nducation and debate
Advances in the clinical practice of psychiatric nursing Ben Thomas, The Bethlem Royal Hospital, Kent U n d erstan d in g m en tal health needs form s th e basis of psychiatric n u rsin g care. A nalysis o f these needs and k n o w in g w hat resources are available determ ines th e clinical practice o f psychiatric nu rsin g.
w
* * hen people talk about advances in the practice of psychiatric nursing, refer ence is made to its historical development. The chronology of events begins with cus todial care, moves onto working within the medical model and ends up with the array of treatment strategies that nurses deliver as independent therapists, e.g. behavioural therapy, counselling, cognitive therapy and psychotherapy. Without disputing the lessons that his tory can teach us, it is important to note that such descriptions are at best simplistic and at worst misleading. While consider able advances have been made in specialist areas, e.g. liaison psychiatric nursing, many nurses are still primarily engaged in a caretaking role. The focus of this is on as sisting patients with daily living tasks, al leviation and rehabilitation rather than fa cilitating recovery or significant change. The primary function of many nurses is to maintain patient safety. Such a role should not be underestimated. Keeping safe clinically depressed patients who are intent on killing or harming themselves and others demands many skills. Considerable progress has been made in these more traditional nursing activities. Primarily, there has been a shift away from authoritarian attitudes and behaviour which forced patients into dependency and de prived them of responsibility. Today, more humane and effective responses are imple mented based on research findings and sound clinical principles (Table 1).
Ouality at the Maudsley Hospital and The Bethfeir Royal Hospital, Special Health Authority, Monks Orchard Road, Beckenhan Kent BR3 3B X , and the Honorary Lecturer at the Institute of Psychiatry, London
292
Advances in clinical practice Attention is seldom given to these advances in psychiatric nursing practice. According to Altschul (1986), this has resulted in pa tients in mental hospitals being the con sumers who are the least well served. Re sults of a review of psychiatric nursing re search covering the period 1983-88 suggest that this situation is improving, albeit slow ly. Davis (1990) identifies that out of 124 reports, research relating to the practice of
Table I. Aspects of the psychiatric nurses's role Assessing patients at risk
M edication Mr Thomas is Chief Nurse Advisor and Director of
procedure demands sound professional judgment as nurses need to have a working knowledge of basic anatomy, physiology, pharmacology and legislation in relation to drugs, as well as communication and obser vational skills. Recent advances in this im portant aspect of nurses’ work include teaching patients to self-medicate and the possibility of nurse prescribing. These issues are raised not to defend their appropriateness but rather to emphasize that such practices continue to form a large part of the day-to-day work of the 80 000 nurses employed in psychiatric hospitals and units in the UK and the 3000 commu nity psychiatric nurses (CPN). Tradition ally, the CPN role has always been associ ated with the administration of depot drugs in the community and the monitoring of their side effects (Brooker, 1990).
Medication remains one of the major forms of treatment for people with mental health problems and accounts for 25% of NHS pharmaceutical costs. Research shows that psychiatric nurses’ distinctive contribution to mental healthcare is the administration of medication, either orally or intra muscularly, to patients with a mental illness (Management Advisory Service, 1989). This
Defining specific problem behaviours Planning realistic approaches to care Observing and recording patient behaviour Reviewing situations Making decisions according to the available evidence
Downloaded from magonlinelibrary.com byJournal 129.215.017.190 on 1992, January 2019. British of Nursing, Voi19, l,N o6
Advances in the clinical practice of psychiatric nursing
(T h ere has been enormous grow th in th e num ber o f p sy chiatric nurses w ho h av e b ecom e specialists in certain field s. All o f these nurses h av e undertaken ad v an ced training an d a re highly skilled. 5
psychiatric nursing forms the largest cat egory (52% ). This demonstrates that the main thrust of research is very much prac tice-related. Many more research studies are examin ing the effects of reorganizing patient care and nursing interventions (Lavender, 1987; Lemmer, 1986). Among the changes most commonly introduced and evaluated are: the nursing process (Richards and Lambert, 1987), primary nursing (Armitage et al, 1991), and the use of various nursing models (Bristow and Callaghan, 1991).
