5. Nursing in Specialist Community CAMHS Settings
5.1 Nursing in Community CAMHS
In the first chapter, we saw how nurses moved out of their original role in inpatient units when child and adolescent mental health provision developed a more community-based approach. The inclusion of nurses seemed a natural part of a multidisciplinary team, and the fact that nurses were part of those teams seemed to have evolved rather than being a well-planned and thought out part of the development. With the focus on ‘New Ways of Working’ (DH 2005) and ‘Creating Capable Teams Approach’ (DH 2007), the focus on skills increased the uncertainty about role definitions and allowed a range of other workers to be part of a multi-professional approach to CAMHS provision. Most recently, in England at least, CYP_IAPT has developed a pathway model of evidence-based care, which relies on staff trained in the particular models of care to deliver the pathways for different conditions. Most NHS Foundation Trusts insist that their staff have an original professional training and registration with a national body, so the main staffing has continued to include staff who are registered with the Nursing and Midwifery Council (NMC), the Health and Care Professions Council (HCPC), or the General Medical Council (GMC). This gives the employers a fall-back position in terms of professional accountability, and ensures a level of assumed competence in basic professional skills for all staff. What it continues to assume rather than define is that these different professional groups have something to offer beyond the ultimate sanction of removal from those professional registers. This chapter then will focus on how nurses perform the community CAMHS role more than what they do.
5.2 Nursing Assessments
Prior to the CAMHS Outcome Research Consortium (CORC), there was certainly a lack of standardisation as to assessments, and across the UK individual services varied considerably in how they approached this, usually influenced by the dominant therapeutic model or orientation of the staff involved. In 2002, when I was seconded to the Department of Health for a short while to look at the training needs of staff ahead of the introduction of the National Service Framework for Children (see Baldwin 2005), I had to do a scoping of services in England because at that time they actually did not have a list of what was being provided across England. Generally speaking, the dominant therapeutic model during the 1980s and 1990s was systemic family therapy, so my first community CAMH service was called Child and Family Therapy Services (CAFTS) to reflect this, the term CAMHS itself did not become widespread until after the HAS report (1995) and even then it took a while to be adopted across all services.
Assessments therefore lacked a standardised format in the earlier period of community CAMHS, but would be standardised to a degree within each service, even if there was not an actual form to follow. Clinicians tended to keep a ticklist in their head, which would include family history, developmental history, school and social contextual issues, presenting problem and impact. Risk assessment was not a major issue at this time, and became more important later as services better understood the potential for high-risk behaviour in younger individuals. The dominant culture of family and systemic thinking at the time largely shifted risk issues across to the family as being their responsibility.
One model that did attempt to address all of these issues from a nursing perspective was the ‘family nursing’ model from Canada (Wright and Leahey 2009), which was first published in 1984 and attempted to marry nursing concepts with the basically structural model of family therapy thinking that was dominant at the time (see Barker 1998). Whilst systemic psychotherapy has since put more emphasis on narrative and postmodern philosophical understandings of human functioning, the structural model has more focus on disruptions to optimal family functioning, the underlying reasons for it, and interventions, which have a systemic impact on changing patterns of family interaction. Wright and Leahey (ibid) saw this as a useful adjunct to a holistic approach to the nursing care of individuals and families, so they brought the two ways of thinking together to create the Calgary Family Assessment and Intervention Model. Their central thinking is that this model is: “…an organizing framework for conceptualizing the relationship that helps change to occur and healing to begin.” (p 15) The model is useful in providing some structure, partly based on nursing thinking and partly based on systemic thinking (which places less emphasis on historical factors, and tends to concentrate on the current situation). Nurses undertaking assessments need to consider a range of elements when they conduct an assessment (be it in just one or over several sessions), but also be reflexive enough to understand that their own perceptions and experiences, as well as those of the child, young person and family are inevitably going to shape the assessment and have elements of subjectivity.
Box 5.1 Calgary Family Assessment Model (CFAM): After Wright and Leahey (2009: 52)
Internal—family composition, genders, sexual orientations, rank order, subsystems, boundaries.
