The conceptual
basis of mental health nursing
Philip J Barker
‘I‘his paper traces the historical roots of mental health nursing relating these to contemporary practice in the case of people with all forms of mental illness. An attempt is made to explain the current interest in the nurse’s interpersonal role with reference to specific theoreticals models and the development of care practices which emphasise social systems or social relationships. Emphasis is given to reports in the British literature, although some reference is made to North American nursing commentators. It is argued that although research evidence is weak, strong indications exist to suggest that the nurse’s primary role lies in the imagination of their interpersonal relationship with the patient in an attempt to effect lasting change in the patient’s capacity to live an ordinary life.
THE NIGHTINGALE of nursing
‘I‘he concept Typically,
The
nitions
embraces
ence
in terms
common
thread
the
of practice of
concept
of
of
most
defi-
caring
for,
tending, promoting or fostering growth. These stem from the old French ‘norice’ and the late Latin
‘nutrire’,
Although and
both
an association
dying
or
the
strong,
the
planted
to protect
stry), or even a good definition
meaning with
rearing
term
can
the ‘action
position
for
of nursing
not, however. meanings have
quite been
nourish’.
tending
the
sick
of children
is very
represent
‘a tree
also
another
‘to
during
growth’
used to keep
cannons’ so clear. influenced
(fore-
the balls in
(billiards).
in a professional
‘The sense
of’ modern Nightingale.
‘person
care is not easily defined.
it is expressed
nursing.
concept
HERITAGE
is
Contemporary greatly by the
Philip J Barker Clinical Nurse Consultant, Behavioural Psychotherapy Nursing Service, Royal Dundee Liff Hospital, Dundee DD2 5NF (Requests for offprints to PJB) Manuscript accepted 6 December 1988
trained
under
added).
this role
Nightingale
work.
professional.
Many role
model
if one
physician. maidens
the
can
has had
examines
from
and Dingwall
nurses
(1977)
‘style’
01
as a reflection
01
life. over
Doctors women
doubt ever
whethet be
argued
a profound
of’ nursing,
the
that
derives
( 198 1)
not only upon the practice how nurses see themselves:
1976:
generalI?,
developed
Cohen
Nightingale’s
concept of the defined
(Watson.
that
a subordinate
to a
sick or infirm
middle class family patriarchal authority
and women’s such
the
bv Florrefer
assistant’
(1977)
suggested nursing
Victorian svmbolised
for
of’ a doctor’
Austin
have
developed
dictionaries
It is accepted
as the ‘doctor’s
Nightingale. both
to care
the direction
emphasis
nursing Most
called that effect
but
professional
upon
self-
in the Nightingale tradition, the root problem is easy to see. Nightingalr the nursing role as handmaiden to the and
it has
remained
are not professionals.’
so. (Cohen.
Hand198 1 )
NURSE EDUCAI‘IOK
340
Such a critique new.
TODAY
of the traditional
For more
than
a decade
role is hardl)
there
calls for nursing of obedience
to ‘free itself from and subservience’
Koberts,
influences
1974);
saw as the ‘ghosts
have
been
the tradition (Group 8c
which
these
necessary
strength,
likewise
the function
gain
emphasis
however
Nightingale’s extended tion
of health
concept
of
defined.
the traditional
of emphasis
appears
upon
to have
religious
meaning,
conviction.
a reflection
of her fellow man:
express
such committment.
nursing
This own
care itself. as ‘putting
to the
being
a way to
She appears
had little faith in the direct nursing
base. of her
She was committed
service
of nursing
by the addi-
a vocational
been
therapeutic
Instead,
Such
10 have potential
she saw the act of
the patient
in the best condi-
tion for nature to act upon him’ (Nightingale, 1969) It may be concluded that by ‘nature’ she included
the
already,
intervention
the term
of
God.
is associated
As
much have and
care:
Nightingale,
broader
philosophy
tried the
and
however,
to preserve
popular
Nite
‘Crimean
(1978),
Nightingale
which against
for
saw nursing
live. She saw body
a
her successors erosion
by time
Henderson
example,
note
as helping
that
people
and soul as inseparable,
to and
looked upon the patient as a member of a family and community. Nursing, therefore, was an expression in
the
of citizenship patient
Nightingale
sense,
of a renaissance specific patient
as
a
and
religion.
‘whole
person’,
has experienced
recently,
even
focus upon the (Simsen, 1986).
Interest in
this
something
to the extent
of a
spiritual status of the Henderson and Nite
(1978) developed the ‘modern’ version of the Nightingale nursing model with a definition which
addresses
suggested was:
people,
whether
that the unique
ill or not. They
function
from
as a ‘ministering
clinical
workers,
of the nurse
of religion,
it
expressed
in similar
or
also blurs
even
further.
professions.
Apart teachers,
‘therapists’.
might
even
see their
vocation
of nursing
is much
terms.
A quasi-anthropological perspective ‘I‘he concept
of the vocation
than Nightingale. Colliere older reminded us that care serves a basic function
in any community,
species.
This
function
had
the
or indeed
( 1986) survival
within
any
is (or was) principally
a
female vocation. This basic caring or mothering role involved the promotion of growth and development
both
which
as an integral
served
Colliere
was drawing
the ‘nourishing’
of children
and part
obvious
role of mothers
the
of their
parallels
plants diet.
between
and gardeners.
A similar. parallel was made earlier by Barker (1986) where a comparison was made between the practices of the nurse and the nurseryman (see also Barker, 1988). Colliere also noted that women helped those wounded men.
the sick and dying, though in combat, who were cared
In her view, women
by priests:
if they
role
various
ministers
they
unaided
the
which.
psychologists,
. . . to help people, sick or well, in the performance of those activities contributing to health or its recovery (or to a peaceful death) that perform
all of
nurse’s
role in the development through their work with quently in the development the development of writing
would
its
virtually
Such a definition
of the
doctors,
without
to embrace
experience:
of
angel’
of sickness.
however,
her work with other
social
with its root so to speak,
with
embraced
model’.
merging
of health,
play a part in the promotion
of’ ‘health’.
borders
nursing
is not,
of human
recovery
of
only in the alleviation
be argued,
possible.
development
the bond,
It appears
people
noted
commonly
the care of the sick or dying. Holistic
whole
the
reunites
a definition
could
as
promotion
of the nurse
problems.
rapidly
the
the
and breaks
with an interest
nursing’
It is
to help
1978)
upon and
the concept
‘modern
as
8c Nite,
independence, definition.
The promotion
of nurses
independence
(Henderson ‘l’he
authors
of the Crimea’.
will or knowledge.
also played
rarely for by
a primary
of pharmacology, plants, and conseof medicine. With and its exclusive use
. men started ledge,
to confiscate
transferring
from
them,
whal
and
assimilating
understanding.’ Religious Christianity modern care
(Colliere,
roots: nursing
under
towards
crated
virgins’),
major
role
noted
servile
generating
the
dependent torian
which status
values.
firmly
reminded
Church’s
influence
nursing.
Indeed.
reminder
Colliere.
strongly
both
the
ministering meaning.
unto
the
In modern
tions concerning traditional
Social Security,
a
in both
a
politi-
image
pervasive
by
in the care of concept
of
popular
this has led to quesfor nurses
in certain
the most obvious
of Health
&
1979).
observations
about
with contagious
role
where
diseases,
men
often
at
they dealt with the consequences
Men’s
mentally
association
ill people
and
vocation
experience
with
psychiatric
social outcasts
ing his religious
conversion.
John
figurehead
for
of God’. the order of
continued
his vocational
sick,
ordered
which
(Cross of the
shown Lazare
work
the
Catholic
the work who
the name
with
the dis-
1983). The
influ-
Church
a leper
France
to be
mentally
was also
of St Vincent
turned
in southern
follow-
becoming the same
8c Livingstone,
through
(1581-1660)
having
episode
He was later
included
Roman
by his own
as a lunatic,
to be a manic
canonised which
in Portu-
was influenced
of confinement
had what appeared
de Paul
hospital
into
that
at St
country’s
first asylum.
Development
ance
of the care system
various
England
since
grew
asylums
had
12th
century,
the
with the influence of the ‘enlightenment’
Century
(Locke,
the creation
1964).
of more
been
in
import-
in the late
Britain
17th
led the world
humanitarian
bv the emerging
present
their
of the intellectual
tradition
in
care settings,
science
of medicine.
