Section 3: Culture and values - strengthening the climate for care
Rights, principles and values- based practice
Mental health nursing is fundamentally about caring, about spending time with people, and about developing and sustaining therapeutic relationships with service users and their families and carers.
The review devised a statement that articulates a values base for mental health nursing which reflects these core elements (Box 2). It should act as a checkpoint for mental health nurses, those who are involved in their initial preparation and ongoing education, those who provide leadership and management, and the organisations that employ mental health nurses.
Box 2. The values base for mental health nursing.
Putting positive working relationships supported by good communication skills at the heart of practice
Maximising time to build relationships and challenging systems that detract from this. Recognising when relationships are unhelpful and taking steps to address this.
Based on principles in legislation, safeguards and codes of conduct.
For diversity of values and placing the values of individual users at the centre of practice.
Listening to what people say and not basing practice on assumptions about what people need.
Seeing the whole person and not just his or her symptoms.
Seeing the person as the 'expert' in his or her experience
For the contribution of families and carers.
For the contribution of other professionals and agencies.
For the social context of people's lives.
Promoting recovery and inspiring hope - building on people's strengths and aspirations.
Increasing capacity and capability to maximise choice.
To make best use of resources available in the wider community.
To other agencies involved in mental health care.
Being proactive about opportunities for change and mobilising opportunities to work with others to bring about change.
At corporate, individual and shared levels to translate the vision and values into practice by evolving current models for practice and challenging and shaping institutional systems and procedures to accommodate this.
Support for the human rights principles underpinning mental health legislation in Scotland was present from the outset of the review. The principles are seen as the 'blueprint' that will guide the practice of mental health nurses (and others) (Table 2).
Table 2. The principles of the Mental Health (Care and Treatment) (Scotland) Act 2003
People with mental health problems should, wherever possible, retain the same rights and entitlements as those with other health needs.
There should be no direct or indirect discrimination on the grounds of physical disability, age, gender, sexual orientation, language, religion or national or ethnic or social origin.
Respect for diversity
Service users should receive care, treatment and support in a manner that accords respect for their individual qualities, abilities and diverse backgrounds and properly takes into account their age, sexual orientation, ethnic group and social, cultural and religious background.
When society imposes an obligation on an individual to comply with a programme of treatment or care, it imposes a parallel obligation on health and social care services to provide safe and appropriate services and ongoing care.
Wherever possible, care, treatment and support should be provided without the use of compulsory powers.
People should be fully involved, as far as they are able to, in all aspects of their care, treatment and support. Their past and present wishes should be taken into account. They should be provided with support and information to enable them to participate fully.
Respect for carers
Those who provide care to service users on an informal basis should be afforded respect for their role and experience, should receive appropriate information and advice, and should have their views and needs taken into account.
Least restrictive alternative
Any necessary care, treatment and support should be provided in the least restrictive manner and environment compatible with the delivery of safe and effective care.
Any intervention under the Act should be likely to produce for the service user a benefit that cannot reasonably be achieved other than by the intervention.
The welfare of a child with mental health problems should be paramount in any intervention imposed on the child under the Act.
Putting the principles into practice and ensuring that the real developmental opportunities afforded by the new Act are maximised requires cultural change, which needs to be supported and developed at every level of organisations. Mental health nurses will be key in bringing about cultural change, and individual nurses need to take responsibility for engaging with the process.
To make the principles work in practice, the capacity for values-based care needs to be supported and developed. Values-based practice recognises that decisions taken in mental health care are based on values as well as evidence, and that practitioners, service providers, service users, families and carers may have differing and sometimes conflicting values. It aims to support mental health workers to provide care and services that reflect people's rights and the underpinning principles of practice, and to:
- achieve the space to reflect on their practice
- understand different values
- negotiate conflicts
- make decisions based on strong value systems
- reaffirm, shape and challenge roles and practices.
People at the most senior levels in organisations delivering mental health services need to acknowledge this, ensure values and principles are embedded in organisational policy, and facilitate the change necessary to translate values and principles into practice.
Positive practice example
An organisational approach to embedding rights-based practice
The State Hospital is the only hospital providing care in conditions of special security in Scotland.
Since 2002, innovative work based on using the Human Rights Act (1998) as a vehicle for cultural change has been undertaken there. Using the Act as the bedrock to support other rights-based legislative drivers (including the principles of the Mental Health (Care and Treatment) (Scotland) Act 2003, racial equality and diversity agendas and freedom of information), a range of policy development and training activities has been developed.
