Mental health and learning disability nurses need to be able to detect, assess and at least initially manage physical health presentations, as much as adult and children’s nurses need to be able to detect, assess and at least initially manage mental health and learning disability presentations.
Hopefully, the latest Nursing Times learning unit ‘Psychosis: Understanding and Working with Psychotic Symptoms’ will contribute to this cross-pollination of competencies.
“Where a measurable competency can be established it should be, but that should not be the end of the learning and development process for the nurse”
But to help a person experiencing any mental health or learning problem takes more than the direct application of factual knowledge that competencies represent. It requires critical and self-reflective thinking as well as advocacy and less tangible skills in engagement and empathy.
One of the drivers of the Nursing and Midwifery Council’s Future Nurse proficiencies, published in 2018, was the poor physical health outcomes experienced by people with mental health problems.
Given this and Covid-19, competencies such as infection control procedures, thoracic auscultation and electrocardiogram monitoring are clearly positive additions to the core skills of the mental health nurse.
However, there are currently strong arguments being made by mental health nurses about competency-based nurse training replacing less tangible clinical skills (Connell et al, 2022) as well as critical thinking, self-reflection and more sociopolitical interventions (Collier-Sewell et al, 2023).
I can see the sense of the argument, and I have heard the informal feedback of mental health nursing students about their university teaching being almost exclusively general nursing skills. But I am also ambivalent and would feel more comfortable were there a methodologically solid evaluation of the skills and experiences of the ‘Covid cohort’ of student nurses.
Taking a dialectical approach, competencies as a solution to nursing’s myriad challenges is an important ‘thesis’, and the counterarguments made by Connell et al (2022) and Collier-Sewell et al (2023) are a reasonable ‘antithesis’. The ‘synthesis’ might be to recognise that where a measurable competency can be established it should be, but that should not be the end of the learning and development process for the nurse.
Here is an example. A stoma nurse is working with a patient who comes round from surgery with an unplanned colostomy. The stoma nurse uses competencies in stoma assessment and management. But they also inspire the patient’s confidence and trust, not only to teach them how to manage the stoma, but to understand, empathise, give hope and adjust to this major life event.
Finally, they advocate for the patient, facilitating communication with the surgeon. The intangible and advocacy skills are as important as the competencies in stoma management. This mix of competencies, intangibles and advocacy, while at the core of mental health nursing, is not the exclusive domain of mental health nursing.
The poor physical health outcomes of people with mental health problems is an issue that can be viewed from two perspectives. A recent umbrella review of systematic reviews and meta-analyses (van Niekerk et al, 2022) found rates of depression in general hospital inpatients ranges from 13-20%, with 8% for anxiety disorder and 15% for delirium. Dementia ranged from 3-63% from only one systematic review (Mukadam and Sampson, 2011) which noted higher rates of diagnosis in wards for older people with less than a third of studies screening for depression and delirium. All these studies predate Covid-19, which has contributed to an increased prevalence of mental health problems (Daly et al, 2022).
The need for skills in mental health on general wards is only increasing. This is recognised to some extent by the development of ‘dementia and delirium’ teams in general hospitals across the UK, staffed mostly by general nurses. The question can be posed, why are these not ‘dementia, delirium and depression’ teams? These three common comorbidities are often misdiagnosed and confused (for clarity see the Nursing Times learning unit on this topic).
This exemplifies the divide in thinking about who should respond to mental health problems that have physical causes, as opposed to those seen as having more psychosocial causes. Given the close interplay of physical and mental health this divide is not justifiable.
It seems to me that the new four-year MNurs schemes developing across the UK that allow dual registration – adult or children’s combined with mental health or learning disability – might be the future basic nurse qualification. This mix and (a controversial) extra year could allow student nurses the space to develop competencies and the less tangible skills needed to enable their intended outcomes, while critically reflecting on them and their sociopolitical context. Though I would like to see a methodologically sound evaluation.
James Tighe is advanced nurse practitioner (mental health), Royal Marsden Hospital, and visiting fellow in advanced clinical practice in mental health, London South Bank University
Collier-Sewell F et al (2023) Competencies and standards in nurse education: the irresolvable tensions. Nurse Education Today; 125: 105782.
Connell C et al (2022) Mental health nursing identity: a critical analysis of the UK’s Nursing and Midwifery Council’s pre-registration syllabus change and subsequent move towards genericism. Mental Health Review Journal; 27: 4, 472-483.
Daly M et al (2022) Longitudinal changes in mental health and the COVID-19 pandemic: evidence from the UK Household Longitudinal Study. Psychological Medicine; 52: 13, 2549–2558.
Mukadam N, Sampson E (2011) A systematic review of the prevalence, associations and outcomes of dementia in older general hospital inpatients. International Psychogeriatrics; 23: 3, 344-355.
Van Niekerk M et al (2022) The prevalence of psychiatric disorders in general hospital inpatients: a systematic umbrella review. Journal of the Academy of Consultation-Liaison Psychiatry; 63: 6, 567-578.