External—extended families, larger systems.
Context—Ethnicity, race, social class, religion and/or spirituality, environment.
Instrumental—activities of daily living
Expressive—emotional communication, verbal communication, nonverbal communication, circular communication, problem-solving, roles, influence and power, beliefs, alliances and coalitions.
As the model developed and was used in practice, the authors also tried to tease out what nursing skills were being used by family-oriented nurses who employed the assessment and the accompanying Calgary Family Intervention Model (CFIM). The intervention model is essentially structural family therapy based and uses a lot of the tools and techniques of that way of thinking, but Wright and Leahey (ibid) put a lot of emphasis on the employment of nursing skills to effectively employ the model, and the assessment phase, rather than using it as a tick-box exercise. They thought of these in three domains, perceptual, conceptual and executive:
Perceptual skills relate to the ability to make appropriate observations. These are influenced by the individual nurses’ own background, experience and training, and are necessarily subjective, but that subjectivity can be mitigated by being reflective on why individuals may interpret what they see in front of them. This domain also includes the ability to observe multiple interactional elements simultaneously within a family in order to inform the thinking about what is being observed and hypothesise on what changes could aid the therapeutic journey.
Conceptual skills involve thinking about what is being involved, and formulating this into a meaningful understanding of patterns of behaviour and interaction. Again there is a degree of subjectivity and the authors refer to ‘intuition’, although they go on to clarify that actually they are referring to a reflective use of previously learnt skills, which are then consciously brought to bear on understanding the complex situation in practice.
Executive skills are the observable therapeutic interventions which the nurse chooses to make as a result of observing and formulating an idea about what change might be helpful for the family to make.
Whilst these are processes which will be familiar to structural family therapists, what Wright and Leahey do is highlight some of the strengths which nurses have by virtue of their underlying training. Observation skills at a high level are traditionally important for nurses, either physical observations like skin tone, respiration rate and quality, or mental health observations such as mood, responsiveness or heightened reactions. They emphasise the need to engage at a meaningful level that demonstrates care and interest, and the importance of maintaining a therapeutic relationship with different members of the family.
The Calgary Model is useful in illustrating the natural link between nursing’s focus on holism and the systemic and social aspects of community nursing. It pulls together and attempts to make explicit the nursing element of a systemic application and gives a framework for a fairly comprehensive assessment and intervention from an autonomous nursing professional (though it also lacks a risk assessment element). As such, it is a good reflection of how nurses in general put their skills into practice prior to the more standardised approach that is required today, though most CAMH nurses were not explicitly using this model. It does, however, assume a level of autonomy which is fast disappearing within current CAMHS practice, and a freedom to spend the amount of time with families that clinical judgement deems necessary, rather than accepting the constrictions that some pathway models assume or dictate. These pressures, and the criticism that the model, whilst comprehensive, is potentially quite time-consuming, led to a ‘fifteen-minute assessment’ version of the Calgary Model (Martinez et al. 2007), which retained the essential features of the model.
5.3 Nursing Skills in a Structured Assessment Framework
Another prominent theme was that of concerns relating to philosophical and staff resistance, in that the use of quantitative clinical measures were seen to advocate a psychiatric/medical model, and would be at the expense of qualitative clinical judgements. (Johnston and Gowers 2005: 138)
CYP-IAPT from the start set out to be transformative of services, rather than an add-on to existing services, as CORC had been. It recognised that it must be part of the whole way of treating children, young people and families, unlike the adult version of Improving Access to Psychological Therapies (IAPT), which was aimed at mild to moderate mental health issues and remains entirely separate from other parts of community mental health (Wolpert et al. 2012a). Whilst there was some opposition to the process (Tamimi 2015), and even an offer of an alternative model (Tamimi et al. 2012), the model has been rolled out over several years across England, now covering 100% of the NHS CAMHS provision (Wales, Scotland and Ireland have devolved health administrations) (NHS England 2019). The process has centred on the use of evidence-based practice, in contrast to previous CAMHS practice, which had always suffered from a lack of evidence base and therefore consistency of approach. During the same time period, NICE guidelines had increased their breadth, so more of them included this age range rather than, as previously, focusing on adult mental health. It has also put great emphasis, and continues to do so, on participation of young people, and that is a major achievement which has contributed much to the success of the programme. So this movement has been beneficial in many ways, it has certainly been productive in ensuring that new money came to CAMHS by demonstrating the effectiveness of services, but at a cost of emphasising some elements of practice over others. The programme is largely based on psychological theory, and emphasises the evidence-base of Cognitive Behavioural Therapies (CBT) in particular, though it has been careful to explore the differences in applying CBT theory to young people, which means that more emphasis is put on establishing a relationship with young people and taking longer on this phase than is the case in the more manualised approaches used in adult CBT.
