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The implementation of the Mental Health Nursing Specialty in Andalusia. A community approach
Enferm Clin. 2019;29(6):369---374
www.elsevier.es/enfermeriaclinica
SPECIAL ARTICLE
The implementation of the Mental Health Nursing Specialty in Andalusia. A community approach夽 Evelyn Huizing a , Susana Rodríguez-Gómez b,∗ , Nieves Lafuente Robles b a b
Plan Integral de Salud Mental de Andalucía, Servicio Andaluz de Salud, Consejería de Salud y Familia, Junta de Andalucía, Spain Estrategia de Cuidados de Andalucía, Servicio Andaluz de Salud, Consejería de Salud y Familia, Junta de Andalucía, Spain
Received 1 October 2019; accepted 2 October 2019
KEYWORDS Registered nurse; Psychiatric nurse; Mental health; Community mental health model; Health care system
Abstract Health systems have a responsibility to respond to the new health needs of the population, which are characterized by factors such as aging, chronicity and / or dependency situations and which requires quality and specialized care adapted to different areas where care is provided, care offered by trained and increasingly qualified professionals to improve the health outcomes of the caregivers. In 2016, in Andalusia the regulatory framework by which is created the statutory professional category of nurse/specialists is published, including the specialty of Mental Health Nursing in the Andalusian Health Service. In the field of Mental Health, the development of this normative framework and the definition and occupation of positions, will allow the health system to combine the role of specialist nurses with that of nurses who provide general care, Registered Nurses, in order to advance in the best response to the health needs of citizens in this area of care. In this context, the functions and competencies that these specialist nurses will contribute differently to the mental health care model are defined. The development of the specialty will be an added value both to improve the health outcomes of people with mental health problems, and to improve the quality of care, efficiency and sustainability of health systems. © 2019 Published by Elsevier Espa˜ na, S.L.U.
DOI of original article: https://doi.org/10.1016/j.enfcli.2019.10.003 Please cite this article as: Huizing E, Rodríguez-Gómez S, Lafuente Robles N. La implantación de la especialidad de Enfermería de Salud Mental en Andalucía desde un enfoque comunitario. Enferm Clin. 2019;29:370---375. ∗ Corresponding author. E-mail address: [email protected] (S. Rodríguez-Gómez). 夽
2445-1479/© 2019 Published by Elsevier Espa˜ na, S.L.U.
370
PALABRAS CLAVE Enfermeras; Enfermeras especialistas; Salud mental; Modelo de salud mental comunitario; Sistema sanitario
E. Huizing et al.
La implantación de la especialidad de Enfermería de Salud Mental en Andalucía desde un enfoque comunitario Resumen Los sistemas sanitarios tienen la responsabilidad de dar respuesta a las nuevas necesidades de salud de la población, que se caracterizan por factores como el envejecimiento, la cronicidad y/o las situaciones de dependencia y que requiere de cuidados de calidad, especializados y adaptados a diferentes ámbitos donde la atención se presta, cuidados ofertados por profesionales formados y cada vez más cualificados para mejorar los resultados en salud de las personas que cuidan. En el a˜ no 2016, en Andalucía se publica el marco normativo por el que se crea la categoría profesional estatutaria de enfermero/a especialistas entre las que se incluye la especialidad de Enfermería de Salud Mental en el Servicio Andaluz de Salud. En el ámbito de la Salud Mental, el desarrollo de este marco normativo y la definición y ocupación de puestos, permitirá al sistema sanitario conjugar el papel de las Enfermeras Especialistas con el de las enfermeras que prestan cuidados generales, Enfermeras de Graduadas, en pro de avanzar en la mejor respuesta a las necesidades de salud de la ciudadanía en este ámbito de atención. El desarrollo de la especialidad podrá suponer un valor a˜ nadido tanto para la mejora de los resultados en salud de las personas con problemas de salud mental, como para mejorar la calidad asistencial, la eficiencia y la sostenibilidad de los sistemas sanitarios. © 2019 Publicado por Elsevier Espa˜ na, S.L.U.
Introduction Health systems are responsible for meeting changes in the health needs of the population they serve, which is currently characterised by the triad of ageing, chronicity and dependency, and by the greater expectations of the population in terms of improved accessibility, speed of response, as well as the personalisation and greater specialisation and quality of the care they receive. In this context, it is necessary to move from polyvalence to specialisation in care and to acknowledge the existence of professionals with higher qualifications and training, capable of caring for people with better specific competences and improving health outcomes and efficiency in the planning of services. The inevitable scientific-technical development in the field of health in particular makes specialisation in any of the areas of knowledge a necessity to which the public authorities must respond, and regulate its implementation and updating.1 The Ministry of Health of the Regional Government of Andalusia has issued the Order of 10 November 2016, by which, within the scope of the health centres of the Andalusian Health Service (SAS), the statutory professional category of the specialist nurse is created, a category that includes the specialty of Mental Health Nursing The mental health nurse specialist (MHNS) is the health professional who, with a responsible scientific attitude and using clinical and technological means appropriate to the development of science at all times, provides specialist care in Mental Health through the provision of nursing care. This specialist care is provided in the different levels of care: mental health promotion, prevention, treatment and rehabilitation.1
For the incorporation of the MHNS to the positions established in the area of healthcare, it is the responsibility of the health systems to define the professional competences that these new profiles include, in order to extend the care response to specific areas of a specialty, in this case, mental health. MHNS competences will provide added value for achieving care excellence in the specific area of healthcare.2 However, as stated in the Order by which the training programme in the specialty of Mental Health Nursing is approved and issued,1 it is not a question of mimicking or repeating the model implemented for other specialist professional groups, such as the physician collective, or of obliging all nurses in the field of mental health to be specialists. Rather, it is a question of combining the role of these professionals, who have specialist training, with the needs of citizenry and the possibilities of the health system, making, where appropriate, the role of the specialist nurse compatible with that of the nurse who must continue to perform their professional role within society and who constitutes a key, flexible and useful professional profile for the health system, such as the graduate nurse who provides general care.
