Scottish Mental Health Nursing Review

6. Theme 1: Strengthening the Contribution and Impact of the Mental Health Nursing Profession

6.1 What we heard

Through our engagement we heard about the positive impact mental nurses can have on people's lives. We also heard a clear ask to articulate and affirm the unique role, values, principles, and identity of mental health nurses. The literature also suggests that clearer articulation would help mental health nurses develop a stronger professional identity and improve job satisfaction (de Cruz Piedade et al, 2023, Herceilinskyj, 2022, Hurley et al, 2022). This in turn could lead to more effective patient care and positive care outcomes. Therefore, strengthening the contribution and impact of the mental health nursing profession was the first key theme agreed by our Advisory Groups.

Role clarity was a recurring issue that arose from the literature and National Conversations, and we heard how role ambiguity affects job satisfaction, team integration, and care delivery. The literature suggested that efforts to define and promote the value of nursing roles are essential for improving recruitment, retention, and workforce stability (Hercelinskyj, 2022 and McCrae et al, 2014). This will also help the profession more consistently describe the purpose, role, and impact of a mental health nurse to people who access care and treatment, and to fellow colleagues, peers, and the wider community.

Participants of the National Mental Health Nursing Conversation also suggested that this would help address many wellbeing concerns currently faced by the workforce and students. This included supporting nurses to feel valued and respected as a skilled professional supporting them to convey their unique skills set and further enhancing pride in their profession. This was also suggested as helping address concerns around perceived stigma, relating to feelings that some wider colleagues do not understand or respect the role.

Providing a clear framework and a contemporary identity was said to be integral to mental health nurses' effectiveness and can help support strengthening the contribution and impact of the profession, whilst supporting recruitment, retention, and professional development.

In collaboration with our three Advisory Groups, we have developed a set of Principles for Care and Practice, which underpin the work of mental health nurses in Scotland, and help stakeholders understand their work and impacts.

The care and interventions mental health nurses offer, and the standards they uphold, are fundamental to realising the delivery of high quality, person centred, safe mental health care. Mental health nurses in Scotland are involved in the care and treatment for people at all life stages – from childhood through to older years.

Mental health nurses have a complex and multifaceted role in providing care, supporting recovery, and enhancing patient outcomes. Nurses play a leading role in facilitating decision-making, particularly in recovery-oriented care, using strategies such as empowerment and self-management (Cleary et al, 2018).

The role involves facilitating an effective relational environment from which meaningful therapeutic relationships can be established and sustained, with relationships being the basis for supporting personal recovery, positive care outcomes and maximising benefit to the individual.

A relational lens helps move away from a diagnosis-led/medical model and more towards a deep understanding of relationship-oriented approaches for understanding and responding to the impact of mental distress and human suffering, as well as mental illness. People rightly expect this from those providing care, and mental health nurses themselves express a desire to be more able to provide such support.

Creating a safe therapeutic space requires conscious, deliberate action and effort from both people involved. Trust in therapeutic relationships cannot be assumed and is earned through shared investment over time.

“It does help you – that regular contact with someone trained to understand what you need. I had a Community Psychiatric Nurse (CPN) for 15 years, it was consistent, I knew and could trust them. They used to say themselves ‘it takes at least a year to get to know each other’ (patient and nurse) – building relationships takes time.”

VOX Scotland Member

As a mental health nursing profession in Scotland, with responsibilities for delivering, managing and leading care and services, as well as supporting the education of the current and future mental health nurses, it is crucial to clearly articulate, affirm and uphold the values and principles that are at the heart of the care and practice of a mental health nurse working in Scotland.

Mental health nursing values are the cornerstone of the profession. They help guide nurses in their work, shape their sense of purpose and identity and help ensure that the highest standards of care are met, aligned to the NMC Code and Standards of Practice. It is incumbent on all mental health nurses to uphold the values and embed them into their day-to-day practice.

Mental health nursing values are integral to creating a culture of care and compassion, within which excellence in mental health nursing care can flourish, and through which, positive care, goals and outcomes can be achieved. They help focus practice on the person, in a way that is trauma - responsive, rights-based, and that enables recovery and supports people to live meaningful and fulfilling lives in the presence or absence of symptoms of mental illness. Central to this, is the mental health nurse’s duty to clearly articulate their role and communicate the therapies, treatments and support they can offer to individuals, carers, and their families.