Religious vi&, however, also played a significant role in the development of the enlightened view
of the
treatment’ into more
British
nursing
in general
approach humane
disordered. are
important also to the understanding of psychiatric nursing. People with mental disorder have been down
in lazarets,
possibly has its roots in the work of Joao (1495-155(I), who set up a shelter for
gal. Cuidad’s
ence
contain-
asylum
tradition.
William
Tuke, who founded the Retreat at York in 1792, was one of the foremost pioneers of the ‘moral
THE ORIGINS OF PSYCHIATRIC NURSING These
battle.
nursing Cuidad
embraced
example
the ‘care’ of people
(Department
for those
sea: and where
Although
Nightingale
most
developed
forcible
the ‘male nursing’
of
strongly
the
had
needed
role paralled
phil-
base. Although
sick is the
concerning
handicap
More as
nurse’s
even
‘well’,
the ‘need’
the debate
The The
times
care areas:
with a mental
nursing,
of nursing.
the
in a
habit.
served
a religious
the place
of
to dress
which
of
in the care of the mentally
who often
This
poor
Catholic
is a mirror
and
‘sick’ and
perconcept
also is influenced f&m
Henderson
assert
being
of sense.
relationship.
stemming
of Vic-
Roman
thesis
roots
of nursing
values
as a
of nurses
our modern
to doctors
the nun-priest
role’
Austin
the grip
continue
a
post-
serves and
of the nun’s
linguistic
cal subservience osophy
us of the upon
the
and
played the
the origins
Colliere’s of
cultural
of
thesis
within
version
importantl),
Catholic
quasi-anthropological
nurses
disguised
of
‘invisible
of Dingwall locate
This
spective
thinly
Colliere’s
views
on
(the ‘conse-
status,
by nurses
period.
earlier,
of the
of nuns
and their
to the
influence
prominent
ment. cared
that
institutionalisation
attitude
adopted
Nightingale contrast
by the
in
own
further
key
the sexuality
subsequently
disordered,
it for their
the
The
were more
collect
argued
as
nuns.
church
know-
could
1986)
Colliere
served
women’s they
the recipients of various forms of care the ages. By virtue of their strength, men
which tried to turn asylums ‘havens’ for the mentally
It has been suggested,
however,
the principles of Tuke’s approach were: based not on the scanty medical ledge of the time, but on Christianity common sense.’ (Bockoven. 1963) Early training initiatives: The asylum of this period
represented
the hrst
that knowand
attendants official
care
342
NURSE EDUCATION
agents,
and
were
the
nurse.
chiatric Apothecary
TODA\’
predecessors
John
to the
of the
Bethlem
psy-
( 1764- 1844),
Haslam
Asylum,
was,
in
of
psychiatric
nursing
1817, one of the first to propose that these attendants should be given some kind of formal
base is evident
training
exclusive
(cited
recorded course
Leigh,
training
exercise
five
lectures
delivered
at the Royal
Montrose
in 1834 on ‘what asylums be.’ When Crichton
Browne
attendants
begun
similar
Springfield
The
on
stimulus
Psychological hundred
for
the
P-year cept
the
old. The their
nursing,
formal
a by a
research
path,
in 1906
Medico-Psycho-
the
emerged,
of the medical
therefore, profession
was much in vogue. nursing developments
from
of Health
of nursing’
Midwifery impact
strongly
(Scottish
Consultative
of these
changes
in general
of recent
illustrates
has been
period
nursing.
research
in psy-
that very little clinical
generated
1980-1984.
in the UK, even
His review
shows
in
that
most research deals with nurse or general features
the education of the of the nurse’s role.
Also,
consider
some
centred
nursing
(Department
and
review
nursing
education,
for a research
1972) and the generalisation
felt most
Davis’s (1986) chiatric
such
last decade
in nursing
1976). The
has been
of
of the
The
of the need
Nursing
Committee.
con-
less than
a similar
arrangements
Association.
in for
use
have contri-
the definition
in the ‘process
National
successfully represented
the aegis of the American
the patronage
and
of interest
nurses
1985).
1983).
practice
nursing demon-
(Drummond.
over
changes
and Social Security,
in training
is, therefore,
logical
when philanthropy that most of the
Medico-
By 1889, one
The
USA followed training
major
concept-
the actual
by nurses’
(Cormack,
&
some
these
and some
models
also exists role
has seen
of Atten-
Royal
handbook
under
Psychiatric
culminated
nurse’s
Although
about
made
nursing’
con-
(Kershaw
has not been
terms,
to care
‘generic Confusion
of
the first register
1961).
and register
bution
various
of psychiatric
value
is not
1986; Riehl &
to relate
reservations
basis for nursing
the
completed
100 years
spread
1986).
to the practice
in research
and
described
8c Vaughan,
1986), their
Instruction
had
formalising
1961).
which
(Walk,
of psychiatric
qualification
(see Walk,
an
In the wake of
of nursing.
Wright,
with the acceptance
instituted
who
strated
for
remains
in general
have attempted
expressed
had later to
the
1980;
(Barber,
Asylum,
for
Roy, authors
ual models
Browne’s
participated
on
to
he extended
(RMPA).
had
based
training
1986; Pearson
to the
Britain
nursing.
have been
of ‘the red handbook’: by
Association
1890 the RMPA attendants,
the
Insane,
hospitals
programmes
Savage,
of instruction
of instruction
Handbook
Asylum
Morrison,
course
in 1885 in the preparation dants
in the process models
1854-1855.
Hospital
as the
courses
interest ceptual
later
Alexander
a formal
served
a short William
male and female
in 1843 at the Surrey
become This
period
Sir
attendants
to both
in nursing
to psychiatric
by
are and ought
in Dumfries,
in the
first
was Lunatic
were,
given
contemporary,
The
was appointed
Institution
this to 30 lectures
already
1961).
staff of
Browne
by
in
insecure, if not hazy, concept. Refinement of the concept of- pyschiatric nursing: Confusion and conflict over its conceptual
commentators
model
incompatible
at a time
ing
It is clear of the
approach
the
nursing
with psychiatric
instead
nurses
of
more
emphasis
(Altschul, have
been
1978). more
the personprocess
practice, upon Other
optimistic
to be suggest-
a syst~ems psychiatric about
the
past century have continued to depend upon the benificence of psychiatrists and the development of psychiatric medicine. Not until the beginning
potential value of the process of nursing, seeing an opportunity for nurses to make their own
of the second half of the 20th century psychology and sociology begin to make
has written:
own important of nursing -
influences influences
did their
on the knowledge base which were to prove
useful in helping nursing see itself in more objective relief (Skevington. 1984). However. despite such recent developments, the concept
statements
about
care.
In this context
Bradshaw
’. . nurses are raising issues about the conceptual framework of psychiatry and asking important questions about the which psychiatrists have purported for so long.’ (Bradshaw, 1986)
behaviour to explain
NURSEEDU(:A’I-ION‘fOD-\1 drugs and ECT. care and treatment
THE INTERPERSONAL ROOTS OF PSYCHIATRIC NURSING For much
of nursing’s
history,
care has been shrouded man might be forgiven about ‘looking
in confusion.
The
for assuming
of lay-
that care is
after’ and is to be distinguished which signifies
tive interaction
with the patient.
a more produc-
tion appears
to be evident
level of the
profession.
those nurses
who see themselves
purely supportive
Such a distinc-
even at the highest
The
conflict
between
as carers,
in a
sense, and those who attribute
dimension
highlighted
has been
the concept
from treatment,
a therapeutic
the practice
recently
to their work, has been
by Vousden
(1986).
