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Community psychiatric nursing—a literature review
Inr. J. Nurs. ‘0 Pergamon
Stud. Vol. 17, pp. 197-210. Press Ltd., 1980. Printed in Great
0020-4878/80/0801-0197
Britain
$02,00/O
Community psychiatric nursinga literature review J. H. GRIFFITH* and S. P. MANGEN Department of Psychiatry, St. George’s Hospital Medical School, Blackshaw Road, Tooting, London S. W. 17, England.
In the last 25 years, the management of psychiatric patients has changed from a hospitalbased to a community-centred policy. The availability of psychotropic drugs, the overcrowding of hospitals, and the recommendations in the 1959 Mental Health Act to promote community care were some of the important factors influencing change in attitude towards psychiatric illness. One of the recent innovations in the area of mental health is Community Psychiatric Nursing. As with any new approach, the early development of community psychiatric nursing was slow and limited but increased in momentum over the last 5 years. As a consequence, an increasing volume of literature has started to appear. Much of it comprises descriptions of services, of goals, patterns of care and special aspects. There have been few evaluative studies. One hundred and twenty-nine articles covering aspects of community psychiatric nursing were extracted from the Nursing Times, Nursing Mirror, The International Journal of Nursing, Health and Social Service Journal and other journal sources which dealt with mental health. Very few attempts have been made at a comprehensive review of the literature published in this area; therefore, the purpose of this article is to bring them together. One such attempt was made by Hunter (1974) who published an historical review of community psychiatric nursing in Britain up to 1974. Community psychiatric nursing originated in Britain at Warlingham Park Hospital in the early 1950s. This was recognised by Hunter, who saw this and the development of subsequent psychiatric nursing services as being concerned with “after care or continuing care stage” and, more generally, with the enormous diversification of skills acquired by the psychiatric nurse within the developing services. At that time, the nursing staff of 42 hospitals in Britain were involved in community care. By 1979, this number had not only increased, but there had been significant developments in community based services. *To whom reprint
requests
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Types of services
The literature reveals several perspectives in community care: the extending of services, crisis intervention, community-based after-care services, observation and assessment, and behavioural psychotherapy. The extension of care was a significant feature of the,earlier hospital-based services, as Maisley (1975) pointed out in her survey of the participation of hospital-based nurses in an after-care programme. She found that, although nurses spent a quarter of their working week in the community, the standard of their inpatient care was not affected. The community approach was also recognised as advantageous since it greatly enhanced relations and communications between hospital and community. Moore (1961, 1964), Mandleson and Stevens (1972), Nickerson (1972), Wallace, Robinson, McPherson and Martin (1972), Llewellyn (1974), Stewart, Kerr and Dunlop (1974), Williams (1974), Sladden (1977), Hildebrandt and Davis (1975), Kelly (1976), Barker (1977), Manning (1978) and Todd (1978) describe similar schemes in other hospital-based services designed to rehabilitate patients into the community. Home visits were made by ward-based nurses who were allocated specific responsibility for the community. At that time, the extension of care was mainly through the use of long acting phenothiazines which reduced the relapse rate amongst schizophrenic patients (Passamanik et al., 1964); Scarpitti, Lefton, Dinitz and Passamanick, 1964; Warren, 1971; Keener, 1975; Stanford, 1976; Scott, Sharma and Temple, 1977; Hunter, 1978). Furthermore, their use in conjunction with the development of therapeutic relationships within their own environment demonstrated that the majority of these patients can be treated without admission to hospital. That this is so, has been shown by Greenblatt, Moore, Albert and Solomon (1963) in a project in which 128 patients referred for admission were allocated to a community extension service. They reported that 52% of these patients remained out of hospital a year after referral in comparison with 18% of these patients who were not in contact with the service. The sample was equally divided into schizophrenics, depressives and neurotic/personality disorders. The work of the nurse concentrated on the alleviation of illness, care of the ill and practical help.