6.2 Our Principles for Care and Practice - ‘The Principles’

Mental health nurses often hold the principal role in the multi-professional team and for prioritising the creation of a healthy relational environment through initiating and maintaining a broad range of relationships, including with people receiving support, carers, families, wider members of the multi-disciplinary team and a diverse range of external colleagues.

It is a foundational value that mental health nurses respect and value different and distinct roles and approaches in mental health care and proactively seek to work together to ensure that people get the support they need to recover.

The importance and value of honesty, openness, transparency, and an understanding of how we as individuals influence therapeutic relationships are central to our relational practice and the realisation of ‘The Principles.’

Our ability to take a critically reflective view of mental health nursing practice, both as individuals and as a profession, is just as important. Fundamental to this is access to, and participation in restorative clinical supervision. This must be prioritised by all mental health nurses at all levels in all services and organisations in which mental health nurses are employed. Alongside this, robust monitoring and governance of clinical supervision activity and impact must be led by local mental health nursing leads. This forms the foundation for effective interventions and improved care outcomes and experiences.

Mental health nurses operate among many different competing and conflicting interests and with an evidence base that at times is limited or contested. Our capacity to question, advocate, and make space for alternative perspectives is essential for the provision of human-rights based mental health care.

“Mother and Baby Unit nursing staff have enthusiastically engaged in health promotions and services delivery initiatives. These are designed to improve and enhance the lived experience of the women and families within the unit. All interventions take a whole system, relational and right-based approach with the principles of recovery and self-advocacy at the heart of everything we do. The aim is to improve the mental health and wellbeing of the women, their babies, partners, siblings, and wider family members. We work collaboratively with colleagues across health, social care and the third sector to adapt the packages of care and support that wrap around the women, their babies, and their families.”

West of Scotland Mother and Baby Unit

The Principles & Definitions

We put people at the centre of their care

Treating everyone with respect, dignity, and compassion, being trauma-informed and trauma-responsive. It recognises intersectionality, and patients’ unique needs and preferences, and the importance of offering care that is inclusive, holistic, coordinated, and personalised to support the person.

We work through therapeutic relationships

Demonstrating empathy, kindness and compassion in the development of therapeutic relationships which are valued by and help improve outcomes for the people we work with. This can be supported by drawing upon frameworks such as Time Space Compassion.

Our care is ethical and rights-based

Adhering to ethical standards, including confidentiality, informed consent, and our legislative framework in the protection of vulnerable individuals. It also includes being honest, accountable, and transparent in our professional decision making, and the impact of such decisions.

Our practice is recovery orientated

Through connectedness, empowerment, and enabling hope, optimism, meaning, and personal agency and positive sense of identity as core aspects of the therapeutic relationship.

Our practice is culturally sensitive

Being aware of and respecting cultural differences and incorporating this understanding in the delivery of care that is without any form of discrimination.

We focus on reducing coercion

Being aware of the power imbalance that can exist within therapeutic relationships. Minimising restrictive and coercive practice in all settings enabling more choice and control over care and treatment, and greater self-determination at all stages of their recovery journey – truly putting them at the centre.

We help reduce inequalities

Being aware of and respond to intersectionality and the impact on people’s mental health from multiple perspectives, including social, environmental, physical, economic, geographical determinants and spiritual perspectives.

We proactively address mental health stigma and stigma by association

Being alert to and challenge negative attitudes, prejudices, and negative behaviours towards people with mental ill health and mental health professionals.

We advocate for people

We enable self-advocacy and advocate for people through speaking up for the rights and needs of patients, carers, and families, ensuring they receive appropriate care and support and are treated fairly, with dignity and respect.

We are curious and collaborative

Working collaboratively with patients, their families, carers, and wider colleagues across all sectors and settings seeking to understand what matters to the person to help enable recovery.

Our practice is evidence- based

Utilising the latest research, data, and evidence to inform clinical decisions, enabling quality and safety, and providing the best possible care and treatment. This includes sources of evidence such as qualitative studies and lived experience feedback.

