Introduction

This chapter discusses key issues related to the professional practice of mental health nursing. The past twenty years have seen the final devolution of mental healthcare from predominantly hospital-based services to integrated hospital and community care, together with the development of a wide range of clinical specialisations within mental health nursing. In parallel with that process of change has been the move within nursing education to degree-based generic preparation for practice and, in some centres, the development of mental health nursing as a postgraduate specialty. Mental health nursing has responded to these challenges by developing standards of practice, practice competencies and models of advanced practice. The scope of practice has been extended to include the nurse practitioner role and prescribing. At the same time that the profession has been developing its own structures and processes, it has developed responses to the complex ethical issues that the changing mental health context demands. This chapter explores the professional context of practice, including the roles of professional and industrial nursing organisations, mechanisms of professional self-regulation, and development of advanced practice and nurse practitioner roles. It also outlines the principles of ethical conduct and discusses some ethical issues commonly encountered in mental health nursing.

Regulation of professional practice

Regulation of nursing is managed by statutory authorities in each Australian state and territory and in New Zealand. Their primary purpose is to ensure public safety through maintaining professional standards. Regulatory authorities set and monitor standards in the interests of the public and the professions, and maintain registers of individuals licensed to practise nursing. In addition, they accredit educational institutions and nursing programs, provide complaints and disciplinary processes, and produce publications on key areas of policy. Individual nurses are granted a licence in the form of a practising certificate, entitling them to practise, subject to meeting criteria for registration. In both Australia and New Zealand there are two levels of nurse: enrolled and registered. In both countries, enrolled nurses, while accountable for their practice within the relevant framework of competencies, work under the direction and supervision of registered nurses. Enrolled nurse programs have been discontinued in New Zealand in favour of programs for nurse assistants. Although existing enrolled nurses retain their title, few are employed in mental health settings.

Changes in educational preparation for practice have meant that qualifications for practice and categories of registration vary from one authority to another. There are even problems with the terms ‘mental health nurse’ or ‘psychiatric nurse’ because there is no accepted credentialling process that regulates the use of either term. For example, while a nurse gaining registration in New Zealand is licensed to practise in any nursing specialty within New Zealand, the same nurse may have to undertake additional educational preparation to practise in some Australian states or territories. Similarly, the individual states and territories set their own registration criteria, creating a plethora of regulatory regimens throughout Australia and New Zealand.

Mutual Recognition Acts in the states and territories provide mechanisms for nurses to have their registrations recognised from one state or territory to another. The New Zealand Trans-Tasman Mutual Recognition Act (TTMRA), which came into effect in 1997 (ACT Parliamentary Council), allows applicants with nursing and midwifery registration in all Australian states except Western Australia to apply to the Nursing Council of New Zealand under TTMRA for recognition of their registration. Contact details for the various Australian and New Zealand registering authorities are provided in Box 5.1.

Although states and territories manage the process of regulating nursing, the Australian Nursing and Midwifery Council (ANMC) provides a coordinating national role on regulatory issues affecting Australian nurses. The ANMC is a representative body comprising members from each of the states and territories, and two members of the public. The ANMC maintains a national set of competency standards for nursing, guidelines for accreditation of nursing courses, and frameworks for dealing with ethical, professional and disciplinary matters.

Because of the move towards comprehensive education and the closer collaboration between the states established by the ANMC, all states have reviewed their registers, and nurses are placed largely on a single register, with the employing authority making the decision as to whether they are competent to practise. This has, in effect, deregulated the market for nursing, but has largely disregarded the need for specialty preparation in mental health. Western Australia and South Australia have maintained separate registers of mental health nurses, while other states such as Victoria and Queensland have made provision for endorsement of a mental health specialty qualification. New South Wales and New Zealand each maintain single registers. In most Australian states, nurses who hold current registration, even without a mental health qualification, can work in mental health. However, in most states, restrictions exist for nurses who hold only mental health qualifications and wish to work in general health settings. Changes to legislation in Australia are under way, with the likelihood of a single national nursing and midwifery register coming into existence in 2008.

In New Zealand, registered nurses can work in any health setting, although some services will only employ new graduates who are enrolled in a specialty mental health nursing program. However, there is no restriction on employment of nurses, and those without postgraduate preparation in the specialty are not prevented from practising in mental health. Under the Health Practitioners Competence Assurance Act 2003, nurses must practise within their scope of practice, meaning that general nurses prepared in the previous hospital-based programs cannot practise in mental health.

As mental health nursing develops, regulatory bodies need to develop regimens to credential those with specialist education in mental health, and to support new roles such as nurse practitioner. This includes specifying competencies and educational requirements, and providing processes of accreditation and monitoring, and systems of accountability. However, it should be noted that nurses are professionals who practise with a high degree of autonomy, and so are expected, in addition to the regulatory controls of registration bodies, to maintain their own systems of professional monitoring and review.

