By Richard Lakeman (1995)
The notion that nurses working in mental health settings are loosing
their identities as nurses and that institutional roles are blurring in the mental health
field is not new. Nurses in New Zealand need to examine whether this is true for them in
the context of the present health system. Relatively new roles are evolving in the
community which require generic mental health skills and challenge previously held ideas
about how nursing is practiced. Nursing is struggling to articulate what it has to offer
which is unique to nursing.
This paper examines some of the phenomena that may be contributing to
the difficulties that nurses have in articulating and more importantly actualizing a
distinctly nursing perspective in the field of mental health. The sources of nursings'
identity from a historical point of view are examined first, leading onto a critical
appraisal of some of the ideals expoused by nursing. The perceptions that nurses hold of
what they do are examined and the implications for nursing education and research are
discussed.
Psychiatric nursing and its' alliance with medicine.
The profession of psychiatric nursing evolved as a result of the
medicalisation of the insane. In England, by 1774, a physicians certificate was required
to commit a person to a madhouse, "despite medicine at that time having no
explanatory theories or curative treatments for insanity" (Conrad & Schneider,
1980, p.45). The 18th century was a time of medical entrenchment in the realm of authority
over madness. In New Zealand "between 1854 and 1872, a network of provincial lunatic
asylums was established throughout New Zealand" (Williams, 1987, p.5). Medical
officers were appointed, with the responsibility of classifying mental illness and
overseeing the moral management of the patients, although in the early days, much of the
therapeutic process was left to lay superintendents or keepers.
Most of the care and domestic duties in the asylums were delegated to
untrained attendants. It wasn't until 1905 that organized training for psychiatric nurses
began in New Zealand and a register of Mental Nurses was established in 1907. Part of the
examination for registration involved an oral examination conducted by the medical
superintendent (Williams, 1987). It was believed that these moves would "raise the
status of mental nurses and stimulate interest in the calling" (Williams, 1987,
p.58). Thus the profession of psychiatric nursing arose from a need to attract, retain,
and train suitable people to attend to the needs of the mentally ill in asylums, under the
authority and direction of doctors. For most of the twentieth century most psychiatric
nurses have remained as workers in the asylum or large psychiatric hospital.
That psychiatric nursing and medicine are closely aligned is a
historical fact. Nurses have been trained to work closely with doctors and have often been
trained directly by them (Barker, Baldwin, & Ulin, 1989). The psychiatric nurse has in
the past been described as "little more than an extension of the medical staff"
(Conolly, 1856). Most nurses would argue that nursing has a contribution to make which is
quite independent of medicine. Some however suggests that nurses are trapped within a
medical and institutional model which adversely affects the care they provide (Clay,
1987).
Taylor (1994) contends that psychiatric nursing was acknowledged as a
major health care profession when most people with mental illness were housed in large
psychiatric hospitals. She suggests the value of psychiatric nursing is now being
questioned as these hospitals are closing. Indeed the identity of psychiatric nursing as a
specialty area has been defined by its association with psychiatric hospitals and with
their demise the identity of psychiatric nursing is on shaky ground. This is not helped by
psychiatric nursing having not effectively demonstrated its therapeutic worth, or cost
effectiveness in the changing health care system (Taylor, 1994).
Psychiatry remains to this day, the dominant profession in the mental
health field in New Zealand. Psychiatry will remain entrenched in its position of
authority and dominance over other disciplines due in part to a resurgence of interest in
biological explanations and treatment of mental illness. Suzanne Lego (1992) cites a
number of reasons why American society has so readily accepted the biological model
including, biological treatments being fast and cheap; failure of deinstitutionalisation;
a societal move towards externalization of cause; the greater value placed on
"hard" sciences as opposed to "soft" behavioral sciences; and
psychiatrists seeking there own exclusive domain in the face of large numbers of
non-medical psychotherapists such as nurses, social workers and psychologists. How closely
psychiatric nurses are, or should be aligned to biological models of explanation and
treatment is a matter of conjecture which serves to reinforce the notion that there is
little consensus about the role of the psychiatric nurse. Barker, Balwin, and Ulas (1989,
p.292) warn that "attempts to distance psychiatric nursing from its traditional
ancillary relationship with medicine will prompt an evaluation of its professional status
and therapeutic worth"
Peplau (1989) suggests that the biomedical thrust occurring at a
national level in America is likely to be supported by the public due largely to the
visibility of the mentally ill amongst the many homeless people as a result of
deinstitutionalisation. She sees some nurses aligning themselves with the current trend
while others will develop private psychotherapeutic services. McBride (1990) suggests that
nursing has narrowed its scope primarily to the study of the social and behavioral
sciences and must stop devaluing biological knowledge. She suggests that re-emphasising
biological science will narrow the gap between nursing research which is largely in the
social sciences, and practice, which is primarily orientated to providing physical care,
administering medications and managing deviant behavior. Lego (1992) expresses concern
that psychiatric "nurses are jumping on the biological band wagon" and warns
nurses to keep their minds open to the complex, multi-causal nature of mental illness. She
posits that "there are no sound scientific data proving that mental illness is either
caused or cured by biological factors" (Lego, 1992, p.149). There appear to be
contradictions in the literature about the present position and future direction that
psychiatric nursing should take as a profession. However as Peplau (1989) points out,
psychiatric nurses are involved in all forms of treatment, from merely monitoring
medication to behavioral modification and various psychotherapeutic modalities. The quest
for a universal ideology which guides nursing practice may be too ambitious.