We embrace innovation, improvement, and creativity

Creating and applying innovative and creative approaches and solutions to support high-quality person-centred care, address service demand and respond to unmet needs.

We support and utilise research

Undertaking research or supporting research, mental health nurses are in an ideal position to set the profession’s research priorities and undertake their own research objectives. This will enhance care delivery and outcomes and build the evidence base for the profession.

We are reflective practitioners

Continuously evaluating and analysing one’s actions to improve practice, safety, and care quality, before, during or after a care event. This also enables self-care through increasing self-awareness and building self-compassion.

We engage in clinical supervision

Actively engaging with supervision supports mental health nurses to process the challenges they experience in a productive, psychologically safe, and supportive way and provides an opportunity to discuss challenges, raise any concerns and potential solutions. Access to and participation in supervision is an essential component of safe care delivery.

We are role models for leadership and professionalism

Leading at all levels of practice through displaying professionalism and professional behaviours in your role, in support of people in your care, with colleagues, peers and team members.

We each have a voice that counts

Through championing these principles, we will individually and collectively amplify the voice of mental health nursing in Scotland, promoting the profession, and the positive impact on the people we support.

2. ACTION: To ensure The Principles are embedded in practice, working with the

Implementation Group and Mental Health Nurse Leads across sectors, the

Scottish Government will develop a Mental Health Nursing Principles for Care and Practice Framework that can be used to guide supervision discussions, and as a complementary template for NMC revalidation discussions.

Mental Health Nurses should also share the Principles for Care and Practice with people with lived/living experience, carers, and colleagues to help communicate their role and the principles of their practice.

“We relate to everyone – this has a massive personal and professional impact. We are truly holistic professionals – mind, body, and soul.”

Comment from National Conversation Participant

Findings from the literature review suggested that, despite mental health nurses possessing a broad range of capabilities, including emotional intelligence and communication skills, they can be undervalued in clinical settings and remain an underutilised resource, despite their expertise (Hurley et al, 2022). The evidence shows that the integration of advanced roles into various care settings, from primary care to forensic mental health hospitals, shows promise, however, requires continued research and investment in education and policy changes.

In Scotland, we know that the mental health nursing role has evolved significantly to respond to the growing complexity and demands seen across our health and social care settings. Across various roles and settings, the introduction of advanced and highly-specialist roles such as Mental Health Consultant Nurses, Advanced Nurse Practitioners (ANPs) and Clinical Nurse Specialists has enhanced mental health care delivered by nurses and helped improve patient outcomes through tailored evidence-based care and advanced practices. Mental health nursing roles have expanded to include prescribing, advanced assessment, autonomous practice, and complex care delivery, including the delivery of psychological therapy interventions, education, and practice development as key components of their roles. These advanced and highly specialised roles focus on integrating holistic and evidence-based care, often tailored to specific care settings.

The Scottish veterans’ charity Erskine appointed Advance Nursing Practice (ANP) roles working across two care homes, leading and managing three hundred staff. The ANP works in partnership with the homes’ nurses and local GP practice.

Having an ANP on site has been a positive development for residents. The ANP has provided early intervention, access to enhanced knowledge, skills, assessment, and decision making and early recognition of deterioration, resulting in avoidance of hospital admission where possible. Other advantages of having an ANP on site is continuity of care for residents and continuity of support for staff. The ANP can follow up residents and ensure recommended treatments or interventions are correctly delivered and adhered to.

The introduction of the ANP role within the care home is a development that has seen the extension of the mental health nurse's role and function where they have enhanced their knowledge and skills through the national Transforming Nursing, Midwifery and Allied Health Professional Roles programme.

Building on previous experience and awareness of the positive change the role has brought, the enhancement of this role for mental health nurses within Erskine was a positive development.”

Erskine Veterans Charity

Through our engagement, we heard that mental health nurses are motivated to expand their practice and would like to achieve this through having more clearly defined clinical career pathways. The importance of systemic support and policy reform to maximise and realise their contribution, and to further promote mental health nursing as a specialised and valued profession was highlighted in both the literature and engagement findings (Mason et al, 2008, Elson et al, 2008 and 2009, McAllister et al, 2017, Laing, 2012, Caldwell et al 2012).

