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Date published : 11 November, 2022 Date last updated : 15 August, 2023 Download as a PDFClassification: Official
Publication reference: PR1011
Version 1.1, August 2022
The mental health nurse’s handbook has been endorsed by the Royal College of Nursing (RCN).
The past two years have been unlike any in the history of the NHS and they have presented huge challenges for our profession. Mental health nurses have seen significant increases in demand for mental health support at a time when delivery of that support has been very challenging. I would like to say a personal thank you to mental health nurses across England for your commitment to the NHS and the people you support. You have responded to the COVID-19 pandemic with resilience, compassion, dedication, and innovation, underpinned by an absolute commitment to excellent person-centred care. Mental health nurses have the privilege of caring for people of all ages during some of the most difficult times in their lives and supporting them in a highly personalised way towards recovery. They deliver care using a range of evidence-based interventions, tailored to meet each person’s individual needs, preferences and goals. This requires great skill combined with insight, empathy, compassion and careful judgement, and great personal resilience.
Mental health nursing requires leadership at every level – including system working, addressing health inequalities, leading service transformation, educating, developing, recruiting, and retaining staff, research, and quality improvement to inform practice. This leadership is always focused on improving care for the people we are here to serve and always being their advocate
This handbook is intended as a brief practical guide to support preceptorship and supervision conversations; both absolutely critical in welcoming and supporting the newest members of our profession and retaining the richly diverse and highly skilled mental health nursing workforce we have.
Thank you once again for everything you do. Your commitment to delivering compassionate, safe and effective mental health care is so highly valued and it changes lives every day.
Dame Ruth May, DBE, Chief Nursing Officer, England, NHS England.
The mental health nurse’s role is pivotal in delivering holistic, high-quality care to people of all ages who are experiencing a range of difficulties, emotional distress and/or mental illness. The unique nature of mental health nursing means it is an emotionally demanding but rewarding career choice requiring exceptional dedication. The role encompasses a wide range of healthcare functions including system working, reducing health inequalities, leading service transformation, staff retention and recruitment, staff education and development and using research, evidence, and quality improvement to inform practice. It requires humility, passion and commitment to deliver care using evidence-based interventions combined with personal attributes, insights, perceptions and judgments.
This Mental health nurse’s handbook is a resource for mental health nurses to guide their preceptorship and supervision conversations, helping to focus on some key areas of practice. It is intended as a brief practical guide and provides links to other important and helpful resources. It has been developed following research and feedback from newly qualified nurses, one-to one interviews with experienced nurses, nurse consultants and people with lived experience of mental health services. It is guided by the Nursing and Midwifery Council (NMC) professional standards of practice and behaviour that registered nurses must uphold.
Service-user, family, and carer feedback is a required aspect of registered nurse revalidation and will helpfully guide your reflection on practice, your individual supervision, appraisal and continuing professional development. You can use it to measure and improve individual, team, organisational and system outcomes. The crucial insights we get from patient, families, and carers – either through specific engagement events and involvement or from more direct and individual feedback – must be central to personal, team, service, and system development.
The importance of using direct feedback to inform and evaluate the quality of practice at all levels is increasingly recognised across health and care professions. The most important themes from the feedback we collected when writing this handbook are summarised below. Find ways to ensure you remain focused on this feedback in all of your work.
The Nursing and Midwifery Council (NMC) Code highlights the need for nurses to “prioritise people using or needing our support”. This means nurses must have people’s interests, care needs, aspirations and safety at the forefront of their minds and practice. Working in partnership to treat people with kindness, dignity and respect is the golden thread throughout all actions, but it is also important to be able to challenge practice if you observe any deviations from this.
The mental health nurse must ensure people are not inadvertently excluded because of service thresholds, positive risk and/or diagnosis. The mental health nurse must uphold hope, highlighting the person’s unique strengths and contribution.
Mental health nurses need to have an understanding of the context in which care is delivered as well as key priorities identified within the long-term plan for mental health. This means ensuring that care and treatment is timely, effective, close to home and the least restrictive as possible. Mental health nurses achieve this by working in partnership with the wider system including primary care, local authority, social care and integrated care boards.