Table 2. Examples of different specialisms within psychiatric nursing Behavioural therapy Psychotherapy Family therapy Cognitive therapy Counselling Validation therapy Bridging therapy
Developing the role However, for the most part, advances in clinical practice relate to developing the role of the mental health nurse as therapist. There has been enormous growth in the number of psychiatric nurses who have be come specialists in certain fields (T able 2). All of these nurses have undertaken ad vanced training and are highly skilled. They have also enhanced the status of psychiatric nursing by demonstrating how specific interventions produce specific clini cal outcomes and have proved the effective ness of psychiatric nurses in comparison with other professional groups, e.g. in costeffectiveness (Brooking, 1991).
Specialized practice The role of the specialist practitioner and the notion of advanced practice is likely to continue with the implementation of the EN B ’s Framework for Continuing Educa tion and Training and the U K C C ’s Post registration Education and Practice Project (1990). Specialization is considered a necessary component in most professions. This is par ticularly true of psychiatric nursing with its vast and varied subject matter. Specializ ation is integral to contemporary psychi atric nursing and rightly so; as Krauss (1987) points out, specialization leads to depth and richness and familiarity that breeds expertise. People with mental health problems have a right to be treated and car ed for by skilled professionals. O f course, not all psychiatric nurses are likely to become specialists or advanced practitioners. According to Ritter (1991), in the UK the proliferation of post-basic clini cal courses has led to the notion of the specialist within a speciality, whereas in the USA psychiatric nursing is itself a specialty of nursing generally. She suggests that it is imperative to decide which is the most de sirable approach as the resource implicaBritish Journal of Nursing, 1992, Vol 1, No 6
tions have implications will effect the long term future of clinical psychiatric nursing and education. An example of this is the training of com munity psychiatric nurses. At present, all CPNs have the minimum qualification of Registered Mental Nurse. In addition there is a specialist course: EN B811/812 Nursing Care of the Mentally 111 in the Community. Many CPNs develop their skills further by training in family therapy, gestalt therapy and behavioural therapy. Specialization is further compounded by CPN services being organized into separate teams. These deal with acute/primary men tal health, long-term care, rehabilitation, di agnosis, drug addiction or alcohol abuse, and the provision of mental healthcare for specific groups determined by age, e.g. children or adults over 65 years. The effectiveness of specialization must be judged on its ability to identify and meet the mental health needs of patients. Care needs must be matched with the appropri ate skills. It is estimated that in the UK each year 5 million people consult their general practitioner because of depression and anxiety, 2 million attend psychiatric hospi tals and unit outpatient departments, and 60 000 require hospitalization. There are over 250 000 people in Britain who have been diagnosed as having a schizophrenic illness at some point in their lives, of whom 150 000 are significantly affected and still in need of treatment or some form of sup portive care. There are also 250 000 individ uals suffering from senile dementia (Office of Health Economics, 1989). The sheer scale of these figures demonst rates that most patients with mental health problems will receive care from first level nurses in mental health and not for ad vanced practitioners or psychiatric nurses who are specialists.
293 Downloaded from magonlinelibrary.com by 129.215.017.190 on January 19, 2019.
Advances in the clinical practice of psychiatric nursing
‘During the last fe w years one o f the m ajor influences has been an increasing em phasis on patien t p articipation in the planning an d delivery o f care. 5
Advances at this level are of the utmost im portance as they affect and benefit the largest number of patients. Mauksch and Miller (1981) suggest that change in nursing is brought about by a combination of societal demands, inter-professional expec tations, inter-professional decisions and an overall climate of change in society. During the last few years one of the ma- ' jor influences has been an increasing em phasis on patient participation in the plan ning and delivery of care. There is move ment, albeit slowly, to provide a consumerorientated service as opposed to one that is provider led (Rogers and Pilgrim, 1991). Such a change has occurred through pres sure exerted by patients themselves, their families and friends. People with mental health problems are no longer prepared to be passive recipients of care. They want to be well informed, empowered and able to make a contribu tion to service improvement. Nurses have an enormous role to play in educating pa tients and informing them what resources are available. Many nurses use patient satis faction surveys to establish whether the ser vice provided meets the needs of the users. The results show that patients still feel de prived of information, particularly in rela tion to medication and its side effects.