Empowering mental health nurses to reach their full potential, whilst ensuring mechanisms are in place to support and respect the autonomy and better utilisation of the mental health nursing profession’s unique skills and expertise, is pivotal in addressing job satisfaction, and ongoing mental health service challenges, such as workforce shortages, recruitment, and retention (Procter et al, 2011, McCrae et al, 2014, Matsumoto, 2019 and Kipping et al, 2022 Hercelinskyj, 2022, Perkins et al, 2023).

The Review and wider policy development such as the Nursing and Midwifery Taskforce Implementation, Mental Health Legislation Reform and development of new service delivery models, brings substantial opportunities to ensure that the mental health nursing profession is at the forefront of the ambitious steps to reform and renew service design and delivery of our health and social care services, and to deliver the changes that best meet the needs of the people in Scotland.

3.ACTION: Working with Mental Health Nurse Leads Group, we will ensure mental health nurses can access sustainable and progressive opportunities to influence policy, practice, national and local strategy to achieve change. This includes, but is not limited to:

a. Mental Health Core Standards

b. Excellence in Care in mental health

c. Transforming Roles

d. NMT implementation

e. Scottish Patient Safety Programme.

4. ACTION: Linked to the Mental Health and Capacity Reform Programme, we will explore opportunities to further develop the mental health nurse role within the context of ongoing mental health legislation reform.

5. ACTION: Working with the regional and national Advanced Practice Academies, NES and wider colleagues, we will promote, support and further develop specialist, advanced, and Consultant Nurse mental health nursing practice, aligned to the national Transforming Roles programme.

In addition, through the Transforming Roles programme and linked to NMT Action 6, we will work with relevant colleagues to further promote mental health care support worker frameworks for colleagues who would like to progress their careers into registered practice.

6. ACTION: Working with NES, we will promote and build capacity for the Psychological Therapies Education and Supervision Skills Pathways within mental health nursing and identify and address any local and systemic barriers to uptake for the workforce.

7. ACTION: Working with NES, the Mental Health Consultant Nurse Forum, Mental Health Nurse Academics Group, and wider stakeholders, we will identify, prioritise, and share the mental health nursing research priorities in Scotland. This links to NMT Action 13.

8. ACTION: Working with the Mental Health Nurse Leads and nurse leaders from other sectors, we will actively promote the use of the Triangle of Care and other similar frameworks to facilitate and enable the involvement of carers.

6.3 Stigma

Stigma surrounding mental ill health is an important, pervasive issue that must be addressed. Discrimination often manifests in subtle ways, such as through language, media portrayals and social exclusion. It often perpetuates a harmful narrative that mental illnesses are personal failures rather than health conditions. As the largest mental health workforce, mental health nurses are in unique positions to counteract these prejudices, not only by providing empathic, person-centred, evidence-based care, but also through public education and advocacy.

Evidence highlights that mental health nurses can often struggle with their professional identity due to the stigma associated with mental illness, which creates both a stigmatising and stigmatised professional identity. Addressing stigma is vital for improving nurses' mental health and professional recognition. The evidence highlights the importance to take proactive measures to reduce stigma within the nursing profession, by promoting positive representations of mental health nursing, improving public understanding, and supporting nurses in managing their identity within the broader health and care system (Sercu et al 2015, Bonham and Kwasky, 2021 and Croguennec et al, 2024).

Following the publication of the Workforce Action Plan, Scottish Government funded a research study with See Me Scotland, Mental Health Foundation, in collaboration with the Mental Health Nursing Leads Group and Abertay University to investigate if (and how) stigma surround mental health nursing impacts recruitment and retention of the workforce. The findings revealed that mental health nurses face significant stigma, which affects their professional and personal lives. The full report can be accessed here, with findings summarised below.

The research study comprised a mixed-methods survey, and follow-up focus groups and interviews with people who have previously or are currently working in or studying mental health nursing in Scotland. 636 current and former mental health nurses and nursing students participated in the research, sharing their individual experiences and perspectives of how stigma by association affects the profession.

