Perspective
Defensive practices in mental health nursing: Professionalism and poignant tensions
Oladayo Bifarin RN(MH), MSc,
Anne Felton RN (MH) PhD,
Zoe Prince RN(MH), MSc,
Corresponding Author
Oladayo Bifarin RN(MH), MSc
School of Nursing and Allied Health, Faculty of Health, Liverpool John Moores University, Liverpool, UK
Centre for Applied Dementia Studies, Faculty of Health Studies, University of Bradford, Bradford, UK
Local Service Division, Risk and Governance Department, Mersey Care NHS FT, Liverpool, UK
Correspondence: Oladayo Bifarin, School of Nursing and Allied Health, Faculty of Health, Liverpool John Moores University, Liverpool, UK. Email: [email protected]
Search for more papers by this authorAnne Felton RN (MH) PhD
Institute of Health and Allied Professions, Nottingham Trent University, Nottingham, UK
Search for more papers by this authorZoe Prince RN(MH), MSc
Associate Director of Nursing and Patient Experience, Local Service Division, Mersey Care NHS FT, Liverpool, UK
Search for more papers by this authorOladayo Bifarin RN(MH), MSc,
Anne Felton RN (MH) PhD,
Zoe Prince RN(MH), MSc,
Corresponding Author
Oladayo Bifarin RN(MH), MSc
School of Nursing and Allied Health, Faculty of Health, Liverpool John Moores University, Liverpool, UK
Centre for Applied Dementia Studies, Faculty of Health Studies, University of Bradford, Bradford, UK
Local Service Division, Risk and Governance Department, Mersey Care NHS FT, Liverpool, UK
Correspondence: Oladayo Bifarin, School of Nursing and Allied Health, Faculty of Health, Liverpool John Moores University, Liverpool, UK. Email: [email protected]
Search for more papers by this authorAnne Felton RN (MH) PhD
Institute of Health and Allied Professions, Nottingham Trent University, Nottingham, UK
Search for more papers by this authorZoe Prince RN(MH), MSc
Associate Director of Nursing and Patient Experience, Local Service Division, Mersey Care NHS FT, Liverpool, UK
Search for more papers by this authorDeclaration of conflicts of interest: Not applicable.
Abstract
Mental health nursing is a skilled profession, well positioned to support patients towards recovery with evidence-based therapeutic interventions. However, the profession continues to be challenged by tensions surrounding the delivery of restrictive interventions and concerns over tendencies towards defensive practices. This paper examines the ambiguity this creates within the mental health nursing role. Organizational cultures that overvalue metrics and administrative tasks create barriers for therapeutic engagement while contributing to role confusion and stress within nursing. We need to address such structural constraints on nurses as mental health nurses’ well-being is crucial to service delivery and the realization of therapeutic goals. From the UK perspective, authors argue that there is a need to examine service structures that foster compassionate and transformational leadership to enable mental health nurses to exercise the agency to practice therapeutically. Education and quality nursing research have a pivotal role to play in enabling this shift.
References
- Australian College of Mental Health Nursing. (2010). Standards of Practice in Mental Health Nursing. ACT: ACMHN.
- Barker, P. & Buchanan-Barker, P. (2011). Myth of mental health nursing and the challenge of recovery. International Journal of Mental Health Nursing, 20 (5), 337–344.
- Beckett, P., Field, J., Molloy, L., Yu, N., Holmes, D. & Pile, E. (2013). Practice what you preach: Developing person-centred culture in inpatient mental health settings through strengths-based, transformational leadership. Issues in Mental Health Nursing, 34 (8), 595–601.
- Berzins, K., Baker, J., Louch, G. & Albutt, A. (2020). A qualitative exploration of mental health service user and carer perspectives on safety issues in UK mental health services. Health Expectations, 23 (3), 549–561.
- Bifarin, O. (2017). Reinforced therapeutic alliance: The way forward in nursing practice. British Journal of Mental Health Nursing, 6 (2), 95–100.
