Preparing mental health nurses

Sarah Rutherford, Practice Trainer at the Faculty of Health, Psychology and Social Care, Manchester Metropolitan University, UK, summarises her paper Assessing parenting capacity: are mental health nurses prepared for this role? The paper, first published in the Journal of Psychiatric and Mental Health Nursing in May 2009, is based on a review of current policies and about 30 social work, medical and nursing studies.

In some inpatient mental health facilities, mental health nurses are undertaking the task of assessing parenting capacity. Women with severe and enduring mental health needs are assessed to ensure that they are able to meet their infant’s developmental and well-being requirements and that they do not pose a risk to their baby.

Mental illness and motherhood

An estimated 90% of women with a serious mental illness have or had children. The advent of community care, an increased awareness of human rights and improvements in drug therapies for mental health problems have resulted in more mothers with mental health needs being involved partially or wholly in the raising of their children.

Motherhood is as important among women with a serious mental illness as it is for the rest of the population. However, the effects of a mother’s mental illness may affect her ability to respond to her child’s needs despite her wish to parent her child. A number of studies has consistently shown that mothers with schizophrenia may be less responsive to their child’s emotional needs, less encouraging, have difficulty in showing affection and be less positive than mothers without a mental illness.

It has also been claimed that mothers with a mental illness often have difficulty in differentiating their own needs from those of their children and in prioritising these above their own. It is important to bear in mind that there is evidence that socio-economic factors such as employment and the support of a partner have greater impact on parenting than mental health illness. However, where there may be concerns about a mother’s parenting capacity due to her mental health needs, a parenting assessment may afford an opportunity for her to parent her child.

Parenting assessments

The assessment takes place in an inpatient unit for a designated period of time, with extensions if necessary. The mother’s parenting of her infant and her capacity to meet the baby’s needs are observed. For example, how aware is she of safety issues? How able is she to respond to the changing demands of her baby? Does she prioritise her baby’s needs above her own? Are her interactions appropriate? And so on.

Local authorities or family courts are provided with written and verbal progress reports, with a final submission at the end of the assessment. In extreme circumstances the consequence of the assessment may be the termination of the mother’s parenting rights.

The question arises about why mental health services are carrying out assessments in what is, traditionally, the role of child and family social services. Assessment of parenting skills is usually the primary responsibility of child social workers who may have relatively little experience of mental illness. In response, social workers seek specialist mental health opinion from nursing staff on psychiatric mother and baby units.

The Children Act 1989 stated that children were best brought up in their own families with the result that it became incumbent on local authorities to explore all avenues to this outcome. Guidance from the Assessment of Children in Need and their Families (Department of Health 2000) advised that adult mental health services have a key role to play in the assessment process where parental mental health problems have an impact on parents’ capacity to respond appropriately to their children’s needs.

Mental health nurses do have specific training and knowledge which makes their contribution to safeguarding children significant. They are able, for example, to differentiate between chronic problems associated with serious mental illness which may have a long-term negative effect on parenting and the symptoms of acute relapse which will resolve with proactive treatment, care and implementation of contingency plans. Mental health nurses will be aware of the mother’s long-term mental health history and risk concerns, and they have the skills and training to recognise signs of relapse and to implement early treatment.

Concerns

However, despite this contribution, there are a number of concerns about this role. It may compromise the therapeutic role of mental health nurses, especially if the result is the termination of the mother’s parenting rights. Women with a mental illness have frequently experienced multiple losses due to their illness, such as family, homes, relationships, ambitions and, very possibly, other children. The removal of a baby adds to these losses. This outcome can undermine the relationship between the nurse and the mother, especially where the nurse may have been involved in this decision.

Poor preparation and support for this role can have an emotional impact on nurses involved in the separation of the mother and child, especially as mental health nurses have to support the mother through their distress at this traumatic event despite feeling they contributed to this outcome.

The need for the provision of guidelines for assessing or predicting risk to infants was highlighted as far back as 1995. However, there is still limited training available to mental health nurses working with mothers with severe and enduring mental health needs or in the process of conducting parenting assessments. Guidelines are particularly vital for mental health nurses who have to address the competing needs of their client group, mothers with mental health problems with those of the infant. It may not be possible to reconcile these two conflicting needs.

Although one study showed that social workers described the assessment as central to their decision-making, it is currently, unclear how many units are doing these assessments, who is undertaking them, what training is available, and if and what tools are being used to assess.

Recommendations

In the first place, a survey of current practice of assessment of parenting within mother and baby units is essential to establish the number of parenting assessments being undertaken in each mental health unit. Information needs to be gathered about the assessment tools being used; the format of the assessments and reporting in different regions, and the training available to mental health nurses.

A study is required to establish the training needs of mental health nurses conducting assessments of parenting capacity. Further follow-up studies of mothers who have undergone parenting assessments are necessary to ensure that the assessment reflects the needs and outcomes for these mothers. Joint training among mental health nurses, child protection nurses, and child and family social workers needs to be developed for effective inter-disciplinary working and to optimise outcomes for mothers and their infants.

References

Children Act 1989. Chapter 41. London: HMSO.

Department of Health. 2000. Framework for the assessment of children in need and their families. London: The Stationery Office.

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