Dear Colleagues,

As you are aware this has been a particularly challenging year for the PNA with two ongoing major disputes.

The nursing Recruitment and Retention dispute and our Ambulance Personnel branch dispute in relation to the right to join and be represented by, the union of their choice. An update on this issue is provided within the newsletter.

Recruitment and Retention continues to be a critical issue in the Mental Health Services with a 20% vacancy level in some services and an unsustainable reliance on overtime and agency to maintain services.

There are also challenges from market competitors both within the private sector in Ireland and overseas.

The campaign to address this crisis has been protracted and frustrating with direct engagement with the employer, numerous WRC’s and Labour Court hearings. The lack of urgency shown by the employer to address this dispute demonstrates the Governments disregard in relation to the provision of mental health services.

Our negotiations continue on the week commencing 24^th June with direct engagement within the HSE and a Workplace Relations conciliation on the 28^th of June. It is envisaged that a final proposal will emanate from the WRC process addressing the outstanding issues, i.e.; the new enhanced nurse contract and other elements. On receipt of a final proposal an NEC will be convened to consider the proposal and the next steps to be taken.

Thank you for your patience and continued commitment in respect of this protracted process.

Yours sincerely

Peter Hughes

General Secretary

As part of her address Aisling offered a conceptual framework of what she believes are key factors for associations like Horatio and the ICN to provide information delivery and global platforms increasing networks and connections with national, regional and international nursing and non-nursing organisations in policy development.

Identity

Aligning around common principles is a large part of what an organization of the future is all about: members making decisions under defined rules of engagement, collaborating to create value, and earning the credibility to lead rather than having “leadership” be imposed from on high. Organisations like Horatio reach higher when their energies are channelled toward a higher purpose . Because different people find inspiration from different sources, it takes range to strike a chord that will resonate with almost everyone. Cultivating purpose in response to member organisations needs and sharpens our sense of mission and strength keeps us connected to the intended direction and vision of the organization. The recent development whereby Horatio and ICN have collaborated having signed a Memorandum of Understanding (MOU) sets the terms and understanding between Horatio European Psychiatric Nurses and the International Council of Nursing ICN concerning co-operation in International activity in relation to Mental Health Nursing. This Memorandum of Understanding ("MOU") is intended to assist and support both Horatio and ICN in performing their individual functions and to maximize effectiveness and efficiency. In particular, it will note areas of potential co-operation and collaboration in the interest of the advancement of nursing knowledge, and the presence worldwide of a respected nursing profession and a competent and satisfied nursing workforce. It will also support the work of psychiatric nurses, educational initiatives, mental health related research liaison with other national and international mental health groups. This approach offers the opportunity to identify key issues for nursing which may/ will impact mental healthcare across all levels of care and community, follow trends, and disseminate each other’s work in agreed areas of interest and participate /organize meetings and responses, optimizing the nursing voice in key areas of policy and strategy.

Some national policy frameworks fail to extend beyond the confines of the health system, failing to emphasise the need for concerted attention from the contiguous fields of housing, education, social care, criminal justice and employment.

In recent years the concepts and language of partnership, coordination, localism and services tailored to individual need have set the strategic directions for service reform. However, translating these concepts into practice has been a major challenge. Partnerships between public authorities, health and other service providers have been slow to form in part because of a lack of administrative and financial structures to integrate services and a lack of emergent agile strategies to simultaneously address matters such as housing, employment, education.

Even when policies are laid out, they may not be actually implemented due to the failure of governance structures to engage with the realities within the mental health sector, by entering into constructive dialogue with service users, personnel, partners and funding.

One cannot but confirm the importance of integrated decision making to respond and serve the interests of the individual .

Agility

Enables the shift towards emergent strategy with an emphasis towards holistic, multi sectoral, multi-dimensional, evidence based approach that can tap into a network of individuals .It involves choosing the foundational elements – the structures, governance arrangements and processes, this platform in turn supports looser more dynamic elements that can be adopted quickly in the face of new challenges and opportunities to meet the needs of the stakeholders and those seeking care. Cross cutting, interconnected choices and cross functional decisions bring together multiple parties who often have different priorities, so they can provide the right input at the right time within policy.

By engaging with abroad range of partners, our members, stakeholders and perspectives we can provide strategic leadership to advance the nursing profession to meet current and future needs of the population and the profession.

Capability

Finally, in order to be truly person centred and pursue the agility that makes performance possible, policy and organisations like Horatio are likely going to have to fill some serious capability gaps along the way. Holistic approaches create the conditions for organisations to be self-managing and individuals to adapt. The challenge of reforming mental health services and creating community based mental health care cascades to all aspects of the system. We can learn about mental health care from other countries and organisations , but we can also reflect on the diversity of societies in general, and the challenge to implement and sustain change in such different contexts. In much of Europe , despite the profession increasingly becoming all graduate, the amount of specialist mental health training for nurse is limited, with only a handful of counties having specialist training at the level of initial qualification, whilst others provide only limited access to post registration courses. The priority given to workforce development can be judged by the proportion of training hours dedicated to mental health. This varies significantly from 67% in Ireland and 49% in the United Kingdom to only 2.9% in Lithuania and 3.3% in Bulgaria. One of Horatio’s key objectives of its Vision 2022 strategy is Support the members and future members’ education, practice and administration in the mental health sector that will contribute to the development of the quality of care.

