Next week I’ll be in London for this year’s Eileen Skellern and JPMHN Award evening, hearing Mick McKeown give his Making the most of militant and maverick tendencies for mental health nursing Skellern lecture and Patrick Callaghan deliver his Lifetime Achievement Award address. The day following, June 14th, I’ll be at Kingston/St George’s chairing the summer meeting of Mental Health Nurse Academics UK. One of the things we’ll we talking about is NHS England’s Interim People Plan, which looks to be prioritising mental health nursing as an occupational group in need of support. Here’s a short piece I wrote yesterday for the MHNAUK website, complete with a toxic-looking figure showing the decline in applications for nursing degrees:
The NHS needs more mental health nurses. The most recently available data on the size and composition of the workforce in NHS England, for February 2019, records a total of 36,290 mental health nurses. This compares to an NHS England mental health nursing workforce in September 2009 of 40,602.
Published on June 3rd 2019, the Interim NHS People Plan is about supporting the people needed to deliver NHS England’s Long Term Plan. Chapter 3 addresses nursing, this being the profession where the greatest shortages are found and where the most urgent and immediate action must be taken. Mental Health Nurse Academics UK welcomes the identification of mental health nursing as a priority group, and notes the Interim People Plan’s statement that what must now happen is:
[…] a detailed review across all branches of pre-registration nursing, including a strong focus on the steps needed in mental health and learning disability nursing to support growth in these areas.
The Plan echos Mental Health Nurse Academics UK’s view that undergraduate degree courses offer the best way to secure a future supply of nurses. It also reproduces a figure pointing to a sharp decline in applications for nursing and midwifery courses in England since the removal of bursary support (specifically, a 31% decrease between 2016 and 2018):
Extracted from Interim People Plan, p24
The Interim People Plan places an emphasis on what it refers to as ‘the offer’ made by the NHS to its staff. Mental health nursing needs a better offer if it is to improve the recruitment, retention and support of its current and future members. Mental Health Nurse Academics UK will be looking for concerted action in these areas.
My view is that this decline in applications was entirely foreseeable in the context of the removal of bursaries in England. As it happens, students of nursing and other health professions commencing their programmes of study in Welsh universities in Autumn 2019 can expect to be supported through the award of a bursary, in return for working for two years post-qualification in NHS Wales. That’s a good deal, in my book, and is something presented as part of the country’s wider #TrainWorkLive initiative. I’m not entirely sure how far this ‘Welsh offer’ (to borrow the language of the People Plan) is known throughout other parts of the UK: so I’m happy to give it a nudge here.
Mental health nursing is important and fulfilling work, and offers a fine and rewarding career. More people also need to be doing it. By way of background, last month Mental Health Nurse Academics UK (MHNAUK) submitted a response to Health Education England (HEE)’s Facing the Facts, Shaping the Futuredraft health and care workforce strategy for England to 2027. Contained in this HEE draft are figures on trends in the numbers of nurses, by field of practice, employed in NHS England over the period 2012 to 2017.
Growth/reduction in NHS employed nurses and midwives by field, 2012 to 2017 (extracted from Facing the Facts, Shaping the Future)
Obvious at a glance from this figure is the decline in both mental health and learning disability nursing numbers over time. Elsewhere HEE also describes a 14% mental health nursing vacancy rate.
Now, the Nursing Times reports a reduction for the second year in a row (£) in the numbers of applications for nursing degrees received via the Universities and Colleges Admissions Service (UCAS). Declining applications need to be viewed in the context of the removal of bursaries for students of nursing enrolling at English universities. In MHNAUK we have said, more than once, that we fear the loss of bursary support poses a particular threat to our field of practice. The same applies to learning disability nursing, where at least one degree programme closed last year (£).
With all this in mind this may be a good time to remind people of this useful page, hosted on the MHNAUK website, on joining the profession. As this says:
Forget all the stereotypes about straitjackets and Victorian asylums; modern mental health nursing focuses on helping and supporting people from all walks of life with a variety of ‘common’ mental health disorders (such as anxiety and depression) as well as more serious disorders such as drug and alcohol problems, suicidal feelings, psychosis, bipolar disorder and dementia. They also play a key role in promoting mental health and well-being among the public and preventing mental health problems occurring in the first place.
This helpful MHNAUK resource also includes suggestions for further reading, included in which are texts describing in detail many of the skills that mental health nurses routinely use and the context in which they go about their work. And, for any reader contemplating applying to any of the 60+ mental health nursing degree courses offered throughout the UK, do give some thought to our undergraduate nursing programmes here in the School of Healthcare Sciences at Cardiff University.
