinician to pose new questions to be answered to improve practice and care provision. To further reinforce this Peplau sees nursing as a scientific discipline and its purpose is to clarify situations found in nursing practice itself. As we have already discussed, advanced practice is seen as the ability to draw on experience gained in practice and focus it through learnt knowledge to identify relevant new and innovative ways of practice.

This idea of integrating theory into practice is summed up by Kitson (2002), who feels that mature organisations and advanced practice is where professionals and patients learn together, and activities are jointly undertaken, not one where care is ‘done to’ the patient.

So, further to positive role modelling to help change the nursing teams attitudes, understanding the importance and the reasons behind Mabel’s view of the relationship was necessary. This was done through collaboration based on the formulation process. This is about looking at four factors pertinent to her current presentation, predisposing, precipitating, perpetuating and protective factors.

Once done, the ability to identify from the large amount of data collected what was pertinent was also necessary. As has been identified this skill of seeing the whole, but honing in on only relevant information is seen as an advanced nursing role.

In going through this process it was possible to lead the team to provide care based on theory and research findings, i.e. using appropriate interventions such as the principles of cognitive and dialectic behavioural therapy (Osbourne and Fry 2006), to work with Mabel. In seeing how an individual conceptualises the world and the meaning they attach to events, it is possible to begin to understand presenting behaviours.

In leading this change, an understanding of what leadership is has been necessary:

• The clear understanding of values and beliefs about nursing (evidence based, client centred);
• Empowerment through example, innovation and creativity;
• Promotion of all that is positive throughout the team and;
• The ability to celebrate all accomplishments both great and small. This is set against the ability to learn from mistakes made at this time.

All this has been driven through the multi-disciplinary team [MDT] process and as stated in the PDRP. Communication skills that facilitate team meetings and the ability to be a skilled communicator in these settings is a core competency for the expert.

A key to reversing the burnt out feelings of the team and at the same time managing the needs of the client involved the co-operation and involvement of the whole MDT. The ability to ensure that all members were seeing the situation similarly and acting accordingly was necessary. Furthermore, using purchasing services outside the CDHB was needed and this has led to involvement with planning and funding, housing corporations, nursing agencies and even participation from the ACC.

As Ovretveit (1995) (cited in Lankshear (2003)), pointed out “an MDT without differences is a contradiction in terms” (p457). Different world views held by differing professions, professional identities, status and the perceived threat of the MDT process itself all need to be negotiated (Lankshear 2003).

As Benner (1982) stated initially, the expert in advanced practice must be intuitive or knowing and have a sub-conscious competence to complete these outlined roles. Also they must have the ability to balance this experience based knowledge against current research and evidence provided from the patient, to arrive at the best clinical decision for care provision (Kitson 2002). To fulfil this Cutcliffe (1996) organised the components into 4 core categories of attitudes, philosophies, knowledge, skills and roles.

Attitudes and philosophies held by the advanced practitioner are seen as caring, self-aware, committed people who place the client centrally and view them holistically.

Knowledge is noted, as above, as an integration of a wide base of scientific knowledge and their instinct intuitive experience. Advanced practitioners must also understand the idea of life-long learning and that all knowledge should not be taken at face value, but examined and critiqued.

Skills, is the pragmatic element of the advanced nurse and is and is critical to the actions and interactions that the advanced nurse uses.

Finally, roles are described as the ability of the advanced practitioner to understand the different roles necessary to practice and move effortlessly from one set of expectations on performances to another effortlessly.

In summing up, Crowe and O’Malley’s (2005), thoughts are pertinent. As outlined in the face of ever changing healthcare provision needs, driven by societal pressures, expectations are ever shifting and are often conflicting as to the nature of advanced practice. The belief that knowledge and skill are sufficient in this atmosphere of change is no longer true. The advanced nurses toolbox now must contain the ability to assess and react to many situations effectively and creatively. To do this the ability to critically reflect on the ever growing accumulating body of knowledge and technologies is essential. The speed of change and the complexity of its nature are ever growing. The ability to swim in the ever murkier waters of advanced nursing will require ever higher levels of reasoning and thinking (Crowe and O’Malley 2005).

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