1. What Nursing Skills Are We Using with Children and Young People Who Experience Mental Health Difficulties?
This book is about nursing skills, a rather vague and undervalued term. Over the years, I have come to the conclusion that nursing does not really have a set of skills which ONLY nurses can do, but it does have a set of skills which it prizes much more highly than other professions, and which comprise a distinctive approach to helping others. It is this set of skills, on which this book will be focusing, and showing, I hope, how nursing does have a unique contribution to the mental health and well-being of children, young people, and their families. Implicit in this approach is a recognition that all of the skills we will be looking at and discussing are actually used as well by other professionals, such as teachers, social workers, psychologists, psychiatrists, and counsellors. But none of those professional trainings stress the importance of these skills as being central to the work; usually they have another core underlying belief which is central to their way of working. The skills we will be discussing, and the importance nurses attach to them, are what makes a nursing skills approach distinctly important and unique. I hope we can also demonstrate that these skills, and this nursing skills approach, match up very well with what children and young people actually prize most highly in the people from whom they seek help when they are in emotional distress. In that sense, I hope this book will be of use to other professionals as well as to nurses, who are in regular contact with distressed young people of all sorts.
1.2 Background to Nursing Fields in the UK, and Their Distinctive Approaches
Nursing is a very ‘broad church’ with a lot of variations and ways of enacting the central essence of being a nurse. This book will concentrate on its enactment in the United Kingdom, but will make reference to how nursing is done in the rest of the world. Unique to the UK is the separation of training into four ‘fields’, so nurses train in either ‘adult nursing’, ‘children and young people’s nursing’, ‘mental health nursing’, or ‘learning disabilities nursing’ (sometimes called ‘intellectual disabilities nursing’). Whilst these four fields have much in common, and in university settings much of the core curriculum is delivered together, they remain distinct from each other. This allows specialisation at a much earlier stage than in other countries, where psychiatric nursing, for example, becomes a postgraduate training, and what the UK regards as ‘adult nursing’ is the first-level training for every nurse. But it also means that there are gaps in knowledge, so specialist CAMH nurses may be trained in any of the above fields initially and therefore have a skew to their knowledge. Historically, most CAMHS specialists came from mental health nursing, but that training does not generally focus on children and young people’s mental health, it spends a great deal of time on how mental health issues manifest themselves in working age and older adults, because historically that is where services have focussed, and where the demand has been for nursing skills (in adult mental health inpatient and community services). Likewise, children and young people’s nursing has focussed on the physical health of its age specialisation, and how this manifests itself differently from physical health needs in adults. Traditionally, it has relatively little emphasis on the emotional well-being of young people and on mental health, although for both these fields of training this has been improving recently as more awareness of children and young people’s emotional needs has improved. Learning disabilities nursing covers the lifespan much better, given that intellectual disabilities are lifelong conditions, and does have some emphasis on the comorbid mental health conditions which can develop in this group of people, but it is only relatively recently that these transferrable skills have been recognised as being important for CAMHS provision.
One way of illustrating this gap into which CAMH nursing has fallen is to look at how the textbooks for these fields deal with children and young people’s mental health. A recent series by Sage Publications released textbooks on mental health nursing (Wright and McKeown 2018) and children and young people’s nursing (Price and McAlinden 2017), both take a fairly standard approach to textbook production, which reflects how nursing is taught in the UK. The volume on mental health nursing has chapters on eating disorders (which generally start before the age of 18), which mention aetiology and treatment in younger people, and a chapter on child and adolescent care, with 27 pages from a total of 712 pages. The volume on children and young people’s nursing likewise has a chapters on care of the child or young person with mental health problems (which is 15 pages long), and three chapters on communicating with children and the development of emotions and well-being issues. If we include these, we get a total of 61 pages out of a total of 688 pages. Both of these books are excellent textbooks, and I use each of them in the teaching I do on undergraduate and specialist courses at my home university, but this disparity illustrates well the way both fields of nursing seem, historically, to treat children and young people’s mental health problems as an SEP—‘Someone Else’s Problem’ (Adams 1982).