Ironically, the emphasis on participation that has been delivered through the CYP-IAPT programme has not significantly backed up the evidence-base for particular therapies. In an earlier chapter, we looked at what young people want from their therapist, and they largely concentrate on people-based issues, the so-called soft skills that are central to nursing. So while the programme has been uncovering this, it has also pushed for evidence-based pathway approaches to different conditions, because the evidence says that the best way to treat anxiety is with CBT, for example. There is undoubtedly evidence for this, and I would never argue against an evidence-based approach, but what is more difficult for us to provide is the evidence for these ‘softer’ skills. This is not to say that it is not true, just that it is easier to provide the evidence, in an acceptable positivist way, for some methods of treatment than others, and similarly a positivist approach to demonstrating the value of nursing based interventions will always be more difficult. Most of the mentions of patients valuing certain features of nursing practice that we have looked at so far have come from small scale qualitative studies, and these have a more interpretivist philosophy underlying their methods. By definition, it is almost impossible to generalise the results of these studies because they rely on individual responses. This leaves us with the difficulty of using mostly anecdotal evidence to suggest that the weight of this evidence is cumulative, because the same issues come up in many different areas, yet are hard to bring together as one coherent argument.
Throughout the other chapters, there are examples of outpatient encounters with children and young people, which depend on the quality of the relationship which nurses have been able to develop with young people, and this remains central to the how of implementing standardised approaches. Much of the implementation work for the use of standardised assessments has swung to focus on better ways to use the paperwork (or directly inputted answers) in a therapeutic manner (Wolpert et al. 2012b). Allowing the forms to be filled in prior to the first assessment and then giving the clinician more time to pick up the issues raised is one way to do this, but it also means that the clinician needs time to see pre-prepared assessment forms, which can be logistically difficult to arrange, or lead to a pause between arrival at clinic (and collection of the forms, or filling them in whilst in the waiting room) and actually meeting the clinician. This method of working can also lead to awkwardness in raising the issues highlighted in the forms too, if not skilfully handled. Alternatively, the information offered in the forms can interfere with a more natural progression of establishing relationships, and engaging everyone in the room. The information offered on those forms may be partial or lead the clinician to follow one particular line of questioning at the expense of a more holistic understanding of the situation. Some of my most experienced colleagues have fallen into this trap, that of thinking they can see what the primary problem is, and not fully exploring alternatives for what is in front of them. Of course, the biggest mistake that I have heard reported is of getting people to fill in the forms, and then never mentioning them again, in which case you really are getting into the realms of ‘feeding the machine’ without even trying to use the data.
Box 5.2 The Importance of Language…
I usually draw a genogram, or family tree, with families when I first see them. It engages different members of the family, and gives me a visual reference point to refer back to when families are talking about people they are very familiar with, but whose inter-relatedness may be confusing. I used to complete this process by asking ‘Is there anyone else in the family who needs to be on this drawing?’
In one meeting with a new family I did this and then, a little further through the session realised they were talking a lot about ‘Geoff’, who wasn’t on the genogram anywhere. I asked who Geoff was, and they told me he was Mum’s new partner, who had moved into the home a few months ago, but for some reason was not yet considered ‘family’.
After that I started including the question ‘Does anyone else live in the house?’ which usually elicited lots of information about pets, but did mean I did not miss any significant people any more.