4. Proposed changes to Mental Health Nursing Pre-Registration Nursing

Developments in nurse education in England Summary BSMHFT employs 1319 registered nurses and 641 health care assistants 53% of the total workforce. BSMHFT works in partnership with Birmingham City University and Birmingham University to educate the nursing undergraduate workforce. students are in clinical practice at any point in our Trust. This report provides an overview of current national and local policy drivers impacting upon nurse education practices and outcomes and specifically the implications for mental health nursing and mental health nurse education over the next 5 years. It also outlines some recommendations as to the developmental needs for mental health nurses in BSMHFT and the educational provision available or developing to meet this need from BSMHFT and Birmingham City University. 4. Proposed changes to Mental Health Nursing Pre-Registration Nursing Aim of report. This report aims to provide the Board with a clear rationale and overview of the forthcoming changes to pre-registration mental health nurse education and the future requirements for mental health nursing and support roles over the next 5 years. The report will raise awareness of Nursing and Midwifery Council (NMC) and Department of Health (DH) policy which drives these changes. Background The current position in nurse education in England includes an acknowledgement of the need to improve nurse education to ensure appropriate skills and knowledge and a keen desire to move nurse education to all graduate status which will bring England into line with international standards. Scotland, Wales and Northern Ireland have already become an all graduate profession; England is lagging behind the other UK countries and many developed countries across the world. In England a number of graduate nursing programmes have been in existence (some for more than 30 years) However the majority of registered nurses have undertaken diploma level programmes at higher education institutions. In England the funding of graduate and diploma courses is different with graduates taking loans and diploma students receiving bursaries. In Scotland and Wales all graduates receive bursaries. The rationale for moving to all graduate status is to be aligned to EU policy; NMC policy and Department of Health recommendations. There is also developing evidence of graduate nurses reducing mortality rates and length of hospital stays in acute trusts with more nurses per bed (NMC July 2009). Evidence emerging from Kings College Research Rafferty 2008 that higher rates of registered nurses results in safer and better outcomes for patients. The emphasis on having an all graduate profession has arisen from the recognition by the NMC of the following:- Increasingly complex role of the nurse Higher levels of autonomy and inter-professional working Need to attract and retain the highest calibre recruits in nursing 1

The national body for nurses the Nursing and Midwifery Council decision to move to an all graduate profession is supported in the Modernising Nursing Careers Framework (DH) 2008, which has set out the following principles - Minimum award of a degree for pre-registration nursing courses Professional recognition on the register denoting the field of practice (e.g. mental health). All pre-registration nursing courses will need to be a blend of generic and field specific with specific competencies and outcome measures These principles already have employer support. (NHS Employers, June 2009). 2. Review of evidence The evolving role of the nurse and blurring of professional boundaries has reinforced the need to provide excellence in practice, research and education (DH 2005). There are increasing requirements for nurses to be able to respond to and adapt to Lord Darzi s; The Next Stage Review (DH 2008) agenda for improving quality and a developing and changing 21st century health service. This has been influenced by an increase in long term conditions; pathway management; care delivered closer to home, self-care; the public health agenda and the transformation of community services. The New Horizons towards a Shared Vision for Mental Health (DH 2009) document acknowledges that mental health professionals of the future will need to target these specific areas of practice Prevention and public health Stigma and discrimination Early intervention Personalised Care Multi-agency commissioning and collaboration Innovation technologies and research Value for money Strengthening Transition from childhood to adulthood Older People The NHS Workforce Review Team recommended the following in relation to the nursing workforce, from their 2008 final report. Employers need to focus on retaining their current workforce and developing staff. Specifically, nurses must have appropriate clinical and leadership skills to deliver new ways of working. Increasing emphasis on care outside of hospital, support for self care and a growing public health agenda will result in an increased need for nurses working in primary care settings. The NHS Workforce Review teams 2009 draft report suggests the following in relation to nursing - SHAs to consider increasing current commissioning levels in light of the latest workforce forecasts. Employers to focus on retaining and developing the current workforce. 2

