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