Academics and mental health nurses are pushing for specialist postgraduate training as the norm for nurses practising in this demanding area, reports Jeremy Gilling.
The past three decades have seen dramatic changes in the treatment of mental illness. The nursing profession has kept pace with these changes, but tensions over the status of mental health nursing run high.
The Australian College of Mental Health Nurses (ACMHN) has been critical of decisions by Australian nursing regulatory authorities to abolish specialist nursing registers in favour of a single comprehensive register.
“In the main, comprehensive nursing courses provide a variable mental health clinical component, and offer diluted and inconsistent theoretical content with regard to mental health and mental illness,” it says.
“A comprehensive nursing degree does not indicate competence in the mental health arena. It is not sufficient either educationally or clinically to prepare a nurse for mental health practice.”
ACMHN has taken the bull by the horns in establishing its own register of credentialed mental health nurses – numbering more than 300 Australia-wide – and prescribing the postgraduate courses that suffice to gain that credential (see box).
“It’s only a start,” says ACMHN executive officer Kim Ryan. “There are perhaps 12,000 to 13,000 nurses working in the mental health area Australia-wide. It’s hard to be more precise because many would be general nurses with extensive experience but no formal qualifications in mental health. But we’re not the only nursing specialisation that has gone down this credentialing path, and we’ve got more traction than most of the others.”
Ryan estimates that about 1000 nurses graduate each year from the various postgraduate mental health nursing courses on offer across Australia – sufficient to meet demand.
She is optimistic that the national registration and accreditation scheme for health professionals, agreed to by the Council of Australian Governments for implementation from mid-2010, will accept the principle of credentialing for mental health nurses in some form.
Professor Wendy Cross, head of the School of Nursing and Midwifery and previously associate professor in mental health nursing at Monash, says the norm in past decades was for stand-alone training in psychiatric nursing without any threshold training as a general nurse.
This has steadily given way to the current arrangement where mental health or psychiatric nurses – the terms are broadly interchangeable – are general nurses with postgraduate qualifications or extensive experience in their specialisation.
“Victoria was the last state to go down this path, in 1995,” she says. “And now, 14 years later, perhaps it’s time to take stock again.
Ryan says the psychiatric hospital was once the bastion of institutional care.
“It offered respite and asylum – in the true sense of the word – for troubled people. Now the trend is towards smaller mental health units, shorter stays and outpatient or community care. But the worry is that we may be throwing the baby out with the bathwater,” she says.
“If the systems aren’t in place to support community care – to help the people who once would have been treated as long-stay inpatients in things like finding and keeping a job, completing forms, paying their rent and building a supporting network of friends – they’re at grave risk of becoming homeless.”
Most mental health nurses are community-based, in GPs’ surgeries and community facilities. This in turn means that those who are left in the wards tend to be dealing with complex cases, and are confronting difficult situations that can spill over into violence.
“Nurses who move into the community settings tend to be the more skilled and experienced, and those left behind often burn out quickly,” says Cross. “Wastage is high, and resulting staff shortages add further to the pressures they face.”
Ryan says this reinforces the case for mandating specialist training for mental health nurses, in both the ward and community settings.
“Many general nurses with solid mental health experience are terrific at their jobs. But the gold standard should be a credentialed postgraduate qualification combined with solid on-the-job learning opportunities,” she says.
The other growing concern among mental health professionals is over the interaction between drug and alcohol dependency and mental illness. “It’s not just the new illegal drugs that are flooding in and the serious effects they have on mental health,” says Ryan.
“We’re now learning that prolonged use of cannabis, once thought of by many as fairly harmless, damages the brain and is linked to psychosis”.
“So we’re often dealing with co-morbidities,” adds Cross. “Nurses need to be able to screen people presenting with mental illness for drug dependency and vice versa. Mental health professionals need skills in managing drug dependency and withdrawal. This all comes back to specialist training.”
Ryan says that despite such concerns, there is much to be positive about. Modern drugs, for example, are far more reliable and effective.
“The first-generation antipsychotic drugs often had bad side effects such as nausea and severe skin complaints – and this made the patients understandably reluctant to take them. We’re able to control the side effects much better now with the second-generation drugs.
“The dosages are more accurate, they’re easier for the patients to take – some can be dissolved under the tongue – and as a result patients are more amenable. And of course the drugs work much better.”
Patients are now generally treated much better and more respectfully too.
“This is a direct result of the consumer representation movement,” she says. “Australia leads the world in the mental health area in this regard. Area health boards and virtually all higher order committees include consumer representatives – that is, people who have been or are being treated for mental illness – as a matter of course. They have a direct influence on service planning and delivery.”
Cross adds that health professionals are making steady progress in understanding mental health and mental illness, both generally and among vulnerable groups such as young people and indigenous people.
“We’re getting better at targeting services to where they’re needed – for example, rural and isolated youth. As a result, we’re seeing an encouraging decline in youth suicide rates. The Congress of Aboriginal and Torres Strait Islander Nurses is having a major influence on curriculum for general nurses and for the specialisations, and advancing our knowledge considerably in this area.
“But perhaps the most encouraging thing of all is that, because of the work of organisations like Beyond Blue, people talk much more freely and openly about mental illness. Young people in particular – especially those in isolated areas – use the new technologies like SMS to talk to their friends about how they feel. It’s starting to make a big difference.”
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