Severe mental illness, statutory supervision and mental health nursing in the United Kingdom: meeting the challenge

Care Coordination as Imagined, Care Coordination as Done: Findings from a Cross-national Mental Health Systems Study

Introduction:

Care coordination is intended to ensure needs are met and integrated services are provided. Formalised processes for the coordination of mental health care arrived in the UK with the introduction of the care programme approach in the early 1990s. Since then the care coordinator role has become a central one within mental health systems.

Theory and methods:

This paper contrasts care coordination as work that is imagined with care coordination as work that is done. This is achieved via a critical review of policy followed by a qualitative analysis of interviews, focusing on day-to-day work, conducted with 28 care coordinators employed in four NHS organisations in England and two in Wales.

Findings:

Care coordination is imagined as a vehicle for the provision of collaborative, recovery-focused, care. Those who practise care coordination are concerned with the quality of their relationships with service users and the tailoring of services, but limits exist to collaboration and open discussion. Care coordinators describe doing necessary work connecting people and the system of care. However, this work also brings significant administrative demands, is subject to performance management which distorts its primary purpose, and in a context of scarce resources promotes generic professional roles.

Conclusion:

Care coordination must be done. However, it is not consistently being done in the way policymakers imagine, and in the real world of work can be done differently.

Registered nurses as responsible clinicians under the New Zealand Mental Health (Compulsory Assessment and Treatment) Act 1992

The objectives of this research were to determine how many registered nurses are working as 'responsible clinicians', under what phases of the legislation they are functioning, and to describe the enabling processes and barriers to nurses undertaking this statutory role. An anonymous descriptive survey was distributed to the 11 nurses who were currently responsible clinicians as well as five senior nurses selected from each of the 21 District Health Boards and the Auckland Regional Forensic Psychiatry Services (n = 121). The response rate was 88.4% (n = 107). The survey questioned respondents on statutory roles currently undertaken. Respondents were asked whether the responsible clinician role was a legitimate one for nurses and whether they were motivated to attain it. They were also asked which competencies of the role they believed they met, their perceptions of credentialing processes and the educational requirements needed to achieve the role. A descriptive statistical analysis was undertaken and open-ended questions were analysed using content analysis. Of the approximately 395 responsible clinicians nationally, 11 (2.8%) are nurses. Most nurses viewed the role as legitimate. However, many were unaware of competencies for the role and credentialing processes, and were somewhat ambivalent about achieving the role due to current workload, role conflict and lack of remuneration. Competency deficits were highlighted. There are grounds to encourage nurses as responsible clinicians given the intent of the legislation. This will require the promulgation of appropriate mental health policy, and a concerted effort by major stakeholders in mental health service delivery.

Mental health nurses, promoters of inclusion or perpetuators of exclusion?

The literature identifies that mental health services and those individuals working within them have the potential to facilitate inclusion for their client group, because of their power to initiate potential inclusive opportunities. However, evidence suggests that service users themselves perceive many aspects of mental health services as contributing to the problem of exclusion. This has been attributed to an accumulation of messages, attitudes and disempowering practices that have emanated from mental health care providers over a long period. This study employs focus group methodology in a residential rehabilitation unit in an industrial city in the UK. Discussion of the findings highlight how, in spite of alleged inclusive practices, the attitudes held by members of the unit team could impede the clients' opportunities to become socially included, as a result of defensive practice, paternalistic attitudes, expectations of the local community upon the team and the stagnant views that are embedded in the culture of mental health services. While mental health nurses may see themselves as promoting inclusion, the reality may be quite different.

A 'bittersweet pill to swallow': learning from mental health service users' responses to compulsory community care in England

Two forms of compulsory mental healthcare and supervision in the community are provided within the Mental Health Act 1983: Supervised Discharge Orders (SDOs) and guardianship. At a time when the Government are proposing to extend powers of supervision over people with severe mental illness in the community, it is appropriate that service users' experiences of existing legislation are examined and reported. Despite a range of literature that presents mental health service users' views and experiences, it remains unclear how service users respond to compulsory community mental healthcare in England. The present paper presents the findings of a qualitative investigation into service users' perceptions and experiences of living with SDOs. In the interviews, service users communicated their understanding of why mental health professionals placed them on the order and how their lives have been affected. Individual service users are capable of seemingly contradictory responses, simultaneously accepting and resisting the orders. This paper presents a typology of the range of responses. These responses are fatalism and resignation, dependency, ownership, bargaining, cooperation, resistance, and rejection. The study provides a model with which we can begin to understand how service users respond to compulsory community care where their options are legally constrained.

Scoping mental health nursing education

In late 1999 the National Mental Health Working Group of the Australian Health Ministers Advisory Council commissioned the Australian and New Zealand College of Mental Health Nurses to undertake a scoping study of mental health nursing. A final report will be submitted to the National Mental Health Working Group in February 2000. The purpose of this article is to draw attention to some of the systemic problems that confront the education of mental health nurses in Australia. Shortcomings in the preparation of undergraduate students of nursing for commencing practice in mental health nursing are described and comments are given on issues affecting the quality of postgraduate mental health nursing education.