The community mental health model as a basis for the incorporation of mental health nurse specialists into the Andalusian health service In Andalusia, a community care model for the mental health of the population has been implemented for decades. Based on this model, community mental health, with a holistic approach, responds to these specific problems using community resources to ensure that people with mental health problems can exercise their right to receive care and support
Sacrocolpopexy with 24-hour hospital stay in their own environment and thus optimise their possibility of recovery.3 Community mental health requires a clear commitment to the philosophy of recovery, promotes the use of evidencebased interventions in the specific context, and uses the different resources and contacts of a wider community network.4 Within this vision, the professional contribution of the MHNS derives from their work with people, and how they approach mental health disorders, to effect their social integration.1 The importance of the social integration and inclusion of people with mental health problems is in line with European mental health policies4 and with the UN Convention on the Rights of Persons with Disabilities.5 Likewise, the need to develop specialised community care programmes for the treatment of people with more serious problems and the importance of early care in psychosis make it necessary to prioritise the incorporation of specialist professional profiles, such as that of the MHNS, in units that are more community based.6 The Andalusian Health Service (SAS), on the basis of this community model of mental health care, is committed to modifying the nursing positions currently defined in this field to include the MHNS in these facilities. Mental health units that provide care in the community generally have, in many units, one single nursing position, and if there are more than one, each nurse is assigned their own group of patients, and therefore, to prevent fragmentation and to preserve personalisation in continuous care, there is no possibility of differentiating nursing work into two levels: that of the specialist nurse and that of the graduate nurse. Thus, the health system is committed to turning around all the nursing positions in the community area so that they are occupied by an MHNS.
Coexistence of graduate nurses and mental health nurses In line with the Order on the Mental Health Nursing training programme,1 the SAS attempts to combine the incorporation into the system of the MHNS and their training in assisting people in a situation of high demand for specific care, to help them remain in their environment for as long as possible with the best possible quality of life, with the existence of the graduate nurse. The latter being a key figure in delivering general care adapted to the specific area of mental health. In an initial phase of implementing this change, there is predicted to be an MHNS among all nursing positions in outpatient care facilities in the community, by modifying graduate MHNS places. The set of positions defined in this area accounts currently for 37% of mental health nursing positions in the SAS. On this basis, the MHNS will be included in the following services: community Mental Health Unit, Child and Youth Mental Health Unit, Mental Health Rehabilitation Unit and Mental Health Day Hospital, until all the defined positions are filled. In the case of full adult hospitalisation facilities, Mental Health Hospitalisation Unit and Mental Health Therapeutic Community, where 63% of nurses in mental health work, the two profiles will co-exist: graduate nurses and MHNS. Therefore, in these facilities it is necessary to adjust the allocation of positions between the two nurse profiles and to define a
371 care model that allows effective organisation of the functions and competences that each will undertake in delivering care.
Specific functions of mental health nurses The SAS has defined the functions and competences that differentiate graduate nurses and MHNS based on the contents of various reference documents: The Official Programme of the Mental Health Nursing Specialty of the Ministry of Health, Social Policy and Equality,1 The Accreditation Manual for Mental Health Nurses of the Andalusian Health Quality Agency,7 the latest draft of the competence document of the Spanish Association of Mental Health Nursing (2016) and the latest draft of the corporate competence map of the SAS for the mental health nurses of the Andalusian Health Quality Agency. A review was also conducted of the NIC,8 especially in the behavioural, safety, family and health system areas. Nurses from the different mental health facilities of the SAS, the Spanish Association of Mental Health Nursing, the Andalusian Association of Mental Health Professionals, the Comprehensive Mental Health Plan and the Andalusian Care Strategy participated in the working group for their definition. Finally, from the Andalusian Care Strategy9 and the III Comprehensive Mental Health Plan of Andalusia of the SSPA,6 a reference document was designed defining the differential functions and competences that the MHNS will deliver in the mental health care facilities of the SAS where they will work. In this article the specific functions of the specialist nurse are outlined, although the competences linked to these functions have also been defined in a more extensive document.
Functions at community level The differential roles and competences that specialist nurses will perform in community mental healthcare facilities relate to driving care quality in the area of mental health and will combine 3 roles: clinician, consultant to other care professionals and researcher/innovator (Table 1).
