Mental Health Nurse Managers Ireland
Mental Health Nurse Managers, Ireland.
Discussion document on:
The role of Directors of Nursing in Mental Health Services
February 2006
Background;
Psychiatric nursing, which has developed in Ireland since the 1920s’ to the current state where graduate nursing will be the norm, has as its primary objectives the facilitation of the maximum development of the mental health of the individual who is in psychological distress and the promotion of the individual’s mental health (An Bord Altranais 2000). Integral to this role is the development and establishment of the individual therapeutic relationship that enables and empowers patients and their families whether they be receiving in-patient care or care and treatment in the evolving community mental health services. Since Planning for the Future (1984) there has been a wholesale reorientation of mental health services to a community based service provision focus. This has been a significant strategic shift in Irish mental health service provision and Directors of Nursing and Assistant Directors in mental health services have been central characters in this development. In their report in 1998 the Commission on Nursing sought to promote the strategic management capabilities of Directors of Nursing generally, those in mental health services had already been engaged in this manner for many years.
More recently, the national health service reforms have been introduced and from September 1st 2005 Local Health Officers (LHO) have assumed managerial responsibility for PCCC activities in their care areas. This will include mental health service activities, which had heretofore been the responsibility of Programme Mgrs. /Regional Mgrs. /Asst. CEOs’. It is expected that mental health services will continue to be integrated more into the processes’ of primary and community care. On January 24th 2006 the Expert group on Mental health Services reported on their Vision for Change of Irish mental health services over the next decade. From both of these processes great change will emerge. For these changes to produce improved and user centred mental health services it will be important that nurses feel confident in their leaders and it is to their DoNs’ and ADoNs’ that they turn for leadership, guidance and reassurance.
Current management organisation of catchment area mental health services:
Management structures within each of the pre-existing Health Boards have developed to meet a multiplicity of health and social needs in a context of changing demographics, epidemiology, health policy and legislation. During this development much authority, accountability and responsibility for clinical and operational services has devolved to local heads of services and disciplines. Mental health services are currently managed at catchment area level by a management team of Hospital Manager, Clinical Director and DoN, which has traditionally reported into regional managers/ Assistant CEOs’. In some catchment areas Principal Clinical Psychologists and Principal Social Workers are also part of the management team structure. The management team has had the complete responsibility for the maintenance, development and organisation of the service spanning the in-patient to home-based community elements of service delivery and provision. The DoN within this has direct responsibility for approximately 80% of the staff in the organisation (nursing, care and household grades) and shares management responsibilities equally with the Clinical Director and Hospital/Area Manager.
Since Planning for the Future was adopted as the strategic blueprint for mental health services very significant and far reaching changes have been carried out within mental health services and through each change DoNs’ with their ADoNs’ have been central to their formulating theses changes and carrying them through to completion. They have actively provided leadership, both professional and organisational, in making these changes in a number of ways.
· With his/her management colleagues the DoN has described the strategic direction and priorities for each service and has worked across disciplines and within nursing to effect a changed service
· Within nursing and in the general organisation the DoN has managed the specific changes required to move services forward
· Within nursing the DoN has worked to professionally develop staff so that they are prepared for a more advanced and differentiated service delivery. Significant development of specialist roles of psychiatric nurses has occurred providing alternatives for patients in their care pathway.
· A very significant series of developments professionally has been the transition of nursing from a certificate based profession through a diploma based one to the current degree led profession in a relatively short period of time.
· DoNs’ have worked with their management team and senior health service colleagues to effect;
o Closure of large psychiatric hospitals. There are currently only 11 left open and these with only a fraction of the in-patient beds once accommodated in them
o Development of community mental health teams, Assertive Outreach Teams, Crisis Intervention Teams, Addiction Counselling and Liaison teams, all with specialist nurses providing their core staffing
o Developing acute units within general hospitals and helping to de-stigmatise mental illness in this process
o Promoting and developing the role and capabilities of the psychiatric nurse to encompass psycho-social roles, cognitive behavioural therapy roles, family therapy and mental health promotion roles among others
The DoNs’, with their ADoNs’, have worked to convert mental health services against a background of approximately 50% relative reduction of funding to Irish Mental Health Services. Despite this grave shortage of funds they have succeeded in transforming many services and work assiduously to continue development of modern mental health services in this country.
Directors’ of Nursing in the future mental health services:
In considering the position of DoNs’ in future Irish mental health services it may be useful to address the issue under three broad headings;
1. Strategic development and leadership.
2. Organisational development and leadership.
3. Professional development and leadership.
Strategic development and leadership.
A particular strength of mental health services is that they provide treatment and care for patients along a continuum. The journey for the patient through the system is connected and each part of the service has a relationship with the other parts that is supportive and beneficial to patients. The Sainsbury Centre for Mental Health in a recent policy paper on ‘Commissioning mental health services’ (Light & Cohen 2003) pointed to the problems of having primary and secondary care separated and called for coordinated mental health services close to the patient. It also called for a ‘clear vision, a unified budget, co-terminosity and an integrated organisational structure’ in the commissioning of new services. This view of separated and disjointed mental health services that are inimical to effective mental health care is also highlighted by the American Psychiatric Association in its ‘Vision for the Mental Health System’ (2003) as it says;
Timely access to care and continuity of care remain today the cornerstones for quality even as a continuum of services is built that encourages maximum independence and quality of life for psychiatric patients (p2)
Irish mental health services service users want the same. This year the Mental health Commission published its consultation paper with service users who want ‘a holistic seamless (service providing) the full continuum of care… ’ (p9), which echoes what the NHS in Great Britain are also saying (The Journey to Recovery – The Government’s vision for mental health care. 2001).