Huge congratulations to all who, earlier this month, secured the necessary qualifications to begin their mental health nurse education in the coming academic year. Welcome to the profession, and to the start of a rewarding career.
Following the publication of A level results on August 17th, as John Baker was first to point out, over 50 UK higher education institutions (HEIs) went to clearing to recruit new mental health nursing students:
That, as John suggested, seemed a large number by any measure: worth noting is that Mental Health Nurse Academics UK counts representatives from just over 60 HEIs. Also worth noting is that this is the first year of recruitment to nursing degrees to follow bursary reform in England: a policy the Department of Health explicitly linked to an expansion in student places. So have universities been to clearing to recruit increased numbers of students – assuming they wanted, and were able, to accept more? Shaun Lintern from the Health Service Journal has been tweeting extracts from the Universities and Colleges Admissions Service (UCAS) data analysis service, comparing the numbers of students placed with previous years. Here’s an example from three days ago:
Latest update today from @ucas_analysis shows numbers of students placed on a nursing course is 4% down on last year: pic.twitter.com/sz9U4584oB
Between now and September 1st 2017 UCAS is publishing daily updates, and as it happens is paying particular attention to nursing: these are in the separate files marked as ‘B7 reporting’. The most recent report, published on August 24th, still shows a fall in the number of people placed on nursing courses compared to 2016:
Source: UCAS, https://www.ucas.com/file/122081/download?token=7aEZplYEThis is important, but what UCAS is not displaying is data on the numbers of applicants placed to nursing degrees broken down by field (mental health, learning disability, child and adult). Data on the age of placed applicants is available, and as Steven Pryjmachuk points out shows a reduction (compared to 2016) amongst mature students:
That's what I meant too. I think this graph says it all. Increase in 18 year olds taking up places; drops in mature students. pic.twitter.com/DlH1jZuipe
Mental health nursing courses attract older applicants, and so may have experienced a disproportionate reduction in the number of new students compared to other fields. But we can’t know for sure, in the absence of having the data. What we do know, though, is that the evidence so far on overall placements to nursing degrees commencing in the 2017-18 academic year suggests that recruitment will be doing little to plug the hole in nursing vacancies.
Following a discussion involving the event’s steering committee and Mental Health Nurse Academics UK (MHNAUK), what was the International Network for Psychiatric Nursing Research Conference has now become the International Mental Health Nursing Research Conference. Next year we meet in Cardiff on September 14th and 15th, and early information can be found here. This site will be updated as further plans are made, so it’s worth checking in from time to time. We’ve also updated our conference twitter feed; clicking Follow @MHNRconf takes you there. Our hashtag, which is already in use, is #MHNR2017.
For a taster of the conference, here are links to four of last year’s keynote presentations: Steven Pryjmachuk, Elaine Hanzak, Luciana Berger MP and Bryn Lloyd-Evans:
Meanwhile, I’m pleased to have been elected as Vice Chair of MHNAUK. I’ll be working with the Chair, Steven Pryjmachuk, throughout 2017 and 2018 before becoming Chair at the start of 2019 for a further two years. I’m grateful for the opportunity colleagues have given me, and will do my best to lead and represent the group and the wider field. I anticipate having plenty to do, noting changes ahead in the education of nurses, the funding of students and the run-in to the next research excellence framework. More on all these to follow, I’m sure: with time today to draw attention to the decision by the Welsh Government to continue bursary payments in 2017-18 for eligible students of nursing, midwifery and the allied health professionals. As the press release announcing this makes clear, individuals taking this offer up will need to commit ‘in advance to taking up the opportunity to work in Wales, post qualification, for a period of two years’. Entirely unclear are funding arrangements for the period from 2018-19 onwards.
Community mental health teams are often described as the cornerstone of locally accessible, specialist, mental health services. Working with its two local authority partners, Cardiff and Vale University Health Board currently provides eight CMHTS for adults of working age. The team based at the Hamadryad, I was reminded yesterday, covers the south west of the city taking in the Bay, Butetown, Grangetown, Riverside, Canton and Pontcanna. Speaking in the Bowls Pavilion, CMHT manager Phil Ball did a good job in separating out the work of his team from that of the primary mental health support service (which happens to share use of the Hamadryad building).