Psychiatric nursing in search of a unique ideology.
Strauss, Schatzman, Bucher, Ehrlich, and Sabshin (1964) undertook a
study exploring the dominant ideologies held by health professionals working in two
psychiatric hospitals. They concluded that psychiatric nurses were an ideologically
uncommitted group, showing a similar degree of support for psychotherapeutic,
sociotherapeutic and somatotherapeutic ideologies in contrast to other professionals who
identified most strongly with one ideology. They concluded that psychiatric nurses lacked
a genuine ideological commitment to any single approach and in general were nonpartisan.
They suggested that this neutrality was probably adaptive given that nurses must work with
staff members of different ideological persuasions, and that psychiatric ideologies as
such may be dimly perceived by nurses. This study was conducted over two decades ago and
was undertaken in a cultural, social and political context far removed from ours. However
the research by Straus et al (1964) may continue to have some validity. Psychiatric
nursing may be a profession searching for an ideology of its own and the nonpartisan
approach to different ideologies may continue to be a defining characteristic of
psychiatric nursing as a profession.
A study by Barratt (1989) on the self-perceived roles of community
psychiatric nurses (CPNs) again highlighted an eclectic approach in viewing mental illness
and the role of the psychiatric nurse. Interestingly Barrat found that depending on the
source of the nurses referrals they had different priorities, reflecting different
conceptual models of mental illness. Assessment was rated the main role by all but one of
the 16 CPNs interviewed. Assessment encompassed finding out what problems the client had
with a view to solving them, finding out how the client was coping at home, ensuring a
good rapport with the client and for the benefit of doctors. Prevention, counseling,
giving medication, providing physical care, education, advice, specialist therapy,
reassurance/support, monitoring and evaluation all assumed different rankings depending on
whether referrals were received from hospital or other sources. Barrat concluded that the
CPNs did not appear to use a constant model of illness when discussing their functions but
seemed to fluctuate from one model to another. This may well be a functional and adaptive
phenomena but it also may contribute to the blurring of roles of psychiatric nurses who,
rather than bring a uniquely nursing perspective to the work place, may conceptualize a
patients problem in the same way as other health professionals.
The problems inherent in following trends.
New Zealand has been quick to respond to overseas developments in
nursing knowledge. Sometimes these developments are research based but often they are
based on what seems like a good idea waiting to be validated by research. Psychiatric
nursing will embrace a new idea with enthusiasm despite philosophical contradictions with
existing ideologies and a paucity of valid research. As Salvage (1983, p.11) says,
"we tend to latch onto buzz-words which seem valuable because they hint at something
we want to incorporate in our practice". The nursing process and particularly the
notion of nursing diagnostics in psychiatric nursing is a case in point. The nursing
process has been virtually elevated to the status of dogma in many nursing circles. Few
nurses would challenge the usefulness, particularly for beginning practitioners of a
written problem solving approach to care. Most other health professionals use a similar
approach. However nursing diagnosis have been incorporated into psychiatric nursing
despite being at odds with a number of extant nursing theories and despite criticism and
quiet murmurings of discontent from the profession.
Stuhlmiller (1995, p.3) suggests that nurses have jumped too quickly on
the band wagon of diagnosis, "the lists of standardized criteria can serve as useful
guidelines, however, they overlook the essence of nursing - attending to the unique
context of each situation as it presents itself and unfolds". Indeed the notion of
diagnosing problems or responses to problems is quite contrary o the notion of nursing as
primarily an interpersonal process. Hagey & McDonough (1984) claimed that nursing
diagnosis encourage stereotyping, categorization and obliterate the personal meaning of
human experiences. Others such as Mitchell (1991) argue that there is the potential for
real harm to people as a result of the diagnostic process revolving around being judged,
treated as an object, viewed as passive, misunderstood and devalued by professionals.