Q uality care A large part of consumerism in mental healthcare is concerned with the notion of providing a quality service. Psychiatric nurses have always made efforts to improve the quality of care. What is new is that they are now not only concerned with defining what they do but also with how they do it. They are paying increasing attention to their performances, particularly in relation to standard criteria. Donabedian (1989) identifies quality as having three components: quality of techni cal care; quality of the interpersonal rela tionship; and quality of the environment. While all three components are important and closely related, progress in psychiatric nursing has meant that the first two are given more emphasis than the third. Q u ality of technical care
Quality of technical care includes the knowledge and skills offered by the psychi atric nurse. These should be based on upto-date information and training. Patients expect and have a right to be cared for by nurses who are safe, competent practi tioners and are obligated to provide the
294
best care that they can for each patient. Q u ality of the interp erson al relationship
Psychiatric nursing places enormous em phasis on the second component: quality of the interpersonal relationship. This should conform to the requirements of all professional relationships, i.e. it should be based on respect, trust, honesty and confi dentiality; it is also the essence of the tech nical care provided. The nurse-patient relationship is the means of achieving therapeutic change in patients. The role of the psychiatric nurse continues to be supportive to the medical model of care by maintaining its custodial aspects but is no longer routine and task orientated. Nurses assess patients’ individ ual needs and plan nursing care according ly; the emphasis is on meeting these needs and those of the organization. Q u ality of th e en viro n m en t
The third component of quality of care is quality of the environment and the creature comforts that are provided in the care set ting. Nurses have tended to become less in volved with the provision of hotel services and instead these services are being con tracted out. Many nurses see this as prog ress as it gives them more time to concen trate on patient therapy rather than super vising meals and helping with patients’ other daily living activities. However, lack of involvement deprives nurses of valuable time that could be spent forming relation ships with patients, making assessments and teaching social skills. It also deprives pa tients of someone who takes a personal and individual interest in them.
Interventions A distinction is often made between care and treatment, but this is in many ways an artificial distinction. Many treatment inter ventions with mentally ill people occur in the context of long-term, consistent and supportive care. On the other hand, much of the care provided by psychiatric nurses produces powerful therapeutic effects, e.g. helping patients to make sense of their ex perience, improving their functioning and engaging them in daily activities. During the past 20 years, a great deal of work has gone into deciphering the per sonal influence of the psychiatric nurse on the mental health status of patients. Assets commonly cited are establishing and main taining a therapeutic relationship, empathy building, providing support, and the use of British Journal of Nursing, 1992, Vol l,N o 6
Downloaded from magonlinelibrary.com by 129.215.017.190 on January 19, 2019.
Advances in the clinical practice of psychiatric nursing
communication skills, e.g. interviewing techniques and attentive listening. The im portance of these skills cannot be over emphasized and they are widely accepted as the lubricant of good psychiatric nursing practice.
F u tu re developments The current developments in nurse educa tion e.g. Project 2000 (U K C C , 1986) and the National Health Service and Commu nity Care Act (Department of Health, 1990), have enormous implications for the future of psychiatric nursing. The continu ed closures of mental hospitals and the de velopment of locally based health and social services are all aimed at providing effective, continuing care for mentally ill people in the community. It is expected that inpatient care will continue for some patients but this will be minimal. The traditional relation ship between hospital and community ser vices has been reversed so that the hospital is now regarded as a back-up to the com munity. Undoubtedly, psychiatric nurses will play a major role in providing continuity of care across community and inpatient set tings. The recent changes in nurse educa tion are aimed at preparing them for this flexible approach. Such changes are to be welcomed; while training in hospital wards provides experience and develops expertise, it produces a blinkered approach in which hospitalization is seen as an end in itself. The new approach will mean that hospital
K E Y P O IN T S
• Increasing demand on mental health services means that psychiatric nursing skills must be deployed as effectively as possible. • Clinical nurse specialists in psychiatric nursing have demonstrated the effectiveness of their interventions. • Many psychiatric nurses are engaged in alleviation and rehabilitation rather than trying to bring about significant change. • There has to be closer integration of clinical practice, education and research. • Research in psychiatric nursing is becoming much more practice related. • Psychiatric nurses have a major role to play in the development and functioning of new localized services.
