Responsible clinician role offers opportunities for nurses: very few nurses work in the statutory role of responsible clinician. But it is a role that offers opportunities for advanced practice and for improving client outcomes.Statutory roles under mental health legislation offer mental health nurses a means of having advanced practice skills recognised, as well as contributing to improved access to services. In this paper we report on a recent study investigating the statutory role of responsible clinician clinician /cli·ni·cian/ (kli-nish´in) an expert clinical physician and teacher. cli·ni·cian n. . The recently published document, Mental Health Nursing and its Future: A Discussion Framework, highlights challenges in developing a sustainable mental health nursing workforce. (1) The document notes inconsistencies in the development of nursing leadership structures and in the clinical career pathways (CCPs) that ease people into leadership roles. It suggests creative strategies and new ways Of working to address these inconsistencies and to move the profession forward. There is a proliferation proliferation /pro·lif·er·a·tion/ (pro-lif?er-a´shun) the reproduction or multiplication of similar forms, especially of cells.prolif´erativeprolif´erous pro·lif·er·a·tion n. of roles intended to develop nursing readership--nurse manager, clinical nurse lecturer, nurse educator A nurse educator is a nurse who teaches and prepares licensed practical nurses (LPN) and registered nurses (RN) for entry into practice positions. Nurse Educators also teach in graduate programs at Master’s and doctoral level which prepare advanced practice nurses, nurse , and clinical nurse specialist clinical nurse specialist n. A nurse who has advanced knowledge and competence in a particular area of nursing practice, such as in cardiology, oncology, or psychiatry. . (2) However, the position descriptions attached to such roles often signal a move away from clinical practice into management, education or research. This does not mean a nursing perspective is not imperative for these roles, but in most cases they are not primarily clinical roles. Advanced nursing roles The Ministerial Taskforce on Nursing addressed the need to develop advanced nursing roles that were based primarily on clinical expertise, and which maximised the contribution of nursing to outcomes for service users. (3) The taskforce identified the statutory role of "responsible clinician" as a clinical role requiring advanced practice skirls. Subsequently, the concept of "advanced practice" has become a means of developing clinical leadership roles in nursing. (4) The Mental Health (Compulsory Assessment and Treatment) Act 1992 (the Act) reflects an international trend towards a model of service that emphasises both therapeutic intent and the human rights of patients subject to involuntary assessment and treatment. (5) The Act emphasises a shift from the medical discipline's discretion in decision-making concerning compulsory assessment and treatment, towards decision making shared by different health professionals. The Act created a number of generic statutory roles which have been assumed by nurses and other non-medical health professionals. These include Duty Authorised Officer (DAO dao or tao In Chinese philosophy, a fundamental concept signifying the correct or divine way. In Confucianism, dao signifies a morally correct path of behaviour. ), second health professional in judicial reviews, responsible clinician, and Director of Area Mental Health Services health services Managed care The benefits covered under a health contract (DAMHS). Modelling nursing leadership The DAO is certainty a role which can model mental health nursing leadership. The DAO provides advice to the public about the Act, practical assistance in dealing with people who may meet the criteria for implementing the Act and practical assistance in the assessment of such people. (6) Concerns have been expressed about the variable competency of health professionals involved in this role. In response, the northern regional district health boards (DHBs) have recently standardised Adj. 1. standardised - brought into conformity with a standard; "standardized education" standardized standard - conforming to or constituting a standard of measurement or value; or of the usual or regularized or accepted kind; "windows of standard width"; the training for the role and firmly placed it within an advanced practice paradigm. (7) The DAMHS are appointed by the Director-General of Health and are responsible for administering the Act locally. There are 21 DHBs in New Zealand New Zealand (zē`lənd), island country (2005 est. pop. 4,035,000), 104,454 sq mi (270,534 sq km), in the S Pacific Ocean, over 1,000 mi (1,600 km) SE of Australia. The capital is Wellington; the largest city and leading port is Auckland. , each with a DAMHS. In addition, the Auckland Regional Forensic Psychiatry forensic psychiatry n. The branch of psychiatry that makes determinations, as regarding fitness to stand trial, the need for commitment, or responsibility for criminal behavior, in a court of law. Services has its own DAMHS. This role has no disciplinary component. At the time we conducted this research, 15 psychiatrists, six nurses and one psychotogist filled these positions. The DAMHS role provides a small window of opportunity in which nursing readership can be showcased and role modelled. (8) The DAMHS is obliged o·blige v. o·bliged, o·blig·ing, o·blig·es v.tr. 1. To constrain by physical, legal, social, or moral means. 