CommentaryEditor:

Liam Clarke

Submission address:

School of Nursing and Midwifery, University ofBrighton, Robert Dodd Building, 49 Darley Road,Eastbourne, BN20 7UR, UK

Thinking the unthinkable: does mentalhealth nursing have a future?

We would like to revisit the discussion articulatedby Holmes (2006) from an Australian perspectiveand more recently by Hurley & Ramsey (2008)regarding the potential demise of mental healthnursing. Currently in the UK, the Nursing &Midwifery Council (NMC) is reviewing nurse edu-cation. The NMC state that the review is requiredbecause:

Changes in policy and delivery of healthcare willallow us to ensure that nursing education acrossall four countries enables nurses to meet thefuture needs of patients. (NMC 2008a)

Furthermore, between November 2007 and Feb-ruary 2008, a consultation was conducted by theNMC; the initial results of this survey were recentlypublished (NMC 2008b), which will be commentedupon later in this article. The consultation focusedon four key questions:1. Should nurses be prepared to diploma or degree

level?2. What proportion of a pre-registration pro-

gramme should be spent learning in practice?3. Should shared learning be a requirement?4. Should there be generalist and/or branch pro-

grammes, and if so, what should the branchesbe?In this commentary, we would like to focus

upon the fourth point, for it is the possible shifttowards a generic programme of nurse educationthat concerns us the most. Alarm bells have begunto ring in some quarters (Hurley & Ramsey 2008)where the mental health nursing profession in theUK is warned that it is ‘sleepwalking towardsoblivion’. This picture is reinforced by the ‘Reviewbody for nursing and other health professions’report (DH 2005), which only mentions mentalhealth nursing once, and then because of the lackof new recruits. Should mental health nurses feel

threatened, or should we, as Barker (2006) recom-mends, see this as an opportunity to conduct aradical appraisal of our core function? To ourknowledge, there are no international compari-sons of whether generic or specialist models ofnurse education are ultimately best for patientcare (Brimblecombe & Nolan 2008 reinforce thisobservation). Nor is there evidence of whichmental health nurses in which countries have thegreatest status, power and freedom to practise. AsBritish mental health nurse educators, we believethat although the British system is good for thedevelopment of the mental health nursing profes-sion, there is now an opportunity to strengthenthis position. However, we need to consider thethreats as well as the opportunities.

In their King’s College London report on nurseeducation, Robinson & Griffiths (2007) conducteda review of the literature of 17 countries fromaround the world. They concluded overwhelminglythat a move to generic training would have a nega-tive impact on the mental health nursing professionin the UK. Some of these impacts include:1. Minimal focus in the curriculum on clinical and

theoretical aspects of mental health nursingknowledge and skills;

2. Perceptions that graduates are not adequatelyprepared to work in present day community andinpatient mental health settings;

3. Difficulties in providing mental health place-ments for all students;

4. The need to provide post-registration courses/support to develop basic competencies;

5. Problems in having sufficient numbers of expe-rienced staff to provide preceptorship and super-vision during these post-registration courses;

6. Increased difficulties over recruitment and reten-tion (Robinson & Griffiths 2007: ExecutiveSummary).

What is most concerning from the report is theirassertion that:

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The international evidence suggests that werethe UK to consider moving from the core plusbranch model to the generic model, this wouldgenerate significant challenges to the productionof competent beginning practitioners in mentalhealth. (Robinson & Griffiths 2007: ExecutiveSummary)

They further report that some countries whichhave experienced generalist training are now optingfor something akin to the existing British model.In a very recent editorial by some nurse educationleaders from around the world, however, there is acall for a ‘. . . global alliance for nursing education. . .’ (Daly et al. 2008, p. 1115) that does notmention the specialist areas in nursing. The empha-sis is more upon finding solutions to the globalproblem of the shortage of nurses. Internationally,therefore, there are more important issues for nurseeducators than whether or not to retain specialismsor branches in education.

