A guide to community mental health nursing

How does mental health nursing differ in the community compared to the hospital environment? Laura gives us an insight into working in the community in this blog.

Laura explains what working in the community as a mental health nurse is like

NHS England published the “Five Year Forward View” (NHSE 2016) in February 2016.

It set out the mental health service provision at that time and made recommendations for all mental health services, the recommendations are to be implemented by 2021.

The plan placed significant emphasis on community services with a focus on community mental health services being more responsive and accessible.

Mental Health Nurses have worked within the community for many years following the mass closure of psychiatric “asylums” in the 1970’s and 80s, however it is perhaps now more than ever that RMNs (Registered Mental Health Nurses) are provided with career opportunities and pathways which do not involve working in a hospital at all.

"The appeal of community nursing is the level of autonomy a nurse will have." - Laura Woods

This article will explore the varied roles open to RMNs who want to work in the community and what education and training will help to support their career.

As a RMN working in the NHS for the last 12 years I will reflect on my own experience of community mental health nursing.

Mental health services which are delivered in the community are incredibly diverse.

There are mental health teams which work with children, adults, older people, the homeless population, offenders, or specific mental health issues like dementia, psychosis, neurodevelopmental disorders, eating disorders and post-natal services.

Nurses who work in the community will be employed predominantly by the NHS however some services may be run by local authorities, charities or educational institutions.

As with any healthcare services agency nurses are used at times.

It is likely that agencies will provide RMNs for set time periods through block bookings as opposed to inpatient services which will use agencies on a more ad-hoc short-term basis.

The typical jobs a community nurse might do

The appeal of community nursing is the level of autonomy a nurse will have.

In any of the possible community roles, nurses will have the responsibility and autonomy to manage their work load.

They will be assigned a case load of individuals to work with and provide either long-term or short-term work.

Some community nurses will work as part of a team yet maintain the autonomy of managing the daily tasks.

Other nurses will work independently as Advanced Nurse Practitioners or Clinical Nurse Specialists running nurse led clinics.

There is not really a typical day for community RMNs; it will very much depend on the team and area of practice you work in.

Some of the possible teams that RMNs work in within a community setting

• Early Intervention Service: Early intervention services or EIS are small teams of mental health professionals who work with people during their first episode of a mental health illness such as psychosis or mania.

RMNs will work alongside Psychiatrists, Occupational Therapists, Social Workers, Psychologists and Support Workers to support people over a period of one to two years.

EIS teams often work with younger adults and nurses will meet their patients in the community or in their own homes.

As an RMN you will build therapeutic relationships to support people to make sense of their experiences and help prevent future crisis episodes.

You may discuss medications, psychological support and work closely with family members and carers.

RMNs will be responsible for a caseload of individuals, anywhere between 5-20 and offer appointments based on need.

• Crisis Resolution Home Treatment Teams: CRHTT were developed to support people in the community who would otherwise be in a mental health hospital.

RMNs will assess a person’s needs and create care plans and a visiting schedule based on how acute and at risk a person is.

Nurses will visit people in their homes up to twice a day to prevent an admission to hospital.

"Working in the community also gave me a sense of freedom and I benefited from being “out of the office” throughout my day."

RMNs will work as part of a team and more senior RMNs will be in charge of co-ordinating the team and visits for that day.

CRHTT will work with people for a short period during a crisis and liaise with other mental health teams to support ongoing care.

• Assertive Outreach Teams (AOT): AOT work with people who can be more difficult to engage with.

RMNs will work intensively with people who have chronic mental illness such as schizophrenia or bipolar affective disorder and who may have further issues such as drug use, criminal histories and who have been admitted to hospital multiple times.

RMNs working in AOT will have a smaller case load of people in order to offer assertive engagement.

• Specialist Teams: Across the UK there are a range of specialist teams which support people in the community.

RMNs can undertake further training and education to focus on a particular clinical area of mental health.

Nurses may work with children and adolescents, those with neurodevelopmental disorders, homeless people, mentally disordered offenders and older adults.

A key role for RMNs working in the community is that of Care Coordinator or Lead Practitioner for people subject to Care Program Approach (CPA). CPA is the way in which mental health services in the community are delivered to people with serious mental illness.

The approach ensures health and social services develop care plans, assess needs and regularly review treatment.

Under CPA an individual must be allocated a Care Coordinator.

RMNs working in the community will often fulfil this vital role.

The role requires RMNs to ensure the safe delivery of interventions to support people in the community.

RMNs will develop care plans in collaboration with the people they work with and often their families and carers.

Care will be reviewed every six months and RMNs as Care Coordinators will facilitate and lead CPA reviews with the other professionals involved.

What kind of person makes a good community mental health nurse?