Con-
nolly (1856) appears to have been one of the first to recognise ing,
the therapeutic,
potential
as well as damag-
of attendants
in the
Victorian
asylum. noting that:
.
labour,
if he has attendants rules.’ (Connolly,
most
challenged
psychoanalytic chological,
plans, all his care,
must be counteracted,
who will not observe
impact
on nursing
1856)
need
subsequently
of training
nurses.
of the psychiatric
to be an expedient
tinued
to stand
psychiatric
and
psychiatric
Indeed,
nursing
in the ideological
medicine,
nurse’s
way of ensur-
ing the quality of medical treatment. most of its history,
part in
of attendants
Viewed from this perspec-
tive. the clarification role appeared
for
has con-
of nurses
medium
as providers
of medical
practice
treatment),
in Great
involved
in
although
their
so-called
‘neurotic’
1968).
this
The
to the medical model
of the
1968).
late
which
grew
social
model
work focused patient
‘neurotic’
range
Psychosocial models: The medical, or clinicalmodel of psychiatry has been the somatic, governing influence on policies of care of the mentally disordered (Ramon, 1985). From the earlv experiments with water-torture and flog&g. to today’s invasive treatments with
the
(Barnes, came in
treatment
model
more
(Marks
chronic
was more
eclectic
model
nursing
a slightly
and
& Fraser,
different (Butler
therapy
appropriate
X:
nursing’.
to outline to almost
problems
1985;
patient
set of psy-
methods
in its attempt
populations
1982; Barker
psychiatric
‘Behaviour
1978).
was geared
a different and
of
amenable
et al,
which
therapeutic 1978).
the selection
considered
of therapy
Rosenthal,
patient
upon
alternative
emphasised
principles,
of
psychiatry,
population
patients
emphasised
of
of
mainly
rehabilitation,
the
chological
and
out of modern behaviourism. psychotherapy, described by Marks
and his colleagues,
population,
1950s
Many nurses became
next significant
1985).
the first formal acknowledgement of the interpersonal basis of psychiatric nursing.
to a
population.
movement
The experience
the
Britain,
was restricted
of the patient
early 1960s (Jones.
as
(and
of
community
of
also represents
model
made little
came in the form of the therapeutic
mainly
of care
the
a psy-
of psychiatry
shadow
functioning
medical support system (see Cormack, 1976). However, Connolly’s recognition of the importance
to physical.
The first serious alternative
towards and effective
The
from
This development
very small minority
Behavioural
support in his absence playecl a significant the formalisation
came
where this model of treatment
certain
for adequate
in the
which proposed
as opposed
disorder.
Behavioural
his
influences
‘l-he doctor’s
alternative
mental
orientation
points
care and treatment.
movement
to this form
Seminal
at various
of psychiatric outstanding
has reflected
This
the form of the psychological
all his (the physician’s)
all his personal
history
of the physician.
343
a all
(Barker,
Barker
8c Wilson,
of the nurse in the LISA: Soon
after the end of the Second World War, some nurses in the USA, who had trained within the psychodynamic psychotherapeutic
movement,
began
to develop
model of psychiatric
a
nursing
(Mereness Xc Taylor, 1978; Peplau, 1952). Although some of these nurses stayed within the dominant culture of psychoanalytic thought, others, such as Peplau (1952). transferred their allegiance to the interpersonal enced by the work of Harry Psychiatry,
in Sullivan’s
to the study of mentally
school, influStack Sullivan.
view, was not restricted ill people,
or even of
344
IVURSE EDUCATION
processes,
successful
may be observed psychiatry
TODAi’
and
in groups.
unsuccessful,
which
Instead Sullivan saw
as:
field of interpersonal all circumstances complex the
relations,
exist
can never be isolated
from
of
interpersonal
relations
lives and
has his being’.
person
(Sullivan,
under any and
in which these relations
. . a personality the
(JCMHNO,
sciences
and
skills
training.’
1986)
That group saw the client (sic) population
‘. . . the study of processes that involve or go on between people. The field of psychiatry is the
which
physiological
in
1947)
‘outside work
conceptualisation
namic
won favour
of psychody-
with many
who saw within this model a theoretical
nurses
perspec-
the parameters (existed)
medical
of general
medicine’
within
models
of
social
psychiatry’.
1986) Psychiatric
Nurses
( 1986) articulated
mental (sic) nursing
.
Association-Scotland
a similar set of views: is clearly based on the
social model of psychiatry
within which inter-
personal
tegies, are central to their role’. (PNAS,
away from traditional forced further
psychotherapy
by the influence
psychology
movement
(Rogers,
eschewed
emphasis
of
195 1) which also
intrapsychic
nations.
Although
medicine
in the USA is influenced
biophysical
contemporary
model,
psychiatric
to have moved further such an orientation the interpersonal ments
strongly
and further
by a
appears
away from
in favour of an extension
ambitions:
of
1986).
Nursing
develop-
within the UK over the past 2 decades,
combined tric
expla-
psychiatric
nursing
model (Peplau,
Contemporary
was rein-
of the humanistic
with vicarious
nursing
support
experience
in the
to an interpersonal
psychiatric suggest
culture nursing.
that
roles continue (Armitage,
to dominate
1986; Cormack,
it has become interpersonal
or
common
have
model
Although
custodial
of psychia-
USA,
lent
of British
psychiatric
nursing
1976: Towell. practice
basis of psychiatric
1975)
to assert
the
nursing.
In
anticipation of major reform of all forms of nurse training (United Kingdom Central Council for Nursing and Midwifery, 1987), the Joint Committee of Mental Health Nursing Organisations stated that psychiatric nursing operates within ‘a conceptual framework of social psychiatry’ characterised by:
and
that the nurse’s
role
skills,
is
. . a synthesis of knowledge built up from medicine, social and behavioural sciences,
used
within
systematic
stra1986)
This group suggest that the role of the mental nurse: ’. . operates
on a social model
in which the
emphasis
is on
regardless
of whether
traditional
medical model or social model they
constitute
patient/client
the most important
It is not clear,
self
nurses
patient’s social environment.’ however,
help.
work under influence (PNAS.
whether
terms such as ‘interpersonal’
a
in the 1986)
the use of.
and ‘social’, as used
by both these groups,
reflect the same meanings
originally
by Sullivan
theorists
articulated
or later field
such as Lewin (195 1).
Nurse-patient
close observation medical-expressive
than
(JCMHNO,
personal
The move
frame-
rather
tive which could be related directly to the interworld of nurse and patient.
(the
as
and believed that nursing’s ‘ideological
The
This alternative thought
mentally disordered)
relationships:
Interest
in
the
interpersonal basis of psychiatric nursing in the UK can be traced back to the series of searching questions enquiry
asked
by Altschul
into nurse-patient
as a result of her
interaction
(Altschul,
1972). She was interested in defining the theoretical basis of sound nursing practice and wanted to know what kind of training nurses received to help them form relationships with patients. More than a decade later she was still uncertain of the answers to the questions (Altschul,
1984).
One of the key studies of psychiatric nursing undertaken in the UK (Towell, 1975) concluded that the term ‘psychiatric nurse’ encompassed a cluster of roles. which varied according to the setting.
Contrary
to the
‘interpersonal
view’
expressed that
above,
the
which
Towell,
formation
is emphasised
limited
feature
a sociologist,
of
personal in the
noted
literature,
of the nurse’s
role
relationships was
a
Cormack
(1983)
nurses
should
do
and
observations
(the
decriptive
within
of what
nurses
literature).
role:
attendants
(1956)
suggested
doctors
and being
patient
that
group.
and
position
towards
the
its goal’ of doctors
13cMartin,
popularisation
of the
role’ as a description expedited
giving injections The social role:
the
term
medical
treatment,
their
role
been
opportunities
has waned
where
medical.
since
due
to lack of formal
that
Colledge
logical
by John-
have
most
1970).
kind
of
have
traditional
USA. Although
staff
as the
nurses
the individled to the
LISA remained American therapeutic
worh
activities such
as
is multidimensional
in
character (see World Health Organisation, 1957). More recently, *James (1972) noted the ‘demanding nature of the range of tasks evident
prospered the
01‘
of psycho-
in Britain
kind
but
of following
psychotherapy
gained
in the
hospitals
in the
in nature.
man)
largely
custodial
nurses developed a formal psychorole following training with various foundations.
8c Fowler,
As
noted
197 1) was largely
psychotherapeutic
replaced
model
interpersonal
was among therapeutic
the first to describe role for nurses. an idea
taken
LIP
Peplau
factors.
by others sub-role’
Peplau
role’
( 1952)
a psychowhich was 19.58).
a ‘counselling as distinct
formal ‘deep psychotherapy’ (Peplau. 1962). a concept which considerable international support. ‘4 ‘psychotherapeutic
by a which
(Kalkmann,
was 10 emphasise
psychotherapeutic
earlier.
psychotherap)
emphasised
Later,
base,
care in the State
psychodynamic
soon
nurses exercise a interpersonal and
psychiatr! eclectic
schools
neo-Freudian (Brown
ot
and social forms
psychoanalytic
broadel
British
Various
commanded
In
institution.
by a broad
psychological
treatment never
which
role:
co-exist.
the
‘l‘ibits.
of the large
characterised
of’
in
and for
psychotherapeutic
treatment
or dispensing medication. Various groups and individuals
suggestkd that, since of specific technical,
training
has been
of the
‘moved
nursing
ethos
19’iOs (Morton
this may have
interest
The
doctor
‘medical-expressive
of those
formal
community
early
whole
196X). Elements
between
the
This
but
the
demise
by ‘maintaining
1958).