Mitchell (1991, p.103) concedes that the principles underpinning the biomedical model and
the diagnostic process "may prove fairly effective for controlling pathophysiologic
alterations" but states that these principles are not congruent with nursing as a
humanistic science or the concept of unitary humans.
The frustration of Smith (1993) with the nursing process is clearly
evident. He claimed that "systems and processes eliminate any chance of using flair,
imagination or innovation and force you to look for common denominators, sameness"
(Smith, 1990, p.16). Smith may well have been experiencing what Benner (1984, p.31)
describes as "a regression to an analytic, competent level of practice when novelty
or the demand for an analytic, procedural description of practice is required".
Benner (1984, p.38) makes it quite clear that a major limitation of the nursing process is
that "without including the context, intentions, and interpretations of skilled
practice the relative importance, relational aspects and outcomes of skilled practice are
not captured". Despite this, the work and worth of nurses is increasingly being
judged on how well they conform to writing the ideal care plan. In the pursuit of the new
ideal of accountability the most readily quantifiable aspects of nursing practice are
being measured and the less tangible, qualitative elements are being placed in the too
hard basket.
The diagnosis debate reflects a number of divergent paradigms, the
positivist paradigm with the implicit assumptions that social behavior is able to be
defined, measured and predicted and post-positivist paradigms such as holism which hold
that an individual can best be understood by looking at the whole rather than the parts.
Street (1990) identifies the limitations inherent in the positivist paradigm in explaining
and predicting nursing practice. Using a typographical analogy she argues that by taking
the high, hard ground overlooking the swamp, manageable problems lend themselves to easy
solutions. However she challenges nurses to descend to the swampy lowland through the
process of reflection, where messy confusing problems defy technical solution but where
the realities of practice in its context may be found. The swamp is an uncomfortable place
to be. In the swamp the reflective practitioner can view things as they really are,
complete with philosophical contradictions. The dimensions of uncertainty, uniqueness and
value conflict will be visible in problematic areas of practice. There are many value
conflicts apparent in the application of the diagnostic process (Hagey & McDonough,
1984, Mitchell, 1991) and we would be deluding ourselves if we did not admit that as a
profession the practice of nursing has been far removed from the ideals that we have
expoused. Indeed often our practice are quite incongruent, albeit unintentionally, with
our ideals.
In order to differentiate what mental health nurses do that is
different from other health professional groups it must first be determined what
commonalities exist within the psychiatric nursing profession. Clearly we do not share a
single unifying ideological approach to care, in fact ideological eclecticism in the
pursuit of meeting peoples health needs may well be a defining characteristic.
Psychiatric nurses: The natural generic health worker?
There is a difficulty in attempting to define psychiatric nursing by
the tasks that they engage in, as roles are rapidly being redefined. Once the psychiatric
hospital was the domain of the psychiatric nurse with its well defined tasks and
institutional culture, today with the provision of care being shifted to the community the
culture of psychiatric nursing and the roles that nurses are expected to play are
changing. The association with medicine that psychiatric nursing has traditionally had is
being challenged by some nurses taking the opportunity to practice as psychotherapists
independently or in services where their accountability to medical practitioners is
minimal. As Ian Whenmouth (1995, p.5) stated in a list of concerns about the future of
psychiatric nursing in New Zealand, "There are no formal nurses' roles/expectations
in situ and no way of measuring how effective/therapeutic these nurses are".
Nurses' have extended their domain of practice into areas such as
psychotherapy, child therapy and relationship counseling. Dumas (1994, p.12) suggested
that in extending our boundaries "we have become more closely identified with the new
subculture and we often have neglected that culture that identifies us as nurses"
although she does not specifically elaborate on the identifying nursing culture. The roles
of carrying out medical treatment and ensuring that basic physical and safety needs are
met has been a traditional nursing role. Psychiatric nursing is a combination of the
psychotherapeutic and traditional roles and Sanggaran (1993, p.13) suggests that "to
dismiss one and to pursue the other will result in confusion over whether one is engaged
in psychiatric nursing".
Traditionally psychiatric nurses have carried out whatever roles have
been required of them. Psychiatric nurses once functioned as a composite nurse,
occupational therapist, social worker, physiotherapist, psychotherapist and dietitian as
the need arose. I have heard nursing likened to a piece of scone dough, full of holes
reflecting the dough that has been claimed and shaped by other disciplines. Smith (1992)
states that the disciplines of health psychology, social work, nutrition science, health
science, physical, respiratory and occupational therapy all evolved as a result of
claiming activities traditionally associated with nursing, developing specialized
knowledge relating to these activities and a defined base of research and theory. I
believe one of the characteristics of psychiatric nurses is their willingness to resume
these roles when one of these disciplines is unavailable. So nurses will do what needs to
be done in order to meet peoples needs and are not so constrained by boundaries as are
other disciplines. Psychiatric nurses are the natural generic health workers.
