12.1 Reflections

Why is nursing important in helping with children and young people’s mental health? At my interview for my first community CAMHS post I was asked, by a clinical psychologist, what I thought I would bring to the team by virtue of being a nurse? They had already asked what I might bring as an individual, so I was a little baffled, but I managed to get through the question, and got the job, but I can’t honestly recall what I said. I do remember than thinking that it was a rather inadequate answer, and that I needed to discover what nurses did do in the community that was a nursing function. On the adolescent in-patient ward where I was working at the time, the essential 24/7 nursing care approach was fairly obvious, so I hadn’t really thought about it in any depth. When I started the community job, the overlap between what the different disciplines brought to the task, the generic function of community CAMHS, made me wonder for a while if there as anything different about what we did. The only other CPN in the team, however, worked in a very similar manner to me, despite having trained in New Zealand, so I thought there must be something about that training and orientation that made us a bit different from the social worker (who became a systemic psychotherapist), the clinical psychologist, and the child and adolescent psychiatrist. As the team started to grow and include other disciplines, a couple more nurses, an art psychotherapist, another doctor, the feeling that there were some distinctive differences grew, but it was very difficult to articulate what those differences were, and whether they were because the nurses had something different to add to the mix from their nurse training.

For a while I felt that the idea that nurses have an eclectic approach and were essentially the glue that held other teams together had a lot going for it as the answer. This was based on observations about what jobs nurses did that others were reluctant to do, because their vision of what their role entailed were much better defined. Some of this became more obvious at critical times, when I noticed, rather flippantly, I admit, that it was always the nurses who put up the Christmas tree and decorated the waiting room. It’s difficult to speculate on why this happened without offending colleagues that I admire and respect, but there was something about the nursing approach which made us feel we had to create the right atmosphere for families when they arrived, whilst others did not see this as quite so important. One year we refused to do it and it was a miserable atmosphere in the waiting room! I later discarded this theory anyway when I worked elsewhere and the reception staff were the ones who did the Christmas decorations. But it did make me notice other things that some professions did which seemed ‘wrong’ to me, but were part of the ‘taken for granted’ element of professions. Doctors are happy to have ‘Thank You’ cards up on their walls, and wear smart suit and tie, or more formal styles of clothing for the female doctors, whilst nurses tend more to wear ‘smart casual’ (I never wore a tie, unless I was going to a management meeting!). This seems to reflect the expert position which the medical profession takes, and which the public expects of them. Clinical psychologists seemed much more wedded to specific models and attached a lot of importance to maintaining fidelity to those models, and the social worker was much more aware of child protection issues and social models of care. All of them, however, also had engagement skills and developed therapeutic relationships with the children and young people, and their families, which I thought was what nursing was about, but they didn’t attach as much importance to this as the nurses did, and maybe spent less time on those aspects because they also had core philosophies from their professions which had primacy, and added on the ‘people skills’ parts.

In terms of professional identity I learnt that defining yourself by what you don’t do—as my colleagues were doing, and which as nurses we often do, at the time we didn’t prescribe, we couldn’t perform some reserved psychologist’s assessments, and we didn’t diagnose—is called ‘othering’ (Davies 2003) and is a rather negative way of defining yourself. It is most classically expressed in the studies which look at how nurses and doctors interact, the ‘Doctor-Nurse game’ (Stein et al. 1990). As expended roles have developed the list of things that nurses don’t do has reduced—I took the independent prescribing course much later in my career, for example, so that also affects what defines the difference between nurses and medical doctors. As I wrote up and presented my early thoughts (Limerick and Baldwin 2000; Baldwin 2002), people started to ask me what was the answer to the questions I was asking them, and I still didn’t have a good answer. The difficulty in verbalizing things continued, mostly because many of my colleagues who were from different professions also exhibited the skills which I saw as essential to nursing. Through a rather in-depth process of study (Baldwin 2008) I came to think that the skills we have looked at in this book were not something which were exclusive to nursing, but which were the ones which, as nurses, our underlying philosophy and training put the most emphasis on. In fact, very few things are exclusive to one professional group in mental health teams, and CAMHS teams in particular, and hanging your identity on those things which only you can do is also a rather precarious position to take. Much of the exclusive parts of medical profession, prescribing, diagnosis and application of certain parts of the Mental Health Act, have been eroded and can now be performed by other professions, which allows some managers to question the need for how many of them we need, or to fill positions with other staff when there are shortages. Many of the clinical psychologists I have worked with have been very reluctant to be pigeon-holed with performing the copyrighted assessments that others cannot do. At the same time other professional groups, clinical psychologists, psychotherapists and medical doctors still put time and effort into maintaining a clear professional identity, and being clear about why it is important that they are part of the team. Nursing has always been reluctant to spend too much time on this and has continued to struggle to define what it does.

12.2 Is There a Unique Contribution That Nursing Brings?

Nursing is both simple and complex, and the best nurses (as with every profession) make the complex task that they perform look effortless and natural. This brings with it two main difficulties, firstly that other people may think that it is just a simple task, one that can be done by anyone, perhaps even without much training, even ‘intuitively’. The second problem is that explaining, or verbalizing the complexities of an apparently simple task becomes more difficult, to the point that some people seem to be so much part of their role that they forget that what they are doing is complex, and that they ‘take for granted’ what they do, maybe even assume that others would do the work in the same way. The famous oil well firefighter Red Adair allegedly said: ‘If you think getting a professional to do a job is expensive, try getting an amateur’. Whilst his area of expertise was more explosive, nursing, even child mental health nursing, deals with life and death situations, and can potentially have fatal outcomes, or long-standing poor health outcomes if not done well.

