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Rights, Relationships and Recovery: The Report of the National Review of Mental Health Nursing in Scotland

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Appendix III: Mental health nursing: literature review synthesis and recommendations

Dr Richard Gray, 1 Ms Pamela Barnes, 2 Dr Penny Bee, 2 Professor Charlie Brooker, 3 Joe Curran, 3 Professor Karina Lovell, 2 Dr Philip Keeley, 2 Mr John Playle, 2 Jo Rance, 1 Deborah Robson. 1

1King's College London
2University of Manchester
3Sheffield University

This review is divided into four parts:

1. Service users' and carers' views of mental health nursing.
2. The efficacy of interventions delivered by mental health nurses.
3. The clinical effectiveness of these interventions when delivered by mental health nurses.
4. The experience of being a mental health nurse in specific relation to satisfaction and stress.

The review will locate, review and synthesise existing literature (particularly focusing on systematic reviews), identify the current gaps in this literature and provide recommendations for practice, education, service provision and research in relation to mental health nursing. Each of the four parts of the review will be addressed using a different review methodology.

Background to the project

Mental health nurses make up the largest proportion of the mental health workforce; 96,269 mental health nurses are registered in the UK. They are pivotal to the delivery of the NSF and the delivery of clinical guidelines. It is timely to review their role and the contribution that mental health nurses can make to the delivery of modern effective mental health care.

Understanding service users' and carers' views of mental health nursing and the experience of mental health nurses themselves will also inform an understanding of the part the profession can play in the modern NHS.

Part one: service users' and carers' views of mental health nursing

Part one dealt with service users' and carers' views of mental health nursing. We undertook a systematic search of the academic and grey literature. Broad inclusion criteria enabled the systematic review to be exploratory and inclusive. Each study was rigorously assessed against pre-defined quality criteria. We identified 143 studies, the majority of which examined service-user experiences in adult settings. There was a lack of evidence regarding the views of Black and minority ethnic groups, child and adolescent users and elderly users.

There was evidence that service users view mental health nursing as a multi-faceted role that requires both human qualities and specific clinical skills. Generally, mental health service users held mental health nurses' listening skills in high regard. However, service users report a lack of adequate information, poor inter-professional communication and a lack of opportunity for collaboration in care. Service user views of inpatient mental health nurses were less positive than in other settings. Service users expect mental health nurses to deliver both practical and social support alongside clinical skills and more formal psychological therapies. Service users expect mental health nurses to:

  • have a positive attitude to working with mental health service users and treat users with respect and dignity.
  • have both human qualities (such as warmth, empathy and compassion) and therapeutic clinical skills
  • recognise their symptoms and deliver the relevant treatment
  • provide honest and appropriate information.

There was evidence that carers are most satisfied with mental health nurses' professional skills and comparatively less satisfied with their abilities to provide information and involve an individual's relative in their care. People who care for people with mental health difficulties have unmet needs and require their own psychological and practical support.

Part two: interventions

Mental health nurses are involved in delivering a range of discrete interventions to service users with mental health problems. The aim of this review was to explore the evidence for the efficacy of interventions considered to be important to the role of the mental health nurse. The highest form of evidence is a meta analysis of randomised controlled trials. Cochrane systematic reviews and meta analyses and National Institute for Health and Clinical Excellence ( NICE) guidelines are highly regarded by clinicians and academics and are a rich source of evidence about the efficacy of interventions.

We generated a consensus list of ten interventions that were considered important to the role of the mental health nurse. Of these, there was good evidence for the efficacy of CBT (in depression, PTSD, anxiety, bulimia nervosa), family interventions, psychoeducation, counselling (modest short-term improvements), and assertive community treatment. There was equivocal evidence for the efficacy of medication management, CBT (in psychosis, early intervention, deliberate self harm, anorexia nervosa, cognitive rehabilitation for dementia), and physical health promotion. There was a paucity of RCT evidence for the efficacy of interventions in the management of violence, and engagement. There was evidence for a lack of effect of case management. The majority of the evidence we reviewed was focused on the efficacy of interventions in working-age adults.

