Helping young people ‘a speciality’

Nurses working with children and adolescents fear the low profile of their work may mean less experienced workers are used in their place. Mardi Chapman reports.

Despite recent and significant expansion of mental health initiatives such as headspace centres, there is some concern that child and adolescent mental health (CAMH) nursing is at risk of losing its identity.

A research article in the Journal of Psychiatric and Mental Health Nursing earlier this year briefly explored the proposition that the role of CAMH nurses needs to be better defined.

It suggests CAMH nursing may suffer from “limited visibility” and that “unless nurses were able to clearly articulate and identify the specific contribution they made, there is a danger of the role being filled by generic workers”.

Cheryl Green, lecturer in mental health and substance use in the University of Adelaide’s School of Nursing, says there is already a blurring of the lines between the professions in some CAMH settings.

“Mental health nurses in community practice almost renounce nursing to become part of the multidisciplinary team. The difficulty is they can then be replaced by anyone.”

Green, who has worked in CAMH nurse roles for more than 20 years, says it is more important than ever to have the knowledge and skills associated with physical health assessment and monitoring within the mental health team. “The new mental health act (in SA) mandates that we attend to the physical health of people with mental health issues. This has been taken up in the adult population but less so in younger clients.”

She says assessment of growth and development or identification of potential side effects of medications are not part of the core discipline of other mental health professionals such as psychologists, social workers or occupational therapists.

Guidelines on the physical healthcare of mental health consumers (NSW Health, 2009) say there can be “confusion around who is responsible” and “a lack of knowledge and training” in regard to assessing and monitoring physical health within mental health services.

The comprehensive document highlights the value of partnerships between GPs and mental health services but does not recognise the potential contribution of nurses already working in these services.

Spokeswoman for the Australian College of Children’s and Young People’s Nurses (ACCYPN) Associate Professor Jenny Fraser agrees that nurses are in the best position to provide that holistic approach especially in the community CAMH setting. “As well as their training in normal child behaviour and development, nurses can have easier access to families as they enjoy such a trusted relationship in the community.”

She says nurses have established positions of trust in roles such as home visiting and in schools and are not perceived by vulnerable families as “wolves in sheep’s clothing” as sometimes happens with other professions such as social workers.

In its 2011 Mental Health Services in brief report, the Australian Institute of Health and Welfare (AIHW) says there are over 15,000 mental health nurses employed around the country.

CEO of the Australian College of Mental Health Nurses (ACMHN) Kim Ryan says the numbers are rubbery because the AIHW’s definition of mental health nurse could be disputed. “We would say there might be 15,000 nurses working in the area of mental health but many of those may be comprehensively trained nurses rather than specialist mental health nurses.”

The size of the CAMH nurse workforce is even less clear.

Some people are still smarting from the loss of the remaining state-based mental health nurse registers when national registration was introduced in 2010. Perceived as a loss of recognition for the specialty, it was one of the professional issues identified in focus groups with CAMH nurses in the Journal of Psychiatric and Mental Health Nursing article.

“Some would say mental health nursing is as different from general nursing as midwifery is from nursing. There is capacity within the legislation to separately identify mental health nursing but they have chosen not to do so at this time,” Ryan says.

The college is in the early stages of a “scope of practice” project to better define the discipline of mental health nursing as a whole, which Ryan says will help inform the education and clinical preparation of the future workforce. They are also working hard to demystify mental health nursing and turn around its poor image with an active ambassador program to high school and nursing students.

“It doesn’t matter where they work, nurses need a good foundation in mental health. The quality of their education and particularly their exposure to clinical practice in a well supported clinical placement needs to be championed,” Ryan says.

Green says that the addition of a part-time position to actively support student nurse placements in the Boylan Ward at Adelaide’s Women’s’ and Children’s Hospital has boosted recruitment and retention of staff in the psychiatric inpatient facility for children and adolescents.

The ACMHN has a special interest group in perinatal and infant mental health but other members in CAMH do not have such a formalised network.

With momentum around the newborn to 2-year-olds and the high profile of youth and adolescent services, there is an argument that children in the 2-12 years age group might be missing out.

But the mental health sector has grown used to living lean and school nurses pick up some aspects of mental health promotion, screening and referral. “We used to say that in CAMHS we receive 5 per cent of the mental health budget for 30 per cent of the population,” Green says.

Ryan says any concern about loss of professional identity would be as valid for all mental health nurses as for the subgroup of CAMH nurses.

Sydney Nursing School’s Associate Professor Kim Foster agrees that especially in community settings, members of the multidisciplinary mental health team can perform similar roles.

“Nurses are often a small group in the team but their role is integral to the service. Many have consolidated their general training before moving to mental health and with increasing awareness of and focus on co-morbid mental and physical health problems, there is ongoing demand for people with that knowledge and experience.”

Research in CAMH nursing is also growing and will help drive awareness of their unique contribution to the sector as well as improvements in service delivery.

Not an exact science

Bernadette Flynn enjoys being part of a multidisciplinary team supporting families with many different and complex mental health issues.

She has worked in the Barwon Health CAMHS (Child and Adolescent Mental Health Service) in Geelong for more than four years – predominately with 4- to 16-year-olds and more recently with the newborn to 4-year-olds. “You frequently see change and it’s very rewarding to see lives taking a different path. There is a hopefulness about early intervention in children as compared to adults – that we can help change their trajectory before they develop chronic disease.”

A hospital-trained nurse, Flynn previously worked in emergency care, surgical and plastics wards for many years with an additional stint in district nursing in rural Victoria. She has also been a nurse educator but opted for a degree in social welfare and later a Graduate Diploma in Family Therapy after a move to Geelong.

After working as a children’s community support worker for a non-government organisation, Flynn realised she was missing the clinical component to her work. Her transition to a nursing position in CAMHS was made easier with the help of practical and relevant training including the developmental psychiatry course offered jointly through the University of Melbourne and Monash University’s Mindful Centre for Training and Research in Developmental Health.

“Transferring to this type of work I initially found it harder to engage with people quickly as you are used to doing that in the context of physical activities such as washing patients or taking blood. It is much harder to engage without those bridges and yet we expect people to talk and share very personal experiences.”

Flynn believes she is more alert to problems that may have a physical component to them such as a child with persistent encopresis and will suggest GP or paediatric referral.

“It’s been a steep learning curve but I feel that my broad experience is helpful and that I’m open to a variety of views,” says Flynn. “CAMH nursing is not an exact science and it’s harder to find a solution for families but I can be a facilitator to help parents think differently about their child and respond differently, make recommendations and explore options with them.”

Mardi Chapman

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