Specialist CAMH nursing has, therefore, long been seen as an orphaned discipline, and as ‘someone else’s problem’, belonging neither fully to mental health nor to children’s nursing. In some ways, it has also been seen very much as a speciality, despite longstanding efforts to see children and young people’s mental health and well-being as ‘everybody’s business’ (MHF 1999). The nursing training routes in the UK which have neglected this area, by concentrating on what they see as their core business, have contributed to this, and the same is true for other disciplines. Clinical psychology has done better in this respect, and has always had a focus on children’s developmental psychology from an early age (Faulconbridge et al. 2018), so their training does tend to emphasise this area well, but they remain a relatively small discipline, though very influential in policy and service development terms. Social work has vacillated between a generic and more specialist focus in its training (Pierson 2011), and has a historic influence through the child guidance movement, which preceded current CAMHS provision. Its present focus, however, within the area of children’s care, is primarily on safeguarding and protecting children, and within this field has a particular approach that focusses on physical abuse and sexual abuse, with a more difficult relationship when dealing with neglect and emotional abuse. Medical psychiatry has a strong emphasis on the medical model of understanding mental health and illness, despite a long tradition within the speciality of child and adolescent psychiatry of a sociological perspective on the understanding of children and young people’s needs. Psychiatrists in the UK are medically trained doctors first and then specialise in psychiatry, with at least one placement with younger people, but it does struggle to recruit into the CAMHS posts (BMJ 2016). Amongst the Allied Health Professions, the most prominent group working regularly in this area is Occupational Therapy, which brings its own central perspective of the value of meaningful activity (either in employment, education, or other forms of purposeful activity) to the mental health needs of this group (RCOT 2019). These are very broad brush descriptions of the central preoccupations of other professional groups and apologies are due for some inevitable level of stereotyping. Each of these professional groups will employ the sort of skills which we are going to look at as being central to a nursing approach, and some individuals within each professional group will give these skills prominence and deliver them very well, but they are not core to the professional training, in the same way as they are to nursing. The underlying philosophy of each profession is often buried so deep into those who practice that they become part of their identity and lose the ability to verbalise those ‘taken-for-granted’ ways of working, which are central to their identity (Baldwin 2008).
1.3 What Makes Nursing Distinctive in Its Approach to Working with CYP?
In order to look at the emphasis of different professional groups and tease out the distinctiveness of nursing strengths in CAMHS, we need to go beyond the current political context and look little more deeply. There is, of course, a huge body of literature relating to the theory and conceptual frameworks that different professions bring to the task of providing care or therapy. This often relates to the broader context of the parent profession for those groups, who have wider professional allegiances; the history and development of physical health nursing is very different to that of mental health nursing. So, whilst, for example, mental health nursing usually benefits from the positive press that nursing enjoys (despite the Mid-Staffordshire tragedy) its evolution has differed over the years. Nolan’s (1993) history shows how adult mental health nursing moved from asylum-based care to its present format, and CAMH nursing has followed on the back of those changes. It is important to look at what constitutes a particular intervention, particularly within mental health teams, to see if there is anything distinctive about those interventions that can be seen to add value beyond the application of a set of skills and competences. There are several different professional groups working within mental health teams and CAMHS as we have seen. For some, the conceptual framework in which they work pertains purely to mental health work. Psychology and the psychotherapies fall within this group, even where they are applied to physical healthcare, whilst other professional groups come from a wider umbrella, forming only a subgroup of the wider profession. These groups follow often quite divergent paths from their parent professional body and the specialisation into mental health, and for our purposes into child mental health, which gives a degree of distance from those parent bodies. Psychiatrists (and specialist Child and Adolescent Psychiatrists), for example, work in a way that is connected to, but distant from, the work of many other medical doctors. Allied Health Professionals in mental health, such as Occupational Therapists, are also seen only as a subgroup of their main profession, and a dietician in a mental health trust will work with a very different client group to a dietician in a physical healthcare setting.