British Journal of Nursing, 1992, Vol l,N o 6
ization, if it occurs, will be seen as part of a continuum of care. The overall pattern of psychiatric services is likely to change substantially over the next few years. Collectively, these services should provide a wider and more effective range of care for people with mental illness, e.g. day centres, group homes, outreach teams, community hostels, walk-in centres and family support. Psychiatric nurses have a major role to play in the development and functioning of these new services. We must learn from the lessons that have emerged from our experi ence so far, identify those aspects of care and organization that are regarded as good standards of psychiatric nursing practice, encourage the exchange of information and build on what has already been achieved. ijTk Altschul A (1986) Forward In: Brooking J(ed) Psychi atric Nursing Research. John Wiley and Sons, Chichester 11-12 Armitage P, Champney-Smith, Andrews K (1991) Primaiy nursing and the role of the nurse perceptor in changing long-term mental health care: an evalu ation. J Adv Nurs 16: 413-22 Bristow F, Callaghan P (1991) Using Peplau’s model in affective disorders. Nurs Times 18: 40-1 Brooker C (1990) The application of the concept of expressed emotion to the role of the community psychiatric nurse: a research study. ] A dv Nurs 27: 277-85 Brooking JI (1991) Inaugural Lecture. Towards an Evaluation o f Psychiatric Nursing. University of Birmingham Davis B (1990) Research and psychiatric nursing. In: Reynolds W, Cormack D (eds) Psychiatric and M ental H ealth Nursing. Chapman and Hall, Lon don 434-67 Department of Health (1990) N ational H ealth Service an d Comm unity C are Act. HM SO, London Donabedian A (1989) Institutional and Professional Responsibilities in Quality Assurance. Q Assur ance H ealth C are 1(1): 3-11 English National Board (1991) Fram ew ork f o r the H igher Award, English N ational B oard f o r Nurs ing, M idw ifery a n d H ealth Visiting, London Krauss J (1987) Nursing, Madness and Mental Health. Arch Psychiatr Nurs 1(1): 3-15 Lavender A (1987) Improving the quality of care on psychiatric hospital rehabilitation wards. Br J Psy chiatry 150: 476-81 Lemmer B (1986) The M anagem ent o f C hange in Five Wards o f a London Hospital. Conference proceed ing of the RCN Research Society Conference, 1013 April, University of Reading Management Advisory Service (1989) R eview o f Clini ca l Psychology Services. Management Advisory Service, London Mauksch IG , Miller MH (1981) Im plementing Change in Nursing. CV Mosby, St Louis Office of Health Economics (1989) M ental H ealth in the 1990s: From Custody to Care? Office of Health Economics, London Richards DA, Lambert P (1987) The nursing process: the effect on patients’ satisfaction with nursing care. J A dv Nur 12: 559-62 Ritter S (1991) Development in psychiatric nursing. In: Paine L(ed) British H ospital M anagement: T h e• Annual R eview o f British H ospital a n d H ealth C are Planning an d D evelopm ent, London 101-7 Rogers A, Pilgrim D (1991) Pulling down churches: accounting for the British mental health users' movement. Sociol H ealth Illness, 13(2): 129-48 U K CC (1986) Project 2000: A N ew Preparation fo r Practice. U K C C , London U K C C (1990) The Report o f the Post-registration Education an d Practice Project. U K C C , London
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Downloaded from magonlinelibrary.com by 129.215.017.190 on January 19, 2019.