The regulation of nursing practice is a political and professional issue. Definition of the mental health scope of practice and protection of consumers through employing only practitioners prepared within that scope are issues that require an assertive approach on the part of professional nursing bodies. What is at stake is the specialist nature of mental healthcare, recognition of the skills of mental health nurses, and acceptance that mental health consumers have needs that cannot adequately be met by generalist nurses without specialty preparation. The Australian College of Mental Health Nurses has developed a credentialling process for mental health nurses. The process requires specialist postgraduate mental health nursing education, current practice in mental health, and an auditable record of professional development (Chesterson 2002). Credentialling recognises the specialist nature of mental health nursing, and provides protection for consumers in the form of uniform minimum professional standards.

Professional and industrial bodies

Mental health nurses practise in a complex professional environment that requires a clear sense of professional identity and clear frameworks for practice. While broad frameworks for professional practice are provided by legislation and by nursing regulatory bodies, a wide range of professional issues are addressed through professional nursing bodies. In addition, the profession has a role in monitoring the social context of practice through involvement in the development of legislation, policy and local services. A related issue is the maintenance and improvement of nurses’ employment conditions. Much of this work is carried out by nurses within the various professional and industrial bodies.

Professional and industrial nursing bodies can be divided into those whose primary focus is professional issues, such as the colleges of nursing, and those whose primary focus is providing workplace representation and bargaining over salary and conditions of employment. However, this distinction disguises the overlap between these bodies, as conditions of employment have a direct effect on ability to meet professional standards, and the realisation of the expectations of professional bodies can affect conditions of employment. The issues of numbers of beds provided by a mental health service and the number of staff allocated to different sections of the service demonstrate the overlapping functions of professional and industrial organisations. While these may be primarily industrial issues because of their immediate impact on nurses’ conditions of employment, they also have the potential to affect standards of clinical practice. Both professional and industrial bodies have an interest in quality-of-service issues. Many nurses belong to more than one nursing body, as the functions of those bodies meet differing needs.

There are many organisations representing the professional and industrial interests of mental health nurses. As employees and as a professional group, nurses have a wide range of interests that require professional advocacy and articulation. While membership of professional bodies or industrial bodies is not compulsory in Australia or New Zealand, individual nurses need to reflect carefully on the advantages of membership and their responsibilities as health professionals to support the representative bodies that maintain their conditions of employment and advocate on professional issues. Professional and industrial bodies negotiate with employers and policy makers on employment and professional issues, and have an important role in informing members on current issues in healthcare. They may also play an advocacy role in the case of disputes or inquiries, and provide legal advice to nurses facing complaints or disciplinary proceedings. Some organisations provide indemnity insurance, which can provide valuable protection against the costs of legal advice. Some of the key professional and industrial bodies in Australia and New Zealand are listed in Box 5.2.

In both Australia and New Zealand, changes to employment law throughout the 1990s saw a reduction in the power of industrial unions, and a loss of national award structures. Employers argued for greater flexibility in industrial matters, negotiating with individual worksites rather than unions covering a range of sites, or with national unions. The changed industrial environment coincided with recruitment and retention problems in mental health nursing, and affected the ability of services to provide an appropriately skilled workforce (Clinton & Hazelton 2000a; Mental Health Commission 1998).

A related issue is the development of a ‘casual’ nursing workforce, especially in inpatient settings. Nurses employed on a casual basis may not have the familiarity with consumers that is gained by regular employment in mental health services, and are frequently not union members, thus diminishing the resources available to unions to advocate on industrial and professional issues.

Nursing education

The first training programs for psychiatric nurses were in Sydney in 1887 and in Auckland in 1907. Registration for psychiatric nurses began in New Zealand in 1907 and in Australia in 1911 (Maude 2001). The early programs of education in psychiatric nursing were based in psychiatric institutions and were apprentice-style programs with students spending the greater part of their time meeting the service needs of the institutions. While this had the benefit of providing nursing students with a great deal of exposure to the clinical practice of nursing, it provided limited opportunities to develop academic and theoretical skills.

Educational preparation for practice in mental health nursing underwent tremendous change in the latter half of the past century. From a specialist, service-based training based in psychiatric hospitals, mental health nursing came to be included in generic (comprehensive) nursing degree programs within the tertiary education sector. This process began in New Zealand in 1973 (Department of Health 1986) and in Australia in 1984 (National Education Review Secretariat 2002). The last hospital-based programs ceased in New Zealand in 1987 and in Australia in 1994. Although there are distinct advantages in separating education from employment, the change in the educational preparation of nurses for practice in the mental health specialty has not been without problems. Reviews of nursing education have stressed the importance of including mental health in undergraduate education, citing the need to maintain an effective and skilled workforce (KPMG Consulting 2001; National Education Review Secretariat 2002). However, problems that have been identified are the loss of specialty focus in undergraduate programs (Prebble 2001; Stuhlmiller 2005), recruitment into the mental health specialty, and access to postgraduate education. In 2001 the Australian Deans of Nursing commissioned a research project to examine the extent of mental health nursing content in undergraduate and postgraduate courses. The report identified disparities in Australian University content despite these students being able to register as comprehensive nurses. Opportunities were limited for funded support for postgraduate specialisation in mental health nursing. The Australian Health Ministers (2003) reviewed the situation from a workforce perspective and found a lack of promotion of mental health nursing as a career pathway and poor knowledge of the role. A negative image and lack of opportunity were deterrents to recruitment. A number of recommendations were made, aimed at changing promotion and educational preparation, including the funding of scholarships for mental health nursing postgraduate education. During 2006 the Australian Commonwealth Government funded placements in approved programs with scholarships of up to $8000. The Royal College of Nursing Australia (RCNA) coordinates a funding scheme for mental health nursing education in postgraduate and higher degrees of up to $10,000 per year (RCNA 2007).