Hurley & Ramsey’s (2008) alarm call has a strongreactionary component, and with good cause. Whathas become ‘normal’ in nurse education in the UKhas been, since the introduction of Project 2000(implemented around 1991), a Common Founda-tion Programme, usually of about 12 months, andspecialist branches for the subsequent 2 years.On the basis of the responses to the NMC pre-registration consultation, many mental health nurses(91%) have expressed their wish for the branch toremain. Immediately following the results from theconsultation, the NMC issued a press release (NMC2008a) referring to ‘Fields of Practice’ rather than‘branches’, and there is a hint that some commitmentto specialisms remain. However, there is obviousresistance to the 2 years of specialist preparationbeing reduced to, an as yet unspecified, post-registration short course. With a generalist pro-gramme, recruitment into mental health nursing willbe drawn from the larger pool of generic nurses (as inmany other countries). In his useful internationalsurvey of mental health nurse education, Holmes(2006) observes that this kind of model inevitablyleads to a decline of the numbers of people whochoose mental health. Overall, though, the evidenceon the best model of preparation for nursing ispatchy. However, Holme’s analysis of what has hap-pened in Australia is a word of caution for the UK:

The decision of the early nineties to cease psy-chiatric nursing training has led to a collapse inthe supply of psychiatric nurses . . . (Holmes2006, p. 407)

In their overview of the state of mental healthnursing in Europe, Brimblecombe and Nolan(2008) observe that to create harmony in mentalhealth nurse education, some countries would needto ‘dumb down’. Opting for a generalist educationin the UK might strengthen the position of adult(medical) nursing; however, we believe that thiswould be at the expense of the quality of mentalhealth nurse education.

Once a generic model is introduced in the UK,there might be no turning back. There would becomethe potential, therefore, for the implementation ofgeneric nursing to sound the death knell for mentalhealth nursing in the UK. In the neo-liberal capitalistsociety in which we find ourselves, however, mentalhealth nursing (including the education) is an expen-sive option. It might be considered even more expen-sive to get them to promote recovery and socialinclusion (which is the current agenda for mentalhealth nurses in the UK, DH 2006). Although mentalheath nurses are by far the biggest profession pro-viding mental health care, this critical mass is notalways reflected in the power that mental healthnurses wield. Mental health services use a (largely)medical model where psychiatrists often retainthe levers of command and control of the servicesoffered to users. There is evidence, however, that thismight be changing in the shift towards using recov-ery approaches and increasing access to psychologi-cal therapies (this shift is in evidence in countriesother than the UK too). Psychiatrists, however,might feel defensive in the light of these latest trends;a recent paper in the British Journal of Psychiatry,for example (Craddock et al. 2008), suggests thatmany psychiatrists are feeling under threat from thisshift as they argue for a repositioning towards tradi-tional models of mental health care. These contem-porary arguments are not new to the profession, andneither are they limited to the UK.

Going back to the NMC rationale for the review,they are seeking to: ‘enable nurses to meet thefuture needs of patients’. Therein lays a conceptworth challenging. Should people who experiencemental health problems, in the future, become‘patients’? In other words, might the death ofmental health nursing herald the birth of mentalhealth professionals that are not nurses at all, butworkers who do not ‘treat’ ‘patients’? Such workers(we might confusingly refer to them as genericmental health workers) who are not nurses might befreed from the shackles of the medical model ofmental illness.

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We could imagine replacing mental healthnursing with generic mental health workers, whohave been educated in a non-medical way in acourse of education that is dedicated to enablingthem to meet the needs of people with mental healthproblems. This course (unlike any other profes-sional course) could be based on service user-defined and service user-led recovery approaches, toinclude values based on hope, optimism and beliefin recovery, skills in promoting self-managementand control, community development and socialinclusion. Some of the advantages of such a coursemay include chances of improving recruitment, par-ticularly to people who bring their own experienceof mental health problems. For example, the successof peer support workers is now well reported in theUSA and in New Zealand. Such approaches moveaway from the medical model and subservienceto psychiatry, and are more compatible with cur-rent service user-focused health and social carepolicies. Such a model has already been piloted inSouthampton in the UK with a mental health prac-titioner course funded by the local NHS trust.

In the UK, a new Mental Health Act is in theprocess of being introduced. When it was presentedto UK Parliament, it incorporated the provision tocompulsorily treat anyone deemed a danger to them-selves or others by virtue of being mentally ill. Giventhat the Department of Health estimates that one insix of the entire population may experience mentalhealth problems at any one time (SEU 2004), thismove to potentially increase compulsion may beproblematic as it supposes that all people deemedmentally ill (including those with so-called danger-ous and severe personality disorder) are treatable,and that services will be readily available. The actwas amended by the House of Lords, following theprotest of an alliance of opponents (includingnursing bodies). Nevertheless, this gives a flavour tohow New Labour views mental health problems.One the one hand, they are keen to promote recoveryand social inclusion (DH 2001, 2006, NIMHE2004, SEU 2004, CSIP, RCPsych & SCIE 2007),but on the other hand, they need to be seen to beprotecting the public and it is not yet clear howcompatible this may be with the principles of recov-ery and social inclusion. How these tensions mayimpact upon the mental health profession has beenarticulated in the Journal of Psychiatric and MentalHealth Nursing (Lakeman 2006).