Advances in the clinical practice of psychiatric nursing Ben Thomas, The Bethlem Royal Hospital, Kent U n d erstan d in g m en tal health needs form s th e basis of psychiatric n u rsin g care. A nalysis o f these needs and k n o w in g w hat resources are available determ ines th e clinical practice o f psychiatric nu rsin g.
w
* * hen people talk about advances in the practice of psychiatric nursing, refer ence is made to its historical development. The chronology of events begins with cus todial care, moves onto working within the medical model and ends up with the array of treatment strategies that nurses deliver as independent therapists, e.g. behavioural therapy, counselling, cognitive therapy and psychotherapy. Without disputing the lessons that his tory can teach us, it is important to note that such descriptions are at best simplistic and at worst misleading. While consider able advances have been made in specialist areas, e.g. liaison psychiatric nursing, many nurses are still primarily engaged in a caretaking role. The focus of this is on as sisting patients with daily living tasks, al leviation and rehabilitation rather than fa cilitating recovery or significant change. The primary function of many nurses is to maintain patient safety. Such a role should not be underestimated. Keeping safe clinically depressed patients who are intent on killing or harming themselves and others demands many skills. Considerable progress has been made in these more traditional nursing activities. Primarily, there has been a shift away from authoritarian attitudes and behaviour which forced patients into dependency and de prived them of responsibility. Today, more humane and effective responses are imple mented based on research findings and sound clinical principles (Table 1).
Ouality at the Maudsley Hospital and The Bethfeir Royal Hospital, Special Health Authority, Monks Orchard Road, Beckenhan Kent BR3 3B X , and the Honorary Lecturer at the Institute of Psychiatry, London
292
Advances in clinical practice Attention is seldom given to these advances in psychiatric nursing practice. According to Altschul (1986), this has resulted in pa tients in mental hospitals being the con sumers who are the least well served. Re sults of a review of psychiatric nursing re search covering the period 1983-88 suggest that this situation is improving, albeit slow ly. Davis (1990) identifies that out of 124 reports, research relating to the practice of
Table I. Aspects of the psychiatric nurses's role Assessing patients at risk
M edication Mr Thomas is Chief Nurse Advisor and Director of
procedure demands sound professional judgment as nurses need to have a working knowledge of basic anatomy, physiology, pharmacology and legislation in relation to drugs, as well as communication and obser vational skills. Recent advances in this im portant aspect of nurses’ work include teaching patients to self-medicate and the possibility of nurse prescribing. These issues are raised not to defend their appropriateness but rather to emphasize that such practices continue to form a large part of the day-to-day work of the 80 000 nurses employed in psychiatric hospitals and units in the UK and the 3000 commu nity psychiatric nurses (CPN). Tradition ally, the CPN role has always been associ ated with the administration of depot drugs in the community and the monitoring of their side effects (Brooker, 1990).
Medication remains one of the major forms of treatment for people with mental health problems and accounts for 25% of NHS pharmaceutical costs. Research shows that psychiatric nurses’ distinctive contribution to mental healthcare is the administration of medication, either orally or intra muscularly, to patients with a mental illness (Management Advisory Service, 1989). This
Defining specific problem behaviours Planning realistic approaches to care Observing and recording patient behaviour Reviewing situations Making decisions according to the available evidence
Downloaded from magonlinelibrary.com byJournal 129.215.017.190 on 1992, January 2019. British of Nursing, Voi19, l,N o6
Advances in the clinical practice of psychiatric nursing
(T h ere has been enormous grow th in th e num ber o f p sy chiatric nurses w ho h av e b ecom e specialists in certain field s. All o f these nurses h av e undertaken ad v an ced training an d a re highly skilled. 5
psychiatric nursing forms the largest cat egory (52% ). This demonstrates that the main thrust of research is very much prac tice-related. Many more research studies are examin ing the effects of reorganizing patient care and nursing interventions (Lavender, 1987; Lemmer, 1986). Among the changes most commonly introduced and evaluated are: the nursing process (Richards and Lambert, 1987), primary nursing (Armitage et al, 1991), and the use of various nursing models (Bristow and Callaghan, 1991).