Crisis intervention
Crisis intervention and other forms of group-oriented therapy have been one area in which psychiatric nurses have become involved in the community. Farewell (1976) and Hopkins (1972) described the work of psychiatric nurses through the crisis theory model. They showed that crises ranging from normal developmental situations, e.g. adolescence, to acute crises experienced by most psychiatric patients can be effectively dealt with through such intervention. In such situations, the psychiatric nurse works in conjunction with other professionals from the health and social services. The crisis scheme operates on a 24-hr basis, and members of the team effectively deal with crises within the patients’ own environment. This progressive approach diverges from the disease process adumbrated through the medical model in the treatment of psychiatric illness. Crisis theory is seen in terms of a complex dynamic process involving the patient, his environment and significant others. Resolution of crises through chemotherapeutic agents and hospitalisation are regarded as maladaptive since these present problem-solving through suppression of symptomatology. Crisis theory advocates confrontation with traumatic events of life since these are unavoidable. Since environmental factors are main precipitants, proponents of crisis theory emphasise
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that resources should be readily available to deal with these problems in the community.
In this manner, potential crises such as alienation from families and fantasies activated by hospitalisation can be avoided. The model, however, does not conceptualise all disruptive elements in terms of family disorders or an impoverished, unsupporting environment. It is perceived more in terms of a living and learning situation whereby individual and group ties are strengthened, rather than dispersed as inevitably results through hospitalisation. Intervening in the environmental context also helps to desensitise the community from the stigma surrounding mental illness. Psychogeriatric services Psychiatric morbidity in elderly patients involves organisational and clinical problems which have been reduced significantly through the introduction of these new trends. The development of community psychogeriatric services partially reflected this, as less emphasis was being placed on isolated and segregated methods of care which were characteristic of the previous approaches to treatment. Aire and Isaacs (1978) give a comprehensive account of community intervention through a multidisciplinary team based at Goodmayes Hospital and in the community. The hospital-based team operates through a crisis theory method which is in operation on a 24-hr basis, and gives practical nursing care and psychological support to patients and their families. In addition to this, community psychiatric nurses based at a health centre take referrals not only from the hospital, but also from general practitioners. Health visitors and district nurses liaise with this system, and through their methods of surveillance, are able to report any psychiatric disturbance observed or reported during the course of their duties. Barker and Black (1971) described an experiment in which hospital-based community psychiatric nurses managed psychogeriatric patients in a day hospital setting as well as in their homes. They found that their work consisted mainly of counselling and advising relatives on problems concerning management. The majority of their patients were demented with concomitant psychiatric conditions, but some were manic depressives or in confusional states. A significant number of these patients lived with elderly relatives or friends, but a large proportion lived by themselves. They reported that liaising with general practitioners, geriatricians, psychiatric nurses, health visitors and district nurses was valuable and helpful since all these worked towards a common goal of keeping the patient at home. They further described a ‘relative relief scheme’ which was implemented as a relief of family burden in situations where family life was restricted as a result of the patient. Similar schemes for the after-care of psychogeriatrics (Moore, 1973; Goldstein, 1973; Whitehead, 1974; Leopoldt and Robinson, 1975; Brown, 1976; Ainsworth and Jolley, 1978; and Tipping and White, 1978), have been outlined, and provided encouraging evidence of their effectiveness in managing such patients in the community. The general approach is a multidisciplinary one which incorporates psychiatrists, general practitioners, geriatricians, psychiatric nurses, health visitors and district nurses. The needs of patients are assessed at domiciliary visits, and intensive preventive measures are adopted so as to avoid hospitalisation. However, if admission to hospital becomes a necessity, most patients are rehabilitated to the community at the earliest opportunity. Mental handicap services The mentally handicapped represent a large subdivision of mental patients, and the literature cited indicated that limited care and after-care facilities exist in the community for these patients. The needs of these patients present unusual difficulties when con-
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sidered, and demand special nursing skills for a community service to be effective. In discussing mental illness and the district nurse, Smith (1970~) highlighted one fundamental management problem-the psychological strain imposed on families by such patients. This was particularly evident as district nurses and health visitors were not sufficiently equipped to deal with the care of the mentally handicapped. Strong and Sandland (1974) carried out a survey to assess the need for nurses in the community to care for the mentally handicapped. Questionnaires were sent to principal and senior nursing officers of 53 mental handicap hospitals, together with an outline of aims and objectives of the survey. They found that there was a need for a better supportive service for the mentally handicapped in the community, and that this service could be effectively provided by trained and experienced nurses in mental handicap. These views are supported by Marchant (1978) following a survey carried out with the aim of establishing a community psychiatric service for the mentally handicapped. In this survey, the role of the nurse was examined and perceived as supporting and advising families and relatives, giving instructions and training through the promotion of self help skills, and the management of behavioural problems associated with the mentally handicapped. The location of this service was envisaged as being hospital based or community based, with the nurse functioning as part of a multidisciplinary team. Interest in community schemes for the mentally handicapped is belated, but the implementation of behavioural principles into the training programme of psychiatric nurses have created a new therapeutic dimension through which operant techniques buttressed with a good nurse/patient relationship can be applied successfully in the care and management of the mentally handicapped.