This distinction can also be drawn for social workers and nurses. Yet all of these professional groups retain links to their parent group and need to conform to the professional regulation and governance of those groups. The identity of ‘nurse’ compared to ‘mental health nurse’ is one of conflict, for arguably a mental health nurse has more in common with other staff in mental health services in terms of skills and competences than they do with most physical healthcare nurses, yet they retain a nursing identity. Nursing, and particularly nursing within CAMHS, therefore faces a challenge of identity in that it is distant from its parent group, and in many ways shares more in common with the other members of the mental health team, including the social workers and psychotherapists, than it does with other nurses. During my career this has become very stark at times. As a Nurse Consultant, for example, I was part of my Trust’s senior nursing team looking at minimum standards for nursing competencies, and had to resist the directive that all nurses would be doing refresher training in performing injections. This seems a sensible safety feature except that injections are not a routine part of a community CAMHS nurses work (parents administer medications, and we generally do not use any injectable medications), so the last injection I administered as a nurse was in 1989!
1.4 The Development of Adult Mental Health Nursing
Nolan (ibid) traces current mental health nursing practice primarily back to the asylums and the initial role of attendants, who were largely subservient to the medical profession in the treatment of the insane. In fact there is a longer history of the mentally disturbed being humanely treated through the more enlightened monastic and religious houses, to which he alludes in his references to Bethlem Hospital and its predecessors. This function, along with the mainstream healing and hospital facilities provided within religious organisations, failed, he contends, to cope with the expansion of population that the Industrial Revolution brought to this country. The expanded unmet needs led to the establishment of asylums. Indeed, there remains a link between the religious vocation and secular caring through mental health nursing and other caring professions (Crawford et al. 1998).
In the modern era, however, Hildegard Peplau is largely credited with focussing psychiatric nursing on the therapeutic relationship between the nurse and the person they are nursing. In the early 1960s (article reproduced in Peplau 1982), she was looking at this in relation to nursing people with schizophrenia, and much psychiatric and mental health nursing theory has developed from this approach. In the UK, Annie Altschul (Tilley 1999) brought many of Peplau’s ideas across the Atlantic and translated them into a British context, adding her own distinctive element by emphasizing the ‘common sense’ approach as being a particularly nursing contribution. In the same tradition, Professor Phil Barker and others in Newcastle have explored ideas about what is the ‘proper focus’ of psychiatric nursing (explicitly drawing on Peplau’s work), and the reasons people might need psychiatric nurses (Barker et al. 1995, 1999). Barker’s main thesis is that, while ‘caring’ is often seen within wider nursing as a core element, there does not exist an adequate definition of ‘caring’. He feels that, whilst there is no harm in nurses identifying what caring means to them, this could not, however, become the ‘raison d’étre’ of nursing. Barker points out that if caring is the essence of nursing, not only must all nursing involve caring, but that caring must only occur in nursing, or occur in some unique way. This is clearly not the case. He concludes that if nursing is to be defined, globally, by any one thing, it is the social construction of the nurse’s role. The nurse’s role changes more as a function of societal shifts than as a result of any actualisation of the ‘essential’ nature of the profession. Barker has been scathing about the ‘nursing theology’ of nursing as caring, and religious overtones of nursing apologists like Watson (1985). Professor Barker (1999) noted, for example, that many of Watson’s defining features of nursing can also be found in the psychotherapy literature, when the nature and role of psychotherapy are described. Barker concludes with the important point that, as long as nursing is defined in terms of what nurses do, rather than what nursing is meant to achieve, an evaluation of its worth will be impossible, however its ‘core’ is defined.
