ANMJ Featured Story

Lean on me: The challenges and opportunities facing mental health nursing

Saturday 22nd July, 2017

As reform continues to shape Australia’s mental health system, greater access to mental health nurses across all levels of healthcare is crucial. When allowed to work to their full scope, mental health nurses possess the ability to engage and connect with people while helping them drive their own recovery journeys. Robert Fedele reports.

Several decades ago it was considered normal for a person experiencing mental illness to be shipped off to an asylum to live out their days. Such was the thinking that the concept of recovery was off the radar and largely regarded as unattainable.

Ideas started to change when Australia’s asylums were shut down in the 90s and mental health services shifted into general hospitals, GP clinics and the community.

The move into mainstream settings occurred alongside the growing philosophy that people experiencing mental illness had the capacity to shape their own recovery journeys.

Ingrid Cother, a mental health nurse at Eastern Community Mental Health Services in Adelaide, engages with clients across the care continuum as part of an integrated community team.

The role includes assessments, building care and treatment plans and linking clients with other programs and services. Clients range in age from 16-64 and experience everything from anxiety and affective disorders to psychotic disorders.

“My focus is across the whole care continuum,” Ingrid says. “It could start with assessment and crisis intervention and treating people when they’re acutely unwell, but also moving through to providing longer term care co-ordination, which tends to be goal focused. You’re looking at what people want to achieve with their treatment and trying to link them in with services that can help.”

Ingrid’s objective reflects the sector’s gradual shift from the hospital into the community and recovery oriented services. In that time, important programs such as Better Access were introduced, the federally funded initiative increasing community access to mental health professionals such as psychiatrists and psychologists.

“It’s a fundamental shift because it’s actually about people with mental illness being able to live in the community just like anyone else and there’s a fundamental principle underlying that which is essentially human rights – the right for people to choose how they live their life and supporting people with their personal recovery to live the best life possible with or without their symptoms.”

Despite inroads, Ingrid says mental health nursing remains underutilised.

She maintains there’s greater scope for advanced practice roles that enable earlier initiation of pharmacological treatment, which may prevent hospitalisations and improve health outcomes.

Currently, Ingrid could assess a client and identify their mental health diagnosis, yet the person would likely need to wait to see a doctor to receive pharmacological treatment.

It leaves her having to weigh up whether to take a person to hospital so they can access care promptly or hold off. It’s merely one example of how mental health nurses could be better utilised to benefit consumers, Ingrid says.

Ultimately, while Ingrid trusts modern mental healthcare is heading in the right direction, she stresses true change can only occur through a combined effort involving governments investing in services, the community viewing mental health as a shared issue and a reduction in stigma achieved by normalising the experience of living with mental illness.

THE STATE OF PLAY

According to the 2007 National Survey of Mental Health and Wellbeing, around 7.3 million people or 45% of Australians aged 16-85 will experience a mental health-related condition such as depression, anxiety or psychotic disorder during their lifetime.

The Australian Institute of Health and Welfare (AIHW) estimates $8.5 billion is spent each year on mental health services
in Australia.

Various healthcare professionals deliver care, including 20,834 mental health nurses.

Mental health nurses work in both public and private healthcare settings, yet the discipline isn’t present in all mental health settings.

Specifically, many Commonwealth funded programs continue to exclude nurses from being funded to be direct providers of specialist healthcare, favouring other health practitioners and subsequently depriving communities of nursing services without barriers.

Conceivably, core issues facing mental health nursing aren’t unique to the profession – staffing ratios, skills mix, chronic bed shortages, limited community mental health nursing positions, increasing workload burdens and an overarching lack of funding head the list.

However, as reforms continue to shift the system’s architecture, the speciality faces shared challenges that will likely determine its impact moving forward.

One major test concerns safeguarding the employment of mental health nurses across all levels of healthcare through promoting nursing care and the profession’s unique skill-set.

Having a fragmented public mental health system has contributed to the frustration felt by consumers and workers, together with historical policy directions that focused on a generic approach to specialist service provision that have created barriers for discipline specific nursing care.

The push for recognition stems partly from the Nursing and Midwifery Board of Australia’s (NMBA) move to a national register, which brought all nurses and midwives under the one umbrella, but left some specialties like mental health lamenting lost identity.