Responding to its mandate Horatio has most recently embarked on the following two initiatives.

Reform of Psychiatric Care in the Czech Republic

The population of the Czech Republic is 10 million.Compared to other EU countries, mental health care is severely underfunded at 3.5% of the overall health budget.

The process of reform started in 2013. The Ministry of health signed a Strategy of Psychiatric care. This Strategy is a core document, which contains the main principles and goals and describes necessary changes in the future. There are many projects regarding the psychiatric reform with different aims and focuses. These projects are funded from the EU.

• Deinstitutionalization
• Multidisciplinary cooperation
• New services
• Information structure and support
• Destigmatization

The Ministry of health of the Czech Republic established an International advisory group. The International advisory group is part of the project Deinstitutionalisation

Project Deinstitutionalisation

The project aims to contribute to change the system of providing care for mentally ill from institutional model to community model.

The project focuses on these major steps:

• Quality of care
• Creation of regional networks of care
• Transformation of psychiatric hospitals
• Awareness of the ongoing changes Expected finish date: December 31, 2021

A Specific part of this project focuses on psychiatric hospitals and their transformation. Activities are focused on supporting the transformation of existing psychiatric hospitals and the creation of regional networks of care for the mentally ill.

The activity consists of the following sub activities:

1) Educational Programs

- training programs for hospital management, which will focus on change management and strategy)

- training program for the staff involved in the transformation, which will aim to strengthen knowledge especially in the areas of system of health and social services of the Czech Republic, the role of state and local governments in the care of the mentally ill, the issue of human rights and the rights of patients and clients in general, the best practice in treatment methods and procedures, community forms of care, etc.

2) The strategy of deinstitutionalization

Strategic workshops defining targets for transformation for each specific hospital will be held to determine the specific strategies in individual areas.

3) Transformation Plans for Psychiatric Hospitals

Transformation plans will be prepared with regard to medium- (5 years) and long term (10-20 years) aspects of the future of psychiatric hospitals.

Individual transformation plan will include:

• Vision of the transformation
• Collaboration with other providers of care
• Competences of individual professions providing care
• Education and Training needed to support the transformation
• Restrictions on entry of patients into inpatient care (prevention, education)
• Layoffs of patients into community care (cooperation and continuity of services)
• Regional communication and activities
• Infrastructure and Networks
• Investment plan
• The economy of care
• Conditions for implementation
• Stages of implementation and action plan
• Risks and limiting factors

The intention is to achieve maximum participation of the staff of the hospital, thereby helping to change attitudes and thinking towards a significant preference for community care.

One of the goals is also effective interconnection of inpatient care and services newly formed.

Activities of the International Advisory Group

• Counselling during the process of implementation of changes, giving feedback to planned steps and strategic documents.
• Providing and sharing examples of good practice from abroad
• Helping with setting up appropriate way of training of professionals
• Giving experts opinions on various issues raised during the process of reform.
• These experts will be involved in selected project activities such as attending expert conferences, conducting thematic workshops, giving expert opinions, or counseling in specific areas during the process of implementation of the Strategy of psychiatric care. HORATIO has been recognized as relevant partner, to help during the process of reform.

Horatio’s main focus is the support of nurses transiting from working in in-patient settings to community based teams, and the educational systems designed to prepare nurses for this process. In April 2019, with the support of the Horatio board, Martin undertook a series of discussions regarding the preparation of Mental Health Action Plan in Czech Republic 2020 – 2030. Horatio has become an important partner during the process of psychiatric reform in Czech Republic.

Cooperation with Horatio will include:

• Consultation during the setting up an appropriate way of education of psychiatric nurses mostly in the field of community psychiatric nursing and psychotherapy
• Advisory and help during the process of exchanging experiences, finding clinical settings across the Europe suitable for hosting teams of Czech professionals to gain new knowledge and experience.
• Proposed adequate data to support psychiatric nurses and help to empower their role in providing psychiatric care
• Share practical information, projects, skills and knowledge with potential to improve everyday practice not only in community but also in acute and long-term inpatient settings (examples: Safewards, examples of creating a safe environment in acute psychiatry, screening and assessment methods for nurses etc.)