2. to assign a "responsible clinician" to each person committed under the Act. The "responsible clinician" is defined as the clinician in charge of the treatment of that patient and is responsible for assessing if people meet the criteria for implementing the Act; arranging on-going care and treatment; and discharging people from the Act. Responsible clinicians must be: a psychiatrist approved by the DAMHS; or some other registered health professional who, in the opinion of the DAMHS, has undergone training in, and is competent in, the assessment, treatment and care, of persons with a mental disorder mental disorder Any illness with a psychological origin, manifested either in symptoms of emotional distress or in abnormal behaviour. Most mental disorders can be broadly classified as either psychoses or neuroses (see neurosis; psychosis). Psychoses (e.g. . (6) The possibility of health professionals other than psychiatrists undertaking this role has been facilitated by the Ministry of Health through the development of competencies for those appointed. (9) This document specifically acknowledges nurses as one of the health professional groups with the skirls necessary for the role of responsible clinician. Statutory roles such as those outlined above do not of themselves constitute advanced practice in mental health nursing. However, they are roles that require advanced clinical expertise. Our research focused on one such role, that of responsible clinician. Research on responsible clinician role White the responsible clinician is clearly defined in generic terms, the role has been assumed by medical practitioners. We undertook research to determine how many RNs are currently responsible clinicians and to determine enabling processes and barriers to RNs undertaking this statutory role. (8) We located 11 RNs functioning as responsible clinicians. An anonymous descriptive survey was distributed to these nurses and to five senior nurses from each of the 21 DHBs and the Auckland Regional Forensic Psychiatry Services (n = 121). Respondents were asked whether the responsible clinician role was a legitimate one for nurses and whether they were motivated to attain or maintain that role. They were also asked which competencies for the role they believed they met, their perceptions of credentialing processes and the educational requirements needed to achieve the role. A descriptive statistical analysis was undertaken and open-ended questions A closed-ended question is a form of question, which normally can be answered with a simple "yes/no" dichotomous question, a specific simple piece of information, or a selection from multiple choices (multiple-choice question), if one excludes such non-answer responses as dodging a were analysed using content analysis. Lines of accountability were established to Maori mental health nurses through the Maori Caucus caucus: see convention. of Te Ao Maramatanga, the New Zealand Cortege of Mental Health Nurses. Ethical approval was obtained from the University of Auckland Not to be confused with Auckland University of Technology. The University of Auckland (Māori: Te Whare Wānanga o Tāmaki Makaurau) is New Zealand's largest university. Human Participants Ethics Committee ethics committee A multidisciplinary hospital body composed of a broad spectrum of personnel–eg, physicians, nurses, social workers, priests, and others, which addresses the moral and ethical issues within the hospital. See DNR, Institutional review board. . The response rate was 88.4 percent (n = 107). The nurses involved had considerable clinical experience, with only two respondents having less than six years' mental health nursing practice. There are approximately 395 health professionals nationally appointed to the role of responsible clinician (10) thus nurses fill 2.8 percent of these positions. These nurses have been appointed in eight of the DHBs and their appointments only occurred on three occasions when the DAHMS was a psychiatrist. A clear majority of the respondents felt the role of the responsible clinician was a legitimate advanced practice role for mental health nurses. Despite this, some respondents expressed ambivalence ambivalence (ămbĭv`ələns), coexistence of two opposing drives, desires, feelings, or emotions toward the same person, object, or goal. The ambivalent person may be unaware of either of the opposing wishes. about taking on the role. Three quarters of the respondents were either motivated to achieve the role or presently indecisive in·de·ci·sive adj. 1. Prone to or characterized by indecision; irresolute: an indecisive manager. 