Attempts to modernise nurse education

In 2015, the Shape of Caring review (Willis 2015) set out 34 recommendations under eight themes, many of which related to preregistration nurse education. Most pertinent to this debate was the review’s suggestion that mental health nurse education did not focus enough on physical care while adult nurse education did not focus enough on mental health issues. The review emphasised the need for all nursing students to have ‘whole person core training’ as well as ‘a more flexible, generic skillset’ and recommended that they undergo two years of core training followed by one year of training in their chosen field of nursing – that is, either in adult, mental health, learning disability or children’s nursing (Willis 2015).

The NMC (2018) standards of proficiency were developed following the Shape of Caring review (Willis 2015) and were designed to apply across all four fields of nursing. One of the aims of these standards was to ensure that all nurses would be able to ‘meet the person-centred, holistic care needs of the people they encounter in their practice who may be at any stage of life and who may have a range of mental, physical, cognitive or behavioural health challenges’. Another aim was that nurses would be able to ‘demonstrate a greater depth of knowledge and the additional more advanced skills required to meet the specific care needs of people in their chosen fields of nursing practice’ (NMC 2018). The authors of this article argue that this second aim has not been achieved, in part due to a lack of explicit articulation of the mental health-specific knowledge and skills required.

Ion and Lauder (2015) agreed that nurse education was facing challenges and needed to evolve, but rejected the ‘simplistic view’ taken, in their opinion, by the Shape of Caring review (Willis 2015) ‘that a return to genericism [would] solve these difficulties’. Connell et al (2022) argued that the NMC (2018) standards of proficiency sought to rectify deep-rooted systemic issues by improving nurses’ skills in tasks and procedures relating to physical health, yet have led to a ‘dissolution of mental health nursing identity’.

Variations in university curricula

The NMC’s role in nurse education includes setting standards, approving higher education institutions, approving the programmes developed by those institutions and delivering quality assurance for approved programmes (NMC 2022). Communication among members of Mental Health Nurse Academics UK has revealed variations in the nursing curricula used by different universities, which appear to range from students having field-specific modules throughout their training to students having entirely generic content that is the same across all fields of nursing.

This raises important questions; for example, if the standards of proficiency set by the NMC can be interpreted in many different ways and different curricula are all considered to meet the standards, how do these standards protect specialist education and what level of specialist knowledge and skills can one expect of a mental health nurse? The authors suggest that if the standards set by the NMC allow such breadth of interpretation and if the NMC approves such varied nurse education programmes for achieving the same qualification, the NMC may need to review its processes.

According to anecdotal reports from the authors’ colleagues, it seems that many higher education institutions have adopted the Willis (2015) model of two years of core training followed by one year of specialism. However, research has shown that mental health nursing students feel that ‘core’ or generic content in their preregistration education is not adequately contextualised to mental health nursing (Buescher and McGugan 2022). If specialism is an afterthought squeezed into a single final year rather than being incorporated throughout preregistration nurse education, the first two years of ‘core’ content will not prepare students for studying mental health nursing at third-year university level. As a result, students may feel overwhelmed and underprepared, while mental health nurse academics may have to attempt to make up for two years of mental health nursing omissions in the curriculum (Warrender 2022b).

Irrelevant practice assessment documents

Concerns have also been raised regarding the practice assessment documents used during students’ clinical placements. These documents are shaped by the nursing procedures set out in Annexe B of the NMC (2018) standards of proficiency, which all newly registered nurses must be able to demonstrate. Annexe B sets out a long list of nursing procedures, including venepuncture, cannulation, catheterisation, blood transfusion, nasogastric tube insertion, rectal examination and manual evacuation.

Some mental health nursing students have expressed the view that there appears to be a discrepancy between practice assessment documents and the role of mental health nurses in clinical practice (Critical Mental Health Nurses’ Network 2022a). Students undergo practice placements in mental health services and these services are not set up to address service users’ physical health needs. This means that students have little opportunity to practise the physical health skills they are required to demonstrate and that practice assessment documents might be signed by practice supervisors who have not been trained in these skills (Critical Mental Health Nurses’ Network 2022b).

A further risk is that of creating an illusion of competence, with students signed off as competent in providing physical healthcare but their physical health skills then being underused, and therefore quickly lost, after registration. Some mental health nursing students have explained that if, once registered, they encountered a situation where their physical health skills were warranted, ‘their only suitable action [would] be to refuse to do them, on the grounds that it has been too long since they practised them and they no longer feel competent’ (Critical Mental Health Nurses’ Network 2022b). Skills that mental health nursing students may not need in practice are taking up significant placement learning time and it has been argued that the complex role of mental health nurses has been overlooked in favour of ‘redundant procedural based competencies and proficiencies’ (Connell et al 2022).