(Barnes,
patient,
not
the gradual
whereas
within
involved if
Belknap
subordinate
that they
which f-amily
1979) but may also be a reflection
saw medical
equilibrium
ual’ (Johnson
therapeutic
nurses to relinquish mothering, role for
role
remain,
patient’s
(Campbell,
expressed
is perhaps of
in the sense
skills,
was
role described
They
the work
role
the
view
(1958)
of nursing.
system
role
the
the work
by the demands
description
the motivational
social
mediate
preventing
by the nurse/sociologist
Martin
expressed
have range
nurses
A similar
‘instrumental’
which
roles
are par-
from
above.
‘expressive’
significant
care
that
in
and
community
of
noted
patients,
recently
partnership
hospital
traditional
staff stems
overwhelmed
( 1973). The
a
literature)
category
sharper that:
1963)
required supportive,
nurse.
do in practice
the nurse’s
of
son
role
into
suggested
surroundings
approach traditional
part,
to medical
asylum
(Altschu!.
doctor,
A number
prescriptive
and
interest.’
as to what
below.
supportive
more
the nurse’s
prescriptive
as a support
from
that
agent
1968). Altschul
routine
That their
of suggestions
(the
Cormack’s
aphrased The
observed
in terms
(Jones,
’ . the special role of the nurse is to create a wholesome ward atmosphere and to influence
role.
The view from the nursing literature can be defined
as a sociotherapeutic
focus
or
from
a
intervention has gained
is conceptualised
traditional institutional settings: in many #clinician, educator, administrator, social worker,
here as one involving patient interactions,
clerk and domestic innovator, ‘development of the therapeutic movement of the late 1940s brought
model. The psychotherapeutic potential of‘ nurses has been proposed for at least the last 25 vears (General Nursing Council tOr Scotland.
help.
The
community the nurse’s
specific. individual, nursewithin a clear theoretical
346
NURSE EDUCATIOiX
1962). However,
TODA’I
if published
a measure of the realisation demonstration
reports are used as
of such potential,
of a psychotherapeutic
the
nursing
‘carers’ from the nurses who emerged post-Crimean expressed
era.
views of the patient which were essen-
of the nursing
movement
projected
the Crimean
for nurses
through
specific
mes (Marks et al, 1978; involving (Marks
the
long-stay
patients
have emphasised therapeutic
of
role
(Fraser
et al, 1978)
neurotic
patients
et al, 1976).
the value of alternative
models.
Faugier
(1985;
the supporters
of
model
of gestalt
counselling
recognise the ‘alternative therapy’ status of their approach, and the limitations subsequently imposed upon practitioners (Kenny, 1986). Although
many writers have emphasised
‘therapeutic’ described
potential
of
nurses,
or
the have
aspects of the nurse’s role as psycho-
therapeutic,
the meaning
questioned.
Indeed,
of such terms can be
almost
any
interaction
to the work of the ‘atten-
of
involved The
disabled
last
100 years,
psychiatric
how descriptions broadened,
than
medical-expressive
role.
and
the
nursing
first century
(1890-1990).
in psychiatric
uncertainty
over
the true
nature
‘experiments’
in nursing
have
as much
served
care of the last century to confuse,
nurses in realistic model-making. progress
in psychiatric
nursing
has involved,
psychiatrists.
chiatric
nursing.
therapy
as
relationship person’s (Strupp,
Strupp’s
‘the
to effect
cognition, 1986),
definition use
systematic
enduring feelings
with
the
described
patient
and
might prove helpful
which
human
changes
atric nurses wishing to distinguish ing, yet casual, interactions
of psychoof
in a
behaviour’ to psychi-
between help-
and those meetings might,
properly,
be
as psychotherapeutic.
Much
of the contemporary
psychiatric
nursing
in
of influential
clarification
role-theory
involves
of
‘asser-
tions’ about what nursing 2sor .shouli be. As noted in this review, research role model significant
evidence
or another thread
supporting
is noticeably
woven through identifies
most significant.
ence on the outcome
A
most of the
role model descriptions, as the single,
one
absent.
processes
interpersonal
of care. Although
influ-
her work
has taken almost 4 decades to exert any significant influence on psychiatric nurses on this side there are of the Atlantic, Peplau’s interpersonal model
indications of mental
that health
nursing might become a significant plank in any emerging British psychiatric nursing role
CONCLUSION This paper has presented a brief review of the history of psychiatric nursing, emphasising British, and to a lesser extent, North experiences. The review suggests
as to assist The march of
At present,
to exist within psy-
of the
nurse’s role, which exists today. suggests that the
of the terms ‘therapeutic’ appears
by
theory and practice.
as psychotherapy. ‘psychotherapeutic’,
have
to influences
accepted
or
of
shows
of the role of the nurse
the main, following in the footsteps
no commonly
living
rather
mainly in response
developments
who were
the everyday
people,
in a technical
British
The
system,
more in supporting
between two or more people might be described definition
and
to the point of dehumanising
asylum
activities
in the analytic sense,
from
was quasi-medical
dants’ of the British
psycho8c
experience
almost
the approach
which developed
was in stark contrast engaged
Faugier
profession
the person who was the patient. That care system
Others
a psychodynamic
which was not ‘traditional’
technical,
program-
and the rehabilitation
Reilly, 1986) described whereas
training
McPherson
treatment
et al, 1978);
therapeutic
from the
Nightingale
tially ‘holistic’ and humanitarian.
role is a fairly recent innovation. In the early behavioural psychotherapy 197os, the a formal
Although
American that the
original needs of people dehned as mentally disordered, systems and the care which developed between the 17th and late 19th Centuries to meet such needs, distinguished such
theory.
Her description
of the ‘helping’
process
involved between nurse and patient, might assist psychiatric nurses of tomorrow aspire towards Strupp’s goal of ‘psychotherapeutic working’: by using their relationships with patients in a systematic manner,
to effect
lasting changes
in the
patient’s thoughts, feelings and ultimately behaviour. Attainment of such a goal might
bring psychiatric nurses, full circle, into contact with Nightingale’s idea that nurses should ‘help people to live’.
References Altschul A ‘1’ 1963 Trends in psychiatric nursing. In: Freeman H, Farndale J (eds) Trends in the Mental Health Services. Pergamon. London Altschul AT 1973 Patient-Nurse Interaction: .4 stud\ of interactive patterns on acute psychiatric wards. (Churchill Livingstone. Edinburgh Altschul A ‘I’ I978 A systems approach to the nursing process. Journal of Advanced Nursing 3: 333-3%) Altsrhul A T 1984 Does good practice need good principles?: One. Nursing Times 80. 2X: 36-3X Armitage P 1986 The rehabilitation and nursing care of severely disabled psychiatric patients. International Journal of Nursing Studies 23. 2: 113-123 Austin R 1977 Sex and gender in the future of nursing. Nursing Times (Occasional Paper) August 25 Barber P 1986 The psychiatric nurse’s failure therapeutically to mature. Nursing Practice 1. 3: 13X1-11 Barker P 19X2 Behaviour Therapy Nursing. Groom Helm, London Barker P 1986 Keynote speech to the Ps,>c.hiatric Nurses Association +nference. Universitv of 1 ork. June I!#6 Barker 1’ 19X8 ‘Trephotaxis’: Reflections on the concept of’care in mental health. Unpublished manuscript Barker P. Fraser D (eds) 1985 The Nurse as Therapist: .4 Behavioural Model. (;room Helm. London Barker P, Wilson L 1985 Behaviour therap) nursing: new ovine in old bottles. Nursing Times X 1, 39: 3 I-34 Barnes E 19fi8 Psychosocial Xurqing. Tavistock Publications. London Belknap I 1956 Human Relations in a State Mental Hospital. McGraw Hill. New York Bokoven J S 1963 Moral ‘Treatment in P5\chiatrv. Springer-. New I’ot-k BI-adchaw P 1986 Advocating change. Senior Nurse 5. 1: X-1 Butler R J. Rosenthal C; 197X Behavioui- and Rehabilitation: Behavioural Treatment tot- Long-Sta\ Patients. \Vright, Bristol Campbell W 1979The thet-apeutic wmmunit!: problems encountered by nurses. Nursing Times 75. .47: 203X-10
basis of mental health nursing
Philip J Barker
‘I‘his paper traces the historical roots of mental health nursing relating these to contemporary practice in the case of people with all forms of mental illness. An attempt is made to explain the current interest in the nurse’s interpersonal role with reference to specific theoreticals models and the development of care practices which emphasise social systems or social relationships. Emphasis is given to reports in the British literature, although some reference is made to North American nursing commentators. It is argued that although research evidence is weak, strong indications exist to suggest that the nurse’s primary role lies in the imagination of their interpersonal relationship with the patient in an attempt to effect lasting change in the patient’s capacity to live an ordinary life.
