Mary McCardle Interview

I met with Mary in the Department of Health and Children what follows is a a transcript of our conversation:

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Please describe your role as nurse adviser in the Department of Health?
The Nursing Policy Division has been in existence since 1998, having evolved from a recommendation of the Report of The Commission on Nursing: A Blueprint for the Future (1998). The Chief Nursing Officer and the Nursing and Midwifery Advisors play an essential role in strengthening the central planning and strategic development of nursing and midwifery in Ireland. They provide advice to the nursing and midwifery profession, The Department of Health and Children (DoHC) and other government departments. The Nurse and Midwifery advisors influence health care policy formulation and contribute to the shaping and reform of the Irish health system. We work as a team, each contributing to all aspects of policy development.

The main responsibilities of the Nurse Advisor Intellectual Disability are:

  • Support and advice to the Minister for Health and Children and Chief Nursing Officer on pertinent issues relating to intellectual disability nursing
  • Participation /support activities of Nursing Policy Division
  • Membership of the Nursing and Midwifery in the Community (NAMIC) project team, nurse advisors group and any other business deemed relevant by the Chief Nursing Officer
  • Provision of professional expertise on intellectual disability nursing
  • Promotion of the role of the Registered Nurse Intellectual Disability (RNID) and promote intellectual disability nursing as a career of choice
  • Promotion of North/South initiatives.

Do you feel that this role can bring about meaningful change? And if so can you give some examples?
Yes, I have engaged in the process by establishing the intellectual disability forum, which actively involves RNIDs geographically to help formulate advice and thinking to the Nursing Policy Division. We have prepared discussion documents in relation to the change of title of Registered Mental Handicap Nurse to Registered Nurse Intellectual Disability to An Bord Altranais; Submission to UCD on the review of the Five Points of Entry for Nurses and Midwives to the Register Maintained by An Bord Altranais:

Submission to the Primary Care Task Force on the role of the RNID in the community; Submission to The Irish College of Psychiatrists on the role of the RNID as part of the Community Mental Health and ID team and as part of the team in the DoHC contributing to national policy.

How much and what type of contact with service providers do you have?
I work half-time in the DoHC, 5 days out of 10; the other part of my job is in an intellectual disability service in Dublin. I have visited quite a number of services across the country as the ID advisor and I have established a network of contacts. My professional contacts and networks give me awareness to current issues in disability services. I would take approx fifteen calls for advice each week from RNIDs and managers with regard to issues that have an impact on nursing on the ground. I am a member of the Nurse Managers Association in Intellectual Disability, which has members from a large number of organisations. On any issue that requires a collective group of people I would be pivotal to liaison with the key personnel, either meeting with them individually or collectively.

In what ways do you meet nurses in practice in Ireland?
I have met many nurses on my visits to services and via the network which I have personally built up over my years in nursing—through lecturing, graduations, workshops, and conferences. I am also chairperson of the National Intellectual Disability Nursing Forum, which was set up in December 2002. The functions of the forum are:

  • To improve the profile of intellectual disability nursing.
  • To create a formal mechanism to represent intellectual disability nursing.
  • To meet regularly to discuss and debate on issues pertaining clinical practice, management and education.
  • To look at the current developments in the profession.
  • To act as a resource to the Department of Health and Children
  • To produce position papers/reports and review specific topics
  • To produce annual report/newsletter for the Chief Nursing officer.

The membership of the forum is representative of clinical practice, management, education, and statutory bodies.

What are your views on the future of the RNID?
Although the nurse training places have increased, in practice there is still a deficit in the numbers of RNIDs in service. Because of this deficit, care workers and nurses from other disciplines are employed. They cannot, because of their educational background, have the diversity and range of competencies required to meet the needs of this group of people. Therefore I would see the need for RNIDs to develop their scope of practice and complement this with the development of Clinical Nurse Specialists and Advanced Nurse Practitioner roles. Because of the shift in maintaining clients in their homes there is a need to develop the RNID in the community. RNIDs need to be a more cohesive and professional group to create a stronger voice. They also need to be strategic in ensuring that the RNID is involved in all levels of service provision including service planning, delivery and evaluating the effectiveness of service delivery to clients and their families. They need to be innovative and creative to meet clients needs and an example of this would be implementing nurse-led services. We need to build a body of evidence illustrating the effectiveness of intellectual disability nursing which is capable of capturing the essence of that practice as it is lived.

How would you like to see your role in the DOHC develop in the future?
The Nursing Policy Division will be part of the restructuring within the Department of Health and Children (DoHC) and the competencies and role of the advisors in the future will be different. I would like to see a continued role in policy development, strategic planning, relevant legislation and regulation in the context of population health, and further develop the leadership capacity of the nursing profession.