Functions for the hospital environment Social inclusion and care models with a focus on recovery, driven by the Comprehensive Mental Health Plan in Andalusia, are worked on from the more community---based facilities, that provide outpatient care, as well as adult hospital facilities, either short stay (Mental Health Hospitalisation Unit) or medium stay (Mental Health Therapeutic Community), as these are facilities that are integrated in the Community Mental Health Care Network. Transitional care, in both the admission and in the discharge phase, is key to ensuring appropriate coordination between professionals and that the person is included as much as possible in continuity of care arrangements. The MHNS, in these facilities, will play a fundamental role in the area of health safety, in protecting the general health of the people under their care and in promoting healthy lifestyle habits. Likewise, the specialist nurse will play a key role in promoting actions to improve the therapeutic
372 Table 1 Service.
E. Huizing et al. Summary table of the functions of mental health nurse specialists in community facilities of the Andalusian Health
To act as a driving force for change of the care model and the implementation of new strategies To To To To To
implement the promotion of mental health, emotional wellbeing and risk prevention collaborate in the screening of new cases and coordinate the follow-up needs with Primary Care be the point of reference for mental health care for people with more complex needsa promote humanisation of care (reduction of coercive measures, recovery, social inclusion) ensure adequate transition in the admission and discharge phases in coordination with other professionals and to involve the person as much as possible in continuity of care arrangements To promote group work To act as a consultant for other professionals (mental health teams, hospital, primary care and other sectors: social services, education, etc.) and to be part of working groups and committees To encourage and participate in improvements to the unit’s therapeutic environment (spaces, dynamics, relational environment and teamwork) To be points of reference for specific care programmes To encourage dialogue and participation with citizens and mental health professional groups To encourage and participate in graduate, postgraduate and continuous education To advance research and innovation To act as a reference point for the design of guidelines and protocols based on available evidence To develop methodologies for implementing results from research and scientific evidence into practice To promote the achievement of quality standards
Source: Andalusian Care Strategy, Comprehensive Mental Health Plan, Andalusian Health Servic. a Complex needs are considered if any of the following criteria are met: 1) problems of uptake/access to the mental health network; 2) their situation poses or might pose a risk to their life; 3) negative repercussions on different areas of personal functioning (daily life, education, employment, social relations); 4) their condition is or is predicted to be prolonged over time, with the need for comprehensive and integrated care, continuity of care, and internal and external coordination.10
Table 2
Summary table of the functions of mental health nurse specialists in hospital facilities of the Andalusian Health Service.
To act as a driving force for change of the care model and implementation of new strategies To ensure transitional care and continuity of care in complex casesa To promote the humanisation of care (recovery and reduction of coercive measures) Promote group work Consultant for specialist mental health care (hospital, primary care and other sectors: social services, education, etc.) and be part of working groups and committees Encourage and participate in the improvement of the therapeutic environment of the unit (spaces, dynamics, relational environment and teamwork) To be points of reference for specific care programmes To encourage dialogue with citizens and professional groups To encourage and participate in graduate, postgraduate and continuous education To advance research and innovation To act as a reference point for the design of guidelines and protocols based on available evidence To develop methodologies for implementing results from research and scientific evidence into practice To promote the achievement of quality standards Source: Andalusian Care Strategy, Comprehensive Mental Health Plan, Andalusian Health Service.. a Complex needs are considered if any of the following criteria are met: 1) problems of uptake/access to the mental health network; 2) their situation poses or might pose a risk to their life; 3) negative repercussions on different areas of personal functioning (daily life, education, employment, social relations); 4) their condition is or is predicted to be prolonged over time, with the need for comprehensive and integrated care, continuity of care and internal and external coordination.10 .
environment and in preventing the use of coercive measures in mental health hospital units and the Mental Health Therapeutic Community, as these are fundamental areas for working in care teams, due to continuous contact with the people they serve. Graduate nurses will continue to assign patients for general and specific mental health care, referring the case to the MHNS to deliver their competences
during the welcome on admission and on discharge for people whose condition is more complex, in order to ensure appropriate transitional and specialist care. A series of functions have also been identified for the MHNS in the hospital environment (Table 2) aligned with the previous functions of the MHNS in the community-based facilities.
Sacrocolpopexy with 24-hour hospital stay Table 3 Competence dimensions of the Andalusian Health Service mental health nurse specialist. Human rights, citizen participation and shared responsibility
Therapeutic support
Promotion and prevention Detection, care and recovery Safety
Family approach Knowledge management
Source: Andalusian Care Strategy, Comprehensive Mental Health Plan, Andalusian Health Service.11,12
Competences of the mental health nurse specialist The specific and differential competences of the MHNS are organised into 7 dimensions in line with the framework of the Andalusian Care Strategy and Comprehensive Mental Health Plan (Table 3). Each of these dimensions will group together specific competences to be developed by the MHNS within that specific dimension. There is a reference document for developing these competences in the community setting and another for the hospital setting. The purpose of defining these competences is to establish a specific field or intervention for each of these professional roles: that of specialist care in the area of mental health and of general care in this same area. These competences are required of the nurse specialists in the mental health facilities who are participating in the experience of incorporating the specialty.