To truly prioritise people and therefore provide equitable, non-discriminatory, and compassionate care there are some broad but widely accepted essential tasks.
The therapeutic relationship is at the heart of everything we do in mental health nursing practice. This can be best explained as a partnership that promotes safe engagement and constructive, respectful, and non-judgmental intervention (McCormack B, McCance T (2016) Person-centred practice in nursing and health care: theory and practice. London: John Wiley and Sons.).
To create the environment for a healthy therapeutic relationship, mental health nurses must demonstrate genuineness, humility, empathy, and unconditional positive regard (see footnote 2). This in turn will result in positive outcomes and psychological benefits, including an increased sense of value.
Empathy, respect, and empowerment can be felt when an alliance is built on acceptance and trust. Without a therapeutic relationship, patients are a lot less likely to engage with and make effective use of mental health services and may be put off accessing services in the future. This could impact longer term on recovery and beneficial outcomes.
When focusing on therapeutic engagement, it is important to acknowledge the effect of Infection, prevention and control measures such as social distancing and the use of personal protective equipment during the pandemic. In these circumstances the intuitive non-verbal communications need to be conveyed verbally and special attention is required to ensure this compassion is not lost.
To successfully develop and maintain engagement in the therapeutic relationship, there are some key roles (see footnote 3) which are outlined below.
| Purposeful | Clarity between the nurse and service-user about the intention and focus of the relationship |
| Connectedness | An ability to listen, empathise with and validate the person experience and feelings |
| Facilitation | The mental health nurse can make things happen with and on behalf of the service-user |
| Supportive | Being emotionally attuned with the patient’s experience, encouraging, and providing a message of hope |
| Influential | Inspiring and capable of helping a service-user work towards and make positive change |
Advocating on behalf of service users is a key responsibility for mental health nurses, as is seeking to combat stigma and discrimination which people who live with mental health needs can often face. Most importantly, mental health nurses can play an important role in seeking to tackle stigma and discrimination which can exist within the health workforce, particularly in relation to service users who receive particular labels.
Mental health nurses must stand against dangerous and non-evidence-based labelling of service users which in turn lead to access to care and support being denied to some service users. For example, descriptions of service users as “attention seeking” or “manipulative” have no place in modern, compassionate and therapeutic mental health care. It is important to be mindful of the impact of contentious diagnostic labels such as “personality disorder” which can cause much distress to service users, particularly survivors of trauma and to ensure regardless of the diagnosis a service user is given, the care provided is compassionate, respectful and personalised.
Nurses’ professional standards of practice and their behaviour are underpinned by values of equality, diversity and inclusion. Everyone has the right to safe and effective individualised care without fear of discrimination, harassment, or victimisation.
Treating everyone as a unique individual, respecting their dignity, personal choices, and preferences – as well as upholding their human rights – are key principles . Listening to the challenges facing different communities and promoting a culture that encourages openness about challenges, seeking regular feedback on how things felt will advance equality and opportunity for all. Age, ethnicity or national origin, sexual orientation and gender identity interact at different times and influence our needs and as such are fundamental to nursing interventions.
This section focuses on the importance of using clinical audits, evidence-based practice and research to inform the care we provide, harnessing the key elements of the therapeutic relations and using the skills described in Section 2 to practise effectively.
Clinical audit is an approach to support delivery of best treatment options. All NHS trusts are required to ensure they participate in national audits as well as their own audit programme. Nurses play a key role in supporting audit and counteracting any gaps identified following practice audits and benchmarking.
Evidence-based practice is the “integration of best research evidence with clinical expertise and service-user values” (see footnote 4). This means that when health professionals make a treatment decision with the patient, they base it on their clinical expertise, the patient’s preferences and the best available evidence.
In the UK, National Institute for Health and Care Excellence (NICE) guidance plays a key role in providing best evidence to support treatment interventions and is generally accepted as the first point to consider when formulating treatment options. It must be considered alongside your organisational policies to support professional body requirements and recommendations.
Research in nursing is key to generating new knowledge and testing which interventions make a difference to a person’s outcomes.
Research has come to play an ever-greater role in healthcare. NHS trusts facilitating research with the National Institute of Health Research (–the NHS’s research arm) are reported to have better mortality rates than those that do not.