Employers to ensure that nurses have the appropriate clinical and leadership skills to deliver new ways of working. PCTs and employers to increase availability of community placements, including in nursing homes. Recruitment and training initiatives to fill immediate vacancies in areas that are historically difficult to recruit to, such as theatre and critical care nursing. Employers and HEIs to collaborate on developing the future of nurse educator roles. Recruitment initiatives to encourage nurses to work in a primary care setting. There is little data on the higher specialist nurse workforce. SHAs should emphasise the importance of fully completing the existing data fields within ESR to improve data quality on this workforce and assist effective workforce planning. 3. Pre Registration Nurse Education In pre-registration nurse education new standards are being developed. Current consultation is on what should be included (NMC July 2009). However the NMC are clear that at the point of registration the new graduate nurse - Has the knowledge, skills and attitudes to deliver safe, evidence based care in relation to their field of practice. Is an accountable and autonomous practitioner, who cares with compassion. Delivers care across an increasingly complex and diverse health care environment. Demonstrates the ability to continue to learn and develop in skills of caring, management, leadership and research. Following scoping work which was undertaken with the support of the Strategic Health Authority, the Practice Placement Managers identified areas, with respect to the interface between theory and practice, which could be more properly enhanced. From this the SELF Project (Supplementary Enhanced Learning Framework) was developed and commenced in May 2005. It provided an opportunity for all first year pre-registration nursing students to understand and practice essential skills with respect to both physical and mental health care delivery. An essential component was that service users were an integral part of all sessions, which also helped with attitudinal development. The work of the Practice Placement Managers was recognised by the Board by way of a previous Board Challenge Award. This course attracts much interest from other organisations and other disciplines within the Trust, as the model is clearly transferable. There was also an intention to develop the project to run across all years of training. However there are now serious funding issues which may prevent further delivery of the course after the completion of the November 2009 cohort. Previously the course has been funded in a number of non-recurring ways, including a successful CETL (Centre of Excellence in Teaching and Learning) bid via Birmingham City University, and through slippage in the Trust LBR (Learning Beyond Registration) budget via the SHA. These sources are no longer available and other means are being sought, for example via charitable funds. 4. Graduate Nurses Implications for BSMHFT It is assumed that the shift to an all graduate profession will take place in 2011. There are implications in relation to the preceptorship of newly graduated nurses and on how supporting roles of both health care assistants and assistant practitioners will develop. BSMHFT is now running one of the first multi-disciplinary preceptorship courses for nurses 3

and OT s with Birmingham University. This is being positively evaluated and attracting interest from a number of acute mental health trusts. Over the next 5 years for existing qualified mental health nurses in BSMHFT there is a need to take on the following - Mentor/Assessor role to support student nurses education. Sign off mentors role to ensure that student nurses are fit to practice and fit for purpose at the end of their education. Preceptorship role to ensure newly qualified nurses are supported and have a solid foundation for lifelong learning. Educational opportunities to enhance practice. Becoming research active. Taking on leadership and management initiatives. Prescribing role which initial research indicates enhances their service user relationships and increases concordance with medication and satisfaction with mental health services whilst also reducing Dr s working hours. In response to changes in mental health law taking on the Approved mental health professional role which will alleviate pressure on social workers who can respond to new national priorities in relation to child and family services. As well as the Responsible clinician role promoting efficiency of workers reducing needs for consultant psychiatrists and providing opportunities for financial savings and developing mental health nurses portfolio of roles and expertise in mental health. An increasing need for nurses to work at a specialist and advanced level in mental health nursing 5. Health Care Assistants and Assistant Practitioner For health care assistants and assistant practitioners their roles will need to develop in response to the demand for new types of workers, for example in the National Dementia Care Strategy, assistant care coordinators workers that are flexible and can adapt to changing clinical demands alongside a greater skilled but reduced nursing workforce. Although it is acknowledged that this needs to be within a career framework which may include access to nurse education. These roles will include new roles extending to Band 4 competencies to supplement the workforce In light of the evidence around nursing moving to an all graduate profession, the need for assistant practitioner roles and the evolving nature of mental health care services BSMHFT needs to develop a revised professional workforce strategy in which mental health nursing education and continuing professional development for registered nurses, HCA s and assistant practitioners will be an important components. For health care assistants and assistant practitioners a specific Foundation Degree scheme which offers pathways of learning in clinically relevant areas and has an accreditation process for both prior academic and experiential learning for experienced staff. A bridging course for Foundation Degree Scheme students from BSMHFT into the graduate preregistration mental health nursing programme will need to be developed to replace current secondments into diploma level education. 6. Continuing Professional Development for Registered Nurses Continuing professional development for qualified mental health nurses (which could be provided in-house or through local Higher Education Institutions) on the following:- 4