Discussion Positive aspects of this new organisational model for integrating the mental health nurse specialist profile Faced with the demands on the health system posed by the administrative changes necessary to redefine some positions as specialist profiles without associating a proposal for change of the care model that would enable advanced competence, the design of this new model that links the coexistence of nurse profiles with different training and competences has been crucial for the health system to resoundingly commit to the development of the speciality in the reality of care practice. This model enables the health system to define differentiated positions with specific competences. In addition, the definition of functions and competences associated with the position has also enabled the health system to make visible the added value that these specialists will bring in practice, improving care quality in different aspects. The fact that many holders of positions in the area of mental health in Andalusia do not have specialist qualification, calculated at 35%, makes the coexistence of both profiles unavoidable. Moreover, there is currently a very heterogeneous map of permanent nurses with and without the
373 specialty in the mental health services of the SAS. There are facilities where up to 70% of nursing staff have a specialist qualification and other services of the same type with no specialist nurses. Given this situation, the model for uniting both the profiles we have defined is not only necessary, but also serves as support for transition, specifically establishing the differential characteristics of the roles in practice of both of these profiles. This clarity of differentiated functions has allowed the health system to opt for the progressive incorporation of specialist nurses and defend the need to continue to rely on the general care profiles of graduate nurses. The fact that graduate nursing places are maintained in some areas of the mental health services enables nurses with many years of experience, but without specialist qualifications and without a tenured position, to continue to work in the area of mental health. The basic criterion for developing this mental health care model is to reinforce the model of community care in this area, since it is the benchmark model for mental health services worldwide, offering coherence to the future development of the proposed model of care. This model enables the progressive incorporation of specialists, in rural as well as urban areas, where it is always easier to fill positions and allows us to assess the future training needs of specialists. Currently many of the autonomous regions where all positions have been converted into specialist posts need to resort to specialist nurses from other autonomous regions as they do not have a sufficient number to cover these positions.
Possible limitations in the development of this model As in any process of change, this transition from models with conventional teams prior to the incorporation of new, more highly trained and qualified professional profiles in these care areas where nursing specialties are defined will trigger a situation of progressive adjustment due to the unavoidable coexistence of graduate nurses and specialist nurses in the context of mental health care. This is why this framework document has been prepared to define differential competences between both profiles, in view of the discomfort at work and work organisation that can occur in hospital facilities where both professional profiles coincide. All the more so when it is possible that the health system would only define specialist nurse posts in these units, and there are more nurses who hold the specialist qualification in the unit. In these cases, the system will have to study how to facilitate access to a specialist position in the community for these nurses who come from hospital facilities, but who have the specialist qualification. In any case, configuring the map of positions shared between graduate and specialist nurses is not intended to convey the idea that hospital facilities are any less complex contexts of care; we are undertaking an unprecedented organisational model in which we will safeguard the competences of graduate nurses and what they can contribute in practice and where we will incorporate the potential value of specialist nurses in contributing functions and developing differentiated competences. Developing this model
374 of coexistence of profiles, experiencing and testing it and generating evidence on the added value of the work of specialists in this field will enable the health system to evaluate and adapt the number of professionals needed in these facilities in the near future. In this regard, it is extremely important for health systems to ensure the job security of these care teams, due to the specific nature of work in this area of mental health, and thus ensure the efficiency of training and the continuity of specific health programmes in this area of care.
Conclusion The inclusion of specialists in the maps of positions defined by national health systems must be demanded from the perspective of citizens and their specific care needs in certain areas of care, from the perspective of professional development and the need for specialist nurses to be able to exercise the functions and competences in specialist care, for which the health system has trained them, and from the perspective of the health system in being able to gain added value towards improving quality of care, efficiency in the organisation of services and the health outcomes of the population they serve. In order to be able to include the specialist nurse in the current professional scenario, a model of care must be developed in the different health systems that allows both profiles --- specialist nurses and graduate nurses --- to be combined in the specific care area for which the speciality is defined. In the case of mental health, the definition of this care model is based on developing the current model of community mental health aimed at recovery, defined in Andalusia as the basis for guiding professional practice in mental health. In this context, the further development of the Mental Health Nursing specialty in the SAS will focus on promoting this model for the integration and social inclusion of people, and constitute the criterion for defining and progressing in the provision of positions for these specialists within the health system and also clearly defining what the functions and competences of these specialist nurses would be, to make visible and acknowledge the value that these professional profiles provide in the differentiated care of the specific population they serve. The positive repercussions on the health outcomes of the population, supported by scientific evidence, and the appropriateness of the presence of these specialist profiles for the health systems will be the fundamental key to ensure the incorporation of specialist nurses into a health system that truly wants to make progress in improving their responses to the care needs of the population.
E. Huizing et al.
Conflict of interests The authors have no conflict of interests to declare.