THE NIGHTINGALE of nursing
‘I‘he concept Typically,
The
nitions
embraces
ence
in terms
common
thread
the
of practice of
concept
of
of
most
defi-
caring
for,
tending, promoting or fostering growth. These stem from the old French ‘norice’ and the late Latin
‘nutrire’,
Although and
both
an association
dying
or
the
strong,
the
planted
to protect
stry), or even a good definition
meaning with
rearing
term
can
the ‘action
position
for
of nursing
not, however. meanings have
quite been
nourish’.
tending
the
sick
of children
is very
represent
‘a tree
also
another
‘to
during
growth’
used to keep
cannons’ so clear. influenced
(fore-
the balls in
(billiards).
in a professional
‘The sense
of’ modern Nightingale.
‘person
care is not easily defined.
it is expressed
nursing.
concept
HERITAGE
is
Contemporary greatly by the
Philip J Barker Clinical Nurse Consultant, Behavioural Psychotherapy Nursing Service, Royal Dundee Liff Hospital, Dundee DD2 5NF (Requests for offprints to PJB) Manuscript accepted 6 December 1988
trained
under
added).
this role
Nightingale
work.
professional.
Many role
model
if one
physician. maidens
the
can
has had
examines
from
and Dingwall
nurses
(1977)
‘style’
01
as a reflection
01
life. over
Doctors women
doubt ever
whethet be
argued
a profound
of’ nursing,
the
that
derives
( 198 1)
not only upon the practice how nurses see themselves:
1976:
generalI?,
developed
Cohen
Nightingale’s
concept of the defined
(Watson.
that
a subordinate
to a
sick or infirm
middle class family patriarchal authority
and women’s such
the
bv Florrefer
assistant’
(1977)
suggested nursing
Victorian svmbolised
for
of’ a doctor’
Austin
have
developed
dictionaries
It is accepted
as the ‘doctor’s
Nightingale. both
to care
the direction
emphasis
nursing Most
called that effect
but
professional
upon
self-
in the Nightingale tradition, the root problem is easy to see. Nightingalr the nursing role as handmaiden to the and
it has
remained
are not professionals.’
so. (Cohen.
Hand198 1 )
NURSE EDUCAI‘IOK
340
Such a critique new.
TODAY
of the traditional
For more
than
a decade
role is hardl)
there
calls for nursing of obedience
to ‘free itself from and subservience’
Koberts,
influences
1974);
saw as the ‘ghosts
have
been
the tradition (Group 8c
which
these
necessary
strength,
likewise
the function
gain
emphasis
however
Nightingale’s extended tion
of health
concept
of
defined.
the traditional
of emphasis
appears
upon
to have
religious
meaning,
conviction.
a reflection
of her fellow man:
express
such committment.
nursing
This own
care itself. as ‘putting
to the
being
a way to
She appears
had little faith in the direct nursing
base. of her
She was committed
service
of nursing
by the addi-
a vocational
been
therapeutic
Instead,
Such
10 have potential
she saw the act of
the patient
in the best condi-
tion for nature to act upon him’ (Nightingale, 1969) It may be concluded that by ‘nature’ she included
the
already,
intervention
the term
of
God.
is associated
As
much have and
care:
Nightingale,
broader
philosophy
tried the
and
however,
to preserve
popular
Nite
‘Crimean
(1978),
Nightingale
which against
for
saw nursing
live. She saw body
a
her successors erosion
by time
Henderson
example,
note
as helping
that
people
and soul as inseparable,
to and
looked upon the patient as a member of a family and community. Nursing, therefore, was an expression in
the
of citizenship patient
Nightingale
sense,
of a renaissance specific patient
as
a
and
religion.
‘whole
person’,
has experienced
recently,
even
focus upon the (Simsen, 1986).
Interest in
this
something
to the extent
of a
spiritual status of the Henderson and Nite
(1978) developed the ‘modern’ version of the Nightingale nursing model with a definition which
addresses
suggested was:
people,
whether
that the unique
ill or not. They
function
from
as a ‘ministering
clinical
workers,
of the nurse
of religion,
it
expressed
in similar
or
also blurs
even
further.
professions.
Apart teachers,
‘therapists’.
might
even
see their
vocation
of nursing
is much
terms.
A quasi-anthropological perspective ‘I‘he concept
of the vocation
than Nightingale. Colliere older reminded us that care serves a basic function
in any community,
species.
This
function
had
the
or indeed
( 1986) survival
within
any
is (or was) principally
a
female vocation. This basic caring or mothering role involved the promotion of growth and development
both
which
as an integral
served
Colliere
was drawing
the ‘nourishing’
of children
and part
obvious
role of mothers
the
of their
parallels
plants diet.
between
and gardeners.
A similar. parallel was made earlier by Barker (1986) where a comparison was made between the practices of the nurse and the nurseryman (see also Barker, 1988). Colliere also noted that women helped those wounded men.
the sick and dying, though in combat, who were cared
In her view, women
by priests:
if they
role
various
ministers
they
unaided
the
which.
psychologists,
. . . to help people, sick or well, in the performance of those activities contributing to health or its recovery (or to a peaceful death) that perform
all of
nurse’s
role in the development through their work with quently in the development the development of writing
would
its
virtually
Such a definition
of the
doctors,
without
to embrace
experience:
of
angel’
of sickness.
however,
her work with other
social
with its root so to speak,
with
embraced
model’.
merging
of health,
play a part in the promotion
of’ ‘health’.
borders
nursing
is not,
of human
recovery
of
only in the alleviation
be argued,
possible.
development
the bond,
It appears
people
noted
commonly
the care of the sick or dying. Holistic
whole
the
reunites
a definition
could
as
promotion
of the nurse
problems.
rapidly
the
the
and breaks
with an interest
nursing’
It is
to help
1978)
upon and
the concept
‘modern
as
8c Nite,
independence, definition.
The promotion
of nurses
independence
(Henderson ‘l’he
authors
of the Crimea’.
will or knowledge.
also played
rarely for by
a primary
of pharmacology, plants, and conseof medicine. With and its exclusive use
. men started ledge,
to confiscate
transferring
from
them,
whal
and
assimilating
understanding.’ Religious Christianity modern care
(Colliere,
roots: nursing
under
towards
crated
virgins’),
major
role
noted
servile
generating
the
dependent torian
which status
values.
firmly
reminded
Church’s
influence
nursing.
Indeed.
reminder
Colliere.
strongly
both
the
ministering meaning.
unto
the
In modern
tions concerning traditional
Social Security,
a
in both
a
politi-
image
pervasive
by
in the care of concept
of
popular
this has led to quesfor nurses
in certain
the most obvious
of Health
&
1979).
observations
about
with contagious
role
where
diseases,
men
often
at
they dealt with the consequences
Men’s
mentally
association
ill people
and
vocation
experience
with
psychiatric
social outcasts
ing his religious
conversion.
John
figurehead
for
of God’. the order of
continued
his vocational
sick,
ordered
which
(Cross of the
shown Lazare
work
the
Catholic
the work who
the name
with
the dis-
1983). The
influ-
Church
a leper
France
to be
mentally
was also
of St Vincent
turned
in southern
follow-
becoming the same
8c Livingstone,
through
(1581-1660)
having
episode
He was later
included
Roman
by his own
as a lunatic,
to be a manic
canonised which
in Portu-
was influenced
of confinement
had what appeared
de Paul
hospital
into
that
at St
country’s
first asylum.
Development
ance
of the care system
various
England
since
grew
asylums
had
12th
century,
the
with the influence of the ‘enlightenment’
Century
(Locke,
the creation
1964).
of more
been
in
import-
in the late
Britain
17th
led the world
humanitarian
bv the emerging
present
their
of the intellectual
tradition
in
care settings,
science
of medicine.