2. Inconclusive: an indecisive contest; an indecisive battle. in this regard. The rest were not interested, citing workload pressure, role confusion and lack of monetary recognition as the reasons. Despite the ambivalence, the interest expressed indicates the need for clear credentialing pathways for appointment. Only a quarter of respondents were aware of such processes in their DHB DHB District Health Board (New Zealand) DHB Deutscher Handball Bund (German) DHB Deutschen Hausfrauen-Bundes (Darmstadt) DHB DHB Capital Group, Inc. . The research highlighted deficits in knowledge and skills that could become a focus of education for advanced practitioners seeking appointment as responsible clinicians. Deficits included some assessment skills, knowledge of a range of interventions and knowledge of other legislation affecting mental health legislation. Our research explored the possibility of advanced practice CCPs incorporating statutory roles with reference to just one piece of legislation. There are other possibilities for this development. The Intellectual Disability (Compulsory Care and Rehabilitation rehabilitation: see physical therapy. ) Act 2003 was established to meet the care and rehabilitative re·ha·bil·i·tate tr.v. re·ha·bil·i·tat·ed, re·ha·bil·i·tat·ing, re·ha·bil·i·tates 1. To restore to good health or useful life, as through therapy and education. 2. needs of intellectually disabled offenders. Two important roles established by this legislation are possible advanced practice pathways for RNs. The "compulsory care co-ordinator" is a health or disability professional responsible for administering this Act within a defined geographical area. The "care manager" is appointed by the compulsory care co-ordinator and is legally responsible for the care and rehabilitation of the person subject to this Act. The care manager is responsible for the development, implementation and review of the person's care and rehabilitation plan. (11) There are nurses presently fulfilling or training to fulfil such roles. The Auckland Forensic Intellectual Disability Secure Service presently has one trained RN as a care manager and four RNs about to begin the training in order to be credentiated. The Mental Health (Compulsory Assessment and Treatment) Act 1992 signalled a shift from medical discretion in decision-making regarding civil commitment. One way of facilitating a rich multi-disciplinary perspective in decision-making was through the creation of generic statutory roles. Despite this aim, there are few mental health nurses appointed as responsible clinicians. Given the establishment within the legislation of non-discipline specific statutory roles, it is imperative key stakeholders Stakeholders All parties that have an interest, financial or otherwise, in a firm-stockholders, creditors, bondholders, employees, customers, management, the community, and the government. in mental health service delivery take action to enabe the intent of the legislation to be achieved. The Ministry of Health needs to embed em·bed also im·bed v. em·bed·ded, em·bed·ding, em·beds v.tr. 1. To fix firmly in a surrounding mass: embed a post in concrete; fossils embedded in shale. the legislative intent and "road show" the opportunities to nurses, DAMHS, and mental health managers. Meanwhile, DHBs need to align their policies, position descriptions, staff development initiatives and remuneration packages with this drive. There is a real danger that research such as this is completed, shelved as an academic output and has little impact on clinical practice. We sent our report to the Ministry of Heat[h, the outcome of which was that the recommendations would be discussed at the national DAMHS forum. Since this time, we have become aware of two initiatives. A regional alliance of DHBs in the North Island is to hold a meeting involving their DAHMS and directors of mental health nursing (or equivalents) to explore the possibility of nurses being responsible clinicians. A large South Island DHB is developing a strategy to enable this to happen. It is imperative the nursing profession prepares itself for the challenge of statutory roles. For some nurses, involvement in mental health legislation is perceived as supporting a custodial model of care, (12) which compromises the therapeutic relationship, the advocacy role and partnership models directed towards empowering patients. Furthermore, there is concern that statutory roles may subsume sub·sume tr.v. sub·sumed, sub·sum·ing, sub·sumes To classify, include, or incorporate in a more comprehensive category or under a general principle: nursing practice within a psychiatric medical model and without acknow-ledging nurses' distinctive contribution to mental health care. (13) Mental health legislation, with its power to intervene coercively in the lives of patients, is intrinsically connected to men[at health nursing practice. Rather than protest the assumption of statutory roles, nurses might do better to explore ways in which those roles can be enacted in the interests of consumers. (14) This would involve considering how the power inherent in mental health legislation could be used for therapeutic advantage, rather than as a tool of coercion. Decision making on medical authority The alternative to assuming statutory roles such as responsible clinician, is to accept decision-making dependent on medical authority. This abdication abdication, in a political sense, renunciation of high public office, usually by a monarch. Some abdications have been purely voluntary and resulted in no loss of prestige. is contrary to the intent of clinical decision-making under the Act. Furthermore, an inability to