Staff nurse development for the unengaged. Refresher CPD for physical health needs for mental health service users. Assessment skills Medicines management Care planning Named nurse responsibilities and requirements. Recognising the Importance of engaging social networks for clients to promote recovery how to do this. Working with people with personality disorder. Prison staff workshops on Professional boundaries and behaviour. Working appropriately in oppressive environments. Drug calculations. Responding to physical health needs. In responding to these developments it is essential that mental health nurses from BSMHFT have the opportunity to access ongoing further and higher education. Appendix 1 outlines what is currently available in linking with Birmingham City University with some proposed new courses also highlighted. These courses give the pathways for diploma nurses to become graduates. Given the significant number of diploma nurses these courses will become increasingly important for the current workforce and their future career pathway. The proportion of graduate nurses in the workforce will need to be tracked increasing the number of nurses accessing masters level programmes to support advanced practice will be required in the near future. BSMHFT has two nurse consultants engaged in clinical doctorates. One has remitted due to the pressures of full time work and study. One will be complete in 2010. Currently there are no clinical academic positions in BSMHFT, these exist for Doctors and Psychologists. In Summary There is international evidence and recent evidence Rafferty (2008) that graduate registered nurses reduce mortality rates in acute hospitals and that higher staffing ratios of registered nurses improve the quality of care. Most developed countries including Scotland, Wales and Northern Ireland have moved to an all graduate profession intake. It is anticipated England will follow suit in 2011. Not to do so will result in best students moving to the other countries. Nursing is one of the few professions that has embraced and benefits from widening participation from local communities by providing access programmes in to Diploma level education. In future access courses will have foundation degree equivalence; provide entry on achievement of qualification to a shorter period of pre-registration graduate education. Foundation degree places for Mental Health nursing will need to be secured for the future. Given the over supply of graduates particularly social science graduates in the market, a shortened 2 year nursing registration and masters course is being offered by one or both universities in Birmingham. The move to an all graduate profession is both desirable, achievable and necessary for nurses to play their full part in delivering mental health services in the 21 st century. The level of knowledge, skills and expertise expected from current and future roles requires a graduate based education so nurses are equipped both with the competence and confidence to maximise their considerable contribution. 5

Appendix 1 BSMHFT in collaboration with Birmingham City University already offer 2 academically approved modules one is the Medicines Management Module (15 credits at level 6 degree level) and the second is the Preparation for the role of the Clinical Supervisor Module (30 credits at level 6 degree level). These can be the basis for accumulating sufficient academic credits for a degree for those currently at diploma level. Alongside this the medicines management module is BSMHFT s requirement to access the nurse prescribers course. Birmingham City University offer the following, specifically to enhance qualified nurses skills and knowledge with the intention of improving mental health service users experiences:- Post Registration Mental Health Nursing Course leading to one of 4 possible qualifications from Advanced Diploma; Graduate Diploma, BSc and BSc (Hons), in these areas - Adult pathway for mental health nurses working with the serious and enduringly mentally ill the focus is on recovery; cognitive behavioural approaches and interventions as well as working with people with dual diagnosis. Child and Adolescent Mental Health Services this pathway includes attachment theory and early experiences of trauma and their impact on mental health including providing the appropriate therapeutic responses. Eating Disorders - this pathway is delivered by a specialist practitioner who continues to work within the field and offers up to date information and clinical insight on the issues in working with people with eating disorders. Community Mental health nursing pathway this pathway is delivered by a specialist practitioner and CPN who continues working in a Community Mental Health Team and offers up to date information and promotes the development of enhanced skills and knowledge for application to practice. Additional option modules, in Dementia Care and Hearing Voices Work within a recovery context, are also available. From September 2010 the Birmingham City University hopes to offer these pathways at both level 6 and 7 (undergraduate and Master s levels to reflect the changing nature of preregistration nurse education). Masters level courses Nurse Prescribers Course. A Psychological well being practitioner course is offered at post graduate certificate level and is part of the West Midlands regional response to Improving Access to Psychological Therapies (DH 2007). MSc Mental Health (includes new AMHP role) MSc Strategic Leadership New and Proposed developments from BCU MSc Perinatal Mental Health currently being developed with BSMHFT, projected start date January 2010. 6

Advanced practice developments - projected start date January 2011 onwards (impacted by delay in new standards for pre-registration nursing from NMC). Advanced practice assessors projected start date January 2011 onwards. Forensic nursing ascertain service need and response in place by September 2011 Genetic counsellor role developing work on National and Local Dementia Strategy. Regional and locally based work. Foundation degree scheme development September 2011. Mental Health service navigator role ascertain service need and response in place by September 2011. Mental Health promotion & public health perspectives - ascertain service need and response in place by September 2011. Taught doctorate in nursing, including mental health nursing - projected start date September 2010. References. Department of Health (2005) New Ways of Working. London, DH. Department of Health (2008) A high quality workforce: NHS Next Stage Review. London, DH. Department of Health (2009) New Horizons: Towards a Shared Vision for Mental Health. London, DH 2009 Department of Health. Modernising Nursing Careers. London, DH National Health Service Employers (June 2009) Discussion paper 3: The role of the nurse. London, NHS Employers. 7