Meanwhile…
…for anyone wanting to become a mental health nurse, worth noting is that the School of Healthcare Sciences still has some places available for the BN Hons programme commencing in March 2016. The photo here, of a flyer brought to yesterday’s event, gives more information.
In other news, I find myself engaged in a prolonged period of doctoral student activity. I’ve examined a number of theses in and out of Cardiff in recent months, and have sat with students during their vivas as either supervisor or independent chair. This term has been particularly packed. Plenty of writing has also been taking place: papers and reports are being written from COCAPP, RiSC and Plan4Recovery, and from completed theses I have helped to supervise. Data generation in COCAPP-A has almost concluded, and new research ideas are taking shape. Exciting times, if a little frenetic.
York, March 10th 2015Yesterday I joined other members of Mental Health Nurse Academics UK at the University of York, for what turned out to be a particularly lively spring term meeting.
We were treated to two high-quality local presentations in the morning: from Simon Gilbody on smoking cessation interventions for people using mental health services, and from Jerome Wright on developing community mental health in Malawi.
In the early afternoon David Sallah from Health Education England (HEE) took the floor to talk about the Shape of Caring review, the final report from which is due to be published later this week. From David’s presentation it is evident that HEE will be making a case for a significant shake-up to the way nurses are prepared.
MHNAUK members in York were concerned with what they heard. Uppermost for many was a concern that HEE’s wish for future student nurses to commence their courses with two years of Project 2000-style generalist preparation will erode the time available for mental health-specific learning. People were also struck by the apparent lack of a clear evidence base for change. It is, after all, only a handful of years since the Nursing and Midwifery Council introduced its current standards for education, and curricula up and down the country were rewritten in response. In the absence of robust evaluations of what we already have, are we really sure we know what needs fixing in nurse preparation?
The Shape of Caring review is sponsored by a body with authority in England only, but I am under no illusions that any changes flowing from it will be felt equally here in Wales. David Sallah mentioned cross-UK talks as having already opened. As people observed yesterday, however, any changes to nursing education recommended at this point may be lost following a general election where greater priorities occupy the time of a newly formed government.
Meanwhile, and with a firm eye on the forthcoming election, the Council of Deans of Health has been busy making a case for health higher education and research in its new publication Beyond Crisis. This has three main messages, addressing: workforce planning; building on the talents of the current workforce; and investing in research. Amongst other things the Council is asking for proper forward planning to avoid cycles of boom and bust, opening up opportunities for continuous professional development and protecting and advancing research. It is also suggesting that new ways of financially supporting health professional education should be looked at, including models where contributions are made by students and employers.
University departments for the health professions, like Cardiff University’s School of Healthcare Sciences, have long academic years. We welcome intakes of new pre-registration undergraduate nurses every September, which is a time when students of many other disciplines are still enjoying the tail end of their summer holidays. In September we also welcome back existing students, and this afternoon – assuming I can navigate across Cardiff and its NATO summit-encircling ring of steel – I’m off to the School’s University Hospital of Wales (UHW) campus to meet a group of third year undergraduates to talk about the ethical aspects of nursing and healthcare research.
More generally, I start the 2014-15 academic year as incoming Co-Director of Postgraduate Research in the School, sharing this work with my esteemed colleague Dr Tina Gambling. Currently in the School of Healthcare Sciences we have almost 80 students studying for either the degree of PhD or the Professional Doctorate in Advanced Healthcare Practice (DAHP). The student group is a rich and varied one, and includes many who have made significant commitments to leave their homes (and often, their families) in other parts of the world to live and study in Cardiff. An example is Mohammad Marie, who I have written about on this site before.
In the case of new, or intending, postgraduate research students in the School some helpful advice is: keep an eye on the School’s website. We’re in the process of launching a new research strategy with distinct themes, and our aim is to recruit new PhD and Professional Doctorate students whose interests are clearly aligned with these. Research theme groups will, we’re all hoping, become communities of scholars drawing in researchers with all levels of experience: including those just starting out, and those who are internationally regarded.
Perusing, for no particular reason, my fourth edition of the Red Handbook (published, I think, just after the start of the last century) I find this early reference to mental health nursing in people’s homes. Here are the relevant pages for those interested:
Note the sections implying that attendance in private houses is for the higher classes only, along with the description of all those things which should be done to reduce risk.
Interesting, too, that attendants are reminded that drinking alcohol on duty might not be the best of ideas. Advice like that never goes out-of-date.