It is important to embed research into the fundamental structure of the NHS, so it becomes part of everyday business. The Chief Nursing Officer for England has published a strategic plan for research, setting out the ambition for a people-centred research environment that empowers nurses to lead and deliver research for public benefit. Every person receiving NHS services should have the opportunity to take part in research if they wish.
Nurses safeguard and advocate for people by applying research findings to promote and inform best nursing practice. The government set out to reform the NHS so that it “supported outstanding researchers, working in world-class facilities, conducting leading-edge research focused on the needs of people and the public”. To achieve the impact from the research, we need to work towards implementation of the findings from healthcare research throughout our services.
This section focuses on the importance of people, public and staff safety as well as looking after your own wellbeing. We highlight the importance of risk assessment and safety planning, and the structures required within this work to assist with safe practices, as well as the importance of embracing a just and learning culture.
To work effectively you will need to combine the knowledge, skills and personal attributes mentioned earlier, as these will help you keep in touch with what is really going on for people and carers. You will be required to weigh up and analyse complex qualitative and quantitative information every day. Finding time for reflection and support within this is essential.
Assessing and managing risk and safety remains a core task for the MDT in mental health, and it is a widely accepted element of the nurse’s role. However, it can also be one of the most stressful tasks for nurses. Multiple risk factors, warning signs and protective factors associated with physical health, frailty and mental health conditions will present different challenges for the staff carrying out the assessment depending on the therapeutic relationship with the patient.
The personal and practice experience of the assessor, the team/service thresholds, resources, the risk culture within the organisation, team attitudes and the team atmosphere play a part (see footnote 5). Confidentiality, information sharing, safeguarding and mental capacity are also important areas for consideration.
To practise safely and effectively as described in several earlier sections, support and supervision mechanisms must be in place. It is important for mental health nurses to respond emotionally to the therapeutic aspects of their work and be able to nurture the people they are working with as well as themselves.
There is strong evidence that supportive relationships that offer motivation and encouragement can be drawn upon in times of stress. However, this can sometimes be difficult to achieve and finding your own alternatives/coping strategies is important.
Incorporating a compassionate and restorative approach within supervision has been shown to have good outcomes for both staff and service users. For example, the use of a restorative model places value on how participants respond emotionally to the work of caring for others, a key component in the current healthcare climates.
The Professional Nurse Advocate (PNA) programme delivers training for registered nurses in restorative supervision for colleagues across England. It was launched in March 2021, towards the end of the third wave of COVID-19 and is an evidence-based model of clinical supervision. It is a requirement that all nursing staff working within NHS commissioned care have access to restorative clinical supervision as set out in the NHS Contract.
Remember that you can draw on confidential support from local mental health and wellbeing hubs which offer rapid access to assessment and evidence based mental health services and support where needed. Further support is also available from organisational Occupational health services, PNAs, trade unions and local workplace representatives and other independent helplines such as Nurse Lifeline.
The learning culture in any organisation will have a significant impact on safe practice. A learning culture that emphasises accountability and learning equally is important for wellbeing and safety. To work at our best, we need to experience a compassionate and inclusive work environment. Being open with each other and with patients and families is key. There is a legal duty for employers and registrants to meet the professional ‘Duty of Candour’, which is also an important part of a positive, open, and safe culture.
This section focuses on the crucial elements of the nurse’s role in upholding the profession’s reputation. This includes role modelling effective behaviours and instilling trust and confidence through our actions.
We highlight the importance of nursing leadership and MDT working and summarise additional challenges to practice.
Within the nursing context we can differentiate between management – which consists of directing a team or group to achieve a desired outcome – and leadership, which refers to an individual’s ability to influence, motivate and enable others to contribute towards success.
The concept of compassionate and inclusive leadership in nursing has traditionally been associated with senior nurses in matron and management roles. However, from the very beginning of a career, leadership qualities are a fundamental component of the mental health nursing role. Effective leadership qualities are intrinsic to the NMC Code, which reinforces the importance of all nurses demonstrating leadership behaviours regardless of whether they occupy formal leadership positions. Therefore, everybody who enters mental health nursing should acknowledge their leadership role and understand how to develop leadership skills and behaviours. Nurse leaders should also acknowledge that all nurses should have the support and ongoing education to be a nurse leader, irrespective of formal leadership role.