Psychiatric nursing: constrained by it's environment and lack of a common frame of reference.
"A distinguishing characteristic of a discipline is a unique focus" (Donaldson & Crowley, 1978) and "a shared understanding amongst its members as to its reason for being" (Newman, Sime, & Corcoran-Perry, 1991). At the most basic and least contentious level, nurses focus on meeting peoples needs relating to health. In the introduction to the Standards of Practice for Mental Health Nursing in New Zealand produced by the Australian and New Zealand College of Mental Health Nurses Inc (ANZCMHN), mental health nursing is described as:
"... a specialized expression of nursing which focuses on meeting the mental health needs of the consumer, in partnership with family/whanau and the community in any setting. It is a specialized interpersonal process embodying a concept of caring which has a therapeutic impact on the consumer, the family or whanau and the community, within their cultural context by:
The Mental Health Nurse recognizes the need for flexibility, adaptability, responsiveness, and sensitivity as they continually shape their practice to the dynamically changing needs of the consumer, family/whanau and the community"
The standards of nursing practice reflect a valiant attempt to define
best nursing practice in New Zealand and can serve to foster a sense of unity and identity
in the nursing profession. From this description a number of concepts and contemporary
ideologies which may serve to differentiate nursing from other disciplines may be
extrapolated: caring which has a therapeutic impact; nursing as an interpersonal process;
a focus on mental health; a supportive, encouraging and involving role; a partnership.
Like nursing theories this description of nursing reflects an ideal which may be far
removed from actual nursing practice. These concepts need to be explored fully by those
who claim to practice mental health nursing if words such as caring, support and
partnership are not to become yet more clichés without substance or validation.
I wish to suggest that nurses are not completely autonomous
professionals, that the realization of ideal practice is very much constrained by the
environment and context in which they work. Psychiatric nursing may be defined by its
ideals but these do not necessarily reflect what they do. If one takes a holistic approach
to mental illness then one must also accept that the outcomes of psychiatric practice are
also constrained although limitless potentials might exist. A holistic view of the causal
nature of mental illness implies that social, cultural, psychological, spiritual and
physiological factors may all contribute to mental well-being. Sociopolitical factors such
as poverty, homelessness, societal values even contemporary ideologies may all play a part
in causing illhealth in the individual and the social group. Even ideal practice on the
part of the nurse cannot mitigate against the powerful forces that cause ill-health. The
best that nursing can offer for some individuals is to care and attempt to assist in the
realization of their human potential. Peplau (1989) states that psychiatric nurses are
hard pressed to define or predict outcomes of nursing, for many reasons but partly because
of the general lack of specificity about the phenomena of psychiatric nursing.
The practice of psychiatric nursing has changed significantly over the
course of its existence. So to have the ideals of psychiatric nurses changed. Salvage
(1990) describes the reform of nursing as the "new nursing" involving
transformation of relationships with patients towards a holistic approach promoting the
patients active participation in care. `Partnership' between the nurses and patients she
sees as a key aspect of the new nursing which as a concept raises questions about the
rhetoric of ideology and daily experience. According to Salvage (1990) the `new nursing'
ideology claims "the one-to-one relationship between practitioner and patient as the
cornerstone of nursing practice". Realization of this ideology in practice is
constrained by such barriers as existing power relations in the health team, and material
resources. Primary nursing and patient advocacy which are generally considered the methods
of choice for achieving the nursing partnership (Porter,1994) can only be effectively
carried out if there are adequate numbers of staff in an area and if medical and
management teams endorse the approach and allow nurses autonomy in determining what
nursing care is required in partnership with the patient.
The notion that nurses can assume the role of advocate for patients is
also open to debate. Porter (1988, p.30) suggests that as nurses we are agents of social
control and "we have a vested interest in maintaining our exclusive power as
professionals, and the hegemony of the establishment on which we depend". He contends
that "the best we can hope to offer is a `benign paternalism'". Rogers, Pilgrim,
and Lacey (1993) suggest that the role of advocate should be held by consumers or previous
consumers of mental health services. Some areas in New Zealand have accepted this
challenge and are employing and training consumers of services as advocates. Groups such
as Schizophrenia Fellowship offer advocacy services. However such groups require material
resources to function in these roles that are presently not uniformly available across the
country. The ability to access appropriate advocacy for clients is therefore often
dependent on Regional Health Authorities' commitment to the concept of consumer advocacy.
It must also be acknowledged that the realization of such a concept is also fraught with
ethical difficulties.
