I was nominated by my manager for mental health nurse of the year in the BJN Awards 2019 because of my work in mental health nursing education and development. I had never been in this situation before, and it was quite a surprise to be shortlisted.
I have worked as a nurse in education and development for more than 25 years. I started nursing in 1983 and have worked in all the various areas of mental health practice during that time.
My interest in education and practice development started when I realised that mental health nursing practice varied across different services and localities. I also noticed that the training that students received varied between universities. After involvement in training in my local mental health trust, I was given an opportunity to undertake a part-time secondment with the local university. This arrangement allowed me to work part time in the university and part time in the trust each week. This worked well and I was able to develop my teaching skills and move into writing and leading on module developments for pre- and postregistration programmes.
In the trust I supported the nursing strategy on physical health in mental health training for staff, medication management training, and clinical assessment skills, along with my other duties.
Introducing work-based learning
I was able to balance my two roles and found that close working with the university also helped to influence the type of postregistration course that the trust needed for its nurses. It seemed important to change the way in which postregistration models were being delivered. Freeing up staff from their working practice to attend courses at university was becoming harder because of difficulties with staffing levels. Some training courses did not always lead to changes in nursing practice back in the clinical area.
To try to improve this situation, I redesigned a medication management module to be work based. Students used medication workbooks for each mental health condition, and were taught and supported by their consultant psychiatrist teams in the practice area. Attendance time in the university was important, but was limited to one session a fortnight. This comprised a core subject lecture and an exam on the subject they had been studying over the previous 2 weeks.
This type of delivery became popular as it was time- and cost-efficient. The nurses and some occupational therapists who undertook the course found the teaching methods and learning in their practice area were a stimulating and motivating way to learn as they could connect theory to their daily clinical practice, and had a better understanding of the patients' different conditions and treatments.
Influencing assessment skills
Mental health assessments, person-centred care planning and risk-assessment skills were the key areas that students had struggled with in previous programmes. I was lucky enough to work with some very dynamic teaching staff who gave me the confidence to be innovative. Teaching and assessing second-year students in these areas seemed the key to influence nursing-assessment skills. This was achieved by using an objective structured clinical examination (OSCE). The three sections to this OSCE were clinical mental health assessment, care plan and report writing, and a question-and-answer session.
During the OSCE, third-year students were used to role play various mental health conditions while the second-year students conducted assessments. A lecturer and two service users assessed the students.
The challenge in this approach to teaching and assessing was the time it took. The second-year students were very anxious about this assessment method, so additional coaching and practice sessions were needed—these were videoed and peer reviewed. Involving service users as assessors made them feel involved, and led to a better understanding of nursing practice and university work. Some then used this experience to assist them to move on to gaining employment and a few went back into education themselves. Most importantly, the key aim of the module was achieved because the students felt competent and confident in undertaking assessment work with their mentors in the practice areas.
I was able to continue my role as a part-time lecturer practitioner in the university and a part-time practice development nurse in Kent and Medway Trust for almost 9 years on a secondment.
Non-medical prescribing
Teaching nurses psychopharmacology put me in a position to take on the lead role for non-medical prescribing for nurses in the Trust. As mental health nursing requires the skill of instilling hope in patients and developing a trusting relationship with them, the use of concordance skills was a very important part of nurse prescribing.
Medication prescribing in mental health practice is not easy as the types of medication are complex and the selection of treatment requires careful consideration. Supplementary prescribing can be cost-effective, and can offer patients greater choice and improve adherence to treatment. It also allows nurses to spend more time looking at the physical health and lifestyle issues of patients. However, many nurses did not go on to prescribe after completing the course. Many thought that career progression was lacking in this area and their expectations of this role were not reflected in other parts of their role and day-to-day practice. In order to overcome these challenges, I needed to create opportunities to develop nursing roles to include independent prescribing practice. This would show that career progression was possible. This required my pharmacy and medical colleagues to support this strategy, and so a lot of persuasion and enthusiasm on my part was needed to show it could work. Another important factor that made a big difference was the support and commitment of the director of nursing in developing nurses' practice, something that had been lacking in previous times.
Once agreed, and with the careful guidance and support of a senior pharmacist, we created an independent prescribing role held by a pharmacist. This pharmacist could then support nurses to become independent prescribers within their own area of practice. In 2018, two of these nurse prescribers went on to achieve national recognition at the Nursing Times awards.
Developing nurse associates
Most recently, I have been leading on the recruitment and development of the nursing associate role. This has been a very interesting challenge. As this was a new role, we canvassed our healthcare assistants to see if there would be interest and we were inundated with responses from staff who were passionate about caring and eager to receive training. The biggest challenge for this group was that a high proportion did not have the necessary entry qualifications to get on to a university foundation degree course. There were rumours at the time that the Nursing and Midwifery Council (NMC) might validate and register the nursing associate role and this created even more excitement and determination from the healthcare assistants.
To try to select 10 candidates from more than 50 applications was a complex task. Candidates required more than just the ability to study and to hold the necessary maths and English qualifications. I realised that, as a part of a pilot programme, it was important that the candidates selected could complete the course successfully and also that those selected would make a positive difference. The selection criteria also had to include candidates representing all service areas in the Trust in order to see how the role could work within different clinical teams. The trainees also needed to be tolerant and resilient regarding the demands of a new training programme and to accept and deal with changes and additions to the programme over the 2-year course.
I am pleased to say that, of the 10 candidates put forward, 9 completed the course in April 2019 and took up jobs in the Trust. All nine have now registered with the NMC following completion of the pilot.
With the introduction of this nursing associate apprenticeship role, we have formed a consortium between local health and social care providers in order to procure a training programme. Moving forward with this development required close working relationships with other organisations in order to offer the expected variety of placements giving experience across the patient lifespan. Other trusts and social care providers were interested in having training positions for their staff so collaboration was easier as all had the same outcome in mind—to offer their own staff the chance to develop while completing their usual work role of delivering patient care.
The apprenticeship route was ideal for this, although it was not without its problems. It proved to be a steep learning curve in particular around procuring education providers and changing staff posts from care workers to apprentices. It also required a great deal of explanation to managers on the perceived benefits of introducing the nursing associate role.
We are ready to commence training our second group of trainee nursing associates in the Trust this September as part of our consortium. The nine nursing associates have settled into their posts across the different clinical areas in our Trust and some are keen now to think about further career development in nursing.
This has proved to be an interesting and rewarding part of my career.