These have included an ambitious review and organisational audit of policies and procedures, leading to the development of standards for rights and responsibilities that now provide a supportive framework for rights-based clinical decision making.
Rights-based training has also been developed and is being rolled out to all staff, supported by Human Rights Champions.
For further information, contact Stephen Milloy, Nursing Director.
This also calls for focused education and training. Training in values-based practice should be a central feature of pre-registration programmes for mental health nurses, and all mental health nurses must have access to values-based training.
NHS Education for Scotland has led the development of education to support the implementation of the Act. The Ten Essential Shared Capabilities ( ESCs) that all qualified and non-qualified mental health staff working in the NHS, social care, voluntary and independent sectors should acquire as part of their core training were developed by the Sainsbury Centre for Mental Health in 2004 and have a strong emphasis on values-based practice (Sainsbury Centre for Mental Health, 2004).
Learning materials have been developed and piloted to support the application of the ESCs to values-based practice, service user participation, socially inclusive practice, race equality and cultural capability. A workbook providing a framework to encourage professionals to analyse values in their practice has also been developed (Woodbridge and Fulford, 2004). These resources should be disseminated and used throughout NHS Scotland. The exploration and development of values-based practice also needs to be embedded in individual practitioners' personal development plans and clinical supervision.
WE NEED TO:
- Ensure all mental health nurses have access to values-based training. Training should be multi-disciplinary team-focused and should involve service users and carers.
- Ensure that mechanisms are in place to embed values-based practice in practitioners' personal development plans and clinical supervision.
Respect for diversity is a key principle enshrined in the Act. The focus on promoting equality in health was reinforced in Fair for All: Towards Culturally Competent Services (Scottish Executive, 2002a). Following the publication of Fair for All, the National Resource Centre for Ethnic Minority Health ( NRCEMH) was established in 2002 to work with NHS Scotland to promote the race equality agenda.
The NRCEMH note that people in Scotland from Black and minority ethnic communities may have difficulty accessing mental health services that meet their specific needs, and may also have to cope with individual and institutional racism ( NRCEMH, 2005). Since only around 2% of the Scottish population classify themselves as belonging to 'Black and ethnic minority populations', there is a risk that this issue might not be recognised.
Staff working in mental health services must have access to training in cultural competence, awareness and sensitivity, including training to tackle overt and covert racism and institutional racism. Furthermore, evidence suggests the needs of the diverse range of people accessing mental health services will be better met if the mental health nursing workforce reflects the diversity of the Scottish population. This needs to be addressed through future workforce planning and recruitment initiatives.
Equal Services, the report of the race equality assessment in mental health in NHS Boards published by NRCEMH in 2005, builds on the recommendations made by the Department of Health in England ( DoH, 2005) and the Mental Welfare Commission's 2005 report Respect for Diversity ( MWC, 2005a). It notes the progress made in developing culturally competent services and care across NHS Scotland and makes specific recommendations about further training needs. These must inform the pre-registration preparation of mental health nurses.
Recovery, relationships and models for practice
The recovery approach has evolved out of service users' movements around the world. Several states in the USA have committed their mental health services to a recovery ethos, and the approach has been adopted as the national mental health strategy in New Zealand.
Scottish health policy complements the concept of promoting and supporting recovery with a focus on social inclusion and citizenship. Delivering for Health outlines a model for the management of long-term conditions that reflects the recovery approach, building on the strengths and aspirations of people using services. Promoting and supporting recovery from long-term mental health problems also forms an important cornerstone of the National Programme for Mental Health and Well Being, progressed via the Scottish Recovery Network ( SRN).
Recovery is often described as a long-term process or 'journey' and is not simply the absence of symptoms. It is based on hope, involvement, participation, inclusion, meaning, purpose, control and self-management, and emphasises the importance of peer support, meaningful activity, employment, maintaining social networks and activities when distressed and having the chance to contribute, or give back, in some way.
The approach belongs to and is led by the person, and there are risks in attempting to 'professionalise' it. But of the key elements known to promote recovery, staff attitudes and values - particularly the extent to which optimistic or pessimistic messages are shared - are prominent. Current initiatives designed to enhance professional roles in recovery are outlined in Box 3.
Box 3. Initiatives designed to enhance professional roles in recov ery.
- Training for trainers initiatives in recovery-based practice are currently being supported and evaluated by the SRN.
- Values-based practice training.
- The Tidal Model - a specific recovery-focused nursing model for inpatient care.
- Strengths-based models have been developed and evaluated in community mental health teams in the UK and New Zealand.
- Recovery and values-based competencies for mental health workers have been developed in New Zealand.