Horatio Community Mental Health Nursing Position paper

This position paper continues the series of mental health nursing position papers provided by Horatio (available in link provided) and follows the position statement produced in co-operation with other professionals in the mental health area and the WHO Mental Health Workforce group, in which the collaborative efforts to develop mental health issues has been established. Other health professionals besides nurses, like health visitors, public health nurses, psychologists and social workers, have also an important role in mental health promotion, prevention and care. However, service systems differ across European countries, therefore the role of different professionals working within a community setting may also vary a great deal. When writing this paper Horatio acknowledged the differences between educations, service systems and terms describing mental health nursing in communities. Education and competences

Education in mental health nursing differs between countries and sometimes also between the different education institutes. In some countries the curriculums are nationally regulated but in other countries higher education institutions are autonomous and the national regulation is on recommendation level. Therefore, the education towards mental health nursing vary from direct entry educations to generalized nursing educations including mental health nursing or specific post-graduate educations, with some of these at Master’s level. Differences are therefore seen not only in levels of education but also in the lengths of education. (e.g. Petrea 2012). No single education model for nursing, mental health nursing or community mental health nursing exists in Europe and because of several country-specific traditions this might not even be possible (Brimblecombe & Nolan 2012). The recognition of needed competences might be a more fruitful approach and suggested also viewpoint the European Federation of Nurses, have also emphasized this approach with competency descriptors in their Competency Framework for general nursing (EFN 2015).

Psychiatric/mental health nurses represent the largest workforce group in mental health care in a wide variety of clinical roles (WHO 2015b). The reform of mental health service systems itself should lead in the situation where the majority of the (mental health) nursing students are doing their clinical training in community settings. This change would mean in years to come that work in community settings is more common to mental health nurses than work in the mental health institutions, which often is still the case, although there are a lot of differences between countries. During the time of the reform, specific post- graduate educations may be needed.

Recommendations:

• Horatio supports the movement towards recovery-orientated, community mental health services, acknowledging the different phases and background factors affecting this development in different European countries.
• Community mental health nurses work should be recognized as an important factor of successful mental health service reform.
• If community mental health nurses’ previous education has not included knowledge, skills and attitudes/values (competence) needed to work in community settings, education should be provided and secured to meet the needs of high-quality person-centered and right-based community mental health care.

Conclusion to Aisling's address:

"Comparing mental health in various countries is a difficult enterprise, because of linguistic differences, differences in terminologies, different methods used in collecting and analysing data, and different criteria against which efficacy of services are judged. Trying to understand whether services are well designed to work effectively is more difficult.

WHO proposes 2020 as the year of the nurse and midwife, Psychiatric / Mental Health nursing must use this spotlight to celebrate its profession, address what needs to be done into the future of mental health reform and care delivery, from a policy, legislative and education perspective. The essence of Horatio must be grounded in how Psychiatric Mental Health Nursing drives policy that improves the health of people, healthcare and the profession. As a Representative organisation we call attention to the urgent need for robust, coordinated and transformative investments to address the escalating requirement for the supply of, of a competent, enabled and optimally organized mental health nursing workforce.

The Combined Conceptual Framework of Person-Centred Identity, Agility and Capability provides for a collaborative, dynamic, and relevant model for Umbrella Organisations like Horatio which can endure into the future. We are a fledgling organisation in many ways, but we have set a pace in in being part of a community that stretches across the world and enables us to make vital contributions to global health issues. through our future collaborations. Through our work with partners stakeholders and our recent collaboration with ICN we intend to be visible, vocal, and harness our collective strength on a local European and Global scale."

You Can download the Horatio Community Mental Health Nursing Position paper on : https://www.horatio-web.eu/position/Horatio_Community%20mental%20health%20nursing_position%20paper%202019.pdf

Annual Delegate Conference 2019

Thank you to all who travelled near and far to attend the 48^th Annual Delegates Conference Wexford on the 2^nd and 3^rd of May. A big thank you in particular to the Wexford branch for their hospitality and to all delegates and guests who contributed to the conference making it another great success. 

We would like to thank all those who presented at this year’s ADC. Deirdre Mulligan & Anne Brennan Nursing and Midwifery Planning and Development, who provided an insightful overview of planning frameworks, clinical supervision and quality care metrics. Nursing students from Dundalk IT, enlightened delegates with a relevant and interesting presentation about LGBTQ and mental health. The moving story of the O’Toole family was shared by the three confident and competent O’Toole sisters, the driving force behind ‘Jacinta’s Smile’- a charity who provide sibling bereavement support through adventure days, peer support and subsidised therapy. It was an honour this year to host Senator Joan Freeman at conference. Senator Freeman was the chairperson of the joint oireachtas committee on the future of mental health, whose final report was very much welcomed by the PNA in 2018. Senator Freeman addressed conference and gave a refreshingly honest account of the work of the committee and the challenges that lie ahead for the mental health services in Ireland.

The John Gahan Award for best motion, was awarded to Sinead Frain for her well prepared and entertaining motion regarding Dublin weighting. The Gantley Award was awarded to the very deserving Breege Calaghan for her significant achievements to date and her ongoing commitment to fairness and justice. Maith thú Breege!