Part three: effectiveness of interventions delivered by mental health nurses

We undertook a systematic review of the evidence on interventions delivered by mental health nurses. We identified 52 randomised controlled trials that involved mental health nurses delivering a clinical intervention. Thirty studies focused on interventions - for example, CBT, medication management and case management for psychosis delivered by mental health nurses (either individually or as part of a team). Eighteen studies focused on interventions for people with a non-psychotic disorder. Interventions included exposure and response prevention, behavioural psychotherapy and group cognitive therapy. Few studies focused on interventions for older adults. The results of individual trials suggest that mental health nurse-delivered interventions, broadly speaking, have a positive effect.

Part four: stress and burnout

We undertook a comprehensive search of computerised databases and hand searched key academic journals. Compared to other nurses, there was evidence that mental health nurses experience higher levels of stressors and lower job satisfaction. There was evidence that mental health nurses experience less positive affirmation, receive less help than other nursing groups and are not good at dealing with their own psychological needs. We also identified that mental health nurses have the highest rate of burnout of any mental health professional group and that job satisfaction is lower for nurses than for other mental health professions.

Recommendations for practice

  • There is a set of fundamental clinical skills (that include listening and sharing information) that are the essence of mental health nursing and are valued by mental health service users and carers.
  • Mental health nurses should exchange information with service users and carers about a holistic package of care and treatment options and facilitate a process of shared decision making.
  • Mental health nurses should focus on delivering interventions that have established efficacy.

Recommendations for education

  • UK-registered mental health nurses should be provided with the necessary skills and opportunities to fulfil a multifaceted nursing role. To this end, nurse training programmes should focus equally upon the development of clinical skills and the development of more generic skills associated with relationship building, engagement and communication.
  • Mental health nurses should receive education in delivering interventions with established efficacy. Ideally, these education programmes should have been subject to their own evaluation.
  • The attitudes of mental health nurses towards service users should be improved. Interventions most likely to facilitate this process include nurse education programmes.

Recommendations for service provision

  • Future models of service provision must include at their core genuine opportunities for collaborative care and effective systems for information provision, both written and verbal. These measures must be fully accessible to both service users and their carers.
  • Organisational barriers to the implementation of effective nursing care, including nurses' ability to deliver discrete interventions, must be identified and overcome. Particular attention should be focused on providing a consistent, regular and therapeutic alliance through a re-evaluation of staffing levels, staff turnover and occupational health.
  • Organisational measures designed to alleviate staff apathy and increase staff morale may have a positive effect on service users' perceptions of mental health nurses.
  • Mental health nurses should be encouraged both to recognise and to deal with symptoms of psychological ill health among carers. Programmes of carer education and support should be provided to ameliorate such symptoms and facilitate an adequate allocation of resources aimed at improving the nurse-carer alliance.

Recommendations for research

  • There is a need for further large-scale, user and carer-led research examining user and carer views of mental health nurses where findings are implemented and evaluated. In particular, research efforts should focus on child and adolescent, older adults and Black and minority ethnic groups. Research should use measures developed in collaboration with service users and carers.
  • There is a need for more high-quality clinical trials (meeting Cochrane criteria) to establish the efficacy of interventions delivered by mental health nurses. Mental health nurses need to be involved in and lead these trials.
  • Mental health nurses need to participate in the development of emerging health technology and to be actively involved in establishing an evidence base for the efficacy of those interventions.
  • There are two key areas identified in the review of intervention where there is a clear need for research that establishes the efficacy of interventions. They are: - deliberate self harm - prevention and management of violence.
  • Mental health nurses must become more involved and skilled in clinical trials research that establishes the efficacy and effectiveness of interventions.
  • There is an urgent need to develop interventions that address the high levels of stress, burnout and dissatisfaction among mental health nurses.