What DoNs’ have been working to provide is a seamless mental health service to Irish patients’ and despite reducing resources they have largely succeeded in this important strategic task. This task has been achieved by understanding the required strategic direction, understanding the strategic capabilities of their services, and leading their staff to develop services in cooperation with their management team colleagues. Their job has required that they work with the major part of the workforce to describe, shape and lead change and it has been done in circumstances that were sometimes adversarial and rarely ideal. Having direct responsibility and accountability for the major part of the workforce has required the management of this significant resource to lead and achieve the changes. Key partners in this process have been the ADoNs’ who have developed to assume important roles in team development and coordination, especially in developing community mental health sector and specialist teams. It has required significant management and human resource skills that have not often been recognised but in the future should be, so that their strategic role can be more effectively carried out.
In considering the future development of mental health services we have a clear understanding of the strategic requirements for providing a continuum of care across a seamless service that in many situations will cross LHO care area boundaries. We have an understanding of how significant patient groups require local and/or regional focus and are anxious that vital services and developments do not become fragmented and inefficient and can contribute to an understanding to ensure this does not happen. Central to this is the concept of governance, which ensures that through the processes’ of change and reorganisation the efforts of the mental health services remain focused on the patients and communities that they serve. Nursing, as a person centred and caring profession, provides the ideal focus to maintain the vision of a caring, empathetic and knowledge based organisation working to promote and maintain peoples’ mental health. DoNs’ ably assisted by their ADoNs’ have carried out an important and successful role of clinical and organisational governance for many years and it is in the interests of patients and national services management that they are facilitated to continue to provide their strategic leadership and governance function in this way.
Organisational development and leadership;
Responsibility for 80% of the workforce requires considerable organisational skill and leadership abilities. These skills and abilities have been repeatedly called on from DoNs’ as mental health services have developed and changed since 1984. The organisation and management of staff then was quite different to what it is now. At that time virtually all staff were located in the institutions and had little experience of working in more dispersed locations carrying out their practice in more specialised ways. Many services have now dispersed and created differentiated specialities to meet the needs of patients. This change has been largely led by DoNs’ in their management teams and ADoNs’, and is key to the continuing development of mental health services. The Department of Health and Children in its ‘Framework to guide service providers in the establishment of Primary Care Teams’ (Draft of 10 November 2003) is explicit in citing the leadership of change management as crucial to ‘achieving effective integration and interface between services..(and)...in the restructuring process of health service reforms’, (p34). The Mental Health Commission and Inspectorate in their reports for 2004 have called for accelerated change within mental health services. The Expert Group on mental health services has now recommended further and more fundamental changes to the way mental health services are structured and managed. DoNs’ have a very good track record in leading change in their services and have established relationships with unions and nurses that will be critical to achieving the organisational and practice changes required in the coming years.
In a draft review of mental health services in the former South Eastern Health Board the review group drew on the experiences of the NHS for managing mental health services and change. It emphasised the need to have common management of in-patient and out-patient services and the requirement that services be large enough to attract strong leadership to change and develop services. DoNs’ with ADoNs’ have been responsible for developing and managing community and hospital services and developing links into primary care and specialist secondary care. This has been achieved by understanding the strategic goals, developing staff to work towards them and managing change and development of services. DoNs’ have provided leadership within their management teams and by working to empower their nurses’ have enabled these to carry through the changes required. Providing leadership outside their organisation has also been a feature of DoNs’ and ADoNs’ work as links have been developed and exploited for communities’ and patients’ benefit with general hospitals, community care services and primary care services. There will be greater need for this type of leadership to enable mental health services develop in the ways anticipated and DoNs’ will be critical to the process.
Professional development and leadership:
Psychiatric nursing through the 70s’ into the 1990s’ was based in the apprenticeship or traditional training model that was based on a hospital service provision of treatment and care. In a remarkably short period of time the basis of education and training for psychiatric nurses has moved from this through diploma to undergraduate degree based qualification. This remarkable transition has been achieved / recognised through the effective leadership provided by DoNs’ working in partnership with their staff, third level colleges, health boards and An Bord Altranais. We are now turning out nursing graduates who are more flexible and accessible as a workforce available to patients and cementing together the many strands of mental health services (Jackson & Stevenson 2000).
In the last decade the nature of service provision by mental health services has expanded greatly. Working with the third level educational institutions DoNs’ and ADoNs’ have sought to develop nursing capabilities in areas such as Psychiatry of Later Life, Acute Mental Health Nursing, Child and Adolescent Mental Health Nursing, Liaison Psychiatric Nursing and Psycho-Social Nursing. Working with other statutory agencies capabilities have been built in Substance Misuse Counselling, Suicide Prevention and Mental Health Promotion. From a largely institutional based system two decades ago nurses have developed professionally to meet changing needs and demands. Anticipating developing needs in primary care, rehabilitative mental health care, dementia care and mental health promotion, amongst others, we are working with psychiatric nurses, Nursing and Midwifery Planning and Development Units, the colleges and other educational providers to prepare their nurses for changed and changing service delivery. Understanding future service requirements and the need for appropriate specialist practice development, DoNs’ are best placed to mould and shape psychiatric nurses to meet these and have clearly demonstrated their willingness and ability to do so.