The new act introduces approved mental healthprofessionals, replacing approved social workers.

It has already been decided that nurses will beincluded in the approved mental health profession-als collective. Mental health nurses in the future willtherefore be expected to promote recovery andsocial inclusion, but with added powers to enforcemedication concordance and detain people underthe Mental Health Act. It remains to be seenwhether the latter powers will inhibit or enhancethe ability of mental health nurses to facilitaterecovery and social inclusion.

The history of the role of mental health workersduring the last century has been determined bychanging socio-political values regarding the care ofthe mentally ill, shifting from asylum attendants ofthe early part of the 20th century with an emphasison providing sport and recreation (known todayas recovery and social inclusion) activities to themental nurses of the latter part of the century witha greater emphasis on medication and therapy (themedical model). Perhaps the current climate indi-cates a possible new direction of mental healthworkers, taking advantage of a changing healthcaremarket to position themselves as distinct fromnurses and free from the state/NHS control ofnursing that has proved such a dead hand forthe development of the mental health nursingprofession.

Or, is there something more sinister going on? Itis possible that the move away from mental healthnursing, as a specialism, is being driven by the eco-nomic necessity to save money, and open up thepossibility of replacing mental health nurses with‘generic mental health workers’. Such workers maybe free from the ‘shackles of the medical model’;however, potentially, these ‘generic mental healthworkers’ may end up further down the mentalhealth professional food chain, leaving the profes-sion to be led by psychiatrists and others. As inmany outcomes of neo-liberalism, we might end upwith a two-tiered mental health profession. Psychia-trists and psychologists at the top and the genericmental health workers at the bottom, in otherwords, little change from the present, except that itwould be much cheaper and politically easier tomanage. Potentially, there might be less unionrecognition and less solidarity compared with whatis currently enjoyed with nursing as a profession.

Although we might welcome generic mentalhealth workers freed from the shackles of themedical model in a profession that promotes socialinclusion and recovery, we are not convinced thatthis option is on the political agenda. Current

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health spending levels in this country have probablypeaked. In the context of an international economicdownturn, we suspect that policy makers will go forthe cheapest (and not the best) option, and one thatmeets global and not national requirements (Dalyet al. 2008). Mental health nursing in the UK, there-fore, might die not the slow death predicted byHolmes (2006), but a victim of a blade – a cut –determined not by evidence or good practice, but byglobal and national market forces. What is happen-ing to mental health nurse education in the UK issymptomatic of what is happening internationallyto our profession.

There are therefore a number of possibilities forthe future of mental health nurse education in theUK. If the UK does go to the generic mental healthworker model, letting go of the ‘nurse’ identity willnot be easy. Nursing has a clear social identity, role,status and professional distinctiveness. Can weimagine for a moment this journal one day becom-ing re-titled: ‘Journal of Generic Mental HealthWorker’? Clarke (2006, p. 394) engages the argu-ment at this point with a rejoinder:

So much might fall into place were we to ridourselves of the title ‘nurse’ altogether, andabandon the tiresomeness of trying to explainour work against its oppressive and unrelentingpresence.

If, however, we follow Clarke’s advice and ‘letgo’, will we be leaving an empty space that thepowerful ‘others’ will fill? We therefore warn of thedemise of the specialist mental health nurse educa-tion that currently exists that has contributed to thedevelopment of a strong profession over the years.Probably, the worst possible outcome is the devel-opment of generalist education that effectivelystrips mental health nursing of its therapeutic valueand leaves them as ‘custodians in the community’while the new generic mental health workerspromote the recovery and social inclusion.

We therefore argue for a revised model of mentalhealth nurse education in the UK. This model envis-ages a specialist mental health degree informed bymore social than medical approaches, for example,a Bachelor of Mental Health Nursing and SocialCare developed in collaboration with service usesand their carers. Graduates of this programme willexit with the values and capabilities that serviceusers tell us promote their recovery and social inclu-sion, using the best available evidence, delivered atall times with care, compassion and competence.Our fear is that a generic nursing model will emerge

that is driven by financial savings that will fulfilHolmes’s (2006) prophecies of the demise of theprofession and not the strengthening of it.