Religious vi&, however, also played a significant role in the development of the enlightened view
of the
treatment’ into more
British
nursing
in general
approach humane
disordered. are
important also to the understanding of psychiatric nursing. People with mental disorder have been down
in lazarets,
possibly has its roots in the work of Joao (1495-155(I), who set up a shelter for
gal. Cuidad’s
ence
contain-
asylum
tradition.
William
Tuke, who founded the Retreat at York in 1792, was one of the foremost pioneers of the ‘moral
THE ORIGINS OF PSYCHIATRIC NURSING These
battle.
nursing Cuidad
embraced
example
the ‘care’ of people
(Department
for those
sea: and where
Although
Nightingale
most
developed
forcible
the ‘male nursing’
of
strongly
the
had
needed
role paralled
phil-
base. Although
sick is the
concerning
handicap
More as
nurse’s
even
‘well’,
the ‘need’
the debate
The The
times
care areas:
with a mental
nursing,
of nursing.
the
in a
habit.
served
a religious
the place
of
to dress
which
of
in the care of the mentally
who often
This
poor
Catholic
is a mirror
and
‘sick’ and
perconcept
also is influenced f&m
Henderson
assert
being
of sense.
relationship.
stemming
of Vic-
Roman
thesis
roots
of nursing
values
as a
of nurses
our modern
to doctors
the nun-priest
role’
Austin
the grip
continue
a
post-
serves and
of the nun’s
linguistic
cal subservience osophy
us of the upon
the
and
played the
the origins
Colliere’s of
cultural
of
thesis
within
version
importantl),
Catholic
quasi-anthropological
nurses
disguised
of
‘invisible
of Dingwall locate
This
spective
thinly
Colliere’s
views
on
(the ‘conse-
status,
by nurses
period.
earlier,
of the
of nuns
and their
to the
influence
prominent
ment. cared
that
institutionalisation
attitude
adopted
Nightingale contrast
by the
in
own
further
key
the sexuality
subsequently
disordered,
it for their
the
The
were more
collect
argued
as
nuns.
church
know-
could
1986)
Colliere
served
women’s they
the recipients of various forms of care the ages. By virtue of their strength, men
which tried to turn asylums ‘havens’ for the mentally
It has been suggested,
however,
the principles of Tuke’s approach were: based not on the scanty medical ledge of the time, but on Christianity common sense.’ (Bockoven. 1963) Early training initiatives: The asylum of this period
represented
the hrst
that knowand
attendants official
care
342
NURSE EDUCATION
agents,
and
were
the
nurse.
chiatric Apothecary
TODA\’
predecessors
John
to the
of the
Bethlem
psy-
( 1764- 1844),
Haslam
Asylum,
was,
in
of
psychiatric
nursing
1817, one of the first to propose that these attendants should be given some kind of formal
base is evident
training
exclusive
(cited
recorded course
Leigh,
training
exercise
five
lectures
delivered
at the Royal
Montrose
in 1834 on ‘what asylums be.’ When Crichton
Browne
attendants
begun
similar
Springfield
The
on
stimulus
Psychological hundred
for
the
P-year cept
the
old. The their
nursing,
formal
a by a
research
path,
in 1906
Medico-Psycho-
the
emerged,
of the medical
therefore, profession
was much in vogue. nursing developments
from
of Health
of nursing’
Midwifery impact
strongly
(Scottish
Consultative
of these
changes
in general
of recent
illustrates
has been
period
nursing.
research
in psy-
that very little clinical
generated
1980-1984.
in the UK, even
His review
shows
in
that
most research deals with nurse or general features
the education of the of the nurse’s role.
Also,
consider
some
centred
nursing
(Department
and
review
nursing
education,
for a research
1972) and the generalisation
felt most
Davis’s (1986) chiatric
such
last decade
in nursing
1976). The
has been
of
of the
The
of the need
Nursing
Committee.
con-
less than
a similar
arrangements
Association.
in for
use
have contri-
the definition
in the ‘process
National
successfully represented
the aegis of the American
the patronage
and
of interest
nurses
1985).
1983).
practice
nursing demon-
(Drummond.
over
changes
and Social Security,
in training
is, therefore,
logical
when philanthropy that most of the
Medico-
By 1889, one
The
USA followed training
major
concept-
the actual
by nurses’
(Cormack,
&
some
these
and some
models
also exists role
has seen
of Atten-
Royal
handbook
under
Psychiatric
culminated
nurse’s
Although
about
made
nursing’
con-
(Kershaw
has not been
terms,
to care
‘generic Confusion
of
the first register
1961).
and register
bution
various
of psychiatric
value
is not
1986; Riehl &
to relate
reservations
basis for nursing
the
completed
100 years
spread
1986).
to the practice
in research
and
described
8c Vaughan,
1986), their
Instruction
had
formalising
1961).
which
(Walk,
of psychiatric
qualification
(see Walk,
an
In the wake of
of nursing.
Wright,
with the acceptance
instituted
who
strated
for
remains
in general
have attempted
expressed
had later to
the
1980;
(Barber,
Asylum,
for
Roy, authors
ual models
Browne’s
participated
on
to
he extended
(RMPA).
had
based
training
1986; Pearson
to the
Britain
nursing.
have been
of ‘the red handbook’: by
Association
1890 the RMPA attendants,
the
Insane,
hospitals
programmes
Savage,
of instruction
of instruction
Handbook
Asylum
Morrison,
course
in 1885 in the preparation dants
in the process models
1854-1855.
Hospital
as the
courses
interest ceptual
later
Alexander
a formal
served
a short William
male and female
in 1843 at the Surrey
become This
period
Sir
attendants
to both
in nursing
to psychiatric
by
are and ought
in Dumfries,
in the
first
was Lunatic
were,
given
contemporary,
The
was appointed
Institution
this to 30 lectures
already
1961).
staff of
Browne
by
in
insecure, if not hazy, concept. Refinement of the concept of- pyschiatric nursing: Confusion and conflict over its conceptual
commentators
model
incompatible
at a time
ing
It is clear of the
approach
the
nursing
with psychiatric
instead
nurses
of
more
emphasis
(Altschul, have
been
1978). more
the personprocess
practice, upon Other
optimistic
to be suggest-
a syst~ems psychiatric about
the
past century have continued to depend upon the benificence of psychiatrists and the development of psychiatric medicine. Not until the beginning
potential value of the process of nursing, seeing an opportunity for nurses to make their own
of the second half of the 20th century psychology and sociology begin to make
has written:
own important of nursing -
influences influences
did their
on the knowledge base which were to prove
useful in helping nursing see itself in more objective relief (Skevington. 1984). However. despite such recent developments, the concept
statements
about
care.
In this context
Bradshaw
’. . nurses are raising issues about the conceptual framework of psychiatry and asking important questions about the which psychiatrists have purported for so long.’ (Bradshaw, 1986)
behaviour to explain
NURSEEDU(:A’I-ION‘fOD-\1 drugs and ECT. care and treatment
THE INTERPERSONAL ROOTS OF PSYCHIATRIC NURSING For much
of nursing’s
history,
care has been shrouded man might be forgiven about ‘looking
in confusion.
The
for assuming
of lay-
that care is
after’ and is to be distinguished which signifies
tive interaction
with the patient.
a more produc-
tion appears
to be evident
level of the
profession.
those nurses
who see themselves
purely supportive
Such a distinc-
even at the highest
The
conflict
between
as carers,
in a
sense, and those who attribute
dimension
highlighted
has been
the concept
from treatment,
a therapeutic
the practice
recently
to their work, has been
by Vousden
(1986).
