The Canadian Nurses Association (2009) stated that by being aware of and taking action to address the broad range of determinants of health, registered nurses can positively infl uence the health of individuals and their communities and assist them to realise improved health outcomes and to reduce health inequalities. Tagliareni and King (2006) assert that nurses play a critical role in health promotion programs and services and Cohen (2008) observed that health promotion has become the “primary goal of nursing practice” (p. 102). Consistent with this, Cowman et al. (2001) acknowledge that the education role with the public in aspects of health education is increasing.
A report for the European Commission on the evidence for health promotion eff ectiveness, found ample evidence that mental health promotion programmes not only improve mental health and quality of life but also reduce the risk for mental disorder (Hosman and Jane-Lopis, 2002).
Given the consistent fi nding that people with mental health diffi culties are at high risk of developing co-morbid physical health problems, Gray et al. (2006) highlighted the role of physical health- promotion interventions, defi ned as an intervention aimed at improving the knowledge of unhealthy lifestyle habits (e.g. smoking, weight gain, diet, exercise) and capable of infl uencing motivation towards healthier behaviours. Results of the review of studies on physical health promotion showed that there were positive outcomes from physical health promotion interventions with people with mental health diffi culties for smoking cessation, interventions designed to manage weight and interventions to reduce HIV risk (Gray et al. 2006). Nash (2010) concluded that all mental health practitioners should continuously refl ect on their attitudes, their approaches to physical health, their knowledge and skills and ensure that they have equitable access to physical healthcare services.
3.8 Developments in Specialist and Advanced nursing practice roles in Ireland and improved outcomes for service users/careers
The development of specialist and advanced practice roles in Ireland is part of the strategic development of the overall health service and is taking place in the context of contemporary health and social policy, the requirements of population health and the service planning process. National policy documents such as the Report of the Commission on Nursing (Government of Ireland, 1998), the national health strategy Quality and Fairness: A Health System for You (DoHC 2001) and Begley et al. (2010) recommend the development of specialist and advanced nursing practice posts. The National Council for the Professional Development of Nursing and Midwifery was formed in 1999 following a recommendation made by the Commission on Nursing (Government of Ireland, 1998) and the NCNM established the frameworks for clinical career pathway in nursing in 2000. As fi rst signalled in the national health strategy (DoHC, 2001), the Irish health system has moved towards a population health approach to the provision of health services and healthcare. Changing models of care delivery in tandem with the changing demographic and epidemiological profi le of the population will signal the service requirements for specialist and advanced practice nursing and midwifery posts into the future. The Clinical Nurse Specialist (CNS) and Advanced Nurse Practitioner (ANP) are distinct roles. Their levels on the clinical career pathway are defi ned by the scope of practice, levels of clinical decision-making, educational preparation, responsibility and subsequently the autonomy attached to the roles NCNM (2010) The core concepts of clinical practice, advocacy, education and training, research and audit, and consultation, are outlined by the National Council for the clinical nurse or midwife specialist in Ireland (NCNM, 2008a). Four core concepts of advanced nurse practitioners and advanced midwife practitioners are given: autonomy in clinical practice, expert practice, professional and clinical leadership, and research (NCNM, 2008c).
Research indicates that positive outcomes can be achieved through the development of specialist and advanced practice nursing roles, including enhanced service provision, improved staff retention, increased satisfaction and a positive contribution to the delivery of quality care and population health (OECD, 2004). Begley et al. (2010) adopted a three phase mixed method, explanatory sequential design and produced an evaluation of the clinical services provided by clinical nurse and midwife specialists and advanced nurse and midwife practitioners in Ireland and this study examined the clinical outcomes of clinical specialists and advanced practitioners practice. They concluded that care provided by clinical specialists and advanced practitioners improves outcomes, is safe, acceptable and cost-neutral (Begley et al. 2010). This evaluation demonstrated benefi ts for outcomes and service delivery as a result of having CNSs and ANPs as part of the overall nursing team. The formulated a number of recommendations in relation to service delivery and planning, role development, CPD and future research. Benefi ts in outputs from ANPs are considerable, including a higher level of care, increased leadership and greater research output. These outcomes are consistent with a recovery approach to mental health. The feasibility, therefore, of supporting the further development of CNS and ANP posts should be considered. This should be a key focus of the HSE for the future in line with its transformation plans for mental health care.
3.9 Conclusion
As the collective understanding of mental health issues grows more refi ned over time, so do the roles and responsibilities of mental health practitioners. The adoption of a recovery-oriented model of mental health care is now considered best practice in many countries around the world, including Ireland. Publications including the Framework for Development of a Recovery Oriented Approach in Irish Mental Health Services (Higgins 2008) and the Quality Framework for Mental Health Service in Ireland (MHC, 2007), provide frameworks and standards for the development of a recovery-oriented approach in the Irish context. In order to eff ectively implement these standards and work within these frameworks, it is necessary for mental health practitioners to be clear about their evolving roles and responsibilities.
The challenge to policy makers, managers and regulators is to promote the conditions in which a learning society can unfold with professionals, whose creative agency will be the key to social innovation, providing a high quality service. Government policy, organisational and professional regulation within the mental health services, along with the safety agenda emphasise the signifi cance of a service user centred approach to professional practice. This is founded on the provision of continuously improving the quality of practice to deliver quality evidence based safe service user centred care.
Psychiatric/ mental health nursing practice must continue to strengthen its provision of a therapeutic contribution to the journey of the service user. Psychiatric mental health nursing practice must also articulate and document its therapeutic contribution to care. Beyond these essential skills is the capacity of the RPN to continue to maintain competence, to engage in practice audit and to strengthen their focus on measuring outcomes in practice.