Congratulations to all candidates who were elected and re-elected to the officer board at this year’s ADC. The officer board is now formed as follows;

Chairperson                                   Tracy Quigley, Laois/Offaly MHS *

Vice-Chairperson                          Liam Hamill, St Ita’s Portrane *

National Secretary                       Niall O’Sullivan, Forensic MHS Dundrum *

National Treasurer                       John Hughes, South Tipperary MHS

Trustees                                        Andy Myler, St Brendan’s MHS *

HSE Dublin North                         Mick Guilfoyle, St Ita’s Portrane *

HSE Dublin South                          Collette Walsh, Kildare MHS *

HSE Dublin East                            Declan Duffy, Forensic MHS Dundrum **

HSE Mid-West                               Denis Meehan, Clare MHS

HSE South East                             Sandra Forristal, Kilkenny MHS

HSE Midlands                                Ollie Byrne, Laois/ Offaly MHS

HSE South                                      Donal Spillane, Cork CAMHS *

HSE West                                       Damien Conlon, West Galway MHS

HSE North East                             Martin Slavin, Ardee MHS

HSE North West                            Lorraine Hogan, Sligo/Leitrim MHS *

Private/ Voluntary Hospitals       Eoin Ward, St. Patrick’s Hospital *

Intellectual Disability                   Liam Hamill, St Ita’s Portrane

*Elected / re-elected at ADC 2019

**Appointed as previous position holder was elected into positon of National Secretary

We would like to take the opportunity to wish Mary Walsh and Noel Giblin the very best for the future following their service to the officer board and thank them for all their dedication and hard work over the past number of years. Go n-eirí an t-ádh libh!

And finally we look forward to welcoming you all back next year to the 49^th Annual Delegates Conference in The Slieve Russel Hotel, Cavan, on the 2^nd & 3^rd April 2020.

Despite many delays, this report which, identified the future needs and direction of Intellectual Disability Nursing, was finally published and launched in September of last year.

The project represented a comprehensive examination of the present day role of the Registered Nurse Intellectual Disability (RNID) in Ireland. The views of a broad range of stakeholders’ were sought and analysed to address the overall aim of determining the future role of the RNID. The aim of the project was “to determine the future role of the registered nurse intellectual disability (RNID) who provides health and social care services to individuals with an intellectual disability and to their families and carers in this changing landscape”.

This report produced 32 recommendations. There are 31 recommendations for the expansion of the skills and nursing roles of RNIDs to encompass a lifespan approach to care for people with intellectual disabilities, from perinatal to end of life care, in 4 framework themes. There is also a final recommendation of ownership of the delivery of the recommendations, to ensure the future development of the discipline and create and establish much needed new and more specialised roles for RNID’s.

• Theme 1: Person-Centredness and Person-centred Planning
• Theme 2: Supporting Individuals with an Intellectual Disability with their Health, Well-being and Social Care.
• Theme 3: Developing Nursing Capacity, Capability and Professional Leadership
• Theme 4: Improving the Experience & Outcomes for Persons with an Intellectual Disability and their Families

The report states that

‘In the context of integrated workforce planning, this will require senior nurses, planners and managers of services to examine the deployment of RNIDs to ensure that they are assigned to and supported in these roles.

 As care from congregated settings continues to move to community settings, some RNIDs may be redeployed from roles where their predominant activity is the direct provision of care, to roles where they are also managing and coordinating health, well-being and social care for the person with an intellectual disability.

Evidence from this review highlighted the need for new and expanded roles and ways of working, and identified critical areas for the development of specialist and advanced RNID clinical practice to meet the growing challenges of supporting people with profound and complex health needs.’

The specific recommendations which the report suggests are required to progress these components in practice are as follows;

Theme 1: Person-Centredness and Person-centred Planning

Recommendation 1

RNIDs will ensure that their practice is informed by the values and principles of person centredness and person centred support in the assessment, planning and delivery of health and social care to individuals with an intellectual disability in all settings.

Recommendation 2

RNIDs will receive professional development in supporting self-determination and person-centred planning, including advanced advocacy skills in order to continue to assist individuals with an intellectual disability and their carers in linking with and navigating community based and general health and social care services.

Recommendation 3

The HSE will develop specific policy and systems for professional supervision within Intellectual disability services in accordance with the HSE’s overall HR circular on clinical supervision. RNID’s will be supported to engage with regular and effective professional supervision to ensure that the values of person centeredness are applied consistently in practice.

Recommendation 4

The focus, knowledge, skills and competence of RNID’s will support the increasingly interdisciplinary, community based and person-centred services world of individuals with an intellectual disability.

Recommendation 5

RNID’s will work collaboratively with other disciplines to support families in pursuing and achieving positive opportunities in the lives of their family member with an intellectual disability.

Recommendation 6

RNID will be supported to undertake training to understand the components of the Assisted Decision Making (Capacity) Act (2015) in respect of the need for legally recognised decision-makers to support a person maximise their decision making powers and to develop an understanding of what this means for staff caring for individuals with an intellectual disability.

Theme 2: Supporting Individuals with an Intellectual Disability with their Health, Well-being and Social Care.

Recommendation 7

Individuals with an intellectual disability will have access to RNID’s in a variety of roles in primary, secondary and tertiary care settings who have specialist knowledge and skills in their health and social care support requirements and in alternative communication approaches.

Recommendation 8

RNID liaison posts will be developed within acute hospital services to support the individual with an intellectual disability throughout their entire acute hospital journey.

Recommendation 9

RNIDs will be embedded within existing health and social care provision and be clearly identified as key members of multidisciplinary teams working with individuals with an intellectual disability and their carers in intellectual disability-specific and more general health and social care settings with designated leadership and governance roles.