Con-
nolly (1856) appears to have been one of the first to recognise ing,
the therapeutic,
potential
as well as damag-
of attendants
in the
Victorian
asylum. noting that:
.
labour,
if he has attendants rules.’ (Connolly,
most
challenged
psychoanalytic chological,
plans, all his care,
must be counteracted,
who will not observe
impact
on nursing
1856)
need
subsequently
of training
nurses.
of the psychiatric
to be an expedient
tinued
to stand
psychiatric
and
psychiatric
Indeed,
nursing
in the ideological
medicine,
nurse’s
way of ensur-
ing the quality of medical treatment. most of its history,
part in
of attendants
Viewed from this perspec-
tive. the clarification role appeared
for
has con-
of nurses
medium
as providers
of medical
practice
treatment),
in Great
involved
in
although
their
so-called
‘neurotic’
1968).
this
The
to the medical model
of the
1968).
late
which
grew
social
model
work focused patient
‘neurotic’
range
Psychosocial models: The medical, or clinicalmodel of psychiatry has been the somatic, governing influence on policies of care of the mentally disordered (Ramon, 1985). From the earlv experiments with water-torture and flog&g. to today’s invasive treatments with
the
(Barnes, came in
treatment
model
more
(Marks
chronic
was more
eclectic
model
nursing
a slightly
and
& Fraser,
different (Butler
therapy
appropriate
X:
nursing’.
to outline to almost
problems
1985;
patient
set of psy-
methods
in its attempt
populations
1982; Barker
psychiatric
‘Behaviour
1978).
was geared
a different and
of
amenable
et al,
which
therapeutic 1978).
the selection
considered
of therapy
Rosenthal,
patient
upon
alternative
emphasised
principles,
of
psychiatry,
population
patients
emphasised
of
of
mainly
rehabilitation,
the
chological
and
out of modern behaviourism. psychotherapy, described by Marks
and his colleagues,
population,
1950s
Many nurses became
next significant
1985).
the first formal acknowledgement of the interpersonal basis of psychiatric nursing.
to a
population.
movement
The experience
the
Britain,
was restricted
of the patient
early 1960s (Jones.
as
(and
of
community
of
also represents
model
made little
came in the form of the therapeutic
mainly
of care
the
a psy-
of psychiatry
shadow
functioning
medical support system (see Cormack, 1976). However, Connolly’s recognition of the importance
to physical.
The first serious alternative
towards and effective
The
from
This development
very small minority
Behavioural
support in his absence playecl a significant the formalisation
came
where this model of treatment
certain
for adequate
in the
which proposed
as opposed
disorder.
Behavioural
his
influences
‘l-he doctor’s
alternative
mental
orientation
points
care and treatment.
movement
to this form
Seminal
at various
of psychiatric outstanding
has reflected
This
the form of the psychological
all his (the physician’s)
all his personal
history
of the physician.
343
a all
(Barker,
Barker
8c Wilson,
of the nurse in the LISA: Soon
after the end of the Second World War, some nurses in the USA, who had trained within the psychodynamic psychotherapeutic
movement,
began
to develop
model of psychiatric
a
nursing
(Mereness Xc Taylor, 1978; Peplau, 1952). Although some of these nurses stayed within the dominant culture of psychoanalytic thought, others, such as Peplau (1952). transferred their allegiance to the interpersonal enced by the work of Harry Psychiatry,
in Sullivan’s
to the study of mentally
school, influStack Sullivan.
view, was not restricted ill people,
or even of
344
IVURSE EDUCATION
processes,
successful
may be observed psychiatry
TODAi’
and
in groups.
unsuccessful,
which
Instead Sullivan saw
as:
field of interpersonal all circumstances complex the
relations,
exist
can never be isolated
from
of
interpersonal
relations
lives and
has his being’.
person
(Sullivan,
under any and
in which these relations
. . a personality the
(JCMHNO,
sciences
and
skills
training.’
1986)
That group saw the client (sic) population
‘. . . the study of processes that involve or go on between people. The field of psychiatry is the
which
physiological
in
1947)
‘outside work
conceptualisation
namic
won favour
of psychody-
with many
who saw within this model a theoretical
nurses
perspec-
the parameters (existed)
medical
of general
medicine’
within
models
of
social
psychiatry’.
1986) Psychiatric
Nurses
( 1986) articulated
mental (sic) nursing
.
Association-Scotland
a similar set of views: is clearly based on the
social model of psychiatry
within which inter-
personal
tegies, are central to their role’. (PNAS,
away from traditional forced further
psychotherapy
by the influence
psychology
movement
(Rogers,
eschewed
emphasis
of
195 1) which also
intrapsychic
nations.
Although
medicine
in the USA is influenced
biophysical
contemporary
model,
psychiatric
to have moved further such an orientation the interpersonal ments
strongly
and further
by a
appears
away from
in favour of an extension
ambitions:
of
1986).
Nursing
develop-
within the UK over the past 2 decades,
combined tric
expla-
psychiatric
nursing
model (Peplau,
Contemporary
was rein-
of the humanistic
with vicarious
nursing
support
experience
in the
to an interpersonal
psychiatric suggest
culture nursing.
that
roles continue (Armitage,
to dominate
1986; Cormack,
it has become interpersonal
or
common
have
model
Although
custodial
of psychia-
USA,
lent
of British
psychiatric
nursing
1976: Towell. practice
basis of psychiatric
1975)
to assert
the
nursing.
In
anticipation of major reform of all forms of nurse training (United Kingdom Central Council for Nursing and Midwifery, 1987), the Joint Committee of Mental Health Nursing Organisations stated that psychiatric nursing operates within ‘a conceptual framework of social psychiatry’ characterised by:
and
that the nurse’s
role
skills,
is
. . a synthesis of knowledge built up from medicine, social and behavioural sciences,
used
within
systematic
stra1986)
This group suggest that the role of the mental nurse: ’. . operates
on a social model
in which the
emphasis
is on
regardless
of whether
traditional
medical model or social model they
constitute
patient/client
the most important
It is not clear,
self
nurses
patient’s social environment.’ however,
help.
work under influence (PNAS.
whether
terms such as ‘interpersonal’
a
in the 1986)
the use of.
and ‘social’, as used
by both these groups,
reflect the same meanings
originally
by Sullivan
theorists
articulated
or later field
such as Lewin (195 1).
Nurse-patient
close observation medical-expressive
than
(JCMHNO,
personal
The move
frame-
rather
tive which could be related directly to the interworld of nurse and patient.
(the
as
and believed that nursing’s ‘ideological
The
This alternative thought
mentally disordered)
relationships:
Interest
in
the
interpersonal basis of psychiatric nursing in the UK can be traced back to the series of searching questions enquiry
asked
by Altschul
into nurse-patient
as a result of her
interaction
(Altschul,
1972). She was interested in defining the theoretical basis of sound nursing practice and wanted to know what kind of training nurses received to help them form relationships with patients. More than a decade later she was still uncertain of the answers to the questions (Altschul,
1984).
One of the key studies of psychiatric nursing undertaken in the UK (Towell, 1975) concluded that the term ‘psychiatric nurse’ encompassed a cluster of roles. which varied according to the setting.
Contrary
to the
‘interpersonal
view’
expressed that
above,
the
which
Towell,
formation
is emphasised
limited
feature
a sociologist,
of
personal in the
noted
literature,
of the nurse’s
role
relationships was
a
Cormack
(1983)
nurses
should
do
and
observations
(the
decriptive
within
of what
nurses
literature).
role:
attendants
(1956)
suggested
doctors
and being
patient
that
group.
and
position
towards
the
its goal’ of doctors
13cMartin,
popularisation
of the
role’ as a description expedited
giving injections The social role:
the
term
medical
treatment,
their
role
been
opportunities
has waned
where
medical.
since
due
to lack of formal
that
Colledge
logical
by John-
have
most
1970).
kind
of
have
traditional
USA. Although
staff
as the
nurses
the individled to the
LISA remained American therapeutic
worh
activities such
as
is multidimensional
in
character (see World Health Organisation, 1957). More recently, *James (1972) noted the ‘demanding nature of the range of tasks evident
prospered the
01‘
of psycho-
in Britain
kind
but
of following
psychotherapy
gained
in the
hospitals
in the
in nature.
man)
largely
custodial
nurses developed a formal psychorole following training with various foundations.
8c Fowler,
As
noted
197 1) was largely
psychotherapeutic
replaced
model
interpersonal
was among therapeutic
the first to describe role for nurses. an idea
taken
LIP
Peplau
factors.
by others sub-role’
Peplau
role’
( 1952)
a psychowhich was 19.58).
a ‘counselling as distinct
formal ‘deep psychotherapy’ (Peplau. 1962). a concept which considerable international support. ‘4 ‘psychotherapeutic
by a which
(Kalkmann,
was 10 emphasise
psychotherapeutic
earlier.
psychotherap)
emphasised
Later,
base,
care in the State
psychodynamic
soon
nurses exercise a interpersonal and
psychiatr! eclectic
schools
neo-Freudian (Brown
ot
and social forms
psychoanalytic
broadel
British
Various
commanded
In
institution.
by a broad
psychological
treatment never
which
role:
co-exist.
the
‘l‘ibits.
of the large
characterised
of’
in
and for
psychotherapeutic
treatment
or dispensing medication. Various groups and individuals
suggestkd that, since of specific technical,
training
has been
of the
‘moved
nursing
ethos
19’iOs (Morton
this may have
interest
The
doctor
‘medical-expressive
of those
formal
community
early
whole
196X). Elements
between
the
This
but
the
demise
by ‘maintaining
1958).