The MDT is an important process for ensuring evidence-based, compassionate care. Evidence suggests that a well-functioning, well-established MDT consists of members from different disciplines, agencies and system partners such as colleagues from social care and local authority partners, working together with a common aim of providing evidence-based, safe, and effective care.
As set out in the LTP, there is an ambition to improve the therapeutic offer from inpatient mental health services by increasing investment in the level and skill mix on acute MH inpatient wards, as well as the range of interventions and activities they offer. By increasing access to multi-disciplinary staff, it is expected that both the effectiveness and experience of care will be improved, resulting in better service-user outcomes and contributing to a reduction in avoidable length of stay.
The make-up of MDTs and how they function differs depending on setting. Generally, service users, nurse, nursing associates, third sector colleagues, occupational therapists, social workers, support workers, peer-support workers, medical doctors, psychologists, speech and language therapists and administrative support workers should work collaboratively to devise and review plans of care.
The introduction of the Community Mental Health Framework will guide the MDT approaches to care. It describes how the NHS Long Term Plan’s vision for a place-based community mental health model can be realised and how community services should modernise to offer whole-person, whole-population health approaches, aligned with primary care. The move away from the Care Programme Approach, will ensure personalised care planning with person centred outcome measures. Following the essential tasks and key messages below will assist/ensure that mental health nurses are a key part of the MDT.
Recovery means different things to different people. It is a term with two concepts: clinical recovery and personal recovery. Whereas services that had a focus on clinical recovery focused on alleviating symptoms or complete remission of symptoms through psychosocial and medication interventions (see footnote 6), personal recovery orientated services (referred to as “recovery orientated services”) aim to understand and meet the personal needs of individuals to help them thrive and live the best possible life, with or without a diagnosis and related symptoms. Most of the principles of personal recovery are based on Positive Psychology which is the scientific study of well-being.
Recovery oriented models of care encourage a shift from focusing on just managing symptoms towards providing care based on the person’s values and emphasising lasting recovery, which can occur through the discovery of a variety of pathways. By transforming and integrating services, more time can be spent in direct contact with patients. Joined-up, recovery-focused and personalised care and support must be at the heart of this. They ensure timely access to the right care and support, including freeing time to deliver evidence-based care such as psychological therapies or a mode of support focused on what is important to the person.
It should be noted that there have been critiques of the Recovery model by some services users who have experienced it being implemented in a restrictive and homogenising manner, ignoring the “social and political reality that affects a person’s wellbeing”. The Recovery in the Bin Collective provides a more detailed critique and alternative models.”
This handbook has been completed as part of the Nurse Fellow Programme with support from:
Mental health inpatients at Prospect Park Hospital, Reading
Carers Group, Berkshire Healthcare
Preceptorship Group, Berkshire Healthcare NHS Foundation Trust
Nurse Consultant Forum
1. McCormack B, McCance T (2016) Person-centred practice in nursing and health care: theory and practice. London: John Wiley & Sons.
2. Ellis M, Day C (2018) The therapeutic relationship: engaging clients in their care. In: Norman I, Ryrie I (2018) The art and science of mental health nursing: principles and practice, 4th edition, p171.
3. Ellis, M. and Day, C. (2018) The Therapeutic Relationship: engaging clients in their care. In: Norman, I and Ryrie, I. (2018) The art and science of mental health nursing: Principles and practice, 4th ed, pp.171.
4. Stevens K (2013) The impact of evidence-based practice in nursing and the next big ideas: Online Journal of Issues in Nursing 18 (2): Manuscript 4.
5. Bowers L, Whittington R, Nolan P et al (2008) Relationship between service ecology, special observation and self-harm during acute inpatient care: City-128 study. British Journal of Psychiatry 193 (5), 395-401.
6. Isaacs AN, Sutton K, Beauchamp A (2020) PERSPECTIVES: Recovery oriented services for persons with severe mental illness can focus on meeting needs through care co-ordination. J Ment Health Policy Econ. 2020 Jun 1;23(2):55-60. PMID: 32621725.