That nursing can be a therapeutic endeavor in its own right and independent of any other professional group is considered as a given by the nursing profession. Peplau (1952, p.16) described nursing as
...a significant, therapeutic, interpersonal process. It functions co-operatively with other human processes that make health possible for individuals in communities ... Nursing is an educate instrument, a maturing force, that aims to promote forward movement of personality in the direction of creative, constructive, productive, personal and community living.
Again reality is often far removed from the ideal. Psychiatric nurses
often interact with clients in an untherapeutic fashion. Porter (1993) posits that this is
due to a complex interplay between social structures and the actions of nurses themselves.
An organizational need for order in psychiatric institutions, including
the community is often achieved through the use of coercive power. The threat of, or
actual use of coercion in the form of legal sanctions such as application of the Mental
Health Act might block opportunities for therapeutic communication. Watson (1991, p.10)
suggested that the controlling practices that nurses often employ in hospital settings
"might contribute to the stress of mental illness and provoke the behaviors they are
designed to contain". However nurses are far more likely to get into trouble if they
fail in maintaining order or to follow established procedures than if they fail in terms
of therapy (Porter, 1993). Not only do nurses require skills in the therapeutic use of
self and an awareness of how the dynamics of power and coercion can affect a relationship,
employers and institutions need to facilitate an environment where care and therapy is
valued if the therapeutic potential of nurses is to be realized. A great potential exists
for nurses to remove themselves from the mainstream of nursing practice, divorcing
themselves from established nursing roles in order to function to their therapeutic
potential. Hence the rise of the counselor who is a nurse, as opposed to the nurse who
counsels.
Psychiatric nurses and the role of designated authorized officer.
The Mental Health Act 1992 established a role entitled Designated Authorized Officer (DAO). Under the act the DAO, is responsible to the director of area mental health services for the provision of :
This new role has in many areas been claimed by, or assigned to nurses.
On the face of it the role appears to be one which nurses may be well suited to, but some
of the statutory requirements of this role may cause further ideological difficulties for
nurses, particularly if nurses in mass become DAOs. Given that nursing often expouses
philosophies of partnership and that nursing is seen by many as primarily an interpersonal
relationship, what effect will the power held by nurses in the DAO role have on the
development of the interpersonal relationships so central to nursing? This is a question
that nurses will have to answer if the nursing role is not to be subjugated to the role of
DAO. However consideration of such difficulties appears to be secondary to claiming and
holding the role in the face of compelling claims by other professional groups.
Walmisley (1992) believes that psychiatric social workers should be the
preferred professional for the role of DAO. He argues that the concept of DAOs was lifted
directly from British legislation where social workers have held the role for the last
thirty years and have developed a broad perspective to the mental health crisis that
diagnosticians or treatment specialists lack. Bell (1992) however states that any
resemblance to the British role is superficial as the focus is on helping caregivers in
the community rather than promoting the rights of the individual. If Bell's (1992)
assertion is correct then this is even more troubling for nurses than the claim by social
workers. Surely nurses purport to hold the interests of the patient as paramount? I
suggest that the DAO role is not a nursing role but rather it is a role that some nurses
may have the skills and inclination to fulfil.
The need for shared frameworks to guide practice
Buzz words and catch phrases like nursing process, primary nursing,
autonomy, accountability, advocacy and partnership become rhetoric, and when
operationalised conflict with each other unless they are tied to a model or framework
which can provide direction and substance in their application. Christensen (1990) in
describing the use of her `nursing partnership' model provides guidance on, the
application of the nursing process and modification of primary nursing in line with the
model. She states that without a guiding theoretical framework,"nursing will remain
undervalued and consequently its perceived scope and function will be limited"
(Christensen, 1990, p.206).
Presently the workplace where nurses work collaboratively using a
common nursing framework is the exception rather than the rule. Nurses bring to their work
an often superficial knowledge of a large number of models of practice which they may
apply well when the need arises, on an individual basis. However the merit of many of the
nursing models, most often borrowed from the United States has been proven by their
application by groups of nurses, working collaboratively, using them as a common frame of
reference in individual workplaces. Clearly leadership and co-operacy in decision making
is required if frameworks are to be used with consistently in workplaces. As well as
grappling collectively with determining what services nurses will provide, nurses need to
identify how they will provide the service with reference to a common framework.
The ideals of nursing can be used as a tool to compare and contrast
nursing with other disciplines. Standards of practice may also be used to determine the
scope of nursing practice. However ideals and standards do not necessary reflect the
actual practice of nursing.
What do nurses themselves think differentiates their practice from others?
To try and answer the question I initially talked to a twelve nurses who worked in either an acute inpatient unit or a community service and asked, "what do you do differently from others disciplines working in your area?" The nurses who worked in the inpatient unit were most clear about what they did differently e.g.