References 1. Orden SPI/1356/2011, de 11 de mayo, por la que se aprueba y publica el programa formativo de la especialidad de Enfermería de Salud Mental. BOE-A-2011-9081. 2. Lafuente-Robles N, Fernández-Salazar S, Rodríguez-Gómez S, Casado-Mora MI, Morales-Asencio JM, Ramos-Morcillo AJ. Desarrollo competencial de las enfermeras en el sistema sanitario público de Andalucía. Enferm Clin. 2019;29(2):83---9, http://dx.doi.org/10.1016/j.enfcli.2018.12.013. 3. Keet R, De Vetten-McMahon M, Shields-Zeeman L, Ruud T, Van Weeghel J, Bahler M, et al. Recovery for all in the community; position paper on principles and key elements of communitybased mental health care. BMC Psychiatry. 2019:174. 4. Comisión de las Comunidades Europeas. Mejorar la salud mental de la población. Hacia una estrategia de la Unión Europea en materia de salud mental (Libro Verde). Bruselas: CCE; 2005. 5. Organización de las Naciones Unidas. Convención sobre los Derechos de las Personas con Discapacidad. Nueva York: ONU; 2006. 6. Consejería de Salud. III Plan Integral de Salud Mental de Andalucía 2016-2020. Sevilla: Junta de Andalucía, Consejería de Salud; 2016. 7. Consejería de Salud. Agencia de Calidad Sanitaria de Andalucía. Manual de competencias profesionales. Enfermero/a de Salud Mental. Sevilla: Junta de Andalucía, Consejería de Salud; 2015. 8. McCloskey Dochterman J, Bulechek G. Clasificaci´ on de Intervenciones de Enfermer´ia (NIC). 6th ed. Barcelona, Espan˜a: Elsevier; 2014. 9. Consejería de Salud. Servicio Andaluz de Salud. Estrategia de cuidados de Andalucía-PiCuida. Sevilla: Junta de Andalucía, Consejería de Salud; 2015. 10. Consejería de Salud. Proceso Asistencial Integrado Trastorno Mental Grave. Sevilla: Junta de Andalucía, Consejería de Salud; 2006. 11. Picuida. Estrategia de Cuidados de Andalucía: nuevos retos en el cuidado de la Ciudadanía. Servicio Andaluz de Salud. Consejeria de Salud. Junta de Andalucía. Sevilla 2015 [accessed 30 Sep 2019]. Available from: https://www.sspa.juntadeandalucia.es/ servicioandaluzdesalud/sites/default/fi les/sincfiles/wsassasdocumento/2019/estrategia enero media-mediafile 2016.pdf. 12. III Plan Integral de Salud Mental 2016-2020. Servicio Andaluz de Salud. Consejeria de Salud. Junta de Andalucía. Sevilla 2016 [accessed 30 Sep 2019]. Available from: https://www.sspa. juntadeandalucia.es/servicioandaluzdesalud/el-sas/serviciosy-centros/salud-mental/iii-plan-integral-de-salu
www.elsevier.es/enfermeriaclinica
SPECIAL ARTICLE
The implementation of the Mental Health Nursing Specialty in Andalusia. A community approach夽 Evelyn Huizing a , Susana Rodríguez-Gómez b,∗ , Nieves Lafuente Robles b a b
Plan Integral de Salud Mental de Andalucía, Servicio Andaluz de Salud, Consejería de Salud y Familia, Junta de Andalucía, Spain Estrategia de Cuidados de Andalucía, Servicio Andaluz de Salud, Consejería de Salud y Familia, Junta de Andalucía, Spain
Received 1 October 2019; accepted 2 October 2019
KEYWORDS Registered nurse; Psychiatric nurse; Mental health; Community mental health model; Health care system
Abstract Health systems have a responsibility to respond to the new health needs of the population, which are characterized by factors such as aging, chronicity and / or dependency situations and which requires quality and specialized care adapted to different areas where care is provided, care offered by trained and increasingly qualified professionals to improve the health outcomes of the caregivers. In 2016, in Andalusia the regulatory framework by which is created the statutory professional category of nurse/specialists is published, including the specialty of Mental Health Nursing in the Andalusian Health Service. In the field of Mental Health, the development of this normative framework and the definition and occupation of positions, will allow the health system to combine the role of specialist nurses with that of nurses who provide general care, Registered Nurses, in order to advance in the best response to the health needs of citizens in this area of care. In this context, the functions and competencies that these specialist nurses will contribute differently to the mental health care model are defined. The development of the specialty will be an added value both to improve the health outcomes of people with mental health problems, and to improve the quality of care, efficiency and sustainability of health systems. © 2019 Published by Elsevier Espa˜ na, S.L.U.
DOI of original article: https://doi.org/10.1016/j.enfcli.2019.10.003 Please cite this article as: Huizing E, Rodríguez-Gómez S, Lafuente Robles N. La implantación de la especialidad de Enfermería de Salud Mental en Andalucía desde un enfoque comunitario. Enferm Clin. 2019;29:370---375. ∗ Corresponding author. E-mail address: [email protected] (S. Rodríguez-Gómez). 夽
2445-1479/© 2019 Published by Elsevier Espa˜ na, S.L.U.
370
PALABRAS CLAVE Enfermeras; Enfermeras especialistas; Salud mental; Modelo de salud mental comunitario; Sistema sanitario
E. Huizing et al.
La implantación de la especialidad de Enfermería de Salud Mental en Andalucía desde un enfoque comunitario Resumen Los sistemas sanitarios tienen la responsabilidad de dar respuesta a las nuevas necesidades de salud de la población, que se caracterizan por factores como el envejecimiento, la cronicidad y/o las situaciones de dependencia y que requiere de cuidados de calidad, especializados y adaptados a diferentes ámbitos donde la atención se presta, cuidados ofertados por profesionales formados y cada vez más cualificados para mejorar los resultados en salud de las personas que cuidan. En el a˜ no 2016, en Andalucía se publica el marco normativo por el que se crea la categoría profesional estatutaria de enfermero/a especialistas entre las que se incluye la especialidad de Enfermería de Salud Mental en el Servicio Andaluz de Salud. En el ámbito de la Salud Mental, el desarrollo de este marco normativo y la definición y ocupación de puestos, permitirá al sistema sanitario conjugar el papel de las Enfermeras Especialistas con el de las enfermeras que prestan cuidados generales, Enfermeras de Graduadas, en pro de avanzar en la mejor respuesta a las necesidades de salud de la ciudadanía en este ámbito de atención. El desarrollo de la especialidad podrá suponer un valor a˜ nadido tanto para la mejora de los resultados en salud de las personas con problemas de salud mental, como para mejorar la calidad asistencial, la eficiencia y la sostenibilidad de los sistemas sanitarios. © 2019 Publicado por Elsevier Espa˜ na, S.L.U.