One of the things I discussed with Swansea University’s Approved Mental Health Professional (AMHP) students today was how the emergence of a system of community mental health care opened up important new sites for the advancement of professional jurisdictional claims. For more on this idea of jurisdiction (which comes from the sociology of work) check out these earlier posts and embedded links to full-text articles here, here, here and here. It implies that in a dynamic division of labour professions engage in a constant jostling to cement and advance their positions, against the claims of others. The appearance of the AMHP role, fulfilled not just by social workers (as was the case with the old ASW role) but also by nurses, occupational therapists and psychologists, shows how the relationships between professions and tasks can change over time.
It is additionally the case that occupational groups are not homogeneous, but are internally segmented. This means that within a single profession differentiated elements can find themselves battling it out to control work and its underpinning knowledge, or to determine what counts as a necessary preparation for new entrants. And nursing, it appears to me, has plenty of form when it comes to internal divisions and disputes of this type.
Most of the time, I feel eternally grateful for my decision to pursue a career in mental health nursing […] At other times, I despair and wonder about the future of our profession, and the care of people experiencing mental health challenges.
I’ll quote some more, as the full text of the editorial is behind a subscription paywall. Writing about the Australian context in particular (this being a part of the world where nurses are trained as generalists rather than, as here in the UK, for a specific field of practice), Brenda adds:
Some of my concern can be traced back to the professional identity of mental health nursing. Identity is such an important part of being professional, and how we consider and present ourselves both individually and collectively.
[…]
Mental health nursing is becoming integrated into other content, in the absence of any evidence to suggest this is an effective means of education and plenty of anecdotal evidence to suggest it isn’t. Nurses without any specialist qualifications,
and often without experience in mental health, are increasingly teaching the content, medical-surgical wards are being considered suitable places to gain clinical experience in mental health, and nurses who work in mental health for more than 5 minutes are referred to as mental health nurses, despite not having the appropriate qualifications.
That’s a dismal picture indeed. Through a ‘jurisdictions’ prism it might be thought of as a case of one segment within a highly differentiated profession claiming possession of sufficient knowledge to capture the work previously done by another, and to reframe what counts as adequate educational preparation.
Brenda and colleagues’ second paper has just appeared in early online form in Perspectives in Psychiatric Care. Majors in Mental Health Nursing: Issues of Sustainability and Commitment reports findings from an interview study involving representatives of Australian universities which had committed to (or actually implemented) mental health ‘majors’ within their comprehensive undergraduate nursing curricula, but which then discontinued them. Noting the lack of sustainability of embedded mental health nursing options within larger courses of generalist pre-registration education, Brenda and her team conclude:
[…] these experiences suggest that the current comprehensive nursing education programs are not well suited to promoting mental health nursing education as a positive future career destination. While such apparent attitudes prevail, the workforce problems in mental health nursing are likely to persist and indeed worsen.
A dismal conclusion again, linked once more in Brenda’s analysis to a shift away from a pre-qualification route to specialist mental health nursing practice.
Arguments for comprehensive, generalist, nurse education and thus for greater homogeneity in the workforce are frequently made here in the UK. When the Nursing and Midwifery Council opened a consultation on proposed new standards for pre-registration nursing in 2007 it specifically asked people to give a view on whether the branches (Mental Health, Adult, Children and Learning Disabilities) should remain. Mental Health Nurse Academics UK (drawing in part on Sarah Robinson and Peter Griffiths’ National Nursing Research Unit international comparison of approaches to specialist training at pre-registration level) submitted this in its 2008 response:
Experiences from other countries that have gone down the generalist pre-qualifying nursing education route show that this leads to a lack of skilled MHN workforce, difficulties in recruiting to post-registration MHN training and a reduction in the quality of care and service provision for those with MH problems […] In attempting to achieve some unitary, generalist view of nursing to fit with other countries, many of whom are envious of our branch specific pre-registration model, we run the very real and significant risk of simply repeating the errors of others for no gain.
We’ve had changes in formal interprofessional divisions of work (which takes me back to this morning’s AMHP students, notwithstanding that all in this class happened to be social workers). But we’ve hung on to branches (or ‘fields’, to use the current nomenclature) in UK nursing, and continue to prepare nurses to exclusively do mental health work from pre-registration level onwards. Six years on, Brenda Happell’s cautionary tales from Australia remind us of what might have been had decisions been made differently.
Mental health nursing is important and fulfilling work, and offers a fine and rewarding career. More people also need to be doing it. By way of background, last month Mental Health Nurse Academics UK (MHNAUK) submitted 
Following a discussion involving the event’s steering committee and 
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