Mental Health Nurse Managers Ireland
Mental Health Nurse Managers, Ireland.
Discussion document on:
The role of Directors of Nursing in Mental Health Services
February 2006
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Background;
Psychiatric nursing, which has developed in Ireland since the 1920s’ to the current
state where graduate nursing will be the norm, has as its primary objectives the
facilitation of the maximum development of the mental health of the individual who is
in psychological distress and the promotion of the individual’s mental health (An
Bord Altranais 2000). Integral to this role is the development and establishment of the
individual therapeutic relationship that enables and empowers patients and their
families whether they be receiving in-patient care or care and treatment in the
evolving community mental health services. Since Planning for the Future (1984)
there has been a wholesale reorientation of mental health services to a community
based service provision focus. This has been a significant strategic shift in Irish
mental health service provision and Directors of Nursing and Assistant Directors in
mental health services have been central characters in this development. In their
report in 1998 the Commission on Nursing sought to promote the strategic
management capabilities of Directors of Nursing generally, those in mental health
services had already been engaged in this manner for many years.
More recently, the national health service reforms have been introduced and from
September 1st 2005 Local Health Officers (LHO) have assumed managerial
responsibility for PCCC activities in their care areas. This will include mental health
service activities, which had heretofore been the responsibility of Programme Mgrs.
/Regional Mgrs. /Asst. CEOs’. It is expected that mental health services will continue
to be integrated more into the processes’ of primary and community care. On January
24th 2006 the Expert group on Mental health Services reported on their Vision for
Change of Irish mental health services over the next decade. From both of these
processes great change will emerge. For these changes to produce improved and user
centred mental health services it will be important that nurses feel confident in their
leaders and it is to their DoNs’ and ADoNs’ that they turn for leadership, guidance
and reassurance.
Current management organisation of catchment area mental health services:
Management structures within each of the pre-existing Health Boards have developed
to meet a multiplicity of health and social needs in a context of changing
demographics, epidemiology, health policy and legislation. During this development
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much authority, accountability and responsibility for clinical and operational services
has devolved to local heads of services and disciplines. Mental health services are
currently managed at catchment area level by a management team of Hospital
Manager, Clinical Director and DoN, which has traditionally reported into regional
managers/ Assistant CEOs’. In some catchment areas Principal Clinical Psychologists
and Principal Social Workers are also part of the management team structure. The
management team has had the complete responsibility for the maintenance,
development and organisation of the service spanning the in-patient to home-based
community elements of service delivery and provision. The DoN within this has
direct responsibility for approximately 80% of the staff in the organisation (nursing,
care and household grades) and shares management responsibilities equally with the
Clinical Director and Hospital/Area Manager.
Since Planning for the Future was adopted as the strategic blueprint for mental health
services very significant and far reaching changes have been carried out within mental
health services and through each change DoNs’ with their ADoNs’ have been central
to their formulating theses changes and carrying them through to completion. They
have actively provided leadership, both professional and organisational, in making
these changes in a number of ways.

With his/her management colleagues the DoN has described the
strategic direction and priorities for each service and has worked
across disciplines and within nursing to effect a changed service

Within nursing and in the general organisation the DoN has
managed the specific changes required to move services forward

Within nursing the DoN has worked to professionally develop staff
so that they are prepared for a more advanced and differentiated
service delivery. Significant development of specialist roles of
psychiatric nurses has occurred providing alternatives for patients in
their care pathway.

A very significant series of developments professionally has been
the transition of nursing from a certificate based profession through
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a diploma based one to the current degree led profession in a
relatively short period of time.