- Recovery audit tools have been developed.
Examples of positive and innovative practice submitted during the review process have shown that recovery-based approaches are influencing and being embedded in some aspects of mental health nursing practice. These initiatives need to be evaluated, with new learning disseminated on a national basis.
Positive practice example
'Putting Recovery into Practice' - NHS Tayside
With the support of the Scottish Recovery Network, a group of mental health nurses, carers, social workers, service users and occupational therapists in NHS Tayside have taken 'training for trainers' courses in recovery.
The Tayside Recovery Network has now been set up to support culture change to embrace recovery-focused practice. The network has devised a vision and strategy for supporting the dissemination of recovery into practice which includes:
- recovery awareness-raising sessions
- training others as recovery trainers
- an e-mail network and intranet forum
- the development of recovery training packages.
Early indications show that the principles of recovery are taking root in NHS Tayside. The network is increasingly being asked to comment on new procedures and policies to ensure they are consistent with the principles of recovery.
There is a strong belief among nurses in the network that recovery principles are the vehicle to support cultural change and to allow mental health nurses to reclaim and strengthen their art.
For further information, contact Sharlaine Walker, Lead Nurse (Resettlement) Primary Care Division, NHS Tayside.
Existing recovery environmental audit tools are proving useful to practitioners in gauging their current practice and developing a recovery-based approach, and their use should be encouraged in Scotland (see, for instance, Onken et al, 2002). The Developing Recovery Enhancing Environment Measure ( DREEM) was developed in the United States (Ridgeway and Press, 2004) and has been adapted for use in the UK. The use of tools such as DREEM provide a valuable opportunity for mental health nurses to work together with service user organisations to aid the development of practice and services towards a recovery orientation.
In addition, practitioners should form local networks with service users, carers and other mental health workers to support each other in putting recovery-based approaches into action.
WE NEED TO:
- Encourage charge nurses in mental health settings to work with service user organisations to use existing recovery environmental audit tools to gauge their current practice and to help in the development of recovery- based approaches.
Relationships and models for practice
Previous reviews of mental health nursing have affirmed that the relationship between the nurse and person requiring support, based on partnership and mutual respect, is at the heart of mental health nursing practice ( SMH and SNAC, 1966; Department of Health, 1994). This report makes no apology for restating this core element of mental health nursing. Aspirations for role development and expansion have to be built on this foundation.
The relationship between the mental health nurse and the person requiring support is what service users value most. It is about more than the nurse being 'someone nice to talk to'; in developing positive, therapeutic relationships with service users, the nurse requires self awareness, engagement skills and advanced interpersonal skills, applied at times in difficult and highly charged situations.
The review found, however, that in some areas of practice, fulfilling this key part of the role can be challenging.
Evidence from the Mental Welfare Commission (2005b) and others suggests that at times, service users and their families and carers are not getting sufficient access to nurses. Mental health nurses report that competing demands mean they often have little time to spend with people. Some find a significant amount of their time is being spent in meeting the needs of other professional groups, plugging service gaps by fulfilling roles best met by other workers, and managing organisational bureaucracy and risk. At times, they feel they have little authority or opportunity to exercise influence over shaping, controlling, challenging and changing systems.
Mental health nurses, other professionals and mental health services need to embrace models of practice and new ways of working that focus on meeting the rights and needs of people, maximise therapeutic contact time and promote recovery-based working in line with the shifting focus of health care detailed in Delivering for Health. The key components of such models are outlined in Box 4.
Box 4. Models of mental health nursing practice.
Models of mental health nursing practice need to:
- acknowledge and promote people's central role in assessment of their own care needs and in planning and evaluating care, decreasing their need to rely on formal services and support
- respect people, value their contributions and views and preserve their dignity
- focus on people and maximise individual choice
- enable people to take greater control of their lives and instil hope and belief that recovery is possible
- encourage people to retain or regain social networks, work, education and community connections as early as possible
- build on people's strengths and aspirations, emphasising strengths rather than deficits or dysfunction
- foster partnerships between people who need support and people who support them
- acknowledge the key role played by families and carers in the person's recovery
- shift the emphasis of mental health nursing interventions and services from managing organisational risk towards therapeutic management of individual risk.
WE NEED TO:
- Develop a national framework for training in recovery-based practice to support the dissemination of recovery-focused models into practice.
- Support mental health nurses in reviewing and revising assessment and care planning frameworks and documentation in their organisations to ensure they:
- reflect the key models of mental health nursing practice
- maximise therapeutic contact time between mental health nurses and service users
- support values and recovery- focused practice.