Table 2. Examples of different specialisms within psychiatric nursing Behavioural therapy Psychotherapy Family therapy Cognitive therapy Counselling Validation therapy Bridging therapy
Developing the role However, for the most part, advances in clinical practice relate to developing the role of the mental health nurse as therapist. There has been enormous growth in the number of psychiatric nurses who have be come specialists in certain fields (T able 2). All of these nurses have undertaken ad vanced training and are highly skilled. They have also enhanced the status of psychiatric nursing by demonstrating how specific interventions produce specific clini cal outcomes and have proved the effective ness of psychiatric nurses in comparison with other professional groups, e.g. in costeffectiveness (Brooking, 1991).
Specialized practice The role of the specialist practitioner and the notion of advanced practice is likely to continue with the implementation of the EN B ’s Framework for Continuing Educa tion and Training and the U K C C ’s Post registration Education and Practice Project (1990). Specialization is considered a necessary component in most professions. This is par ticularly true of psychiatric nursing with its vast and varied subject matter. Specializ ation is integral to contemporary psychi atric nursing and rightly so; as Krauss (1987) points out, specialization leads to depth and richness and familiarity that breeds expertise. People with mental health problems have a right to be treated and car ed for by skilled professionals. O f course, not all psychiatric nurses are likely to become specialists or advanced practitioners. According to Ritter (1991), in the UK the proliferation of post-basic clini cal courses has led to the notion of the specialist within a speciality, whereas in the USA psychiatric nursing is itself a specialty of nursing generally. She suggests that it is imperative to decide which is the most de sirable approach as the resource implicaBritish Journal of Nursing, 1992, Vol 1, No 6
tions have implications will effect the long term future of clinical psychiatric nursing and education. An example of this is the training of com munity psychiatric nurses. At present, all CPNs have the minimum qualification of Registered Mental Nurse. In addition there is a specialist course: EN B811/812 Nursing Care of the Mentally 111 in the Community. Many CPNs develop their skills further by training in family therapy, gestalt therapy and behavioural therapy. Specialization is further compounded by CPN services being organized into separate teams. These deal with acute/primary men tal health, long-term care, rehabilitation, di agnosis, drug addiction or alcohol abuse, and the provision of mental healthcare for specific groups determined by age, e.g. children or adults over 65 years. The effectiveness of specialization must be judged on its ability to identify and meet the mental health needs of patients. Care needs must be matched with the appropri ate skills. It is estimated that in the UK each year 5 million people consult their general practitioner because of depression and anxiety, 2 million attend psychiatric hospi tals and unit outpatient departments, and 60 000 require hospitalization. There are over 250 000 people in Britain who have been diagnosed as having a schizophrenic illness at some point in their lives, of whom 150 000 are significantly affected and still in need of treatment or some form of sup portive care. There are also 250 000 individ uals suffering from senile dementia (Office of Health Economics, 1989). The sheer scale of these figures demonst rates that most patients with mental health problems will receive care from first level nurses in mental health and not for ad vanced practitioners or psychiatric nurses who are specialists.
293 Downloaded from magonlinelibrary.com by 129.215.017.190 on January 19, 2019.
Advances in the clinical practice of psychiatric nursing
‘During the last fe w years one o f the m ajor influences has been an increasing em phasis on patien t p articipation in the planning an d delivery o f care. 5
Advances at this level are of the utmost im portance as they affect and benefit the largest number of patients. Mauksch and Miller (1981) suggest that change in nursing is brought about by a combination of societal demands, inter-professional expec tations, inter-professional decisions and an overall climate of change in society. During the last few years one of the ma- ' jor influences has been an increasing em phasis on patient participation in the plan ning and delivery of care. There is move ment, albeit slowly, to provide a consumerorientated service as opposed to one that is provider led (Rogers and Pilgrim, 1991). Such a change has occurred through pres sure exerted by patients themselves, their families and friends. People with mental health problems are no longer prepared to be passive recipients of care. They want to be well informed, empowered and able to make a contribu tion to service improvement. Nurses have an enormous role to play in educating pa tients and informing them what resources are available. Many nurses use patient satis faction surveys to establish whether the ser vice provided meets the needs of the users. The results show that patients still feel de prived of information, particularly in rela tion to medication and its side effects.