"We care for people continuously, over twenty four hours."
"We deal with all the crisis that arise for people as a result of their mental illness."
"We administer the prescribed treatments and assess their effects."
"We are available and accessible to our clients twenty four hours a day."
For those that I spoke to who worked in the community the question was far more difficult e.g.
"We may view things differently from others but I don't think we do things differently."
"We have some responsibilities relating to medications and performing as DAOs but apart from that there is not a lot different about what we do."
A large number of respondents from both groups pointed out that they
had a different focus from other disciplines, that they conceptualized the clients
problems in a different way. Some quoted definitions of nursing derived from the North
American Nurses Association's statement, that the phenomena of concern to nurses are human
responses to actual or potential health problems. Others quoted definitions of nursing
from Peplau or Henderson.
I posed the same question to a number of nurses at the 1995, New
Zealand conference of the Australian and New Zealand College of Mental Health Nurses
(ANZCMHN). All conceded that the question was difficult in relation to community
psychiatric nurses (CPNs). I was informed of areas where CPNs retained sovereignty over
their traditional key worker role but the trend towards health professionals assuming the
same roles of case manager was clear. One person observed that the strength of nurses was
their ability to adapt, and their eclectic approach to care. Nursing has a very general
focus while other disciplines functions have traditionally been more narrowly defined.
Nurses have provided care to client groups whose prognosis and amenability to treatment
has been poor where as other disciplines have focused on providing services only to those
who would benefit. It was suggested that other disciplines were the ones having difficulty
adapting not nurses.
In order to better capture how nurses might operationalise the
different focus they claim to bring to the nurse patient encounter and how nurses perceive
this encounter might differ from those of other professionals, I choose to interview 6
nurses using a qualitative technique called narrative picturing, described by Stuhlmiller
and Thorsen (1995). I used a convenience sample, all subjects were known to me and worked
in the same geographic area. All had practiced as psychiatric nurses for over two years. I
utilized a process called snapshot picturing whereby I asked participants to close there
eyes and picture a scene involving a client and a nurse, then a client and an occupational
therapist, psychologist and social worker. Lastly I asked participants to picture a nurse
with an "acutely ill" client. They were then asked to describe the scene that
came to mind in each instance.
The following are examples of scenes which nurses described consisting of a nurse and client. As with all the scenes described, participants acknowledged that they drew heavily on personal experiences.
"I see myself sitting in an interview room with a client. We are both sitting in easy chairs ... its a talking thing a communication thing ... the colors in the room are quite soft ... I'm trying to help this person find something ... a solution to a problem ... something the persons having difficulty with."
"The nurse is sitting in a chair beside the patient ... it's quite a bright room ... they are talking ... the nurse appears quite open ... the patient is looking around to make sure no one else can hear as well as trying to listen to what the nurse is saying ... there are other clients scattered around the room ... it's a dayroom in a hospital ... the patient is upset about something ... looking worried ... perhaps the patients worried about other people hearing ... the nurse is chatting really ... trying to gain trust."
"I see a patient pacing around, smoking ... appears agitated ... the psychiatric nurse is standing ... waiting for the opportunity to talk to the patient ... arms are folded ...wondering whats going on ... leaning against the wall ... there is tension in the air."
The emotional involvement of the nurses recounting these scenes was
palpable, probably due to their personal involvement in the experience. Common to the
scenes recounted were nurses attempts to communicate with the client, to gain trust and to
understand the patients experience.
The stereotypical pictures of the occupational therapist at work, successfully engaging clients in craft activities was common to all participants. A much more convivial emotional tone was evident in the re-telling of these scenes.
"The first thing that springs to mind is an OT doing something at a table with a client ... craft activities ... doing something creative ... making something ... it doesn't seem to be getting into the nitty gritty..."
"In quite a large, busy room, lots of tables and chairs... the patients leaning over a table doing some drawing ... the occupational therapist is looking over her shoulder ..."
"A cluttered room ... a man is leading a group in craft activities..."
A more therapeutic role was associated with the social worker. The social worker was seen as acting as a consultant and helper, with something tangible to offer the client. The work of the social worker was done in private.
"In an interview with a client, discussing issues ... in a helping role."
"The social worker is sitting at a desk with the client sitting across from her... its a small room ... lots of posters on the walls ... they're talking about something serious because the social worker looks as though she's got some information to give to the patient ... the patient looks dumbfounded by everything ... the social worker appears confident ... she's hurrying to get through it."
"Social worker is sitting down ... has rapport with the client ... they are sitting next to each other ... leaning towards each other ... calm..."
The work of the psychologist was also seen as a private transaction. The psychologist was also seen as trying to understand the patient. The psychologists transactions were seen as structured and planned.