Recommendation 10

Specialist RNID roles will be available in all locations to support individuals with an intellectual disability including for example community agencies, schools and other educational facilities, workplaces, legal and business services and the criminal justice system.

Recommendation 11

RNID’s will undertake a care management and liaison role in mainstream health services ensuring timely access to care and support to the person with an intellectual disability.

Theme 3: Developing Nursing Capacity, Capability and Professional Leadership

Recommendation 12

Pre and post registration educational curricula will be strengthened to better prepare RNID’s to respond effectively to the increased complexity of health, well-being and social care needs of people with an intellectual disability across  the lifespan.

Recommendation 13

A broader range of intellectual disability placement opportunities will be developed for undergraduate nursing students and new supervision guidelines developed so that the expectation of RNID supervision does not preclude the utilisation of some placements.

Recommendation 14

Continuing professional development and post graduate education programmes for RNID’s will be developed informed by service need and delivered using a blended learning approach as appropriate. Examples of areas requested for development include (1) autism; dementia; ageing; epilepsy; bone health; behavioural support; advanced and augmented communication; and community care support and (2) general and specialist health assessments, providing health and social care, supporting families, and liaising with other professionals in work with individuals with intellectual disability across the lifespan.

Recommendation 15

Higher Education Institutions will further develop collaborative partnerships with intellectual disability services to enhance the skills and competencies of nurses to ensure positive health outcomes for individuals with an intellectual disability.

Recommendation 16

Persons with an intellectual disability will increasingly be involved in the design and delivery of education programmes and policy.

Recommendation 17

RNID’s will work to ensure their practice is evidence based by strengthening their involvement with practice development initiatives, availing of continuing professional development opportunities, engaging with research activity and participating in professional supervision.

Executive Summary

Recommendation 18

Policies, procedures, protocols and guidelines will be developed to support areas of intellectual disability nursing practice in all settings; to include autism, dementia, ageing, epilepsy, bone health, behavioural support, advanced and augmented communication, primary, community and social care, acute general and mental health services to include hospital based services and primary care practices.

Recommendation 19

Clinical Nurse Specialist and Advanced Nurse Practitioner roles will be developed in accordance with the criteria identified by the Nursing and Midwifery Board of Ireland and in response to identified service need: to address disparities in health policy implementation, health service delivery and health outcomes for individuals with an intellectual disability.

Recommendation 20

Consideration should be given to the appointment of joint posts between intellectual disability services and higher education institutions to progress the development of an evidence base for intellectual disability nursing practice.

Recommendation 21

Bespoke leadership development programmes should be developed and provided for nurses working at all levels within intellectual disability services.

Recommendation 22

RNID’s throughout the health economy will explore mechanisms to network and share practice and research including the use of journal clubs, networks, conferences and seminars and social media. Specifically RNID’s are encouraged to build a network with colleagues at national (including Northern Ireland) and CHO level to be informed of information sessions and training schedules that are provided in relation to specific topics.

Recommendation 23

RNIDs will respond to contemporary health, well being and social care policy and provide clinical leadership ensuring that the needs of people with an intellectual disability are addressed.

Recommendation 24

Opportunities should be created for RNIDs to have a greater voice at national policy level to articulate, advise and inform contributions by intellectual disability nursing in responding and addressing health disparities for people with intellectual disability.

Theme 4: Improving the Experience & Outcomes for Persons with an Intellectual Disability and their Families

Recommendation 25

Nurse leaders and Persons in Charge within intellectual disability services will be supported to undertake and engage in relevant education and provided with subsequent support to develop a systematic approach to quality measurement and improvement within their area of responsibility.

Recommendation 26

Nurse leaders and Persons in Charge will participate in the wider professional nursing fora at regional level and engage in quality related development activities.

Recommendation 27

The capacity and capability of nurses within disability services will be developed to implement and evaluate evidence based quality improvement methodologies through the provision of relevant education programmes and subsequent support.

Recommendation 28

Nurses at all levels working in disability services will access and implement the resources and tools developed by the HSE’s Quality Improvement Division to support governance and quality improvement.

Recommendation 29

RNID’s will be supported to undertake training in the HSE national risk assessment and safety management guidance for intellectual disability services which will take into account overall HSE policy in this regard. The RNID should be key in its application to practice; specifically in areas of incident reporting, investigation and using findings to inform learning and change.

Recommendation 30

The HSE will develop a national advocacy programme for intellectual disability services to support person centeredness. RNID’s should be actively involved in its development.

Recommendation 31

RNID’s will ensure their practice demonstrates an acknowledgement of the dynamic nature of risk ensuring that there is ongoing multidisciplinary and collaborative review of the type and level of risk and associated updating of safety plans of individuals with an intellectual disability.

Recommendation 32

The Social Care Division, in partnership with the Office of the Nursing and Midwifery Services Director will establish the appropriate structures and processes to lead, drive and monitor the implementation of the recommendations of this report.