DoNs’ have worked with their management team and senior health
service colleagues to effect;
o Closure of large psychiatric hospitals. There are currently
only 11 left open and these with only a fraction of the inpatient beds once accommodated in them
o Development of community mental health teams, Assertive
Outreach Teams, Crisis Intervention Teams, Addiction
Counselling and Liaison teams, all with specialist nurses
providing their core staffing
o Developing acute units within general hospitals and helping
to de-stigmatise mental illness in this process
o Promoting and developing the role and capabilities of the
psychiatric
nurse
to
encompass
psycho-social
roles,
cognitive behavioural therapy roles, family therapy and
mental health promotion roles among others
The DoNs’, with their ADoNs’, have worked to convert mental health services against
a background of approximately 50% relative reduction of funding to Irish Mental
Health Services. Despite this grave shortage of funds they have succeeded in
transforming many services and work assiduously to continue development of modern
mental health services in this country.
Directors’ of Nursing in the future mental health services:
In considering the position of DoNs’ in future Irish mental health services it may be
useful to address the issue under three broad headings;
1. Strategic development and leadership.
2. Organisational development and leadership.
3. Professional development and leadership.
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Strategic development and leadership.
A particular strength of mental health services is that they provide treatment and care
for patients along a continuum. The journey for the patient through the system is
connected and each part of the service has a relationship with the other parts that is
supportive and beneficial to patients. The Sainsbury Centre for Mental Health in a
recent policy paper on ‘Commissioning mental health services’ (Light & Cohen 2003)
pointed to the problems of having primary and secondary care separated and called
for coordinated mental health services close to the patient. It also called for a ‘clear
vision, a unified budget, co-terminosity and an integrated organisational structure’ in
the commissioning of new services. This view of separated and disjointed mental
health services that are inimical to effective mental health care is also highlighted by
the American Psychiatric Association in its ‘Vision for the Mental Health System’
(2003) as it says;
Timely access to care and continuity of care remain today the cornerstones for
quality even as a continuum of services is built that encourages maximum
independence and quality of life for psychiatric patients (p2)
Irish mental health services service users want the same. This year the Mental health
Commission published its consultation paper with service users who want ‘a holistic
seamless (service providing) the full continuum of care… ’ (p9), which echoes what
the NHS in Great Britain are also saying (The Journey to Recovery – The
Government’s vision for mental health care. 2001).
What DoNs’ have been working to provide is a seamless mental health service to Irish
patients’ and despite reducing resources they have largely succeeded in this important
strategic task. This task has been achieved by understanding the required strategic
direction, understanding the strategic capabilities of their services, and leading their
staff to develop services in cooperation with their management team colleagues. Their
job has required that they work with the major part of the workforce to describe,
shape and lead change and it has been done in circumstances that were sometimes
adversarial and rarely ideal. Having direct responsibility and accountability for the
major part of the workforce has required the management of this significant resource
to lead and achieve the changes. Key partners in this process have been the ADoNs’
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who have developed to assume important roles in team development and
coordination, especially in developing community mental health sector and specialist
teams. It has required significant management and human resource skills that have not
often been recognised but in the future should be, so that their strategic role can be
more effectively carried out.
In considering the future development of mental health services we have a clear
understanding of the strategic requirements for providing a continuum of care across a
seamless service that in many situations will cross LHO care area boundaries. We
have an understanding of how significant patient groups require local and/or regional
focus and are anxious that vital services and developments do not become fragmented
and inefficient and can contribute to an understanding to ensure this does not happen.
Central to this is the concept of governance, which ensures that through the processes’
of change and reorganisation the efforts of the mental health services remain focused
on the patients and communities that they serve. Nursing, as a person centred and
caring profession, provides the ideal focus to maintain the vision of a caring,
empathetic and knowledge based organisation working to promote and maintain
peoples’ mental health. DoNs’ ably assisted by their ADoNs’ have carried out an
important and successful role of clinical and organisational governance for many
years and it is in the interests of patients and national services management that they
are facilitated to continue to provide their strategic leadership and governance
function in this way.
Organisational development and leadership;
Responsibility for 80% of the workforce requires considerable organisational skill
and leadership abilities. These skills and abilities have been repeatedly called on from
DoNs’ as mental health services have developed and changed since 1984. The
organisation and management of staff then was quite different to what it is now. At
that time virtually all staff were located in the institutions and had little experience of
working in more dispersed locations carrying out their practice in more specialised
ways. Many services have now dispersed and created differentiated specialities to
meet the needs of patients. This change has been largely led by DoNs’ in their
management teams and ADoNs’, and is key to the continuing development of mental
health services. The Department of Health and Children in its ‘Framework to guide
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service providers in the establishment of Primary Care Teams’ (Draft of 10 November