The ANMF has continued to lobby for the National Register to recognise nursing specialties including mental health nursing.

Another important reform involves the Abbott/Turnbull government’s Mental Health Nurse Incentive Program (MHNIP) last year having its funding switched to Primary Health Networks (PHNs).

The incoming model entails PHNs no longer being obliged to employ community mental health nurses, leading to uncertain times and redundancies where services have cut the position.

Optimists view the reform as a chance to advocate the integral role mental health nurses play but remain hopeful rather than confident of renewed uptake.

Elsewhere, issues confronting the sector extend to the contentious debate surrounding the seclusion and restraint of people with mental illness.

The conversation around practices has seemingly reached an important juncture.

Earlier this year, the NSW government launched an independent review into the state’s practices following the death of a patient at Lismore Base Hospital.

Victoria, notably proactive within this space, this year rolled out its $2.4 million Safewards program across all public mental health units.

Based on a successful UK model, Safewards involves a range of nursing interventions that authorise the use of validated measures and strategies to reduce conflict, potentially reducing violence and aggression that can escalate to harm and the need for stressful restrictive interventions.

CHAMPIONING MENTAL HEALTH NURSING

At high school, Donna Hansen-Vella undertook work experience in one of Victoria’s largest asylums, the exposure cementing her aspirations of becoming a mental health nurse and leading positive change within the sector.

It led to a rewarding clinical career across mental health services, then joining the ANMF (Vic Branch) to represent the state’s mental health nurses.

Donna, now the Branch’s Mental Health Nursing Officer, oversees the union’s organisers covering mental health and more broadly promotes the value of mental health nursing in key discussions facing the workforce.

One of her current posts includes sitting on a workforce group where she applies a mental health nursing lens when advising the overarching work of the Mental Health Expert Taskforce.

She describes her vision for the future incorporating approaches where every person and their support system, such as family and friends, has access to nursing services at all time when they need it, without barriers.

The ideal system would focus on preventative strategies and involve the employment of mental health nurses supported by organisations to utilise their unique skill-set across all levels of healthcare, including acute and sub-acute and non-traditional settings.

Donna continues to work clinically in a role she considers crucial to keeping her connected to the profession.

She cites changes to the state’s Mental Health Act 2014, which opened the doors to supported decision making and providing patients with greater choice and opportunities to collaborate, as an exciting development.

“I’m not the decision maker; the people I care for are,” Donna explains. “It’s their life. It’s their experience of mental illness. It’s their journey of recovery. In some aspects I feel like mental health nurses are being allowed, through changes in the legislation, to actually practise nursing how we should practise nursing and how we were trained to practise nursing.”

While mental health nurses operate across the health spectrum, Donna believes their influence is often compromised by ongoing barriers, chiefly relating to resources such as the lack of beds and pressure to discharge patients.

LACK OF FUNDING

It’s a dilemma confronting Tasmania, where mental health bed shortages at the Royal Hobart Hospital is placing the system under pressure.

The hospital’s 42-bed mental health ward was slashed to 32 beds as a result of recent redevelopments.

The state government says the situation will be ironed out once the redevelopment is completed in two years’ time, yet the notion seems improbable given it doesn’t plan to restore bed numbers at the revamped site.

According to the National Mental Health Report 2013, Tasmania should have 105 acute mental health beds to cater for its population.

Right now the state has just over 70, leaving it well short of the preferred average.

The human impact of insufficient services was underscored by a recent case involving a man diagnosed with depression and admitted to Royal Hobart Hospital for treatment before being granted leave from the Emergency Department to go home and have a shower due to no mental health beds being available.

Sadly, the man, who had been assessed as a moderate suicide risk, took his own life not long after returning home.

A Coronial Inquiry into the incident last year concluded the man would likely not have committed suicide if sufficient mental health beds were available.

Mental health nurse Amy Boon, an Information Officer at the ANMF (Tas Branch), says the shortfall must be fixed.

“It’s not about needing in-patient beds because we think that’s where people should be. We want people in the community. But we know that there needs to be something there in the acute stage so that people are safe and able to be cared for.”

Amy cites skills mix as another critical issue, pointing to changes in the state’s 2013 Mental Health Act that removed the requirement for nurses working in the field to hold specific mental health qualifications and adequate training as worrying.