Implementation Steering Group

An Implementation Steering Group has been set up to oversee the roll out of the recommendations of the report. The first meeting of this steering group took place on March 12^th 2019, where Terms of Reference for the group were set out and agreed.  Sub-groups have been formed to examine and oversee the implementation of these recommendations in areas such as

• Education,
• Professional Development,
• Policy Making
• Risk Management.

The Shaping the Future of Intellectual Disability Nursing in Ireland project recognised the value of the RNID in the delivery of high quality person-centred care to people with an intellectual disability. The implementation of the report’s recommendations offers an opportunity for the further development of the RNID discipline. Increased CNS, ANP and leadership roles will be developed to meet the changing needs, demographics and models of service provision for people with an intellectual disability.

 The development of the RNID’s capacity and capability to underpin intellectual disability nursing practice in all settings throughout the lifespan of the individual with an intellectual disability requires expansion into areas such as

• Paediatric services
• School services
• Primary care
• Acute hospital care
• Forensics
• Perinatal to end of life approaches
• Working in conjunction with Government systems e.g. housing, justice, education and employment

The aim of the group is to support the implementation of the recommendations of the Shaping the Future of Intellectual Disability Nursing in Ireland report, and monitor the progress of the plan.

Their role in respect to each of the recommendations will be to:

• Develop a detailed action plan
• Identify who has lead responsibility
• Identify the resources required (human and financial)
• Outline the time frames for the implementation of the recommendations
• Drive and monitor the implementation plan.

The PNA, as a stakeholder, will be involved in this implementation group, and will work to ensure that this will guide ID Services in the creation and establishment of much needed new and more specialised roles for RNID’s.

Gender identity is an ever-changing spectrum that is often misrepresented in the world of today. Mental health as it relates to gender is a contemporary and increasingly prevalent issue amongst the Irish population and across the globe. According to Transgender Equality Network Ireland, gender identity is best described as a person’s intense feeling of identification as male, female, or some other gender. This may or may not relate to the sex they were assigned at birth (TENI 2018). As part of this article,  we will present an overview on Gender Identity terms, prevalence, treatment and stigma.

There are a number of terms associated with gender ranging from ‘cisgender’, a term for someone who exclusively identifies as their sex assigned at birth, to ‘gender fluid’, defining one who has a changing or fluid gender identity (Trans student 2019). However, a universal term for members within this community is ‘transgender’, which is an encompassing term of many gender identities for those who do not identify or exclusively identify with their sex assigned at birth (Trans student 2019). These terms may appear confusing and overbearing at first but respectfully asking those concerned is likely to lead to further understanding for the layman and gratitude from respondents.

Varying and widely held inaccurate beliefs about the transgender community are difficult to ignore in the media and on social media platforms in 2019. For example, while many of us believe that it is impossible to know for sure that one is transgender before reaching a certain age, the overwhelming consensus of the psychological community is that gender identity is formed by the age of 2 or 3 (Tannehill 2017). Furthermore, if the child is still asserting a cross-gender identity at the age of 15 or 16, there is almost zero chance that this will change (Tannehill 2017). ​Dissimilar to other schoolyard-scenarios, parents of gender-nonconforming children are repeatedly criticised for encouraging them and exposing their child to bullying, perhaps the blame is more suited to be placed on those doing the bullying.

The size of Ireland’s transgender population is not known, although a recent peer-reviewed article published in the Irish Medical Journal suggests that the condition is no less frequent in Ireland than anywhere else. To put that into perspective, there are 700,000 estimated people who identify as transgender in the United States alone, roughly 0.3% of the population (Gates, 2011). That translates to over 14,352 transgender individuals in Ireland today. To add to those figures, it is estimated that 1 in 4000 people are receiving treatment for gender dysphoria in Ireland (HSE 2018). These figures are only increasing, as evidenced by a study conducted by Judge et al (2014), stating that 55 referrals were made in 2013 in comparison to only 5 referrals in 2006. The significance of this subsector of the population can no longer be denied.

WHO no longer considers ‘Gender Dysphoria’ to be a Mental Illness, and has reclassified it as ‘Gender Incongruence’, which is merely a Sexual Health condition.  (LifeSIteNews, 2018). Contrary to this development, it continues to predominantly be mental health services who receive referrals for people with gender dysphoria in Ireland. Here the individual is treated only for their relating mental health difficulties such as anxiety or depression. Other treatment options include hormone therapy and gender re-assignment surgery. Not to place an undervalue on the psychological aspects of gender dysphoria, Littman (2018) surveyed parents of children with gender dysphoria and discovered that nearly two thirds of those surveyed had a diagnosis of psychiatric or developmental disorders previously. Almost half having experienced trauma or attempted self-harm (Littman 2018).

People with gender dysphoria are predisposed to a higher risk of emotional and behavioural problems due to transphobic bullying, harassment, discrimination, stigmatization and other triggers for mental health difficulties (Headspace 2019). TENI’s Trans Mental Health and Wellbeing in Ireland report, is the largest survey of its kind conducted in Ireland (2014)​. Discoveries include the following:

• 44% of trans respondents said they self-harmed​.
• 40% had attempted suicide​.
• 22% attempted 2-5 times.
• 64% had been made fun of or called names
• 36% had been physically intimidated or threatened
• 16% had been physically assaulted

The following is an extract from one of the interviews featured in the study.

