It is an old debate: the generalist versus specialist. In nursing it's the divide in the tree of knowledge that gives us the branches of adult - general and mental health nursing. Never unique this physical-mental, mind-body divide is repeated. A fractal feature of being human.
Without checking these two camps have been mentioned on W2tQ previously. Ever defensive I have probably been responding to the critique so readily aimed at Hodges' model:
Well, it is plain to see and read from the model that it is reinforcing the Cartesian division. The model is putting the patient in a box, not only that but using the medical model's reductionist practice by having four boxes. The model acts as an elaborated checklist.
MENTAL HEALTH CARE
On the 15th I am 39. Yes, I wish I was. On the 15th it is 39 years since I started as a Nursing Assistant at Winwick Hospital, Warrington, UK. The change in mental health since then has been phenomenal. Winwick is gone as the local, or one of several regional asylums.
There is a proposal for students to specialise in the last year of training, to ensure there is an adequate grounding in physical care. The concern is that mental health skills will be diluted. There is some progress to be gained, ironically, in that suddenly the training will mirror what is experienced by the public and mental health services in terms of parity and spending.
MENTAL HEALTH CARE
If we want to demonstrate nursing as a science and art let's mix the blue and green:
MENTAL HEALTH CARE and PHYSICAL CARE
Voila! 50% of the work of the model is done. You wanted integrated care; you got integrated care: everything is all 70s Hunky Dory.
Of course, it is never that simple.
I've picked this issue up after it featured in Nursing Times (Stephenson, 2016) last month. Among the points raised:
- Mental health risks being sidelined.
- Dilution of the mental health specialty could have a "devastating" impact.
- Some mental health courses have already be revised to incorporate more generic content. This can leave students with the "the worst of both worlds". There is a risk of a bias to adult nursing.
- Recruitment and differences in the appeal of courses is also noted, mental health candidates may already have related qualifications and more life experience.
- There is a need for a responsive and flexible workforce who can work pretty much anywhere (pp.2-3).
It seems as if there is climate for merger and acquisitions activity. In truth it has been there for a long time.
Mental health has changed. From my limited perspective I have not needed a work-issued briefcase for a decade. There was one case for us to use as needed. This one facet of a service-defined stepped care model that reflects change. From institution issue 3-piece suit plus white coats to smart-casual on the community. It is several years since I last needed to give an i.m. injection. I do feel I could tomorrow if needed, but if it is Risperidone - Consta I would once again need to read about the client and digest the info leaflet before doing the visit. Questions about competence are the constant. Believe me I'm not wishing for a return for the old-days: I remember it very well.
As a sign-off mentor there has been a panic to find a student the necessary experience. Now it seems there is less urgency in this respect. This is a positive sign in terms of mental health nursing and social change and yet a loss of a clinical skill being learned and exercised.
The emphasis over the past 1-2 decades is on nursing assessment. The nurse as therapist in the formal - psychological sense is no longer emphasised. A further diminution of mental health nursing. This may be a bias on my part, as a new community psychiatric nurse in the 1980s.
Where I mention merger and acquisitions above, what of interest rates? What difference will the loss of the student bursary make? Workforce planners may benefit from more certainty and an increase in numbers, but what of the quality of the future workforce? This is a crucial factor in retention. I came to mental health nursing first then did two years for the SRN - RGN. Currently, some courses are structured such that in the first 6 months the student is already committed to the pathway. Change is not possible even if desired.
At the very least this suggests the need for a four year course?
The locus of my nursing career has been the community and begs the question: Is the project complete? The media and countless promises on mental health funding (ongoing) show that this is far from the case. Where would this place children's mental health, women's services and forensic? Has the reduction in beds been compensated for by community resources?
But ALL the above misses another agenda; one that is now: 21st century nursing; (this is also represented in the third rendering of Hodges' model above).
Policy makers must address the social and political foundations upon which all nurses, social workers and allied health professions (theorize and) practice.
Where is the workforce that will help the public to self-care? Where is the focus on prevention? How are those 'troubled families' doing?
There is a prospective dividend to follow from big-data, that can extend this debate to the real questions of - society, policy, and life-styles - and provide evidence for real change. Finally:
Where is the generic conceptual framework to help integrate physical - general nursing and mental health?
Stephenson, J. (2016). Rift over move to 'generic' courses. Nursing Times, 20.07.16. 112:29, 2-3.