“We are getting more and more nurses who are entering mental health with their general training but they haven’t got the surrounding experience with them.”
Amy says.

“If you’ve got a breadth of skill-set that you’ve been formally taught, as well as the experience to go along with it, you’re looking at someone who’s going to hopefully have a few more skills in order to get better outcomes for the patients.”

Nevertheless, Amy remains confident mental health nursing can flourish.

“We need the government to pay attention. We need the skill-set required to be a mental health nurse to be fully appreciated and recognised again. We need a system that is connected – in patient, community, NGOs – all running on a continuum of care to assist consumers to be in their best state of wellness.”

PERSON-CENTRED CARE

Glenn Hayes is a Clinical Nurse Specialist (CNS) at Shellharbour Hospital’s Eloura West mental health observation unit in NSW, treating patients with high-care needs through a strengths-based approach to recovery.

Drawn to mental health nursing because it allowed greater opportunity to engage with patients, Glenn entered the profession three decades ago as asylums were being phased out and a community-based style of care was being activated.

Countless changes have since transpired, with Glenn listing the emergence of Trauma Informed Care, which acknowledges how past distress can contribute to conditions, as among the most progressive.

Glenn believes mental health services need more funding to improve the design and layout of many outdated hospital wards which aren’t conducive to getting well.

“Nowadays, we need to start looking at environments that are a little bit more therapeutic, more relaxing, more normal, so that when people come to a place like this they aren’t feeling as if they’re imprisoned or feeling as if they’re going to be traumatised again.”

Glenn’s unit continually explores emerging models of care and has made recent attempts to reduce practices such as seclusion and restraint.

“The main thing is to realise why we’re there. We’re not there to challenge people to be aggressive. We’re not there to try and impose our will upon people. We’re there to try and be as therapeutic and helpful as we can.”

Like others, Glenn agrees mental health nurses aren’t being utilised to their full scope. But he remains confident positive change can occur if restrictive delivery methods are loosened and mental health nurses are empowered to forge meaningful, person-centred care.

“People just want to be heard. They want to be listened to and know that people have their genuine concern at heart. That’s what we’re there for. We’re there to be therapeutic and we’re there to actually try and get things better.”

INCREASING SCOPE

A Mental Health Nurse Practitioner at the Northern Community Mental Health Service in South Australia, Paula Larsen specialises in affective disorders such as depression and bipolar.

As an NP, Paula is permitted to undertake assessments, diagnose conditions, draft up management plans, prescribe and deliver evidence based psychotherapy.

Working within an integrated community health team, Paula owns a higher level of autonomy and suggests more mental health nurses should be encouraged to undertake advanced practice.

However, she says ongoing restrictions around Medicare rebates leaves little incentive for nurses to pursue the role where at the moment viability is limited under the Medicare Benefits Schedule (MBS).

Questioned about the mental health sector, Paula believes longstanding stigma attached to mental illness is fading as more people access healthcare.

With the sector poised to make a greater impact, Paula pictures a growing role for NPs. “Hopefully, there’s a lot more emphasis on prevention, early intervention and the community being provided care in the home, effectively reducing hospital admissions and involuntary care.”

MENTAL ILLNESS AMONG NURSES AND MIDWIVES

Nurses and midwives aren’t immune to mental illness.

RN Carolyn McDonald has worked within mental health for 11 years, primarily with the Nursing and Midwifery Health Program Victoria (NMHPV) where she supports nurses and midwives experiencing health issues relating to mental health or substance abuse.

The confidential service aims to engage and connect with clients one-on-one whilst providing them with links to other services and further help.

An addiction specialist, Carolyn, says the NMHPV has recently treated more nurses and midwives for anxiety and depression. A maladaptive coping strategy for mental ill health is self-medicating with substance use that can then, escalate into addiction.

It speaks volumes for the profession and confirms the growing need to tackle mental health.

In June, SBS’s Insight program shone the spotlight on the high rates of mental illnesses among junior nurses and doctors, highlighting a 2016 study of suicides over 12 years that found female nurses and midwives had a suicide rate almost triple that of women in non-health professions.