Introduction Health systems are responsible for meeting changes in the health needs of the population they serve, which is currently characterised by the triad of ageing, chronicity and dependency, and by the greater expectations of the population in terms of improved accessibility, speed of response, as well as the personalisation and greater specialisation and quality of the care they receive. In this context, it is necessary to move from polyvalence to specialisation in care and to acknowledge the existence of professionals with higher qualifications and training, capable of caring for people with better specific competences and improving health outcomes and efficiency in the planning of services. The inevitable scientific-technical development in the field of health in particular makes specialisation in any of the areas of knowledge a necessity to which the public authorities must respond, and regulate its implementation and updating.1 The Ministry of Health of the Regional Government of Andalusia has issued the Order of 10 November 2016, by which, within the scope of the health centres of the Andalusian Health Service (SAS), the statutory professional category of the specialist nurse is created, a category that includes the specialty of Mental Health Nursing The mental health nurse specialist (MHNS) is the health professional who, with a responsible scientific attitude and using clinical and technological means appropriate to the development of science at all times, provides specialist care in Mental Health through the provision of nursing care. This specialist care is provided in the different levels of care: mental health promotion, prevention, treatment and rehabilitation.1
For the incorporation of the MHNS to the positions established in the area of healthcare, it is the responsibility of the health systems to define the professional competences that these new profiles include, in order to extend the care response to specific areas of a specialty, in this case, mental health. MHNS competences will provide added value for achieving care excellence in the specific area of healthcare.2 However, as stated in the Order by which the training programme in the specialty of Mental Health Nursing is approved and issued,1 it is not a question of mimicking or repeating the model implemented for other specialist professional groups, such as the physician collective, or of obliging all nurses in the field of mental health to be specialists. Rather, it is a question of combining the role of these professionals, who have specialist training, with the needs of citizenry and the possibilities of the health system, making, where appropriate, the role of the specialist nurse compatible with that of the nurse who must continue to perform their professional role within society and who constitutes a key, flexible and useful professional profile for the health system, such as the graduate nurse who provides general care.
The community mental health model as a basis for the incorporation of mental health nurse specialists into the Andalusian health service In Andalusia, a community care model for the mental health of the population has been implemented for decades. Based on this model, community mental health, with a holistic approach, responds to these specific problems using community resources to ensure that people with mental health problems can exercise their right to receive care and support
Sacrocolpopexy with 24-hour hospital stay in their own environment and thus optimise their possibility of recovery.3 Community mental health requires a clear commitment to the philosophy of recovery, promotes the use of evidencebased interventions in the specific context, and uses the different resources and contacts of a wider community network.4 Within this vision, the professional contribution of the MHNS derives from their work with people, and how they approach mental health disorders, to effect their social integration.1 The importance of the social integration and inclusion of people with mental health problems is in line with European mental health policies4 and with the UN Convention on the Rights of Persons with Disabilities.5 Likewise, the need to develop specialised community care programmes for the treatment of people with more serious problems and the importance of early care in psychosis make it necessary to prioritise the incorporation of specialist professional profiles, such as that of the MHNS, in units that are more community based.6 The Andalusian Health Service (SAS), on the basis of this community model of mental health care, is committed to modifying the nursing positions currently defined in this field to include the MHNS in these facilities. Mental health units that provide care in the community generally have, in many units, one single nursing position, and if there are more than one, each nurse is assigned their own group of patients, and therefore, to prevent fragmentation and to preserve personalisation in continuous care, there is no possibility of differentiating nursing work into two levels: that of the specialist nurse and that of the graduate nurse. Thus, the health system is committed to turning around all the nursing positions in the community area so that they are occupied by an MHNS.
Coexistence of graduate nurses and mental health nurses In line with the Order on the Mental Health Nursing training programme,1 the SAS attempts to combine the incorporation into the system of the MHNS and their training in assisting people in a situation of high demand for specific care, to help them remain in their environment for as long as possible with the best possible quality of life, with the existence of the graduate nurse. The latter being a key figure in delivering general care adapted to the specific area of mental health. In an initial phase of implementing this change, there is predicted to be an MHNS among all nursing positions in outpatient care facilities in the community, by modifying graduate MHNS places. The set of positions defined in this area accounts currently for 37% of mental health nursing positions in the SAS. On this basis, the MHNS will be included in the following services: community Mental Health Unit, Child and Youth Mental Health Unit, Mental Health Rehabilitation Unit and Mental Health Day Hospital, until all the defined positions are filled. In the case of full adult hospitalisation facilities, Mental Health Hospitalisation Unit and Mental Health Therapeutic Community, where 63% of nurses in mental health work, the two profiles will co-exist: graduate nurses and MHNS. Therefore, in these facilities it is necessary to adjust the allocation of positions between the two nurse profiles and to define a
371 care model that allows effective organisation of the functions and competences that each will undertake in delivering care.