Q uality care A large part of consumerism in mental healthcare is concerned with the notion of providing a quality service. Psychiatric nurses have always made efforts to improve the quality of care. What is new is that they are now not only concerned with defining what they do but also with how they do it. They are paying increasing attention to their performances, particularly in relation to standard criteria. Donabedian (1989) identifies quality as having three components: quality of techni cal care; quality of the interpersonal rela tionship; and quality of the environment. While all three components are important and closely related, progress in psychiatric nursing has meant that the first two are given more emphasis than the third. Q u ality of technical care
Quality of technical care includes the knowledge and skills offered by the psychi atric nurse. These should be based on upto-date information and training. Patients expect and have a right to be cared for by nurses who are safe, competent practi tioners and are obligated to provide the
294
best care that they can for each patient. Q u ality of the interp erson al relationship
Psychiatric nursing places enormous em phasis on the second component: quality of the interpersonal relationship. This should conform to the requirements of all professional relationships, i.e. it should be based on respect, trust, honesty and confi dentiality; it is also the essence of the tech nical care provided. The nurse-patient relationship is the means of achieving therapeutic change in patients. The role of the psychiatric nurse continues to be supportive to the medical model of care by maintaining its custodial aspects but is no longer routine and task orientated. Nurses assess patients’ individ ual needs and plan nursing care according ly; the emphasis is on meeting these needs and those of the organization. Q u ality of th e en viro n m en t
The third component of quality of care is quality of the environment and the creature comforts that are provided in the care set ting. Nurses have tended to become less in volved with the provision of hotel services and instead these services are being con tracted out. Many nurses see this as prog ress as it gives them more time to concen trate on patient therapy rather than super vising meals and helping with patients’ other daily living activities. However, lack of involvement deprives nurses of valuable time that could be spent forming relation ships with patients, making assessments and teaching social skills. It also deprives pa tients of someone who takes a personal and individual interest in them.
Interventions A distinction is often made between care and treatment, but this is in many ways an artificial distinction. Many treatment inter ventions with mentally ill people occur in the context of long-term, consistent and supportive care. On the other hand, much of the care provided by psychiatric nurses produces powerful therapeutic effects, e.g. helping patients to make sense of their ex perience, improving their functioning and engaging them in daily activities. During the past 20 years, a great deal of work has gone into deciphering the per sonal influence of the psychiatric nurse on the mental health status of patients. Assets commonly cited are establishing and main taining a therapeutic relationship, empathy building, providing support, and the use of British Journal of Nursing, 1992, Vol l,N o 6
Downloaded from magonlinelibrary.com by 129.215.017.190 on January 19, 2019.
Advances in the clinical practice of psychiatric nursing
communication skills, e.g. interviewing techniques and attentive listening. The im portance of these skills cannot be over emphasized and they are widely accepted as the lubricant of good psychiatric nursing practice.
F u tu re developments The current developments in nurse educa tion e.g. Project 2000 (U K C C , 1986) and the National Health Service and Commu nity Care Act (Department of Health, 1990), have enormous implications for the future of psychiatric nursing. The continu ed closures of mental hospitals and the de velopment of locally based health and social services are all aimed at providing effective, continuing care for mentally ill people in the community. It is expected that inpatient care will continue for some patients but this will be minimal. The traditional relation ship between hospital and community ser vices has been reversed so that the hospital is now regarded as a back-up to the com munity. Undoubtedly, psychiatric nurses will play a major role in providing continuity of care across community and inpatient set tings. The recent changes in nurse educa tion are aimed at preparing them for this flexible approach. Such changes are to be welcomed; while training in hospital wards provides experience and develops expertise, it produces a blinkered approach in which hospitalization is seen as an end in itself. The new approach will mean that hospital
K E Y P O IN T S
• Increasing demand on mental health services means that psychiatric nursing skills must be deployed as effectively as possible. • Clinical nurse specialists in psychiatric nursing have demonstrated the effectiveness of their interventions. • Many psychiatric nurses are engaged in alleviation and rehabilitation rather than trying to bring about significant change. • There has to be closer integration of clinical practice, education and research. • Research in psychiatric nursing is becoming much more practice related. • Psychiatric nurses have a major role to play in the development and functioning of new localized services.