Child and adolescence services The provision of community nursing services in child and adolescence psychiatry is increasing as a clinical speciality. Studies reporting on this service in Britain indicate that provisions for child and adolescence community care/after-care is an integral part of the existing psychiatric domiciliary service. The communication system with hospital and community resources involves the nurse in professional liaison with schools, the probation services, the clergy and youth clubs. Through these contacts, the nurse plays a vital role in preventing, supervising and supporting adolescents exposed to emotionally stressful situations. MacDonald (1972) provides evidence from two case histories in which the Dingleton Hospital team were involved. Two adolescents were referred by their general practitioners to this service for psychiatric advice. The Dingleton team demonstrated the effectiveness of the community-integrated nature of their service in dealing with these situations through the therapeutic mode of family therapy. American studies reported in the literature indicate that some psychiatric nurses care predominantly for children and adolescents as part of their mental health schemes. Birenbaum (1974) describes such a service in which paediatric nurses are trained and utilised to work with familes under stress, either from having a child in the process of recovery from severe illness requiring hospitalisation or from social and emotional stress experienced from members of the family. Parental compliance, psychological preparation for medical procedures, parental anxieties about their children and child abuse and neglect were some of the areas in which the nurses were professionally involved. He concluded that the utilisation of nursing skills in primary health care not only enables
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the children and their parents to benefit from mental health care, but also provides a model for other health practitioners. Hilderbrandt and Davis (1975) described a study designed to lower the drop-out rate of initial outpatient attenders. Patients were randomly assigned to a home visit and nonhome visit group. They found that 33% of the patients in the non-home visit group failed to keep their appointments in comparison with 10% of the home visit group. The low drop-out rate in the home visit group was seen as a result of a form of ‘crisis intervention’ as patients felt that ‘significant others’ were concerned enough to offer immediate help. In other U.S. studies, Drake (1970) reported that the staff of a community mental health centre found schools to be a strategic social unit for the effective provision of mental health services. He concluded that teachers and counsellors should be involved in community mental health programmes since they are vital in terms of prevention, detection and treatment of emotionally disturbed behaviour. McElroy and Narciso (1971) are in agreement with this conclusion as they see the school as one of the main agencies for the socialisation of the young. Consequently, mental health programmes should be designed so as to strengthen healthy development and prevent emotional problems which are located in schools. In comparison with their British counterparts, training programmes for American psychiatric nurses working in child and adolescent services seem to be more specific and goal directed towards preventive methods. Haldane, Smith and Henderson (1971) discussed this issue when they examined training programmes for nurses in child, adolescent and family psychiatry. They described the nature of the work involved and pointed to the emotional and moral demands which adolescents made on the existing services. They emphasised the need for special training, the nature of which involves a change in orientation towards a more unified system. Through this approach, psychiatric nurses in this speciality would provide a more comprehensive service in the community. Community- and family practitioner-based services The positive effects of extending psychiatric care to the community were emphasised by Marais (1976) who defined community psychiatric nursing as an alternative to hospitalisation. He described the service as one which “seeks to identify and develop the potential of a person to solve problems within the framework of tradition and culture in a particular community”. Parnell (1978), in a descriptive study of community psychiatric nursing, concluded that a community-based service offering ‘specialist’ primary care in the community can be beneficial to the mental health service. Community nurses are involved in the understanding of relationships and psychiatric community care involves cooperating with those who, by reason of work, vocation, interest or relationship, come into contact with the mentally ill person. Corser and Ryce (1977) showed that a community-based scheme can be effectively implemented by a multidisciplinary team. They described a scheme which employed a community psychiatric nurse as a member of a multidisciplinary team. From 1974 to 1976, 189 patients were assigned to the psychiatrist and 100 to the community psychiatric nurse. They found that the nurse had observed and reported more problems than the psychiatrist, but symptoms of anxiety and depression were the most common in both treatment groups. The overall attendance rate was 97%, which suggested that patients found this system of care beneficial and without stigma. Communication between team members was efficient and the presence of the nurse was welcomed by other team members because they were able to deal more confidently with emotionally disturbed