We are working in a time when the pressures to provide quick and effective answers to complex problems, using often the cheapest measures, are enormous. In nursing in general work has been done to look at staffing and skill mix, with an increasing amount of evidence that the best care (and the best outcomes in terms of lowering mortality, how many patients actually live and die) is provided when levels of qualified staff are higher. Although most of this work has been done on acute medical wards (Griffiths et al. 2018), the principles must surely be same when looking at an equally complex area of children and young people’s mental health. Professor Alison Leary recently commented (Leary and Punshon 2019) that the weight of evidence is not actually affecting policy as well as one might hope in a sector where high value is put on following an evidence base. She noted that nursing is arguably one of those areas which is only noticed in its absence, or when something goes wrong, as in the Mid-Staffordshire tragedy. Whilst this study concentrates on acute nurse staffing and safety, the authors note in their conclusions that they found no real examination of the impact of numbers in a ‘knowledge intense’ profession and speculated that the complexity of the nursing role makes it difficult to define.

This is in somewhat stark contrast to other professional groups, who are much better at defining what is their exclusive domain and what others cannot do, to the extent of protecting it by law. In the UK, ‘registered nurse’ is a protected title and cannot be used by anyone who is not on the NMC register, but the title ‘nurse’ is widely used by a range of different jobs. There remain a few areas where legally a nurse is required, medication management, for example, and curiously the ‘Named Nurse’ role in Safeguarding Children. It remains harder to define within CAMHS what only nurses can do, the expanded role of independent nurse prescribing being an exception.

Within the therapies the different psychotherapies have been much better at defining their unique contributions to the field, and defining what constitutes a ‘qualified psychotherapist’ within their area of expertise. Both cognitive behavioural and systemic psychotherapy, for example, now insist that you cannot call yourself a cognitive behavioural psychotherapist or systemic psychotherapist unless you are trained at Masters level and registered with the British Association for Counselling and Psychotherapy (BACP). The BACP is not a state registering body, like the NMC, HCPC or GMC, but does regulate the psychotherapies at a technically lower level. Whilst many CAMH nurses have been able to access additional training in CBT and systemic psychotherapies via the CYP-IAPT programme, those trainings are focused at delivering skills for a function, and not at Masters level, so nurses are not accessing full qualification through that programme. This process of protecting knowledge is an interesting one in terms of professional identity and how we see ourselves. In the early days of family therapy (before it insisted on calling itself systemic psychotherapy), the techniques of systems thinking and their alliance with nursing’s tendency to holism meant that some nurse theorists saw this as a fruitful area for development. Shirley Smoyak, writing from an American perspective (1975), described nurses as family therapists, and Wright and Leahey (2008) developed their family nursing model based on structural family therapy as we have seen, though they never refer to nurses as family therapists. Whilst this can be seen as a natural form of protectionism, cognitive behavioural therapies followed a similar route in determining exclusivity by virtue of training which ensures fidelity to the theoretical model, and it does pose the question of whether nurses who train in those therapies lose their nursing identity and instead become therapists. Similar issues exist for social workers and allied health professionals who train in the psychotherapies, and my conclusions over the years have been that the strength of the underlying conceptual base for your identity (Baldwin 2008) determines whether you continue to see yourself primarily as a nurse after fully training as a psychotherapist, or whether that conceptual base takes over your thinking and you think of yourself as primarily a psychotherapist, rather than a nurse (or social worker or AHP).

12.3 Professional Identity and Nursing Strengths in CAMH Nursing

As we have seen throughout this volume there is a strong attachment to the identity of nursing, but rather more difficulty in adequately defining what nurses bring, and what the conceptual basis of nursing brings of value to CAMH. Primarily my colleagues and I have drawn on the mental health nursing concepts of interpersonal relations, the concepts of therapeutic relationships, and therapeutic use of self that were promoted by Hildegard Peplau and consequently by Altschul and Barker, in the UK. However, CAMH nurses also come from other fields, children and young people’s nursing and learning disabilities nursing, where this tradition is not so strongly emphasized, so using this as a unique feature has become problematic. Consequently I have tended to use the idea that rather than having uniqueness nursing brings strengths which it prioritises or ‘privileges’ as being more important than other professional groups do. They tend to use these areas too, but they are not core to the thinking—defining them exactly is tricky, though I tried to outline them in Chap. 1, and Marie Armstrong uses a slightly different (but broadly similar) set of skills, whilst Gemma Robbins and Steph Sargeant give a slightly different slant from a children’s nurse perspective.

Just because it is complicated or difficult to define doesn’t mean we shouldn’t continue to attempt to define what we bring. Many people claim to have an eclectic toolbox of skills they use in their work with children and young people, but the importance of this is knowing what each tool is and when to use it. Katrina Singhatey and Moira Goodman showed in their chapter that their emphasis on putting themselves alongside the people they worked with didn’t stop them from using both CBT and systemic tools when they were useful, but they did so consciously. Annie Cox likewise draws out the differences and similarities of different approaches to therapy, and shows how nurses can ensure that the important issue of children and young people understanding what they are being asked to consent to is addressed thoroughly.

The central thesis of this book has been to try and unpick some of the nursing skills that we use, often referred to as ‘soft skills’ because they are hard to define, and often they are so embedded in our thinking that we take for granted the way in which we work. The idea that actually these very qualities are actually exactly what children and young people need is borne out by Leanne Walker’s conversations with Hannah and Danni, and reflected in the wider participation work that Leanne has been involved in nationally and internationally. Of course children and young people also need people who can diagnose carefully and draw on expert knowledge, and they need people who are highly trained in models of therapy and care which are proven to work, but that they say they most need are simple things like people who care enough to spend time with them, listen to their stories, believe in them as individuals and stick with them through the most difficult parts of their journey. Nurses have those qualities at the heart of what they do, and should be valued or what they bring, even if they aren’t very good at explaining what or why they are doing it.