This is an important point, as much of the literature relating to ‘role’ within nursing does restrict itself to a description of function. Duffy and Lee (1998), for example, make good points about role ambiguity, but essentially describe the way the nurses work, rather than analysing that work in the context of a theoretical or conceptual framework. This phenomenon also occurs in one of the few pieces of work specifically on CAMH nursing (Leighton et al. 2001). Repper (2000) sees the difficulty in defining mental health nursing as springing from the variety of roles inherent in this field of nursing. She notes the essential difficulty of measuring the nature of nursing, compared to the move toward quantifiable evidence-based approaches to service delivery as originally espoused by Gournay (1995). Her solution is to recognise the multiplicity and diversity of nursing roles, whilst reinforcing that service users’ value nurses for their ‘ordinariness’. In particular, she recognises that each nurse will bring individual skills that will be used in different ways with different situations and relating differently to a variety of service user needs. An early study of the general public by Walker et al. (1998) emphasised that those members of the public who had any knowledge or opinion on the role of mental health nurses valued them primarily for caring, talking and listening. Pilgrim and Rogers (1994) had also found that service users valued ‘ordinariness’ and the basic listening skills demonstrated by nurses. They also found that having enough time to employ these skills was directly (and inversely) related to the grade of the staff, so non-qualified staff and student nurses were the most valued, at least in a ward setting, because they were the most available. There is also an implication that this ‘ordinariness’ relates to either a lack of expertise, or consciously adopting a non-expert stance, in contrast to other professionals. The extreme conclusion of this would be that rather than training people, the solution is simply to recruit the right sort of intuitive staff in the first place. Others have attempted to quantify which human qualities can be recognised and enhanced in order to understand the process that allows good nursing. Graham (2001), for example cited holism, partnership and empowerment alongside relationship-building, as essential elements of the meaning of nursing. The conscious employment of skills, and an active use of self-awareness, rather than relying on intuitive or innate qualities, seems, therefore, to contribute towards an understanding of the essence of mental health nursing.
In ‘Working in Partnership’ (DH 1994), it was suggested that psychiatric nursing ‘…should play a central role in the provision of high quality mental health care.’ Yet defining what nursing has to offer, and what nurses actually do, or ought to be doing, remains a contentious and difficult area, even in adult mental health settings. The Chief Nursing Officer’s review of mental health nursing specifically asked for views on the core values and roles of mental health nursing (DH 2005), yet when that review was published (DH 2006), it held back from defining which values actually underpinned mental health nursing specifically. It referred instead to more generic principles such as the Recovery Approach and the need to (p13): ‘…move away from a traditional model of care to a biopsychosocial and values-based approach.’ The review was called ‘From Values to Actions’, yet the values listed are not specifically nursing values; they are based on the wider principles of service user’s need. This is in itself laudable, but does not help in defining the perspective of nursing in any way that might differentiate it from other mental health professions, who also aspire to utilise these general principles. In defining a conceptual framework, or even an underlying set of specifically nursing values, the review is therefore unhelpful. It concentrates instead on the actions, with only Recommendation 5 (of 17) being suggestive of a specifically nursing approach to the task. Recommendation 5 (p29) is that: ‘All MHNs will be able to develop strong therapeutic relationships with service users and carers.’ Again the influence of Peplau and her followers is evident here. Other recommendations, such as the importance of holistic assessments (Recommendation 6) might be indicative of a values based approach, but are harder to define as specifically nursing approaches as many other professional groups espouse holism as important (whilst none have the same emphasis on therapeutic relationship building as central to their approach).
Duffy and Lee (ibid) suggested that there remains a dilemma for many nurses in practice between the ‘clinical support role’, of running the ward, administering medication and completing necessary paperwork, and the development of ‘specialist clinician’ roles. They suggest that nurses are often tolerant of role ambiguity, and would be happy to develop either or both directions for the future role of nursing. However, they also warn that many of the ‘clinical support’ roles could be fulfilled by people who are not trained nurses. The previous Department of Health (1994) review of mental health nursing ‘Working in Partnership’ had also struggled with precisely defining the unique role of mental health nurses. The movement towards looking at what you actually need nurses for, and which of their functions could be fulfilled by others, is also prevalent in some influential areas of policy making. The Sainsbury Centre (1997) published ideas about the increased use of ‘generic workers’ with relevant experience, and was based on skill mix concepts. Their report focused primarily on the needs of those with more severe and enduring mental health problems (and does not mention CAMHS). They note, however, that the role of nurses is often differentiated from other disciplines as ‘caring, rehabilitation, and medication supervision skills’. However the report, whilst addressing the training needs of various professionals within the multi-disciplinary teams who currently provide adult mental health care, suggest a focus on establishing core competences and standards for all workers. The report affirms the genericism of mental health work, with each specialist discipline having a specific contribution to make on top of the generic element of the work. What it fails to suggest is what those specialist contributions might be, beyond nursing being a ‘caring’ profession. Other professions would claim ‘caring’ as a useful addition (though sometimes with a warning about professional boundaries), but not put it at the centre of their philosophy. The Sainsbury Centre has led in this with the Capable Practitioner document (Sainsbury Centre 2001).