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people. Harker, Leopoldt and Robinson (1976) described a scheme in which a psychiatric nurse was attached to a general practice serving a catchment area of 18,ooO in Oxford. Psychiatric advice and guidance were readily available. Consequently, the quality of patient care was enhanced with a reduction in the degree of stigma reported. Group attachment schemes have been implemented elsewhere (Leopoldt and Hurn, 1973; Leopoldt, Hopkins and Overall, 1974; Shaw, 1975; Marks, 1977) and reports indicate that they are equally as effective. Success of these community based schemes have been reported in Great Britain (Hunter, 1962; Brooke and Cooper, 1973; Berry and Gordon, 1976; Dobson, Floyd and Gregory, 1976; Parnell, 1977; Griffith, 1978; Ryce, 1978; Wood, 1978) and overseas (Fried and Fried, 1976; Singer, Holloway and Kolb, 1970; Morgan and Moreno, 1973; Santos, 1975; Garrison, Kulp and Rosen, 1977). Together, these reports suggest that the skills of the nurse have been considerably developed in terms of supportive and preventive methods, family therapy, and more recently, behavioural psychotherapy. The overall view which emerges is that the hospital is gradually becoming one source of treatment, rather than the sole locus of treatment.
Role definition
The extension of care from hospital to community, together with the acquisition of new skills, is leading to the rejection of ancillary and custodial roles for the psychiatric nurse. John (1961), in discussing the role of the psychiatric nurse, judges that in the early 195Os, inadequate nursing care was given to patients. This she claimed arose out of role conflict between trained psychiatric nurses and those untrained. There was an intrinsic need for nurses in training to develop further professional skills, but this was obstructed by the domestic nature of their duties. Cleaning and bed making drastically restricted patient contact; liaison with medical staff was kept at a minimum, Moreover, the nurse was not perceived as part of a team. Decision making was centralised under the aegis of matrons who had restricted communication with ward staff. In the 196Os, many writers (May and Moore, 1963; May, 1965; Sharpe, 1966; Kirkpatrick, 1967; Greene, 1968; Tumilty, 1969; Leininger-Madeleine, 1969; Popkin, 1969) outlined the role of the community psychiatric nurse, and from these several composite functions emerged: (1) Following up patients on discharge from hospital so as to assist them in settling into the community. This sometimes involved assistance with employment and accommodation; (2) Attending mainly to the psychiatric needs of chronic schizophrenic patients by administering phenothiazine injections, supervising medication, monitoring sideeffects and taking appropriate action when necessary;, (3) Attending to practical needs, such as personal hygiene; (4) Giving support and advice to families, particularly in crisis situations, as well as in general management of patients; (5) Co-ordinating between hospital, community and other health caring agencies; (6) Promoting socialisation for patients in the community. These represent a distinct departure from their previous role since empathy was established through formation of relationships not only with the patient, but also with
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his family and those directly concerned with his care. There was considerable overlap in performance with district nurses, health visitors and social workers. Roles were undifferentiated since they were all working towards the common goal of helping patients with emotional difficulties. In outlining their respective roles, Maxwell (1974), Gunn (1969), Hudson (1976), Smith (197Ob, c) and Stickle (1974) have acknowledged the fact that psychiatric nurses had a distinct advantage in dealing with the mentally ill in the community. These workers frequently encountered a wide range of mental illness while caring for patients with a variety of physical illnesses in the community. Because of their basic psychiatric skills, psychiatric nurses were better prepared to identify and deal with psychiatric syndromes at the acute stage. Further elaboration of the community psychiatric nurses’ role is evident in the 1970s. This is reflected in a proliferating literature; a significant departure from their established role is not indicated, but rather a broader and clearer definition of their role in the community (Willey, 1969; Moss, 1972; Richards and Smith Hargrave, 1970; Crow, 1971; Bell, 1970; Duran, 1970; Bryant and Sandford, 1972; Frank, 1974; Forrest, 1974; Bell and Tarnopolski, 1975; Bijman and Van Het Erve, 1975; Copping, 1975, 1976; Sharpe, 1975: Roberts, 1976; Charnock, 1977; Corrigan and Soni, 1977; Kelly, 1976; Harris and Solomon, 1977; Lewis, 1977; Clarke 1978, 1979; Donnelly, 19780, b, c; Green, 1978; Iveson-Iveson, 1978; Martin and Kenny, 1979). The general approach seems to be more social, environmental and interpersonal in nature within a framework of objectives. These have been outlined by Murphy (1977) as follows: (1) (2) (3) (4)
effective and total patient care in the community; a service which gives support to the patient and his family in the times of crisis; to reduce or prevent the effects of institutionalisation on the patient and his family; to promote positive health in the community.