"In an interview in an office .... a closed room ... they're talking ... it's very structured ... they're working on models of behaviour .... focusing on specifics."
"Sitting cross-legged on the floor next to each other ... trying to get on the same level ... its in quite a large room ... there are no other people around ... they're both sitting quietly ... the patient appears confused ... the psychologist has an expression of concern on his face ... he's listening to what the clients saying ... looks bewildered."
"The psychologist has some papers in his hand and appears to be questioning the client ..."
The nurses descriptions of an "acutely ill" client and a psychiatric nurse again reflected the nurses attempts to communicate with the client as well as protecting, persuading and attempting to meet the clients basic needs. Some participants also articulated the nurses perceptions of the clients vulnerability and the power dynamics inherent in the transaction between nurse and client. Lutzen & Nordin (1993) described sensing the patients vulnerability as a dimension of expressed benevolence common, in the decision making practices of psychiatric nurses.
"In reception ... he's resisting any input from us ... not wanting anyone to intervene ... feeling out of control ... the nurse is trying to talk, to persuade ... the client is shouting ... he's raising his voice ... other people are uncomfortable with the scene taking place."
"The patient is in a room by himself ... the nurse is looking through a window in the door ... the nurse is trying to interact but the patient doesn't really know she is there ... the nurse is talking to the patient ... asking if he wants some food or drink ... the persons really angry ... kicking things, yelling at the nurse ... I don't think he realizes its a nurse, I think he's just yelling ... the nurse feels quite powerful behind the door ... the patient senses that ... the nurse is concerned about safety."
"The client is taking off her clothes ... she's off the wall ... the nurse is trying to protect her ... maintain her dignity ... talking in a quiet voice ... trying to reassure ... the situation is emotionally charged."
The scenes that participants described relating to nurse-client
interactions illustrated the nurses attempts to gain trust, build rapport, understand the
client, do therapy and also to reassure, calm, protect and support when necessary. At
least on one occasion the author of the picture was aware of the power dynamics at play.
Other disciplines were seen to perform their functions in certain contexts, occupational
therapists in group settings, social workers and psychologists in private. Nursing was
seen to take place in both public and private settings. Social workers and psychologists
were seen as having consultative and educate roles where as the nurses had an eclectic
role. The role of the occupational therapist was stereotypical of their most public
function and rather simplistic. The results do have some validity in as much as they
reflect the images that some nurses might have of the various disciplines or at least
their traditional roles. An interdisciplinary study using combined narrative picturing and
grounded theory techniques could do much in differentiating how disciplines operationalise
their roles and perceive the roles of others.
There has traditionally been some overlap in the roles of different
disciplines working in the mental health field. It has been suggested that the roles and
ideologies of social workers may be akin to nurses. Callicutt and Lecca (1983, p.50) state
that "the social worker in mental health focuses on the client's cognitive,
emotional, and behavioral responses to events in his life, especially interpersonal
relationships". Such a statement could be used by many nurses to describe their
focus. Gerhart (1990, p.40) concedes that the functions of the psychiatric nurse often
overlap with the therapeutic activities of psychologists and social workers but she states
that "psychiatric nurses tend to spend less time in direct patient contact than in
such relatively impersonal activities such as dispensing medication and record
keeping" . How true this is in contemporary community mental health settings is open
to contention.
Towards a generic mental health worker role.
The trend towards mental health workers assuming key worker roles and
negotiating the passage of the client through the various mental health services is due in
part to the increasingly complex health care delivery system and because the domiciliary
role pioneered by psychiatric nurses has proven effective and popular with clients. Mangen
and Griffith (1982) compared patients satisfaction with sole community psychiatric nursing
follow-up with sole outpatient psychiatrist follow-up at six monthly intervals over 18
months. Their study revealed that patients found nurses more approachable and sympathetic.
Overall patients were more satisfied with the follow-up by psychiatric nurses and were
particularly positive regarding domiciliary visiting. So it seems psychiatric nursing is
on to a good thing with its idea of keyworkers providing follow-up in the community,
particularly in peoples homes. It is not surprising then that other disciplines might want
to be part of this successful approach in caring for clients. Client satisfaction is after
all an indice of success in the consumer driven health system.
Deinstitutionalisation has also led to greater numbers of clients with
chronic illnesses living in the community whose primary needs are for care and support.
These groups have traditionally been considered least amenable to the therapeutic
approaches of other disciplines and assuming a keyworker role may be seen as a means to
increase their effectiveness and domain of practice.