THEODORE STICKLEY PhD MA Dip N

Dip Couns PGCHE RMN

Associate Professor of Mental HealthANDREW CLIFTON MA BA(Hons) PGCE

PGITHLE RMN

Research FellowPATRICK CALLAGHAN PhD MSc BSc RN

Professor of Mental HealthJULIE REPPER PhD MPhil BSc(Hons) RGN RMN

Reader and Associate Professor of Mental HealthNursing and Social Care

MARK AVIS MSc BA(Hons) RMN RGN RNT Cert EdProfessor and Head of School

ALAN PRINGLE PhD BSc(Hons) RGM RMN

Lecturer in Mental HealthGEMMA SSTACEY MN RMN

Lecturer in Mental Health and Social CarePREM TAKOORDYAL MA BA RMN RGN RNT

Lecturer in Mental HealthANNE FELTON MN BA(Hons) RMN

Lecturer in Mental Health and Social CareJANET BARKER PhD BSc(Hons) P.G.Dip.Ad.Ed.

SRN RMN

Associate Professor in NursingLORRAINE RAYNER MSc Dip Health Studies

RMN RGN

Lecturer in Mental Health and Social CareDAVID JONES BA(Hons) PG Cert PG Dip RMN

Lecturer in Mental Health and Social CareDIANE BRENNAN BSc(Hons) Dip N

Practitioner Health Lecturer in Mental HealthJULIE DIXON MA Dip N

Lecturer in Mental HealthSchool of Nursing

University of NottinghamDuncan MacMillan House

Nottingham, UK

References

Barker P. (2006) Mental health nursing: the craft of theimpossible? Journal of Psychiatric and Mental HealthNursing 13, 385–387.

Brimblecombe N. & Nolan P. (2008) Mental healthnursing in Europe. What’s the future? Mental HealthPractice 11, 18–22.

Clarke L. (2006) So what exactly is a nurse? Journal ofPsychiatric and Mental Health Nursing 13, 388–394.

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Craddock N., Attenburrow M.J., Bailey A., et al. (2008)Wake-up call for British psychiatry. The British Journalof Psychiatry 193, 6–9.

CSIP, RCPsych & SCIE (2007) A Common Purpose:Recovery in Future Mental Health Services. Care Ser-vices Improvement Partnership (CSIP), Royal Collegeof Psychiatrists (RCPsych), Social Care Institute forEx-cellence (SCIE), London.

Daly J., Clark M., Lancaster J., et al. (2008) The globalalliance for nursing education and scholarship: deliver-ing a vision for nursing education. InternationalJournal of Nursing Studies 45, 1115–1117.

Department of Health (DH) (2001) The Journey toRecovery – The Government’s Vision for MentalHealth Care. Stationery Office, London.

Department of Health (DH) (2005) Review Body forNursing and Other Health Professions. Available at:http://www.ome.uk.com/downloads/N00003U7.doc(accessed 22 August 2008).

Department of Health (DH) (2006) From Values toAction: The Chief Nursing Officer’s Review of MentalHealth Nursing. Crown, London.

Holmes C.A. (2006) The slow death of psychiatricnursing: what next? Journal of Psychiatric and MentalHealth Nursing 13, 401–415.

Hurley J. & Ramsey M. (2008) Mental health nursing:sleepwalking towards oblivion? Mental Health Practice11, 14–17.

Lakeman R. (2006) An anxious profession in an age offear. Journal of Psychiatric and Mental Health Nursing13, 395–400.

National Institute for Mental Health in England(NIMHE) (2004) Emerging Best Practice in MentalHealth Recovery. NIMHE/DH, Leeds.

Nursing & Midwifery Council (NMC) (2008a) Availableat: http:/ /www.nmc-uk.org /aArticle .aspx?ArticleID=3311 (accessed 24 September 2008)

Nursing & Midwifery Council (NMC) (2008b) Review ofPre-registration Nursing Education: Report of Consul-tation Findings. NMC, London.

Robinson S. & Griffiths P. (2007) Approaches to Special-ist Training at Pre-registration Level: An InternationalComparison. National Nursing Research Unit, King’sCollege, London.

Social Exclusion Unit (SEU) (2004) Mental Health andSocial Exclusion, Social Exclusion Unit Report.Crown, London.

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