In addition, Murphy outlined a variety of roles which the community psychiatric nurse performs: (1) support-day-to-day care and after-care; (2) primary prevention-the prevention of actual mental illness by the alleviation of common psychological stress; (3) secondary prevention-the prevention of recurrence of illness or accelerating its remission; (4) tertiary prevention-the de-institutionalisation of patients at high risk of institutionalisation; (5) advice and guidance. Two fundamental reasons underly the role changes in recent years: the burgeoning of opportunities in nurse education, the changes in health and social services policy and administration culminating in National Health service reorganisation in 1974. The abolition of the role of psychiatric social workers to generic social workers as recommended in the Home Department (1968) (Seebohm Report) resulted in increased contributions of psychiatric nurses to the domiciliary treatment service. Psychiatric nursing began to adopt a more differentiated role in terms of making definite contributions to the treatment of patients in the community. Education
and training
Social science research has validated and attracted attention to the role of environmental factors in the aetiology of psychiatric illness. Community psychiatry aims to
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mobilise resources within the patient’s social network and community. It is an area of specialisation which requires those working within it to gain new theoretical and practical knowledge and create new spheres of competence. One development of note has taken place in the Faculty of Health and Social Studies at Chiswick Polytechnic, London, which initiated an eight week course in community psychiatric nursing in 1970. This is now held in conjunction with The Joint Board of Clinical Nursing Studies, and has been extended to one year. Rawlings (1970) and Cole (197 1) give details of the 1970 course, the substance of which mainly dealt with the role of the psychiatric nurse in the community. The courses are for Registered Nurses of the Mentally Subnormal or Registered Mental Nurses (1979) and for State Enrolled Nurses (1977) working in the community. The main aim of the course is “to prepare a Registered Nurse of the Mentally Subnormal or a Registered Mental Nurse to work effectively in a multidisciplinary team in order to give appropriate nursing care, therapeutic, and rehabilitative support to the patient in the community, taking into account his family and all relevant social contacts”. The syllabus includes psychology, sociology and social administration as well as the principles and practice of community psychiatric nursing. Five objectives have been outlined: (1)
(2)
(3) (4) (5)
Assessing the needs of the mentally handicapped or mentally ill patient, the care, treatment, training and education leading to the optimum rehabilitation of the patient; Skills in developing therapeutic relationships with patients and their families, ability to promote cooperative relationships with colleagues and effective liaison with other relevant services in the patient’s and family’s interest; Skills in organising and assessing the priorities in the day-to-day management of work: ability to contribute to the planning and development of the service; Providing information to the patient and his family on health care and the social resources in the community; Teaching appropriate skills and principles to others.
This extensive and varied range of educational resources involves academic work and supervised clinical practice.
outlined
in the course objectives
Behaviour therapy
In addition to these training courses, principles of behaviour therapy have been incorporated into the therapeutic framework of the psychiatric nurse. Marks (1975) shows that nurses can play an important role in the treatment of behavioural disorders, and views this as “a new form of clinical nurse specialist”. Marks, Hallam, Philpott and Connolly (1975) have pointed out that training nurses in behavioural methods is less expensive and time consuming compared to training psychiatrists and psychologists, since less of the nurses’ education is redundant to the skills actually exploited. The nurse therapist, however, can be easily integrated into the treatment team. McDonald (1975) examined the effects of behavioural psychotherapy in a domiciliary setting and concluded that this form of treatment “is an important ingredient in a behavioural psychotherapeutic service”, but warned that it should be subjected to regular review. Roberts (1978), Lewis (1977) and McDonald (1975) have described case studies utilising this treatment technique and have shown that it can be successfully applied in a community setting.