(Barnes,
patient,
not
the gradual
whereas
within
involved if
Belknap
subordinate
that they
which f-amily
1979) but may also be a reflection
saw medical
equilibrium
ual’ (Johnson
therapeutic
nurses to relinquish mothering, role for
role
remain,
patient’s
(Campbell,
expressed
is perhaps of
in the sense
skills,
was
role described
They
the work
role
the
view
(1958)
of nursing.
system
role
the
the work
by the demands
description
the motivational
social
mediate
preventing
by the nurse/sociologist
Martin
expressed
have range
nurses
A similar
‘instrumental’
which
roles
are par-
from
above.
‘expressive’
significant
care
that
in
and
community
of
noted
patients,
recently
partnership
hospital
traditional
staff stems
overwhelmed
( 1973). The
a
literature)
category
sharper that:
1963)
required supportive,
nurse.
do in practice
the nurse’s
of
son
role
into
suggested
surroundings
approach traditional
part,
to medical
asylum
(Altschu!.
doctor,
A number
prescriptive
and
interest.’
as to what
below.
supportive
more
the nurse’s
prescriptive
as a support
from
that
agent
1968). Altschul
routine
That their
of suggestions
(the
Cormack’s
aphrased The
observed
in terms
(Jones,
’ . the special role of the nurse is to create a wholesome ward atmosphere and to influence
role.
The view from the nursing literature can be defined
as a sociotherapeutic
focus
or
from
a
intervention has gained
is conceptualised
traditional institutional settings: in many #clinician, educator, administrator, social worker,
here as one involving patient interactions,
clerk and domestic innovator, ‘development of the therapeutic movement of the late 1940s brought
model. The psychotherapeutic potential of‘ nurses has been proposed for at least the last 25 vears (General Nursing Council tOr Scotland.
help.
The
community the nurse’s
specific. individual, nursewithin a clear theoretical
346
NURSE EDUCATIOiX
1962). However,
TODA’I
if published
a measure of the realisation demonstration
reports are used as
of such potential,
of a psychotherapeutic
the
nursing
‘carers’ from the nurses who emerged post-Crimean expressed
era.
views of the patient which were essen-
of the nursing
movement
projected
the Crimean
for nurses
through
specific
mes (Marks et al, 1978; involving (Marks
the
long-stay
patients
have emphasised therapeutic
of
role
(Fraser
et al, 1978)
neurotic
patients
et al, 1976).
the value of alternative
models.
Faugier
(1985;
the supporters
of
model
of gestalt
counselling
recognise the ‘alternative therapy’ status of their approach, and the limitations subsequently imposed upon practitioners (Kenny, 1986). Although
many writers have emphasised
‘therapeutic’ described
potential
of
nurses,
or
the have
aspects of the nurse’s role as psycho-
therapeutic,
the meaning
questioned.
Indeed,
of such terms can be
almost
any
interaction
to the work of the ‘atten-
of
involved The
disabled
last
100 years,
psychiatric
how descriptions broadened,
than
medical-expressive
role.
and
the
nursing
first century
(1890-1990).
in psychiatric
uncertainty
over
the true
nature
‘experiments’
in nursing
have
as much
served
care of the last century to confuse,
nurses in realistic model-making. progress
in psychiatric
nursing
has involved,
psychiatrists.
chiatric
nursing.
therapy
as
relationship person’s (Strupp,
Strupp’s
‘the
to effect
cognition, 1986),
definition use
systematic
enduring feelings
with
the
described
patient
and
might prove helpful
which
human
changes
atric nurses wishing to distinguish ing, yet casual, interactions
of psychoof
in a
behaviour’ to psychi-
between help-
and those meetings might,
properly,
be
as psychotherapeutic.
Much
of the contemporary
psychiatric
nursing
in
of influential
clarification
role-theory
involves
of
‘asser-
tions’ about what nursing 2sor .shouli be. As noted in this review, research role model significant
evidence
or another thread
supporting
is noticeably
woven through identifies
most significant.
ence on the outcome
A
most of the
role model descriptions, as the single,
one
absent.
processes
interpersonal
of care. Although
influ-
her work
has taken almost 4 decades to exert any significant influence on psychiatric nurses on this side there are of the Atlantic, Peplau’s interpersonal model
indications of mental
that health
nursing might become a significant plank in any emerging British psychiatric nursing role
CONCLUSION This paper has presented a brief review of the history of psychiatric nursing, emphasising British, and to a lesser extent, North experiences. The review suggests
as to assist The march of
At present,
to exist within psy-
of the
nurse’s role, which exists today. suggests that the
of the terms ‘therapeutic’ appears
by
theory and practice.
as psychotherapy. ‘psychotherapeutic’,
have
to influences
accepted
or
of
shows
of the role of the nurse
the main, following in the footsteps
no commonly
living
rather
mainly in response
developments
who were
the everyday
people,
in a technical
British
The
system,
more in supporting
between two or more people might be described definition
and
to the point of dehumanising
asylum
activities
in the analytic sense,
from
was quasi-medical
dants’ of the British
psycho8c
experience
almost
the approach
which developed
was in stark contrast engaged
Faugier
profession
the person who was the patient. That care system
Others
a psychodynamic
which was not ‘traditional’
technical,
program-
and the rehabilitation
Reilly, 1986) described whereas
training
McPherson
treatment
et al, 1978);
therapeutic
from the
Nightingale
tially ‘holistic’ and humanitarian.
role is a fairly recent innovation. In the early behavioural psychotherapy 197os, the a formal
Although
American that the
original needs of people dehned as mentally disordered, systems and the care which developed between the 17th and late 19th Centuries to meet such needs, distinguished such
theory.
Her description
of the ‘helping’
process
involved between nurse and patient, might assist psychiatric nurses of tomorrow aspire towards Strupp’s goal of ‘psychotherapeutic working’: by using their relationships with patients in a systematic manner,
to effect
lasting changes
in the
patient’s thoughts, feelings and ultimately behaviour. Attainment of such a goal might
bring psychiatric nurses, full circle, into contact with Nightingale’s idea that nurses should ‘help people to live’.
References Altschul A ‘1’ 1963 Trends in psychiatric nursing. In: Freeman H, Farndale J (eds) Trends in the Mental Health Services. Pergamon. London Altschul AT 1973 Patient-Nurse Interaction: .4 stud\ of interactive patterns on acute psychiatric wards. (Churchill Livingstone. Edinburgh Altschul A ‘I’ I978 A systems approach to the nursing process. Journal of Advanced Nursing 3: 333-3%) Altsrhul A T 1984 Does good practice need good principles?: One. Nursing Times 80. 2X: 36-3X Armitage P 1986 The rehabilitation and nursing care of severely disabled psychiatric patients. International Journal of Nursing Studies 23. 2: 113-123 Austin R 1977 Sex and gender in the future of nursing. Nursing Times (Occasional Paper) August 25 Barber P 1986 The psychiatric nurse’s failure therapeutically to mature. Nursing Practice 1. 3: 13X1-11 Barker P 19X2 Behaviour Therapy Nursing. Groom Helm, London Barker P 1986 Keynote speech to the Ps,>c.hiatric Nurses Association +nference. Universitv of 1 ork. June I!#6 Barker 1’ 19X8 ‘Trephotaxis’: Reflections on the concept of’care in mental health. Unpublished manuscript Barker P. Fraser D (eds) 1985 The Nurse as Therapist: .4 Behavioural Model. (;room Helm. London Barker P, Wilson L 1985 Behaviour therap) nursing: new ovine in old bottles. Nursing Times X 1, 39: 3 I-34 Barnes E 19fi8 Psychosocial Xurqing. Tavistock Publications. London Belknap I 1956 Human Relations in a State Mental Hospital. McGraw Hill. New York Bokoven J S 1963 Moral ‘Treatment in P5\chiatrv. Springer-. New I’ot-k BI-adchaw P 1986 Advocating change. Senior Nurse 5. 1: X-1 Butler R J. Rosenthal C; 197X Behavioui- and Rehabilitation: Behavioural Treatment tot- Long-Sta\ Patients. \Vright, Bristol Campbell W 1979The thet-apeutic wmmunit!: problems encountered by nurses. Nursing Times 75. .47: 203X-10