2003) is explicit in citing the leadership of change management as crucial to
‘achieving effective integration and interface between services..(and)...in the
restructuring process of health service reforms’, (p34). The Mental Health
Commission and Inspectorate in their reports for 2004 have called for accelerated
change within mental health services. The Expert Group on mental health services has
now recommended further and more fundamental changes to the way mental health
services are structured and managed. DoNs’ have a very good track record in leading
change in their services and have established relationships with unions and nurses that
will be critical to achieving the organisational and practice changes required in the
coming years.
In a draft review of mental health services in the former South Eastern Health Board
the review group drew on the experiences of the NHS for managing mental health
services and change. It emphasised the need to have common management of inpatient and out-patient services and the requirement that services be large enough to
attract strong leadership to change and develop services. DoNs’ with ADoNs’ have
been responsible for developing and managing community and hospital services and
developing links into primary care and specialist secondary care. This has been
achieved by understanding the strategic goals, developing staff to work towards them
and managing change and development of services. DoNs’ have provided leadership
within their management teams and by working to empower their nurses’ have
enabled these to carry through the changes required. Providing leadership outside
their organisation has also been a feature of DoNs’ and ADoNs’ work as links have
been developed and exploited for communities’ and patients’ benefit with general
hospitals, community care services and primary care services. There will be greater
need for this type of leadership to enable mental health services develop in the ways
anticipated and DoNs’ will be critical to the process.
Professional development and leadership:
Psychiatric nursing through the 70s’ into the 1990s’ was based in the apprenticeship
or traditional training model that was based on a hospital service provision of
treatment and care. In a remarkably short period of time the basis of education and
training for psychiatric nurses has moved from this through diploma to undergraduate
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degree based qualification. This remarkable transition has been achieved / recognised
through the effective leadership provided by DoNs’ working in partnership with their
staff, third level colleges, health boards and An Bord Altranais. We are now turning
out nursing graduates who are more flexible and accessible as a workforce available
to patients and cementing together the many strands of mental health services
(Jackson & Stevenson 2000).
In the last decade the nature of service provision by mental health services has
expanded greatly. Working with the third level educational institutions DoNs’ and
ADoNs’ have sought to develop nursing capabilities in areas such as Psychiatry of
Later Life, Acute Mental Health Nursing, Child and Adolescent Mental Health
Nursing, Liaison Psychiatric Nursing and Psycho-Social Nursing. Working with other
statutory agencies capabilities have been built in Substance Misuse Counselling,
Suicide Prevention and Mental Health Promotion. From a largely institutional based
system two decades ago nurses have developed professionally to meet changing needs
and demands. Anticipating developing needs in primary care, rehabilitative mental
health care, dementia care and mental health promotion, amongst others, we are
working with psychiatric nurses, Nursing and Midwifery Planning and Development
Units, the colleges and other educational providers to prepare their nurses for changed
and changing service delivery. Understanding future service requirements and the
need for appropriate specialist practice development, DoNs’ are best placed to mould
and shape psychiatric nurses to meet these and have clearly demonstrated their
willingness and ability to do so.
Conclusion:
There has been significant and far reaching change in Irish Mental Health services
since 1984 and further more widespread change is now spelled out by the mental
health review group. Mental health services have been poorly resourced through the
changes thus far, yet these changes have been pursued to generally successful
conclusions despite this fact. In describing and implementing these changes DoNs’
and ADoNs’ have been key strategic players who have enabled and led psychiatric
nurses and their organisations through often difficult processes’ to position national
mental health services well for the next phases’ of change.
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Looking forward it is clear that nurses, along with their professional and
administrative colleagues, will be critical to the development and implementation of
recommendations from the national expert group on mental health services. DoNs’
and ADONs’ have a proven track record in developing and leading their staff and are
well poised to accelerate this change process for the improvement of mental health
services.
The advantages of utilising an already skilled, experienced and motivated cadre of
senior service leaders are obvious and will enable change to progress speedily.
Patients, their families and communities will benefit and so too will nurses and the
health service generally.
Recommendations:
1. Directors’ of Nursing be represented at National Care Group level.
2. Directors’ of Nursing be represented at Regional PCCC level
3. Directors’ of Nursing be given adequate resources to maintain and develop
nursing services to meet current and future service needs.
4. Directors’ of Nursing be allowed more Human Resource control in the area of
recruitment and deployment of their staff and be supported in this by
appropriate HR and IR advisors
5. Directors’ of Nursing continue to work at a strategic, regional and national
level to develop services.
Notes;
This brief has been prepared by a nominated sub group for the executive
of Mental Health Nurse Managers Ireland following consultative meetings
with the national group of Directors’ of Nursing, SIPTU, PNA and INO.
Sub group members were Noeleen Price (DoN), Michael Cottrell (DoN), Anthony
Coyne (ADoN), Catherine McTiernan (ADoN), Kevin J. Plunkett (DoN)
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