10.12968/bjmh.2017.6.2.95 Google Scholar
- Bifarin, O. & Jones, S. (2018). Embedding recovery-based approaches into mental health nurse training. British Journal of Mental Health Nursing, 7 (5), 234–240.
10.12968/bjmh.2018.7.5.234 Google Scholar
- Bifarin, O. & Stonehouse, D. (2017). Clinical supervision: an important part of every nurse's practice. British Journal of Nursing, 26 (6), 331–335.
- Bower, P., Reeves, D., Sutton, M. et al. (2018). Improving care for older people with long-term conditions and social care needs in Salford: the CLASSIC mixed-methods study, including RCT. Health Services and Delivery Research, 6 (31), 1–188.
10.3310/hsdr06310 Google Scholar
- Bowers, L., James, K., Quirk, A., Simpson, A., Stewart, D. & Hodsoll, J. (2015). Reducing conflict and containment rates on acute psychiatric wards: The Safewards cluster randomised controlled trial. International Journal of Nursing Studies, 52 (9), 1412–1422.
- Butterworth, T. & Shaw, T. (2017). Playing Our Part: The Work of Graduate and Registered Mental Health Nurses. London: Foundation of Nursing Studies.
- P. Calaminus (Ed). (2013). The service context and organisation of mental health care. In The Art and Science Of Mental Health Nursing, 3rd edn. Open University Press.
- Cleary, M., Raeburn, T., West, S., Escott, P. & Lopez, V. (2018). Two approaches, one goal: How mental health registered nurses' perceive their role and the role of peer support workers in facilitating consumer decision-making. International Journal of Mental Health Nursing, 27 (4), 1212–1218.
- Cleary, M., Visentin, D., West, S., Lopez, V. & Kornhaber, R. (2018). Promoting emotional intelligence and resilience in undergraduate nursing students: An integrative review. Nurse Education Today, 68, 112–120.
- Care Quality Commission 2017. [online]. Available from: URL: [Cited July 2021]. https://www.CQC.org.uk/sites/default/files/201701207b_restrictivepractice_resource.pdf
- De Looff, P., Didden, R., Embregts, P. & Nijman, H. (2019). Burnout symptoms in forensic mental health nurse: Results from a longitudinal study. International Journal of Mental Health Nursing, 28, 306–317.
- Dekker, S. (2016). Just Culture: Restoring Trust and Accountability in Your Organisation, 3rd edn. London: Routledge.
10.4324/9781315251271 Google Scholar
- Department of Health (DH) (2006). From Values to Action: The Chief Nursing Officer's Review of Mental Health Nursing. London: DH.
- Doyle, A. & Clark, L. (2020). How ward rules and limit setting contribute towards restrictive practices and presentations of challenging behaviour in patients on mental health wards. British Journal of Mental Health Nursing, 9 (2), 1–9.
10.12968/bjmh.2019.0008 Google Scholar
- M. Ellis & C. Day (Eds). (2013). The therapeutic relationship: Engaging clients in their care and treatment. In The Art And Science Of Mental Health Nursing, 3rd edn. Open University Press.
- Emerson, R. & Pollner, M. (2019). Contingent control and wild moments: Conducting psychiatric evaluations in the home. Social Inclusion, 7, 259–268.
- Felton, A., Repper, J. & Avis, M. (2017). Therapeutic relationships, risk, and mental health practice. International Journal of Mental Health Nursing, 27 (3), 1137–1148.
- Felton, A., Repper, J. & Avis, M. (2018). The construction of people with mental health problems as risk objects: Findings of a case study inquiry. Journal of Psychiatric and Mental Health Nursing, 25 (9–10), 558–568.
- Felton, A., Wright, N. & Stacey, G. (2017). Therapeutic risk-taking: A justifiable choice. BJPsych Advances, 23 (2), 81–88.
10.1192/apt.bp.115.015701 Google Scholar
- Foster, S. (2017). The benefits of values-based recruitment. British Journal of Nursing, 26 (10), 579.
- Gournay, S. (2017). Turning rhetoric into reality. British Journal of Mental Health Nursing, 6 (3), 109.