How can individual nurses bring about change in nursing in Ireland?
Individuals can change nursing in Ireland by ensuring that they are competent to practise and keeping their skills up to date and this can be supported by education and research, and also as managers within the intellectual disability setting. Nurses need to inform themselves by reading reports, journals, policies, strategies and analysing research.

How can individual nurses exercise influence in health care policy in the DOHC?
Nurses need to know how the health system works and be aware of health and social-care trends. They should make submissions towards health policy, advocate on behalf of service users and their families. They should also become involved in networking, which will support nurses within the field of intellectual disability. Networking facilitates sharing of practice, promotes user and carer perspectives, encourages information exchange and engages with central bodies to highlight needs and achievements within intellectual disability nursing. I am at present in consultation with the NMPDU to set a networking group between ID services in their area.

What do you consider to be the most important issues in ID nursing in Ireland today?
There are a number of issues for the profession at this time; they include the future role of the Registered Nurse Intellectual Disability (RNID) in early-intervention services, education, clinical and advanced nurse practice, reporting relationships and the pay anomaly that exists with the social care professionals. But the issue that nurses present to me regularly is that their role is seen purely within a medical model. The views contained in this response are not necessarily my own views or those of the Department of Health and Children, but those of nursing and education staff around the country.

A number of issues contribute to the difficulties in understanding the role. Attempts to describe the role are influenced by the range of philosophies underpinning employer services, different interpretations of the concept of health, and the perception of actual and potential employers that the competencies of the role of the RNID is orientated to the medical model.

The role confusion and the lack of professional leadership in some intellectual disability services lead to a re-enforcement of these perceptions. Thus there is an obligation for RNIDs to change this—particularly where the immediate need of individuals with intellectual disability is in fact in the community. Most residential services are used primarily by older people with moderate, severe and profound levels of intellectual disability (Department of Health and Children 2002, p.17). Therefore, it is reasonable to assume that young people with a mild level of intellectual disability will require and access services in the community. The RNIDs’ role in the community is underdeveloped and this is partly due to shortages of nursing staff, which in turn place the nurse in the area of most need, i.e. with individuals with severe and profound intellectual disabilities.

As RNIDs are competent to work with all age groups and all levels of handicap, it is incumbent on the profession to highlight and ‘market’ competencies in service provision for these individuals who have been resistant to the traditional role of the RMHN as associated with illness.

What competencies do you consider the nurse of the future requires?
I would like to highlight the competencies of the RNID. The competencies are both broad enough and appropriate to meet future need using a multicontextual model. It is important to acknowledge that consideration of existing and future competencies needs to be cognizant of those students now pursuing the BSc degree programme who will have a different range of competencies on registration to existing RNIDs. The aim of the degree programme is to prepare professional RNIDs who are safe, caring, competent decision-makers, flexible, adaptable and reflective practitioners, integral members of the multidisciplinary team and capable of providing care in any healthcare setting (Nursing Education Forum 2000).

It should be noted that Ireland is the only country in the world currently offering a pre-registration/degree nursing programme of studies devoted exclusively to people with intellectual disability.

RNIDs will continue to access further education, to facilitate developing the additional competencies required to adapt and meet contemporary and future needs. The changes mirror societal changes and thus reflect changes in client needs for example, care of the elderly with an intellectual disability, caring for children with complex needs and caring for individuals with dual diagnosis. Specialist modules have been developed for RNIDs to develop the required competencies and adapt accordingly to ensure the provision of individualized quality care for these clients. Ongoing monitoring and evaluation must be undertaken for a variety of reasons, but particularly to ascertain the need and type of other competencies that may require further development.

Recent emerging evidence suggests that the RNID can make significant improvements in health, including mental health gain for individuals with intellectual disability and their families. This has particular relevance in the Irish context, given that health, and indeed social gain, are key concepts in the Health Strategy, Quality and Fairness (2001). It is generally accepted that people with an intellectual disability have a higher level of health need and a high prevalence of physical and mental disorders. Hence, it is critical that staff caring for such individuals have the necessary education and experience in the recognition of these issues. The RNID is pivotal in meeting this need, and this is a useful marketing strategy to ensure the provision of an adequate cohort of RNIDs for all services for the intellectually disabled. Furthermore, it is the RNIDs who have vital insights into people exhibiting certain behaviors/syndromes, and therefore is in a position to implement focused interventions to the benefit of these individuals and their families.

In the current climate, the value of the RNID as a regulated profession needs to be highlighted as a worthy and positive strength and particularly to the public who are thus protected. RNIDs are safe practitioners who are accountable for their practice within the context of The Code of Professional Conduct for Each Nurse and Midwife (2000) and the Scope of Practice (2000). Ultimately the intellectual disability nurse’s value to people with ID rests on the particular competencies he or she may possess, as well as the management, communication and leadership skills that he or she commands. The synthesis of these skills places the nurse in an optimum position to lead developments in the field of intellectual disability in Ireland.

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