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Psychotherapeutic techniques The nurse, in her therapeutic role, calls on various psychotherapeutic skills when dealing with emotionally sensitive situations. These skills are not pursued in depth, and therefore are not as intensive as formal methods of psychotherapy. Interpretations using defence mechanisms form an integral part of insight-oriented therapy often practiced by psychiatric nurses. Henderson, Leven and Cheyne (1973u, b, c) provided examples of this method in a pilot study describing a domiciliary treatment service. The therapeutic programme was carried out by State Enrolled psychiatric nurses at the Ross Clinic, and was implemented in 1969. The main objective was to equip the-nurse with the skills central to ‘the therapeutic process’. Emphasis is placed on the nurse/patient relationship through which the nurse is expected to discuss and deal with the positive and negative ‘transference’. The importance of communication with the family members and other therapeutic agents was also seen as vital in unravelling the dynamics of the patient in treatment. Several case histories are discussed by these authors in support of their claims. Personality factors played an important role in the selection of the nurses employed. Self-confidence and understanding of their defence mechanisms were seen as two of the basic components relevant to the psychotherapeutic process. Brooke and Haque (1972) and Haque (1973) have described therapy embracing a similar approach. They described a pilot experiment designed to investigate an interdisciplinary exercise involving a psychiatrist and a nursing sister. They were located at the Cassell Hospital, and worked with general practitioners and local authority personnel. The aim of this scheme was to assist professionals in increasing their understanding of psychodynamic issues when dealing with problem families. In so doing, they developed an increased capacity for coping with the anxieties which such patients aroused in them. Haque (1973) provided evidence from another pilot scheme implemented for counselling and helping problem families before a crisis point developed. A number of workers from different disciplines were involved in this community scheme, and it was concluded that this interdisciplinary approach played a significant part in the prevention of crises. The schemes described here are similar to those discussed earlier by Stobie and others at Dingleton. However, the approach adopted by the latter differs in that crisis theory operates through all available therapeutic resources, while in Brooke and Haque’s study, the techniques are predominantly psychodynamic. As the authors have shown, comprehensive community psychiatric services represent a challenging medium for the management of some aspects of psychiatric illness. However, there have been few attempts to evaluate particular services. Those discussed below represent the most comprehensive attempts to date. Both Warren (1971) and Hunter (1978) have reported on schemes with schizophrenic patients. In Warren’s investigation, Medicate injections were administered to 130 schizophrenics by 10 community psychiatric nurses over a 6-month period. The author pays particular attention to an analysis of the overall cost of the service, and the assessment of the value of a psychiatric nurse giving these injections. He found that there was a great financial saving in the use of community psychiatric nurses. However, he emphasised that a good nurse/patient relationship must be established to ensure success. Hunter examined the practice of community psychiatric nursing over a 5-year period during which 94 schizophrenic patients were followed up by community psychiatric nurses. Hunter concluded that less emphasis should be placed on
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the patient-centred approach since social situations and interpersonal relationships play a more vital role for the future well-being of the patient. Coates (1976) and Robinson (1972) have reported on other evaluation studies in Canada and New Zealand, respectively. Coates described a Home Treatment study which investigated the relative effectiveness of community care vis-d-vis hospitalisation for unselected severely disturbed patients. Hospital care, home care and a combination of both were compared in a sample of 212 patients. The analysis indicated that evaluation in the mental health field requires multiple outcome measures to avoid the common assumption that change in one domain is accompanied by concomitant changes in another. Robinson examined the effects of community psychiatric nursing of patients on trial discharge from hospital. The results suggested that after-care by community psychiatric nurses was extremely effective in reducing the rate of readmission. It was concluded that the needs of patients progressed from those of a medical dependency to those which were fulfilled by social incentives, the longer the patient remained in the community. A controlled evaluation of community psychiatric nursing in severe neurotics is in progress at St. George’s Hospital, London. The aim of this study is to evaluate the efficacy of community psychiatric nursing in follow-up care of severe neurotics. Research of the interface between the roles of social workers and community psychiatric nurses is progressing at Glasgow University.