Addressing the physical health needs of service users

There is an inaccurate perception that, in expressing dissatisfaction with practice assessment documents and some nursing curricula, mental health nurse academics do not understand the role of mental health nurses in addressing the physical health needs of people with mental health issues (Holt and Dixon 2022). The authors of this article suggest that this is not the case and point out that mental health nurse academics have argued that (Mental Health Deserves Better 2023):

People with serious mental health issues are at risk of suboptimal physical health and die on average 15 to 20 years earlier than the general population, due to complex reasons such as social determinants of health, diagnostic overshadowing and harmful effects of medicines (Department of Health (DH) and Public Health England (PHE) 2016). To address this, the DH and PHE (2016) produced guidance for mental health nurses on improving the physical health of people with mental health issues. This guidance outlines the following action areas: providing support to quit smoking, addressing obesity, improving physical activity levels, reducing alcohol and substance use, improving sexual and reproductive health, optimising medicines, improving dental and oral health, and reducing falls (DH and PHE 2016).

The DH and PHE (2016) guidance also advises mental health nurses to use the therapeutic relationship to develop person-centred action plans and provide assistance with behaviour change. While this appears to be a sensible approach, mental health nurse academics have anecdotally described nurse education as being so focused on physical health procedures that it overlooks the importance of the therapeutic relationship. This may mean that students do not develop the ability to use the therapeutic relationship as a conduit through which the physical health of service users could be improved.

Mental health nurses’ distinct and misunderstood role

According to May (2005), the French philosopher Gilles Deleuze put forth the notion that identities do not form and reform in isolation, but that differences are actualised into specific forms of identity. This line of reasoning shifts the focus from the commonalities shared by the four fields of nursing to the many differences between them.

There are often competing ideologies in mental healthcare, meaning that understandings of patients’ conditions and approaches to treatment are the source of much more disagreement than in physical healthcare (Connell et al 2022). It can be argued that the physical systems of the human body, which can be objectively studied and measured, are simpler to understand and manage than people’s mental states and experiences.

Mental healthcare has been criticised as being authoritarian, paternalistic and not recovery oriented, with an overreliance on medicines (Wand et al 2022). Furthermore, this area is often overseen by psychiatrists and service users are sometimes viewed as labels with symptoms rather than as people with stories. In contrast with this, it has been argued that mental health nurses should provide genuine advocacy and respect people’s subjective experiences, in accordance with an ethos to ‘meet the person, where the person is’ (Connell et al 2022). However, according to Connell et al (2022), the NMC (2018) standards of proficiency undervalue and underrepresent skills such as human connection, genuine advocacy and the therapeutic use of self.

Furthermore, while all nurses develop therapeutic relationships with patients and service users, in mental health nursing therapeutic relationships are developed and maintained in a legal and ethical context framed by the Mental Health Act 1983 (amended 2007) and a potential power over service users. Mental health nurses may experience the moral dilemmas involved in the use of restrictive interventions, ensuring that these are only undertaken proportionate to risk and as a last resort. They may experience conflict between their sense of accountability to their professional role and their personal values (Mooney and Kanyeredzi 2021). This means that their therapeutic relationships with service users are often delicate and require complex communication skills, which brings us back to the idea of essential field-specific skills that mental health nurses need to have.

Connell et al (2022) argued that, ultimately, the future development of the mental health nursing role should be based on the needs of service users. It has been argued that service users may value ‘simple’ aspects of care such as being shown compassion (Gunasekara et al 2014). However, mental health nurses provide seemingly simple care in a context where the service user may be considered to need care yet not want to receive it; where human experience creates subjectivity; where mental distress can arise from a wide range of circumstances; where there is no guaranteed pathway to recovery; and where the power nurses potentially have over service users makes relationships harder to develop and maintain. Power imbalances can lead to serious iatrogenic harm: restraint and coerced medication can be experienced as degrading, inhumane and embarrassing, while the lack of service user involvement in decision-making and the removal of personal responsibility can make service users feel powerless (Mooney and Kanyeredzi 2021, Warrender et al 2021).

Mental health nurses require excellent interpersonal skills, the capacity to navigate ethical dilemmas and conflicting values, and the ability to be genuine advocates for service users (Connell et al 2022). These abilities and skills need to be explored in depth during preregistration education and should be prioritised accordingly to fulfil the NMC’s (2018) aim of ensuring newly registered nurses are equipped with field-specific skills.

Effective mental health nurse education involves learning about complex concepts such as mental health recovery, debating the validity and utility of psychiatric diagnoses, and facing the ethical issues inherent in treating people against their will. It involves students’ ideas being challenged and students gaining an in-depth understanding of themselves, leading to intellectual and emotional development (Stacey and Stickley 2012). None of these areas should be rushed or tokenistic.