British Journal of Nursing, 1992, Vol l,N o 6
ization, if it occurs, will be seen as part of a continuum of care. The overall pattern of psychiatric services is likely to change substantially over the next few years. Collectively, these services should provide a wider and more effective range of care for people with mental illness, e.g. day centres, group homes, outreach teams, community hostels, walk-in centres and family support. Psychiatric nurses have a major role to play in the development and functioning of these new services. We must learn from the lessons that have emerged from our experi ence so far, identify those aspects of care and organization that are regarded as good standards of psychiatric nursing practice, encourage the exchange of information and build on what has already been achieved. ijTk Altschul A (1986) Forward In: Brooking J(ed) Psychi atric Nursing Research. John Wiley and Sons, Chichester 11-12 Armitage P, Champney-Smith, Andrews K (1991) Primaiy nursing and the role of the nurse perceptor in changing long-term mental health care: an evalu ation. J Adv Nurs 16: 413-22 Bristow F, Callaghan P (1991) Using Peplau’s model in affective disorders. Nurs Times 18: 40-1 Brooker C (1990) The application of the concept of expressed emotion to the role of the community psychiatric nurse: a research study. ] A dv Nurs 27: 277-85 Brooking JI (1991) Inaugural Lecture. Towards an Evaluation o f Psychiatric Nursing. University of Birmingham Davis B (1990) Research and psychiatric nursing. In: Reynolds W, Cormack D (eds) Psychiatric and M ental H ealth Nursing. Chapman and Hall, Lon don 434-67 Department of Health (1990) N ational H ealth Service an d Comm unity C are Act. HM SO, London Donabedian A (1989) Institutional and Professional Responsibilities in Quality Assurance. Q Assur ance H ealth C are 1(1): 3-11 English National Board (1991) Fram ew ork f o r the H igher Award, English N ational B oard f o r Nurs ing, M idw ifery a n d H ealth Visiting, London Krauss J (1987) Nursing, Madness and Mental Health. Arch Psychiatr Nurs 1(1): 3-15 Lavender A (1987) Improving the quality of care on psychiatric hospital rehabilitation wards. Br J Psy chiatry 150: 476-81 Lemmer B (1986) The M anagem ent o f C hange in Five Wards o f a London Hospital. Conference proceed ing of the RCN Research Society Conference, 1013 April, University of Reading Management Advisory Service (1989) R eview o f Clini ca l Psychology Services. Management Advisory Service, London Mauksch IG , Miller MH (1981) Im plementing Change in Nursing. CV Mosby, St Louis Office of Health Economics (1989) M ental H ealth in the 1990s: From Custody to Care? Office of Health Economics, London Richards DA, Lambert P (1987) The nursing process: the effect on patients’ satisfaction with nursing care. J A dv Nur 12: 559-62 Ritter S (1991) Development in psychiatric nursing. In: Paine L(ed) British H ospital M anagement: T h e• Annual R eview o f British H ospital a n d H ealth C are Planning an d D evelopm ent, London 101-7 Rogers A, Pilgrim D (1991) Pulling down churches: accounting for the British mental health users' movement. Sociol H ealth Illness, 13(2): 129-48 U K CC (1986) Project 2000: A N ew Preparation fo r Practice. U K C C , London U K C C (1990) The Report o f the Post-registration Education an d Practice Project. U K C C , London
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