“These boys started​ throwing stones at me, when I ignored them, they took my wig and ran off.”

On a brighter note, the battle has not all been losses. In 2015, the Irish government passed the Gender Recognition Act, the same year as the marriage equality referendum in Ireland. This legislation provides a process for an individual to change the gender marker on their birth certificate and be legally recognized by the State in their true gender, resulting in at least 297 amendments since. Ireland became only the fourth country in the world to give people a right to a gender based on self-declaration. A significant step in the right direction for transgender activism in Ireland. Simply a little more empathy and kindness on our behalf or an attentive ear may well be the most significant impact we ourselves can make going forward.

It was both our pleasure and our privilege to develop and present this project on behalf of Dundalk Institute of Technology Department of Nursing, Midwifery and Early Years. Sincerest gratitude to our supporting lecturers and the PNA for facilitating the exposure and encouraging us every step of the way. Exerting a voice for the voiceless and continuing the fight for change has been a phenomenally rewarding experience for all involved. We hope that the discussion on Gender Identity turns into action in the very near future.

Reference list:

Bauer, G. R., Scheim, A. I., Pyne, J., Travers, R., and Hammond, R. (2015). Intervenable factors associated with suicide risk in transgender persons: a respondent driven sampling study in Ontario, Canada. BMC Public Health. 15, pp.525. 8. LifeSiteNews. (2019). News: Gender [online]. Available from: https://www.lifesitenews.com/news/world-health-organization-removes-gender-dysphoria-from-list-of-mental-diso [Accessed: April 5 2019].

Gates. (2011). How many people are  lesbian, gay, bisexual,  and transgender?. Available from: https://williamsinstitute.law.ucla.edu/wp-content/uploads/Gates-How-Many-People-LGBT-Apr-2011.pdf [accessed 9 April 2019].

Headspace.(2019). Gender Identity and Mental Health [online] Available from: https://headspace.org.au/assets/Uploads/Resource-library/Young-people/Gender-identity-and-mental-health-web.pdf [accessed 9 April 2019].

Headspace.(2019). Gender Identity and Mental Health [online] Available from: https://headspace.org.au/assets/Uploads/Resource-library/Young-people/Gender-identity-and-mental-health-web.pdf [accessed 9 April 2019].

HSE.(2018). Gender Dysphoria [online] Available from: https://www.hse.ie/eng/health/az/g/gender-dysphoria/ [accessed 10 April 2019].​

Judge, C., O'Donavan, C., Callaghan, G., Gaoatswe,G. And O'Shea, D.(2014). Gender Dysphoria Prevalence and co-morbidities in an Irish Adult population. Frontiers in Endocrinology. Available from:  https://www.frontiersin.org/articles/10.3389/fendo.2014.00087/full [accessed 8 April 2019].

Littman, L. (2018). Parent reports of adolescents and young adults perceived to show signs of a rapid onset of gender dysphoria. PLOS ONE. 14(3). Available from: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0202330 [accessed 9 April 2019].

Tannehill, B. (2017). Dispelling Myths, Misconceptions and Lies About Gender-Nonconforming Children. Huffpost [online]. Available from: https://www.huffpost.com/author/brynn-tannehill [accessed 9 April 2019].

Trans Student Educational Resources. (2019).  LGBTQ+ Definitions [online]. Available from: [online]. Available from: http://www.transstudent.org/DEFINITIONS/ [accessed 11 April 2019]. 

Transgender Equality Network Ireland. (2018). Trans Terms[online]. Available from: http://www.teni.ie/page.aspx?contentid=139 [accessed 9 April 2019].

Q. I’ve recently been promoted as a Clinical Nurse Specialist on a 5/7 Monday-Friday Roster from a staff nurse with 6 years experience. My line manager informed me at my induction that my annual leave entitlement has changed. I am unsure what hours I am now entitled to.

A. As a newly appointed CNS your annual leave entitlement increases to 26 annual leave days @ 7.8 hours per day, this is up from the 25 data which a nurse with 5-10 years experience accrues. As a CNS this would entitle you to 218.4 hours which can be accessed in hours, days, a week or a fortnight. This would also mean you would be rostered off duty on each of the official 9 bank holidays we have each year. 

Q. I was asked upon commencing my shift to meet my Director of Nursing today about a complaint that that was submitted against me. I was told I would be given further detail of the complaint at the meeting. What should I do?

A. It is advisable in the first instance to contact your PNA representative. As per S.I. No. 146/2000 - Industrial Relations Act, 1990 (Code of Practice on Grievance and Disciplinary Procedures) (Declaration) Order, 2000, all staff are entitled to fair procedures and natural justice when facing grievance and disciplinary procedures. So what does this mean?