Standards of practice

The professionalisation of mental health nursing is reflected in the development of standards of practice for both Australia and New Zealand (ANZCMHN 1995; Te Ao Maramatanga 2004). The growing emphasis on accountability in mental healthcare means that development of standards has assumed increasing significance (Rodgers 2000). The standards cover the broad scope of professional practice and include a rationale for each standard, attributes related to each standard, and performance criteria. A comparison of the Australian and New Zealand standards of practice is shown in Table 5.1.

Table 5.1 Standards of practice for mental health nursing in Australia and New Zealand

1 Source: Australian and New Zealand College of Mental Health Nurses (ANZCMHN), 1995 Standards of practice for mental health nursing in Australia, ANZCMHN, Greenacres, SA.

2 Source: Te Ao Maramatanga (New Zealand College of Mental Health Nurses) (NZCMHN) 2004 Standards of practice for mental health nursing in New Zealand, Te Ao Maramatanga, Auckland.

The standards represent the commitment of mental health nurses to accountability in the professional practice of nursing. They have been recognised as a benchmark in examining the quality of mental health nursing care (Health and Disability Commissioner 2002; O’Brien 2002/03) and have been used in professional conduct investigations in both Australia and New Zealand. As broad statements of expected quality of care the standards are not directly measurable. However, clinical indicators have been developed to measure their achievement in practice (O’Brien et al 2002; Skews et al 1998, 2000). Clinical indicators are objective statements of specific outcomes or processes of care, which enable quantitative measurement of the quality of care (Idvall, Rooke & Hamrin 1997). They are an accepted means of measuring the achievement of practice standards. The Australian and New Zealand clinical indicator studies found high levels of achievement of some standards of practice, but also a significant number of areas of possible improvement, a finding similar to that of the Australian scoping study (Clinton & Hazelton 2000b). Continued monitoring of achievement of standards of practice is essential for any group claiming professional status, as self-regulation is recognised as a defining characteristic of professions.

Mental health nursing standards of practice describe the expected performance of nurses providing mental healthcare, but nurses in both countries also work within national systems of service standards that govern the practice of all mental health professionals (Commonwealth of Australia 1998; Standards New Zealand 2001). The coexistence of nursing professional standards and national service standards reflects the interdisciplinary nature of mental healthcare (Holmes 2001) and the demand for nurses to meet the standards of their own profession as well as those of the service sector.

Competencies

In order to ensure a framework of safety that will protect the public, professions specify sets of competencies that describe the expected skills of all practitioners within a particular discipline. In nursing, competencies are set by regulatory bodies and by professional nursing organisations. The Australian Nursing and Midwifery Council (ANMC) and the Nursing Council of New Zealand (NCNZ) provide competencies for enrolled and registered nurses, and in addition, state and national bodies provide competencies for nurse practitioners and nurse prescribers. Where renewal of the annual practising certificate was formerly a procedural matter involv ing documentation and payment of a fee, nurses are now required to demonstrate continuing competency in order to retain their registration. Competence-based practising certificates were introduced in New Zealand in 2005. Nurses in both Australia and New Zealand must declare continuing competence in order to renew their annual practising certificate. Regulatory authorities conduct audits of competence in which nurses are required to produce documentary evidence of continuing competence.

In addition to competencies specified by the profession, competencies set outside the profession also have the potential to affect practice. The New Zealand Mental Health Commission (MHC) has developed a set of recovery competencies that apply to all mental health workers in New Zealand (MHC 2001). The competencies are shown in Box 5.3. The recovery competencies focus on attitudes of mental health workers and choices offered to consumers. They are additional to the competencies expected of health professionals, for example in providing skilled assessment and intervention and the safe administration of medication.

Career pathways

When mental health nursing was located primarily in psychiatric hospitals, the hierarchical nature of those institutions provided some structure to the careers of nurses. With the devolution of care to community settings and acute units attached to general hospitals, mental health nurses lost the opportunities for career advancement provided by large hospitals. Nurses wishing to gain career advancement sought academic or managerial, rather than clinical, appointments. This has challenged the profession to develop and advocate for career progression based on experience and clinical expertise.

Career pathways for nurses need to consider the diversity of nursing, and encourage nurses to pursue careers in clinical practice, education, management and research. All these choices require a sound foundation in clinical practice that is further enhanced by education and professional development.

Nurse practitioner development (discussed overleaf) represents a career pathway for nurses that recognises their clinical expertise and its contribution to health outcomes, and encourages their retention in the nursing workforce. Thus the nurse practitioner pathway can be said to work on two levels: maximising health gains to consumers, and providing a career structure that will encourage the retention of the most experienced and skilled practitioners in the nursing workforce.