10.12968/bjmh.2017.6.3.109 Google Scholar
- Harris, B. & Panozzo, G. (2019). Barriers to recovery-focused care within therapeutic relationships in nursing: Attitudes and perceptions. International Journal of Mental Health Nursing, 28 (5), 1220–1227.
- Hazel, L. & Bifarin, O. (2020). Empowerment for mental health nursing beyond Covid-19. Nursing Times. [online] Nursing times. [Cited June 2021]. Available from: URL: https://www.nursingtimes.net/opinion/empowerment-for-mental-health-nursing-beyond-covid-19-19-05-2020/
- Hurley, J. (2009). A qualitative study of mental health nurse identities: Many roles, one profession. International Journal of Mental Health Nursing, 18 (6), 383–390.
- Hurley, J., Hutchinson, M., Kozlowski, D., Gadd, M. & Vorst, S. (2019). Emotional intelligence as a mechanism to build resilience and non-technical skills in undergraduate nurses undertaking clinical placement. International Journal of Mental Health Nursing, 29 (1), 47–55.
- Hurley, J. & Lakeman, R. (2021). Making the case for clinical mental health nurses to break their silence on the healing they create: A critical discussion. International Journal of Mental Health Nursing, 30 (2), 574–582.
- Isobel, S. & Delgado, C. (2018). Safe and collaborative communication skills: A step towards mental health nurses implementing trauma informed care. Archives of Psychiatric Nursing, 32 (2), 291–296.
- Jackson, J. (2021) Rethinking safe staffing. [online]. [Cited April 2021]. Available from: URL: https://www.kcl.ac.uk/scwru/events/international/info/jackson-feb-2021-rethinking-safe-staffing-slides.pdf
- Jones, M. (2020). Risk: A conversation worth having in mental health care? Journal of Psychosocial Rehabilitation and Mental Health, 7 (1), 97–101.
10.1007/s40737-019-00154-8 Google Scholar
- King, M. (2017). Psychiatric nursing: An identity crisis? British Journal of Mental Health Nursing, 6 (6), 254–255.
10.12968/bjmh.2017.6.6.254 Google Scholar
- King's Fund (2019). Closing The Gap. [online] [Cited 23 August 2021]. Available from: URL: https://www.kingsfund.org.uk/publications/closing-gap-health-care-workforce
- Lakeman, R. & Molloy, L. (2018). Rise of the zombie institution, the failure of mental health nursing leadership, and mental health nursing as a zombie category. International Journal of Mental Health Nursing, 27 (3), 1009–1014.
- Manuel, J. & Crowe, M. (2014). Clinical responsibility, accountability, and risk aversion in mental health nursing: A descriptive, qualitative study. International Journal of Mental Health Nursing, 23 (4), 336–343.
- McAndrew, S., Chambers, M., Nolan, F., Thomas, B. & Watts, P. (2014). Measuring the evidence: Reviewing the literature of the measurement of therapeutic engagement in acute mental health inpatient wards. International Journal of Mental Health Nursing, 23 (3), 212–220.
- McKeown, M., Thomson, G., Scholes, A. et al. (2019a). “Catching your tail and firefighting”: The impact of staffing levels on restraint minimization efforts. Journal of Psychiatric and Mental Health Nursing, 26 (5–6), 131–141.
- McKeown, M., Thomson, G., Scholes, A. et al. (2019b). Restraint minimisation in mental health care: legitimate or illegitimate force? An ethnographic study. Sociology of Health & Illness, 42 (3), 449–464.
- McKeown, M. & White, J. (2015). The future of mental health nursing: are we barking up the wrong tree? Journal of Psychiatric and Mental Health Nursing, 22 (9), 724–730.
- McSherry, R. & Pearce, P. (2011). Clinical Governance: A Guide to Implementation for Healthcare Professionals, 3rd edn. Wiley-Blackwell.