Summary and conclusions
The inchoate nature of much of the research covered in the literature mirrors that of the development of community psychiatric nursing services. There has been little in terms of evaluation and liaison of roles between community psychiatric nurses and psychiatrists, general practitioners and social workers. Nonetheless, the articles give a clear indication that community psychiatric nurses play an invaluable role in the community through a worthwhile and effective service. The literature reviewed supports this conclusion; nurses proved to be effective as part of a multi-disciplinary team as well as sole professionals contributing to the treatment of psychiatric patients in the community. Another trend evident in this area of professionalism is the autonomy in decision-making by community psychiatric nurses, and the fulfillment of responsiblities based on such decisions. The psychiatric nurse not only studies and assesses problems presented by patients but also makes decisions about treatment plans and after-care. This is of particular relevance when behavioural techniques are pursued. Economic analyses, moreover, have produced positive evaluation in terms of the costs and benefits to both patient and service, and more active steps should be taken to develop professionalism and this form of specialism. The implications are clear: increasing therapeutic responsibility qualify community psychiatric nurses as planners and decision makers both alongside and together with doctors and other agents in initiating and developing more community mental health schemes. This is one of the most effective ways in which these professionals can be of benefit to their patients. Despite this, however, more research in the area of community psychiatric nursing is clearly needed so as to establish this relatively new approach to treatment. For example, the overlapping of roles between community psychiatric nurses, psychiatrists, social workers, district nurses and other care-giving agents should be closely examined so as to eliminate role conflict which may result from duplication of roles. More training pro-
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grammes in community psychiatric nursing should be set up and examined in areas of forensic, child and adolescent psychiatry to assess the need for community intervention in these areas. Finally, with the predicted increase in numbers of psychogeriatric patients, research resources should be marshalled to provide adequate community care for the elderly. Acknowledgemenrs-The authors would like to thank their comments and helpful suggestions in the preparation
Professor E. S. Paykel of this review article.
and Dr. Peter
Sainsbury
for
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The process
of implementing
the nurse’s
S. P. MANGEN role in the neighbourhood
centre.
J. psychiatric
Nuts. ment. Hith Serv. 12,33-37. Fried, A. L. and Fried, F. E. (1976). Hospital and community psychiatric nursing and mental health services. 14,31-36. Garrison, R., Kulp, C. and Rosen, S. (1977). Community mental health nursing: A social network approach. J.
psychiat. Nuts. ment. Hith Serv. 15,32-36. S. (1973). Community psychiatry and the elderly. Can. med. Ass. I. 108.579-584. M., Moore, R. F., Albert, R. S. and Solomon, M. H. (1963). The Prevention ofHospitulisation: Treatment Without Admission for Psychiatric Patients. Grune & Stratton, New York. Greene, J. (1968). Psychiatric nursing in the community. Int. I. Nurs. Stud. 5, 175-183. Greene, J. (1978). Discharge or be damned-The work of the CPN. R. Sot. Hith J. 98,104107. Griffith, _I. (1978). Community psychiatric nursing. Nurs. Times, Community Outlook. Nov. 9, 357-358. Gunn, M. (1969). Distric nursing and the mentally ill. Nurs. Times 65,497. Haldane, J. D., Smith, J. D. and Henderson, J. (1971). Training nurses in child adolescent and family psychiatry. Nurs. Times, Occasional Papers 67,37-40. Harker, P., Leopoldt, H. and Robinson, J. R. (1976). Attaching community psychiatric nurses to general practice. J. R. Cop. gen. Practnr. 26,666-671. Harris, M. and Solomon, K. (1977). Roles of the Community Mental Nurse. J. Psychiat. Nurs. ment. Hlth Serv. Goldstein, Greenblatt,