incorporate statutory roles into CCPs would be a missed opportunity to recognise the clinical skills of mental health nurses and to maximise their contribution to outcomes for service users. * Acknowledgement: This research was funded by the Gretta and Harry Hamblin Trust, through the Nursing Research and Education Foundation of NZNO NZNO New Zealand Nurses Organisation . This overview is a condition of this funding. The full peer reviewed research report was published in the International Journal of Mental Health Nursing, February 2006. This article was reviewed by Kai kai Noun NZ informal food [Maori] kai noun N.Z. (informal) food, grub (slang) provisions, fare, board, commons, eats (slang Tiaki Nursing New Zealand's editorial review committee in October 2006. References (1) Ministry of Health. (2006) Mental Health Nursing and its Future: A Discussion Framework. Report from the expert reference group to the Director-General, Mental, Health, Dr Janice Wilson. Wellington: Ministry of Health. (2) NZNO's Designated Senior Nurses/Midwives Job Title Working Party (2006) Draft titles for comment. Wellington: NZNO. (3) Ministerial. Taskforce on Nursing. (1998) Report of the Ministerial Taskforce on Nursing. Wellington: Ministry of Health. (4) Lakeman, R. (2000) Commentary. Advanced nursing practice: experience, education and something else. Journal of Psychiatric and Mental Health Nursing
(5) Unsworth, C. (1987) The Politics of Mental Health legislation. New York New York, state, United States New York, Middle Atlantic state of the United States. It is bordered by Vermont, Massachusetts, Connecticut, and the Atlantic Ocean (E), New Jersey and Pennsylvania (S), Lakes Erie and Ontario and the Canadian province of : Oxford University Press. (6) Department of Health. (1992) A User's Guide to the Mental Health (Compulsory Assessment and Treatment) Act 1992. Department of Health: Wellington. (7) Northern DHB Support Agency. (2006) Duly Authorised Officer Training Project. Auckland: NDSA NDSA National Disability Sports Alliance NDSA North Dakota Stockmen's Association NDSA North Dakota Student Association NDSA Notre Dame of St. Agatha (Canada) NDSA North Dakota State Assessment . (8) McKenna, B., O'Brien, A., Dal (1) (Dedicated Access Line) A private "tie line" between a customer and the telephone company. (2) (Data Access Language) A database interface from Apple that allows the Mac to access DAL-supported databases on Macs or Din, T. & Thom, K. (2006). Registered nurses as responsible clinicians under the New Zealand Mental Health (Compulsory Assessment and Treatment) Act 1992. International Journal of Mental Health Nursing; 15: 2, 128-134. (9) Ministry of Health (2002) Competencies for the Role and Function of Responsible Clinicians under the Mental Health (Compulsory Assessment end Treatment) Act 1992. Wellington: Ministry of Health. (10) Spencer, G. (2005) Ministry of Health: personal, communication, 2005. (11) Ministry of Health (2004) Guidelines for the Role and Function of Care Managers. Wellington: Ministry of Health. (12) Fishwick, M., Tait, B. & O'Brien, A. (2001) Unearthing the conflicts between carer carer Noun a person who looks after someone who is ill or old, often a relative: the group offers support for the carers of those with dementia carer n → and custodian bailee (custodian) n. a person with whom some article is left, usually pursuant to a contract (called a "contract of bailment"), who is responsible for the safe return of the article to the owner when the contract is fulfilled. : Implications of participation in Section 16 hearings under the Mental Health (Compulsory Assessment and Treatment) Act (1992). Australian and New Zealand Journal of Mental Health Nursing; 10, 187-194. (13) Street, A. & Walsh, C. (1998) Nursing assessments in New Zealand mental health. Journal of Advanced Nursing; 27, 553-559. (14) O'Brien, A., McKenna, B. & Farrow farrow see farrowing. , T. (2002) Nurses should claim responsible clinician role. Kai Tiaki Nursing New Zealand; 8, 16-18. Brian McKenna, RN, PhD,, is the interim director of the Centre for Mental Health Research, Policy and Service Development, the University of Auckland, and associate director of nursing at the Auckland Regional Forensic Psychiatry Services, Waitemata DHB, Auckland. Anthony 3. O'Brien, RN, MPhil, is a senior lecturer senior lecturer n. Chiefly British A university teacher, especially one ranking next below a reader. at the Centre for Mental Health Research, Policy and Service Development, the University of Auckland, and a nurse at the Liaison Psychiatry Liaison psychiatry, also known as consultative psychiatry or consultation-liaison psychiatry (also, psychosomatic medicine) is the branch of psychiatry that specialises in the interface between other medical specialties and psychiatry, usually taking place in a Service, Auckland DHB. Toni Dal Din, RN, MA (Appld Nursing, PG Cart (Forensic Psychiatry), PG Cert (Mental Health Nursing), is the director of nursing at Hurt Valley DHB, and the Director of Area Mental Health Services for the Hut[ Valley DHB. Katey Them, MA, is an assistant research fellow at the Centre for Mental Health Research, Policy and Service Development, the University of Auckland. |
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