When I made the transition from working in an inpatient setting to working in the community I found I had to develop a new set of skills in order to manage my work load and time.

There is a level of autonomy in any community role which requires you to be organised and boundaried.

You will be required to arrange appointments and maintain consistent engagement with the case load of people you are assigned.

In other community teams you may be required to respond to urgent referrals and the ability to prioritise your daily tasks is vital.

One major difference for me working in the community was the absence of the sense of a team.

"It was a noticeable positive change for me to work with individuals who were well and engaged in life."

On inpatient wards there are always other nurses with you, but lone working is common place when working with people in their homes or in community settings.

This required me to build more resilience and confidence in my own nursing skills.

It is important to maintain a good level of self-awareness in order to recognise stress levels and to access the appropriate supervision

What skills and qualifications are required to become a community mental health nurse?

Mental health services have changed considerably over the last twenty years.

When I qualified as an RMN it was standard practice to work in an inpatient setting for the first one-two years of your career.

Community posts for RMNs required previous experience and were offered at Band 6 and above.

The current landscape is markedly different, with Band 5 newly qualified posts available in many community teams and newly qualified nurses being able to apply for band 6 posts.

The route to Community Mental Health Nursing will include undertaking a degree in mental health nursing.

To gain a place on the degree most students will have three A levels and some experience in a health care setting.

If you are interested in community nursing try and get some practice placements in a community setting throughout your degree, this will help support job applications once qualified.

Once registered as an RMN you will be able to apply for community posts.

Due to the national picture of a shortage of RMNs, community posts are now available to newly qualified nurses and nurses with no previous experience of working in a community setting.

To support any application to a community team it is a good idea to visit the service and have an understanding of the role and responsibilities.

Progression and future pathways

Community nursing remains diverse, but in order to progress your career pathway there are plenty of training and education opportunities which can support you.

After I had been qualified for six years I returned to university and completed a Master’s degree in my chosen field.

Studying at Masters Level will give you the opportunity to narrow but deepen your field of expertise.

An excellent option for community nurses is to train as an Advanced Nurse Practitioner (ANP).

Once an ANP you will be qualified to assess, diagnose and treat individuals and also be qualified as a Non-Medical Nurse Prescriber.

There are then opportunities to have a higher level of autonomy and run nurse led clinics.

As you continue throughout your career there will be options to pursue a clinical or managerial pathway.

As a nurse leader you can progress to managing community teams, initially as a Team Leader then Service Lead.

I have always pursued a clinical pathway and continued to undertake clinical education in order to progress my career.

"Studying at Masters Level will give you the opportunity to narrow but deepen your field of expertise."

However, due to the structure of the NHS you may be required to work in managerial roles in order to progress through the banding.

Newly qualified nurses working at Band 5 can expect to earn between £24K and £27K a year.

Unlike inpatient mental health settings the opportunity to earn enhancements due to out of hour work is minimal with most services being delivered 9-5. This can significantly reduce your incomings compared to nursing in hospital.

Remaining clinical based, mental health nurses in the community can work as Band 6’s earning between £30-37K a year and up to Band 7 Clinical Nurse Specialists earning between £37K and £43K a year.

Within management structures you can progress through to Band 8a and 8b as Service Managers or Directors where you can expect to earn in excess of £60K a year.

The challenges and rewards of working in the community

Working as an RMN in the community has many rewards.

The ability to be flexible and manage your own working day is a great appeal to many nurses and I certainly enjoyed visiting people out and about in the community.

For many people, recovery from mental illness begins in hospital but very much continues back in the community where life continues.

As an RMN you can walk beside individuals in their own homes, when they return to work, meet with their families and rebuild their life.

It was a noticeable positive change for me to work with individuals who were well and engaged in life.

Working in the community also gave me a sense of freedom and I benefited from being “out of the office” throughout my day.

Interestingly I found some of the rewarding parts of the job initially a challenge.

Having worked on inpatient units for many years I was challenged by the autonomy to manage my own diary.

Many a time in the early months I was late for appointments due to miscalculating travel time or the city traffic!

I missed being in one place, the coffee pot on and the team around me.

I was anxious initially that I didn’t have other nurses around me to reflect with and bounce ideas off.

Once I grew accustomed to lone working and improved my organisational skills I found the freedom liberating.

Having worked shifts my entire career I welcomed a 9-5 job and no night shifts!

With an ever increasing focus on mental health care being delivered in the community, the opportunities for RMNs will continue to grow, whether you are newly qualified or wanting a change there are jobs available in every area of mental health in the community.

It really comes down to a matter of preference and lifestyle choices where you choose to work.

Related articles also by Laura

• What to expect from your job as a prison nurse

• What does a Mental Health Nurse do?

• What is forensic mental health, and how did I end up working in it?

• Why I became an independent Nurse Prescriber