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Guest Editorial
Defining Our Scope of Practice
Stephen Elsom
Australian & New Zealand College of Mental Health Nurses; Centre for Psychiatric Nursing Research and Practice, School of Nursing, University of Melbourne; Senior Lecturer, School of Nursing & Midwifery, Monash University, VIC
Article Text
In coming to write an editorial about mental health nursing practice I must inevitably face the challenge of deciding where to begin. It is tempting - perhaps even simplistic to resort to truisms such as 'change is inevitable' or to point to looming crises such as the ageing of our workforce. However, to choose just one theme which captures the nature of mental health nursing practice as I have observed it over the past quarter century, I would have to settle on responsiveness. Mental health nurses respond to changes in the ways in which services are delivered (Cleary 2003), to changes in the physical and social environments in which they work, to seemingly chronic shortages of resources, to changes in the clinical presentations of their clients, to dramatic increases in levels of acuity (O'Brien & Cole 2004), to opportunities for practice development (Chan & Leung 2002), and to the perceived shortcomings of the systems within which they practice. All of these factors challenge us to change the way we practice. It never occurs to us that the new roles and activities that we undertake as a result of such challenges are not still mental health nursing practice. This raises two simple but important questions: what is mental health nursing practice and who decides?
In addressing this question, I turn to some of the research I have been undertaking in Australia concerned with the notion of expanded practice in mental health nursing. In this context, expanded practice refers to practices that have been previously regarded as the exclusive domain of the medical profession and which are not normally considered to be part of the nurse's scope of practice, for example prescribing medication, referral to medical specialists and the ordering of diagnostic tests. The development of the nurse practitioner role has generated considerable interest in these and in advanced practice roles in nursing. Elsewhere we have called for a clear differentiation between expanded practice and advanced practice (Elsom, Happell & Manias 2005).
One of the interesting findings of this work has been the surprising extent of expanded practice already occurring on an informal and perhaps 'illegal basis'. Many community mental health nurses (for example) routinely advise general practitioners about the prescription of psychotropic medications. They also make recommendations about the use of diagnostic tests and the need for referral to medical specialists. Nurses who undertake such practices universally report that they do so in the interests of their clients. Typically their rationale is to prevent inconvenience for a client or family member, or to prevent deterioration in a client's condition. Often an underlying factor is the lack of medical resources or difficulty in accessing appropriate staff in a timely manner. The following quote from one of the participants in my recent research captures a common theme in mental health nurses' understanding of their scope of professional practice:
Historically nurses have always picked up the slack in terms of delivery of health care. [N]ursing tends to fill - oozes into spaces in some ways. Maybe this is just another process of that oozing into the gap that needs filling. Maybe nurses can't help themselves.
And there is national evidence to support the ideas coming directly from the profession. The recently released Australian Government Productivity Commission's report on the health workforce (2005) suggests that the scope of practice of mental health nurses and health workers generally is likely to undergo further changes in response to the needs of Australia's community for a more efficient and flexible workforce. So in the quest for flexibility there is the opportunity to develop a nationally consistent framework for nursing scopes of practice (National Nursing & Nursing Education Taskforce 2005). I am hopeful that this will happen yet it remains to be seen.
Clearly, the scope of mental health nursing practice is so dynamic and responsive to consumer and service needs that it cannot be ignored. It is also a clinical driver inherent in our profession to get the job done, but in so doing it is also a problem for our profession. Mental health services do not overtly acknowledge the existence of expanded nursing practice. And there is little recognition and support for the nurses who are undertaking it. Nursing curricula in universities do not prepare nurses to undertake these roles, either as a result of internal political pressures or simply through a lack of vision. Who teaches mental health nurses how to advise doctors about the appropriate prescription of psychotropic medication?
In digging deeper into this topic, it is important for our profession to consider whether or not we need to have a consistently defined scope or framework for mental health nursing practice. Whose interests would such a framework serve? Do other professions involved in the provision of mental health services have such frameworks? Most importantly, what should such a framework look like? Would it include such practices as training and supervising doctors in the appropriate prescription of psychotropic medications? If not, what message are we sending to the nurses already engaged in such practices?
If mental health nursing needs a defined scope of practice it will be important to ensure that flexibility remains to enable us to continue to respond and to develop the nature of mental health nursing practice. At the heart of the matter is professional self-governance. Mental health nurses must determine what mental health nursing is. To do this, we need to engage with the ongoing dialogue about the nature of the mental health workforce and ensure that our profession continues to develop and thrive into the future.
References
Chan SW and Leung JK (2002) Cognitive behavioural therapy for clients with schizophrenia: implications for mental health nursing practice. Journal of Clinical Nursing 11(2): 214-224.
Cleary M (2003) The challenges of mental health care reform for contemporary mental health nursing practice: relationships, power and control. International Journal of Mental Health Nursing 12(2): 139-147.
Elsom S, Happell B and Manias E (2005) Mental health nurse practitioner: expanded or advanced? International Journal of Mental Health Nursing 14(3): 181-186.
National Nursing & Nursing Education Taskforce (2005) Scope of Practice Commentary Paper. Canberra.
O'Brien L and Cole R (2004) Mental health nursing practice in acute psychiatric close-observation areas. International Journal of Mental Health Nursing 13(2): 89-99.
Productivity Commission (2005) Australia's Health Workforce, Position Paper, Canberra.
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