Survey findings revealed that many mental health nurses and mental health nursing students experience a considerable level of stigma related to their profession, with over half (55%) of survey respondents reported facing stigma in at least half of the situations measured using the Clinician Associative Stigma Scale. Levels of stigma were similar for current mental health nurses and nursing students, although the particular experiences of stigma varied slightly. Current nurses reported higher levels of discomfort when disclosing or discussing their job, and greater exposure to stereotypes about mental health nurses’ mental health. In contrast, students reported experiencing a greater level of stigma relating to the profession’s effectiveness, and more stigma towards people with mental illness. Whilst the survey data consistently revealed that around half of participants feel that they have experienced stigma at work or university, a much higher proportion have had stigmatising experiences such as being told their work must be scary or that they do not know what they are doing. As a result, almost 1 in 10 have taken time off or left a mental health nursing job.

9. ACTION: - Following Phase 1 of the Stigma by association research, the Implementation Group and wider colleagues will work with See Me to consider the survey findings and embed stigma-reduction activity, drawing upon learning and evidence of what works.

6.4 Tackling inequalities

As relational experts, mental health nurses have a significant role in tackling inequalities influenced by social determinants. The NMC also recognises that vulnerable people may be more at risk of harms.

Mental health and wellbeing are influenced by many factors often beyond our control. These include social or economic factors, such as home life, work conditions, physical health, environment and housing, income, relationships, limited employment opportunities, and experiences of prejudice and discrimination, among other influences. Children and adults living in households in the lowest 20% income bracket in the United Kingdom are two to three times more likely to develop mental health problems that those in the highest. (Mental Health Foundation). Employment status is also closely linked with those who are unemployed or economically inactive having higher rates of common mental health problems than those who are employed. (Mental Health Foundation) We know that experience of difficult or traumatic life experiences and/or inequalities also influences our mental health and wellbeing, and influences support needs (Mental Health Equality Evidence Report, 2023).

It is well established that the physical health of people with severe mental illness (SMI) is much poorer than for people without SMI and that the causes of poor physical health in people with a SMI are complex and interactive. (Reilly et al 2015. RCN 2023). The factors that account for this include adverse effects of antipsychotic medication and unhealthy lifestyle behaviours, which increase the risk of physical health conditions. This includes higher prevalence of obesity, asthma, diabetes, chronic obstructive pulmonary disease, coronary heart disease, stroke, and heart failure. Differences are more pronounced for younger age groups with the highest health inequality in ages 15 to 34 for asthma, diabetes, hypertension, and obesity. People living in more deprived areas also have a higher prevalence of severe mental illness (Robson D, Gray R. 2007, UK Government, 2018).

Other barriers to recognising and managing physical conditions may include difficulty in understanding healthcare advice, reduced motivation to adopt new lifestyle changes, poor treatment compliance, cognitive deficits, reduced pain sensitivity (induced by antipsychotic medication), poor communication and poorer social skills (DeHert et al 2011).

Nurse Therapists in NHS Forth Valley Psychological Therapies Services recognised that many people eligible for cervical screening did not attend or had been lost to follow-up, often due to the procedure’s potentially traumatic or retraumatising nature. The service aimed to identify women at increased risk of cervical cancer and to increase attendance in preventative screening, enhancing patient experiences and reducing re-traumatisation.

The project’s aim was to increase confidence and competence in trauma-informed practices within general practice settings. Working in partnership with the local services and stakeholders, the team gained insights from people with lived experience. They also sought feedback from practice nurses and GPs into the challenges they experienced engaging individuals with a history of sexual violence in preventative screening practice.

They also promoted the importance of compassionate enquiry cervical screening status, and the unique support mental health nurses can provide. The team implemented strategies to enhance trauma-informed practice in General Practice, which included educational resources, webinars, and a set of trauma-informed cervical smear pamphlets and complex trauma cards for use within General Practice and Hospital settings.

The team noted that women with a history of sexual trauma have enhanced cervical screening experiences, improved attendance and improved detection rates for early abnormal cervical changes, and reduced distress and adverse effects of re-traumatisation. Enhancing trauma-informed practices broadly improves the probability of favourable experiences and results for those using health services.

The role of the mental health nurse is fundamental to increasing awareness and as a conduit between those we serve and the other services they utilise.