Challenges in achieving holistic care

The NMC (2018) standards of proficiency state that nurses ‘must be able to meet the person-centred, holistic care needs’ of people. Holistic care has been defined as ‘a comprehensive style of care in which patients’ entire needs are addressed as a means of enabling full recovery’ (Jasemi et al 2017). Thus, it may not be possible to prepare nurses for providing true holistic care in the standard model of three years of preregistration education. Dove (2018) stated that nursing curricula are already ‘fit to burst’ and that adding to them may warrant a four-year programme.

With the introduction of additional physical health theory and skills for mental health nursing students, one may question how it would be possible to maintain the depth of specialist knowledge these students will need in practice. It may be considered demeaning to mental health nursing that the NMC’s focus on holistic care has led to less mental health education for many nursing students in that field. It may be that when introducing the ideal of holistic care, the practicalities of how it was going to be achieved were overlooked.

While it could be argued that it is not possible to teach preregistration nursing students everything they need to be able to provide holistic care to patients on registration, as long as the appropriate boxes are ticked, it may appear that this has been achieved. However, this only conveys the illusion of holistic care.

Implications for the present and future

The variations in nurse education may mean that newly registered mental health nurses have differing levels of specialist knowledge. The first author of this article has observed that some universities are advertising for lecturers in nursing without specifying the field of practice, which may be an indication of increasingly generic approaches to nurse education. In the future, the UK may have a mental health nursing workforce with underused and therefore unnecessary physical health knowledge and skills and a deficit in more relevant mental health knowledge and skills. There may also be concerns regarding the retention of mental health nursing students and nurses, who may feel underprepared, and of mental health nurse academics, who may not want to continue teaching courses they do not believe in (Warrender 2022b).

It is important to recognise that the primary concern is the quality of the care provided to service users. Connell et al (2022) argued that the NMC (2018) standards of proficiency would create generically trained mental health nurses with less specialist knowledge and skills, which would lower the quality of mental health nursing care. It may be useful to review the experience of Australia, where ‘comprehensive’ (generic) undergraduate nurse training has not adequately prepared nurses to provide effective care to mental health service users and where there have been calls for a return to specialist training (Box 1) (Lakeman et al 2022).

Failures in mental healthcare uncovered by journalistic investigations led Bladon (2022) to ask whether mental health nursing was ‘going backwards’. These failures give weight to the suggestion that mental health nursing should focus on the therapeutic relationship, trauma-informed care and the ethics of coercive and custodial practice (Ion et al 2020, Wand et al 2022). However, it may be challenging to prioritise these areas at present, since the future direction of mental health nursing is often determined by people from outside the profession (Mental Health Nurse Academics UK 2016).

Mental health nursing has perhaps been more vocal than learning disability nursing and children’s nursing regarding the effects that the NMC (2018) standards of proficiency have had on nurse education. However, serious concerns have been raised by academics that students in children’s nursing ‘were missing out on vital information pertinent to their field of practice’ (Glasper and Fallon 2021). The matter for discussion submitted by the RCN Mental Health Forum at the RCN congress in July 2022 (RCN Mental Health Forum 2022) gained public support from learning disability nurses and children’s nurses during the debate. It has been argued that the education which the NMC intended to be ‘core’ or ‘holistic’ has become, in practical terms, ‘adult-nursing-centric’ (Glasper and Fallon 2021) with all nurses being shaped in the likeness of adult nurses (Warrender 2022b).

Mental Health Deserves Better

Mental Health Deserves Better was created in January 2022 following discussions among mental health nurse academics concerned by the dilution of mental health nurse education (Mental Health Deserves Better 2022). This grassroots movement includes academics, clinical staff, students and interested others. It may not represent a universal view but shows that some mental health nurses have become aware of the issues facing the profession.

More than 25 years ago, Barr and Sines (1996) wrote that ‘generic nursing must not arrive by default due to nurses’ lack of conviction, apathy, a sense of creeping inevitability, a perception of powerlessness or a combination of the above’. It is in that spirit that Mental Health Deserves Better is attempting to bring mental health nursing together, resist the loss of specialist education and look towards the future of the profession.

Conclusion

Many mental health nurses and academics believe that nurse education is heading in a direction that will lower the quality of mental healthcare. The authors suggest that urgent action is required to improve mental health nurse education and consolidate the identity of mental health nursing. The profession also needs to clarify what differentiates it from the other fields of nursing, define how mental health nurses operate in multidisciplinary teams, and work with service users and families to develop the evidence base for mental health nursing interventions. While further debate on the future of mental health nurse education is necessary, the authors argue that the current direction of travel is not the right one.