Specific functions of mental health nurses The SAS has defined the functions and competences that differentiate graduate nurses and MHNS based on the contents of various reference documents: The Official Programme of the Mental Health Nursing Specialty of the Ministry of Health, Social Policy and Equality,1 The Accreditation Manual for Mental Health Nurses of the Andalusian Health Quality Agency,7 the latest draft of the competence document of the Spanish Association of Mental Health Nursing (2016) and the latest draft of the corporate competence map of the SAS for the mental health nurses of the Andalusian Health Quality Agency. A review was also conducted of the NIC,8 especially in the behavioural, safety, family and health system areas. Nurses from the different mental health facilities of the SAS, the Spanish Association of Mental Health Nursing, the Andalusian Association of Mental Health Professionals, the Comprehensive Mental Health Plan and the Andalusian Care Strategy participated in the working group for their definition. Finally, from the Andalusian Care Strategy9 and the III Comprehensive Mental Health Plan of Andalusia of the SSPA,6 a reference document was designed defining the differential functions and competences that the MHNS will deliver in the mental health care facilities of the SAS where they will work. In this article the specific functions of the specialist nurse are outlined, although the competences linked to these functions have also been defined in a more extensive document.
Functions at community level The differential roles and competences that specialist nurses will perform in community mental healthcare facilities relate to driving care quality in the area of mental health and will combine 3 roles: clinician, consultant to other care professionals and researcher/innovator (Table 1).
Functions for the hospital environment Social inclusion and care models with a focus on recovery, driven by the Comprehensive Mental Health Plan in Andalusia, are worked on from the more community---based facilities, that provide outpatient care, as well as adult hospital facilities, either short stay (Mental Health Hospitalisation Unit) or medium stay (Mental Health Therapeutic Community), as these are facilities that are integrated in the Community Mental Health Care Network. Transitional care, in both the admission and in the discharge phase, is key to ensuring appropriate coordination between professionals and that the person is included as much as possible in continuity of care arrangements. The MHNS, in these facilities, will play a fundamental role in the area of health safety, in protecting the general health of the people under their care and in promoting healthy lifestyle habits. Likewise, the specialist nurse will play a key role in promoting actions to improve the therapeutic
372 Table 1 Service.
E. Huizing et al. Summary table of the functions of mental health nurse specialists in community facilities of the Andalusian Health
To act as a driving force for change of the care model and the implementation of new strategies To To To To To
implement the promotion of mental health, emotional wellbeing and risk prevention collaborate in the screening of new cases and coordinate the follow-up needs with Primary Care be the point of reference for mental health care for people with more complex needsa promote humanisation of care (reduction of coercive measures, recovery, social inclusion) ensure adequate transition in the admission and discharge phases in coordination with other professionals and to involve the person as much as possible in continuity of care arrangements To promote group work To act as a consultant for other professionals (mental health teams, hospital, primary care and other sectors: social services, education, etc.) and to be part of working groups and committees To encourage and participate in improvements to the unit’s therapeutic environment (spaces, dynamics, relational environment and teamwork) To be points of reference for specific care programmes To encourage dialogue and participation with citizens and mental health professional groups To encourage and participate in graduate, postgraduate and continuous education To advance research and innovation To act as a reference point for the design of guidelines and protocols based on available evidence To develop methodologies for implementing results from research and scientific evidence into practice To promote the achievement of quality standards
Source: Andalusian Care Strategy, Comprehensive Mental Health Plan, Andalusian Health Servic. a Complex needs are considered if any of the following criteria are met: 1) problems of uptake/access to the mental health network; 2) their situation poses or might pose a risk to their life; 3) negative repercussions on different areas of personal functioning (daily life, education, employment, social relations); 4) their condition is or is predicted to be prolonged over time, with the need for comprehensive and integrated care, continuity of care, and internal and external coordination.10
Table 2
Summary table of the functions of mental health nurse specialists in hospital facilities of the Andalusian Health Service.
To act as a driving force for change of the care model and implementation of new strategies To ensure transitional care and continuity of care in complex casesa To promote the humanisation of care (recovery and reduction of coercive measures) Promote group work Consultant for specialist mental health care (hospital, primary care and other sectors: social services, education, etc.) and be part of working groups and committees Encourage and participate in the improvement of the therapeutic environment of the unit (spaces, dynamics, relational environment and teamwork) To be points of reference for specific care programmes To encourage dialogue with citizens and professional groups To encourage and participate in graduate, postgraduate and continuous education To advance research and innovation To act as a reference point for the design of guidelines and protocols based on available evidence To develop methodologies for implementing results from research and scientific evidence into practice To promote the achievement of quality standards Source: Andalusian Care Strategy, Comprehensive Mental Health Plan, Andalusian Health Service.. a Complex needs are considered if any of the following criteria are met: 1) problems of uptake/access to the mental health network; 2) their situation poses or might pose a risk to their life; 3) negative repercussions on different areas of personal functioning (daily life, education, employment, social relations); 4) their condition is or is predicted to be prolonged over time, with the need for comprehensive and integrated care, continuity of care and internal and external coordination.10 .
environment and in preventing the use of coercive measures in mental health hospital units and the Mental Health Therapeutic Community, as these are fundamental areas for working in care teams, due to continuous contact with the people they serve. Graduate nurses will continue to assign patients for general and specific mental health care, referring the case to the MHNS to deliver their competences
during the welcome on admission and on discharge for people whose condition is more complex, in order to ensure appropriate transitional and specialist care. A series of functions have also been identified for the MHNS in the hospital environment (Table 2) aligned with the previous functions of the MHNS in the community-based facilities.