“I would say that nurses and midwives are more vulnerable to experiencing mental health issues because of the nature of the work that we do and the stresses that we have to deal with on a day to day basis,” Carolyn says.

Carolyn says shift work is one part of the job that can lead to isolation, a major trigger for anxiety and depression.

When working with clients, Carolyn aims to create a safe space for someone to explore their story, support them to manage their health problem and develop more resilience and sustainable coping strategies.

“I feel really lucky to be in this position. I work with my colleagues, helping them get back on the wellness side of the mental health continuum really.”

Critically, Carolyn says nurses and midwives, who identify as caregivers, are often reluctant to seek help themselves. It’s a cultural mindset she hopes unique programs like the NMHPV can continue to shift to the point mental health becomes a priority.

BUILDING RESILIENCE

In a similar vein, CQ University academic and mental health nurse Margaret McAllister is encouraging the profession to better understand and foster resilience.

Margaret, who teaches a Graduate Diploma of Mental Health Nursing and has written a book on resilience, considers nurses one of the most stressed health professionals.

“I suspect mental health nurses experience more stress and I think it’s because these days in acute admissions, patients are coming in acutely unwell, but also having used substances, partly to self-medicate, to help them settle down in whatever way they can. It makes the picture of what’s going wrong quite complicated.”

Margaret’s research, framed by her beliefs in a strengths-based approach to care, examines resilience in the context of nurses, patients, and society banding together to improve the system.

“It can provide a focus with consumers to improve self-understanding or personal and social strengths can be harnessed and activated,” she says.

“It can be trained onto the community to assess strength, resources and willingness and agility to change and develop.

“And it can be used amongst the nursing profession itself to see that emotionally and socially there are things nurses can do to enjoy the work and respond proactively to workforce and social conditions that need reform.”

Margaret says the government’s transition into primary mental healthcare has diversified the profession and created ongoing need for training.

“For that to be sustained, there also needs to be an education and training program alongside it. The whole healthcare system needs to be inextricably linked with education providers, otherwise, those nurses won’t get the professional development they need to sustain in their workforce and also develop their skills.”

Margaret believes the future of mental health nursing now rests in the profession’s ability to promote its unique set of skills.

THE ROAD AHEAD

ANMF Vic Branch Mental Health Nursing Officer Donna Hansen-Vella agrees, predicting mental health nursing could decline unless the profession can better strengthen and market its worth.

Twenty years ago 80% of the mental health sector’s workforce comprised nurses, but today the figure has dropped to 60%.

The fall reflects some services substituting mental health nurses with allied health workers, unqualified to carry out the full scope nurses can, and in other cases not replacing positions altogether.

The ripple effect could create shortages that lead to the diminishment of the speciality, along with depriving the community of vital nursing care.

“It becomes hard to stop the slide. As you have areas of health that have less and less nurses, the task to then get the nursing presence back up becomes more of a challenge and our community is deprived of access to specialist nursing services.”

Donna suggests the broad scope of mental health nursing isn’t widely understood due to historically implemented policies that triggered generic mental health care models still prevalent today.

She says supposed multidisciplinary teams, a group of healthcare workers managing treatment, haven’t been able to achieve their objective.

“It’s not really giving multidisciplinary care it’s having multi disciplines employed in the one team but they’re all employed to do this generic approach.”

Donna maintains there needs to be greater access to mental health nurses across all levels of healthcare.

This includes the establishment of proper multidisciplinary teams so that a person with a mental illness isn’t discriminated against and can theoretically receive the same level of wide-ranging healthcare that a patient does when walking through the doors of a general hospital following an event like a heart attack.

“That’s not the experience of most people that go into the public mental health system. It’s luck of the draw and who you’re allocated to.

“Ultimately, through integrated employment of mental health nurses at all levels of healthcare people with altered mental health would be able to commence their recovery journeys early, inclusive of effective nursing services that are capable of decreasing acute phases of mental illness.”

Essentially, Australia’s fragmented mental health system works in silos, but if synergy and funding is improved, Donna believes mental health nurses are poised to spearhead better health outcomes. “Usually, most people who get a taste of being able to have the opportunity to work in mental health as a nurse usually love it and choose to stay there.”

To read more articles from ANMJ, view the full journal online at https://issuu.com/australiannursingfederation/docs/anmj_august_book_issuu