Nursing appears to be well differentiated in its functions in inpatient
psychiatric units. However the role of psychiatric nurse in the community tends to blur
with other disciplines, with nurses and other disciplines sometimes performing exactly the
same functions. Does this matter? As an occupational therapist commented to me, `we might
have had different initial training many years ago but the influence of our experiences
working in different environments has influenced our practice at least as much as our
training'. Why shouldn't anyone with the necessary skills practice in any role that is
needed? To prevent others from doing so would only lead to a kind of hegemony which nurses
are so vehemently opposed to in medicine. Some nurses believe that we should share our
knowledge and encourage everyone to be health professionals (Porter, 1990).
It also needs to be considered that the roles of other disciplines are
blurring with nursing, not the other way around. Nurses continue to outnumber other
disciplines many times over in most settings. The power of the nurses as a group in
shaping the practice of colleagues from other disciplines needs to be acknowledged. I can
recall many occasions when the comments of a room full of nurses has caused a colleague to
acquiesce to the wishes of the nursing staff. Nurses' as a group, undervaluing the
specific and unique contributions that other disciplines can make might also cause others
to go with the nursing way of doing things.
Research and Education.
Christman, and Johnson (1981, p.11) state that "because of its
systematized knowledge, a profession maintains exclusive jurisdiction over an area of
service to the public". It is clear that psychiatric nursing is struggling to
maintain exclusive jurisdiction over the traditional role of community psychiatric nurse.
They go on to suggest that a broad and vague knowledge base may inhibit the public's
ability to identify and value the service provided by a group and suggest that scientific
research into the phenomena of concern to nurses is the means to develop nursing as a
profession. Peplau (1989) suggests that nurses should pursue evaluation and outcome
studies of their work and that they should also monitor and check any erosion of their
identity as nurse psychotherapists. Psychiatric nursing desperately needs to prove its
worth through research if it is to retain a separate identity from other disciplines.
Dumas (1994) points the finger at nursing education for the erosion of
the psychiatric nurses identity. Psychosocial concepts pioneered by psychiatric nurses and
nurse theorists have become an integrated part of the undergraduate nursing curricula.
However psychiatric nursing courses in the United states have diminished. This may also be
true in New Zealand. This essay was written for an undergraduate elective paper and I am
very conscious that there are only two students enrolled out of a potential pool of over
fifty students. This is interesting given that at the present time mental health is one of
the few domains of nursing practice which is short staffed and is employing nurses.
Post graduate opportunities for nurses to consolidate and study mental
health nursing are also very limited. That is not to say that psychiatric nurses don't
value education. I know of many nurses studying towards qualifications in counseling,
management or the arts. However there is a paucity of opportunities to study nursing
phenomena without great personal sacrifice. The majority of nurses working in mental
health areas hold a diploma in nursing or the equivalent and few employers are willing to
sponsor employees in degree programs. The path to gaining a degree and post graduate
university qualifications is personally costly, time consuming and holds little in the way
of financial remuneration at the end. It is little wonder then that many will choose to
pursue generic qualifications, useful to the client and the employer, and which offer
opportunities to diversify into private practice, rather than pursue nursing
qualifications.
Conclusions
Despite psychiatric nursing, next to medicine being the oldest
professional group involved in the direct care of people with mental illness it remains
very much an evolving profession. The difficulty in defining what psychiatric nurses do in
common, arises from the fact that what they do is largely determined by the context in
which they work. As already discussed the context of health care delivery is rapidly
shifting to the community. Old truisms and norms of practice based in the context of the
psychiatric hospital no longer hold true or are being devalued and relegated to history.
Psychiatric nursings' identity has been closely associated with medicine although this
alliance too is being challenged by the nursing profession itself. The ideals of the
profession and expoused standards of practice may serve to differentiate the profession
from others but there remains a gap between ideal and actual practice, the theory which is
distinctly nursing and the application.
It is difficult to find commonalities in what nurses do as they work in
so many diverse areas. Nursing is an integrated combination of therapy and care roles.
However, for may reasons nurses are constrained in their practice and often do not perform
to the ideal. What is more many of nursings' ideals conflict. Without a shared frame of
reference in the form of a guiding theoretical framework , the scope of nursing will be
limited and nurses' risk further erosion of their collective identity.
The role of the nurse in acute inpatient settings remains fairly well
differentiated from other disciplines and is characterized by the provision of a 24 hour a
day service, delegated medical tasks and accessibility to clients. However there appears
to be a trend towards generic community mental health worker roles. Nurses need to
substantiate their claim that they view people and problems differently to other
professions and that their contribution makes a difference to people. The profession needs
to attract nurses into furthering their education in the field of nursing so that nurses
can become effective consumers and producers of research as well as challenging the
contradictions of contemporary ideologies and professional rhetoric. This is a matter of
survival for nursing as a profession in the field of mental health.
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