It means;

•    That employee grievances are fairly examined and processed;

•    That details of any allegations or complaints are put to the employee concerned;

•    That the employee concerned is given the opportunity to respond fully to any such allegations or complaints;

•   That the employee concerned is given the opportunity to avail of the right to be represented during the procedure;

•   That the employee concerned has the right to a fair and impartial determination of the issues concerned, taking into account any representations made by, or on behalf of, the employee and any other relevant or appropriate evidence, factors or circumstances.

In the above circumstances, a request should be made for the meeting to be postponed until such a time where the nurse is written to. This should include a copy of the complaint and its source, include any evidence supporting the complaint, outline the policy under which the complaint is being investigated, advise the nurse to consider union representation and afford reasonable time to coordinate same, afford reasonable time for the complaint and relevant documentation to be considered in full. 

n January 2017 revised bereavement leave scheme entitlements were published in the form of Circular 01/2017, directed by the Minister for Public Expenditure and Reform. In circumstances where there is a death of a close of immediate relative, the Circular set out the following;

(a)Where there is the death of a spouse (including a cohabiting partner), child (including adopted children and children being cared for on the basis of 'in loco parentis') or any person in a relationship of domestic dependency, the amount of bereavement leave shall be twenty working days.

(b)Where there is the death of another immediate relative the amount of bereavement leave shall be five working days.

(c)Where there is the death of an uncle, aunt, niece or nephew the amount of bereavement leave shall be one day. In exceptional circumstances, where the civil servant lived with the deceased at the time of their death, or has to take charge of funeral arrangements, this limit may be extended to five working days.

(d)In the event of a stillbirth or prenatal death of a child after twenty four weeks pregnancy, bereavement leave of ten days may be granted to (i) the father of the child, (ii) the spouse, civil partner or cohabitant, as the case may be, of the mother of the child, or (iii) a parent of the child under Section 5 of the Children and Family Relationships Act 2015 where the child is a donor-conceived child within the meaning of Part 2 of that Act.

None of the above provisions were available to those working within the health sector.

The Circular also allowed for an increase to five working days for those in the “exceptional” circumstance of having lived with the deceased or who must take charge of funeral arrangements. At that time only three days were grantable within the health sector.

Following a period of engagement with the employer, where no resolution was found, the issue was referred to the WRC where conciliation took place on January 2018. At this, the HSE committed to providing a “comprehensive report” to outline the costing exercise that was completed by them regarding the application of Circular 01/2017. The PNA did not accept the costings provided by the HSE as, by their own admission, the costing exercise was only an estimate as they “Could not provide detailed records on compassionate leave”. We believed that the figures supplied could not be accurate as it suggested a very low uptake in additional days leave following Bereavement leave, even in situations where Immediate family members had died.

Further discussions within the WRC on June 2018 also failed to reach an agreement with the employer completely rejecting the possibility of applying the Circular to the health services. The issue was then referred to the Court by the Health Unions involved, including the PNA and submissions were made to the court outlining the PNAs position and the hearing was held on May 22^nd.

Our arguments were as follows:

1)The application of Circular 01/2017 had created a chasm between what is applicable to Civil Servants and their non department colleagues.

2)Our members terms and conditions of employment set out, in relation to compassionate leave allowed for the following:

• Five working days leave in the case of a death of a spouse or child
• Three working days leave in the case of an immediate relative.

3)The schemes now differ in the following ways;

Our members terms of compassionate leave within the health sector did not allow for instances of still birth or prenatal death. Circular 01/2017 lays out the following in relation to this;

2(d) In the event of a stillbirth or prenatal death of a child after twenty four weeks pregnancy, bereavement leave of ten days may be granted to (i) the father of the child, (ii) the spouse, civil partner or cohabitant, as the case may be, of the mother of the child, or (iii) a parent of the child under Section 5 of the Children and Family Relationships Act 2015 where the child is a donor-conceived child within the meaning of Part 2 of that Act.

The PNA believed that this allowed for circumstances where our members were simply being denied the same entitlements made available, to their colleagues, by the employer. The Unions also disputed the figures and in particular that it was normal practice to have a 100 percent back fill policy, as inferenced by the employer group. Our belief being that the existence of circular 017/2013 made this a unrealistic impediment to implementation.

In its recommendation the court found the following.

 “The Court having read the submissions of the parties and listened carefully to the oral submissions on the day recommends that the HSE and section 38 funded agencies bereavement policies be amended in line with the concessions referenced earlier in the Civil Service to allow for twenty working days for spouse/partner and child (including adopted and 'in loco parentis') and five days for immediate relative as currently defined in the HSE and Section 38's own policies”.

It further recommended, in relation to the backfill question, the following:

“The Court, noting the commitments that exist in HSE HR Circular 017/2013, further recommends that the parties return to Conciliation and constructively engage on the issue of the need for backfill arising from these changes, and other relevant issues, with a view to implementing the changes with effect from 1st October 2019”.

The PNA will now engage, along with the other health unions, on this issue but the outcome must be very much welcomed and seen as a victory for equality in the Public Sector.

The full recommendation may be found on : https://pna.ie/index.php/pay-and-pensions/rights-and-entitlements/1085-labour-court-rec-re-compassionate-bereavement-leave