Sacrocolpopexy with 24-hour hospital stay Table 3 Competence dimensions of the Andalusian Health Service mental health nurse specialist. Human rights, citizen participation and shared responsibility
Therapeutic support
Promotion and prevention Detection, care and recovery Safety
Family approach Knowledge management
Source: Andalusian Care Strategy, Comprehensive Mental Health Plan, Andalusian Health Service.11,12
Competences of the mental health nurse specialist The specific and differential competences of the MHNS are organised into 7 dimensions in line with the framework of the Andalusian Care Strategy and Comprehensive Mental Health Plan (Table 3). Each of these dimensions will group together specific competences to be developed by the MHNS within that specific dimension. There is a reference document for developing these competences in the community setting and another for the hospital setting. The purpose of defining these competences is to establish a specific field or intervention for each of these professional roles: that of specialist care in the area of mental health and of general care in this same area. These competences are required of the nurse specialists in the mental health facilities who are participating in the experience of incorporating the specialty.
Discussion Positive aspects of this new organisational model for integrating the mental health nurse specialist profile Faced with the demands on the health system posed by the administrative changes necessary to redefine some positions as specialist profiles without associating a proposal for change of the care model that would enable advanced competence, the design of this new model that links the coexistence of nurse profiles with different training and competences has been crucial for the health system to resoundingly commit to the development of the speciality in the reality of care practice. This model enables the health system to define differentiated positions with specific competences. In addition, the definition of functions and competences associated with the position has also enabled the health system to make visible the added value that these specialists will bring in practice, improving care quality in different aspects. The fact that many holders of positions in the area of mental health in Andalusia do not have specialist qualification, calculated at 35%, makes the coexistence of both profiles unavoidable. Moreover, there is currently a very heterogeneous map of permanent nurses with and without the
373 specialty in the mental health services of the SAS. There are facilities where up to 70% of nursing staff have a specialist qualification and other services of the same type with no specialist nurses. Given this situation, the model for uniting both the profiles we have defined is not only necessary, but also serves as support for transition, specifically establishing the differential characteristics of the roles in practice of both of these profiles. This clarity of differentiated functions has allowed the health system to opt for the progressive incorporation of specialist nurses and defend the need to continue to rely on the general care profiles of graduate nurses. The fact that graduate nursing places are maintained in some areas of the mental health services enables nurses with many years of experience, but without specialist qualifications and without a tenured position, to continue to work in the area of mental health. The basic criterion for developing this mental health care model is to reinforce the model of community care in this area, since it is the benchmark model for mental health services worldwide, offering coherence to the future development of the proposed model of care. This model enables the progressive incorporation of specialists, in rural as well as urban areas, where it is always easier to fill positions and allows us to assess the future training needs of specialists. Currently many of the autonomous regions where all positions have been converted into specialist posts need to resort to specialist nurses from other autonomous regions as they do not have a sufficient number to cover these positions.
Possible limitations in the development of this model As in any process of change, this transition from models with conventional teams prior to the incorporation of new, more highly trained and qualified professional profiles in these care areas where nursing specialties are defined will trigger a situation of progressive adjustment due to the unavoidable coexistence of graduate nurses and specialist nurses in the context of mental health care. This is why this framework document has been prepared to define differential competences between both profiles, in view of the discomfort at work and work organisation that can occur in hospital facilities where both professional profiles coincide. All the more so when it is possible that the health system would only define specialist nurse posts in these units, and there are more nurses who hold the specialist qualification in the unit. In these cases, the system will have to study how to facilitate access to a specialist position in the community for these nurses who come from hospital facilities, but who have the specialist qualification. In any case, configuring the map of positions shared between graduate and specialist nurses is not intended to convey the idea that hospital facilities are any less complex contexts of care; we are undertaking an unprecedented organisational model in which we will safeguard the competences of graduate nurses and what they can contribute in practice and where we will incorporate the potential value of specialist nurses in contributing functions and developing differentiated competences. Developing this model
374 of coexistence of profiles, experiencing and testing it and generating evidence on the added value of the work of specialists in this field will enable the health system to evaluate and adapt the number of professionals needed in these facilities in the near future. In this regard, it is extremely important for health systems to ensure the job security of these care teams, due to the specific nature of work in this area of mental health, and thus ensure the efficiency of training and the continuity of specific health programmes in this area of care.
Conclusion The inclusion of specialists in the maps of positions defined by national health systems must be demanded from the perspective of citizens and their specific care needs in certain areas of care, from the perspective of professional development and the need for specialist nurses to be able to exercise the functions and competences in specialist care, for which the health system has trained them, and from the perspective of the health system in being able to gain added value towards improving quality of care, efficiency in the organisation of services and the health outcomes of the population they serve. In order to be able to include the specialist nurse in the current professional scenario, a model of care must be developed in the different health systems that allows both profiles --- specialist nurses and graduate nurses --- to be combined in the specific care area for which the speciality is defined. In the case of mental health, the definition of this care model is based on developing the current model of community mental health aimed at recovery, defined in Andalusia as the basis for guiding professional practice in mental health. In this context, the further development of the Mental Health Nursing specialty in the SAS will focus on promoting this model for the integration and social inclusion of people, and constitute the criterion for defining and progressing in the provision of positions for these specialists within the health system and also clearly defining what the functions and competences of these specialist nurses would be, to make visible and acknowledge the value that these professional profiles provide in the differentiated care of the specific population they serve. The positive repercussions on the health outcomes of the population, supported by scientific evidence, and the appropriateness of the presence of these specialist profiles for the health systems will be the fundamental key to ensure the incorporation of specialist nurses into a health system that truly wants to make progress in improving their responses to the care needs of the population.
E. Huizing et al.
Conflict of interests The authors have no conflict of interests to declare.
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