The Sainsbury Centre had begun this push towards the genericisation of skills when it published a report on the working of Community Mental Health Teams (Onyett et al. 1995), which looked at the roles, relationships, and job satisfaction of team members in terms of core profession. It also specifically excluded from its study teams for older people, alcohol and drugs misuse and learning difficulties. The report does not seem to recognise the existence of CAMHS (neither excluding nor including them, simply omitting any reference to them). Many of the issues they report (p21), however, are very familiar to professionals in CAMHS, particularly the ‘special dilemma’ of being members of, and having loyalty to, both discipline and team. These difficulties are defined as being torn between the egalitarianism inherent in the aims of the community mental health movement, with its associated role blurring, and the desire to maintain traditional, socially valued role definitions and practices. They felt that ideal conditions would be for each discipline to have a clear and valued role within the team, and that the team as a whole has a clear role. With regard to nurses, the report makes some curiously conflicting conclusions. Nurses are seen as an essential element of Community Mental Health Teams, being present in 93% of them, but are amongst the most exhausted, with the least satisfaction about their work relationships. However, they are also reported to be the members of the team with the highest team identification and professional identification. They are described as having a high degree of clarity about the role of the team and their own role within the team, which was previously noted as ‘ideal conditions’ for working in such a team. The report does not expand on what these nurses saw as being their role, or how it differed from that of the other disciplines.
What this demonstrates, then, is the difficulty of nurses in mental health in articulating what they bring by virtue of their professional background and training, to the task. This in turn opens up the question of whether that is important, or if, as the Sainsbury Centre reports suggest, this is no longer relevant, as long as the task is completed.
1.5 The Evolution of Child and Adolescent Mental Health Nursing
Within CAMHS, there is very poor documentation and very little published about the development of services. Whilst there are many academic papers on child development and specific syndromes, and a large body of literature on the individual therapies used, the development of services and the contribution of different disciplines to service delivery have not been extensively recorded. CAMH nursing has always seen itself as a ‘Cinderella service’, being a speciality within a speciality, and falling between two camps, i.e., neither truly belonging to mental health nor to paediatrics. Nurses have been involved in caring for children and young people with mental health problems since the 1960s, but have only in the last 25 years been involved in their outpatient care. The use of nurses on inpatient units is easier to understand in terms of traditional nursing skills. Direct care on wards was a natural place for nurses to have input as child psychiatry units developed in the UK. Child and adolescent psychiatric inpatient units were developed in the 1960s and 1970s following a Ministry of Health Memorandum of 1964 (cited in Horrocks 1986). Haldane (1963) first looked at the ‘functions’ of a nurse on such a unit, from a medical point of view. This concentrated on what would now be called ‘milieu therapy’, the establishing of an environment conducive to change, and the development of therapeutic relationships between children and the nurses (i.e. Geanellos 1999). Much of what Haldane (ibid) describes could be seen as a substitute parenting function for children whose parents were not present on the wards. Even at this stage, however, a need for flexibility amongst the nursing staff is stressed, and he made a point of saying that the nurses required on these units needed slightly different qualities to those employed on adult wards. It is worth noting that this is a medical point of view and there is no credit for any nursing input into the preparation of the article. When Haldane et al. (1971) later revisited this subject, he laid more stress on the part played by nurses in the psychotherapeutic work of the unit. The way nurses were involved in running therapeutic group work was becoming much more established, whilst the intensity and depth of the relationships developed between nursing staff and the young people were again noted to be very important.
…each profession should define its own role in the management of disturbance in adolescence, and state what it can contribute to the work of others.