From wimples and capes to suits and medical scrubs, the role of nurses in health care has changed as dramatically as their uniforms over the past 50 years. There is no area of health care today in which nurses do not play a critical role but the way in which they work, both independently and as part of a health care team, has evolved differently in the various sectors of the health system. Mental health is one distinct area in which specialised nurses are relatively new and many people working in the health system may not be familiar with their role.
In the following piece, Kim Ryan, Adjunct Associate Professor Sydney University, CEO, Australian College of Mental Health Nurses, outlines the role of mental health nurses in primary health care and describes the policy framework within which they operate. She also highlights some of the current barriers preventing mental health nurses from working at their maximum capacity, despite robust evidence supporting their value, and argues for the need to remove these barriers to ensure mental health nurses can work to their full potential.
Kim Ryan writes:
In 2006 the Coalition of Australian Governments had mental health clearly on their agenda and made some vital decisions to support the mental health system in Australia. It was at this time a forward thinking COAG made the decision to establish the Mental Health Nurse Incentive Program.
The Mental Health Nurse Incentive Program was implemented the following year, in July 2007. It was the first program established to enable Credentialed Mental Health Nurses to work in primary health care settings, with General Practitioners, Psychiatrists or other eligible providers, to deliver coordinated clinical care for people with severe and persistent mental disorders. Over the past 8, years the MHNIP has proven to be an innovative and cost effective mental health program, being lauded as a resounding success across the sector – by consumers, their families, medical and allied health colleagues, and mental health nurses.
Over time, there have been many assumptions made about what the role of a mental health nurse really is. For example, people often say to me… ‘Mental nurses don’t do psychological interventions like Cognitive Behavioural Therapy (CBT)… do they?’ During the development of the MHNIP framework, I remember on many occasions my GP colleagues asking ‘What do I need a mental health nurse for?’ and, ‘What they can do for me?’. Not long after the Program was implemented and Credentialed Mental Health Nurses began working alongside GPs and others in primary care, the question very quickly changed to ‘So, where we can get a Credentialed Mental Health Nurse?’
There has been an assumption from outside the profession that the role Credentialed Mental Health Nurses undertake is threefold – to coordinate the consumer getting to other health professionals that they may need to see; to monitor the consumer’s condition based on the intervention or services that other professionals recommend; and to dispense medication that other practitioners prescribe, monitoring and reporting on the effects and side effects.
However, research undertaken by the Australian College of Mental Health Nurses in 2013 found that some of the key activities undertaken by Credentialed Mental Health Nurses working under the MHNIP included: assessment, care planning, consultation, assessment, linkage and liaison, medication management, physical health monitoring and intervention, psychotherapy and other psychological interventions as per their area of specialisation (e.g. family therapy, CBT), psycho- social interventions, skills training and coping enhancement. They worked in collaboration with the person and their family to a recovery model, focusing on strengths and skills, and hope-based approaches. Clearly, Credentialed Mental Health Nurses do much more than people think – they adapt and tailor interventions and collaborate with others as necessary to assist people to resolve problems, develop skills, and meet their psychosocial and individual recovery needs.
The scope of practice of Credentialed Mental Health Nurses is significantly greater than the narrow limits set within the MHNIP. By removing restrictions on the scope of work that Credentialed Mental Health Nurses are able to provide, allowing them to work with people across the lifespan with mental disorders at any stage of the illness trajectory, they can do much more and provide much greater support to the community. Promotion, prevention and early intervention are what the mental health sector is focused on, and mental health nurses have the skills to be able to provide these kinds of services, as well as other services required by consumers who have more complex health needs.
The management of clients who experience eating disorders is a perfect example. Eating disorders, such as anorexia nervosa, are severe, complex and life threatening. At present, according to the MHNIP guidelines, a Credentialed Mental Health Nurse can only provide services to a client with anorexia nervosa once the illness is entrenched and meets the criteria of ‘severe and persistent’. I would argue that Credentialed Mental Health Nurses should be able to work with a person newly diagnosed with anorexia nervosa, to avoid the illness becoming severe and persistent, and decrease the risk of long-term poor outcome, morbidity and mortality. And, they should be able to work with someone who has been referred for early intervention – to avoid them developing anorexia nervosa in the first place.
The release of the National Mental Health Commission’s Review of Mental Health Services, Contributing lives, thriving communities, finds us at a significant juncture in mental health reform. We need to embrace this reform opportunity and act quickly on a number of recommendations:
1. End the freeze on the MHNIP as an identified priority to enable more equitable access to mental health services.
2. Commit to maintaining funding and increase from $41.7 million to $72.million a year.
3. Extend MHNIP eligibility to residential aged care facilities and multipurpose services.
4. Examine the cost effectiveness of extending Better Access to mental health nurses (MHN) with a post graduate qualification in mental health nursing, so that MHNs can provide mental health nursing services to meet the needs of the community more broadly.
There are a number of ways the MHNIP can be enhanced, reducing unnecessary red tape and duplication, and allowing the Program to do what we know it can – provide specialised mental health nursing care to people who need it, where they need it and when they need it.
It is also time to look at the role that nurses play more broadly across the health care system. All nurses, not just mental health nurses, need to be given the opportunity to expand their role and to work to their full scopes and extended scopes of practice. Nurses can contribute much more to the health care system if they are allowed. Nurses are highly educated, highly skilled, competent and confident health professionals. There are many examples of nurse-led services that provide high quality health care to people in an efficient and effective manner – with good outcomes for service users.
An example of an innovative program is the ‘Homeless to Home Healthcare After-Hours Service’. This is a nurse-led outreach and healthcare service that is embedded within a broader ‘Housing First’ approach to homelessness. It integrates nurses within a community-based assertive outreach team called the ‘Street to Home’ service in order to enable both housing and healthcare responses to be provided in a coordinated way. Recent evidence from the UK, for instance, shows that homeless people have an average length-of-stay that is three times that of the general population and average treatment costs that are approximately four times those of the general population, so innovative nurse-led solutions such as this will be an essential part of the future health care system ().
Aged Care and Chronic Disease Management are two perfect examples of where nurses can play a key role in service provision – working collaboratively with other health care providers to provide high quality health care.
There is constant pressure to do more for less and to find new solutions to old problems. There seems to be a lot of discussion around how we can provide greater access to quality health care, but without recognising that a significant proportion of the health workforce is currently underutilised. We know that nurses are the largest part of the health profession and that they are the most geographically well-distributed – nurses have been providing services in rural and remote parts of Australia in the absence of other health professionals for years.
Nurses are ready, willing and able to work with governments and the health sector to develop new and innovative ways in which we can work to provide greater access to quality health care in efficient and cost effective manner. Nurses are #heretohelp.