- Mersey Care NHS Foundation Trust, (2021) Restorative just and Learning Culture. [Cited 12 August 2021]. Available from: URL: https://www.merseycare.nhs.uk/about-us/restorative-just-and-learning-culture
- Muir-Cochrane, E., O'Kane, D. & Oster, C. (2018). Fear and blame in mental health nurses’ accounts of restrictive practices: Implications for the elimination of seclusion and restraint. International Journal of Mental Health Nursing, 27 (5), 1511–1521.
- NHS England. (2015). The five year forward view mental health taskforce: Public engagement findings. A report from the independent Mental Health Taskforce to the NHS in England. Available from: URL: [Cited 23 August 2021]. http://www.england.nhs.uk/mentalhealth/wp-content/uploads/sites/29/2015/09/fyfv-mental-hlth-taskforce.pdf
- NHS England. (2019) NHS Mental Health Implementation Plan 2019/20- 2023/4. Available at NHS Mental Health Implementation Plan 2019/20 – 2023/24 (longtermplan.nhs.uk)
- NHS England (2019b). The NHS Long Term Plan. [online]. [Cited 23 August 2021]. Available from: URL: https://www.longtermplan.nhs.uk/wp-content/uploads/2019/01/the-nhs-long-term-plan-summary.pdf
- NHS Providers. (2019) Mental Health Services; Addressing the Deficit Mental health services: addressing the care deficit (nhsproviders.org). [Cited July 2021].
- Nolan, P. (2017). Nineteenth century mental health care and its relevance today. British Journal of Mental Health Nursing, 6 (6), 261–264.
10.12968/bjmh.2017.6.6.261 Google Scholar
- Nursing Midwifery Council (2018). [online]. [Cited 23 August 2021]. Available from: URL: https://www.nmc.org.uk/globalassets/sitedocuments/nmc-publications/nmc-code.pdf
- Pazargadi, M., Fereidooni Moghadam, M., Fallahi Khoshknab, M., Alijani Renani, H. & Molazem, Z. (2015). The therapeutic relationship in the shadow: Nurses’ experiences of barriers to the nurse-patient relationship in the psychiatric ward. Issues in Mental Health Nursing, 36 (7), 551–557.
- Power, T., Baker, A. & Jackson, D. (2020). ‘Only ever as a last resort’: Mental health nurses' experiences of restrictive practices. International Journal of Mental Health Nursing, 29 (4), 674–684.
- Rio, J., Fuller, J., Taylor, K. & Muir-Cochrane, E. (2020). A lack of therapeutic engagement and consumer input in acute inpatient care planning limits fully accountable mental health nursing practice. International Journal of Mental Health Nursing, 29 (2), 290–298.
- Royal College of Nursing. (2019). Nursing staff stretched to breaking point over workloads, report reveals. Royal College of Nursing. [online]. [Cited April 2021]. Available from: URL: https://www.rcn.org.uk/news-and-events/press-releases/staff-survey
- Sawyer, A.M. (2017). Negotiating the interface between risk management and human rights-based care. In S. Stanford, E. Sharland, N. Rovinelli Heller, & J. Warner (Eds.) Beyond the Risk Paradigm. (pp. 103–118). London: Mental Health Policy and Practice Palgrave.
- Simpson, A., Hannigan, B., Coffey, M. et al. (2016). Recovery-focused care planning and coordination in England and Wales: a cross-national mixed methods comparative case study. BMC Psychiatry, 16(1), 1–18.
- Stacey, G., Felton, A., Morgan, A. et al. (2016). A critical narrative analysis of shared decision-making in acute inpatient mental health care. Journal of Interprofessional Care, 30 (1), 35–41.
- Terry, J. (2019). ‘In the middle’: A qualitative study of talk about mental health nursing roles and work. International Journal of Mental Health Nursing, 29 (3), 414–426.
- Thorne, S. (2020). Rethinking Carper's personal knowing for 21st century nursing. Nursing Philosophy, 21 (4).
- Vincenti, C., Grech, P. & Scerri, J. (2021). Psychiatric hospital nurses' attitudes towards trauma-informed care. Journal of Psychiatric and Mental Health Nursing, 00, 1–11.
Citing Literature