15,35-39. Haque, G. (1973). Psychosocial nursing in the community. Nurs. Times 69,5 l-53. Henderson, J. G., Leven, B. and Cheyne, E. (1973a). The role of the psychiatric nurse in domiciliary treatment service-The treatment team and clinical operation of the service. Nurs. Times 69, 1334-1336. Henderson, J. G., Leven, B. and Cheyne, E. (1973b): The role of the psychiatric nurse in domiciliary treatment service-An examination of the patients. Nurs. Times69, 1377-1378. Henderson, J. G., Leven, B. and Cheyne, E. (1973~). The role of the psychiatric nurse in domiciliary treatment service-Illustrative case histories. Nurs. Times 69, 1418-1419. Hildebrandt, D. E. and Davis, J. M. (i975). Home visits: A method of reducing the pre intake dropout rate [Visits by two psychiatric nurses prior to the scheduled hospital appointment]. J. psychiat. Nurs. ment. Hlth
13,43-44. Homes Department (1968). Report of the Committee on Local Government and Allied Personal Social Services (Seebohm Report). Hudson, B. (1976). The community psychiatric nurse and the social worker. Nurs. Times 72, Community Care Supplement, 18-22. Hunter, P. (1962). After care for the mentally ill as a British hospital provides it. Nurs. Outlook 10. 604606. Hunter, P. (1974). Community psychiatric nursing in Britain: An historical review. ht. J. Nurs. Stud. 2,
223-233. Hunter, P. (1978). Schizophrenia and community psychiatric nursing. Report published by National Schizophrenic Fellowship. Iveson-lveson, J. (1978). Role of the psychiatric nurse. (Symposium organised by CPNA.) Nurs. Mirror 146, 137. Edinburgh. John, B. L. (1961). A Study ofthe Psychiatric Nurse. Livingstone, Joint Board of Clinical Nursing Studies (1977). Short course on the principles of community psychiatric nursing for state enrolled nurses (M. or MS). Course No. 989. Joint Board of Clinical Nursing Studies (1979). Outline of curriculum in the nursing care of the mentally handtcapped in the community. Course No. 805 and 810. Keener, M. L. (1975). The public health nurse m mental health follow-up after-care. Nurs. Res. 24, 198-201. Kelly, P. (1976). Community psychiatric nursing: A psychiatric day unit. Nurs. Times 72, 1717. Kirkpatrick, W. J. A. (1967). The in and out nurse: Thoughts on the role of the psychiatric nurse in the community and the preparation required. ht. J. Nurs. Stud. 4,225-230. Leininger-Madelaine, M. (1969). Community psychiatric nursing. Perspect. psychiat. Cure 7. 10-20. Leopoldt, H. and Hurn, R. (1973). Towards integration (An experiment in psychiatric domiciliary nursing in group practice attachment). Nurs. Mirror 136,38-42. Leopoldt, H., Hopkins, H. and Overall, R. (1974). A critical review of experimental psychiatric nurse attachment scheme in Oxford. Practice Team 39,4-6. Leopoldt. H. and Robinson, J. R. (1975). Hospital based community psychiatric nursing in psychogeriatric care. Nurs. Mirror 141,54-56. Lewis, D. (1977). Bridging the gap (The work of a community psychiatric nurse illustrated by case studies).
Nurs. Times 73, 132- 134. Llewellyn, B. M. (1974). Community psychiatric nursing. Midwife Hlth Visitor 10.7-9. MacDonald, D. J. (1972). Psychiatric nursing in the community. Nurs. Mirror 68,80-83. McDonald, R. (1975). Behavioural psychotherapy in a domiciliary setting. Nurs. Mirror 140,57. McDonald, R. (1975). Social phobia. Nurs. Mirror 140,60-61. Maisley, M. A. (1975). Community psychiatric nursing. Hospital based psychiatric nurse in the community.
Nurs. Times 71,354-355.
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Mandelson, M. and Stevens, D. W. (1972). Community psychiatry at Park Day Hospital. Nurs. Times 68, 733-734. Manning, M. (1978). Open minds in a rural community. Community Care, 28 June, 22-24. Nurs. Times 72, Marais, P. A. (1976). Community psychiatric nursing. An alternative to hospitalization. 170881710. Marchant, R. (1978). Examination of the feasibility and the need for community psychiatric service in the Laybourne Grange Area. Unpublished report. Marks, 1. M. (1975). A symposium on the psychiatric nurse-therapist: A new form of clinical nurse specialist. Nurs. Mirror 140,46. Marks, 1. M., Hallam, R. J., Philpott, R. and Connolly, .I. C. (1975). Nurse therapists in behavioural psychotherapy. Br. Med. J. 3, 144148. Marks, I. (1977). Overview of a new clinical speciality. Nurs. Mirror 140,46-50. Martin, F. M. and Kenny, W. T. Patient or client: A study of social work and community nursing services for the mentally ill in Scotland. Department of Social Administration, University of Glasgow (in press). Maxwell, A. (1974). The health visitor’s role in community psychiatry. Nurs. Mirror 139,74-76. May, A. R. and Moore, S. (1963). The mental nurse in the community. Lancet 1,213-214. May, A. R. (1965). The psychiatric nurse in the community. Nurs. Mirror 121,409-410. McElrov. E. and Narciso. A. (1971). Clinical specialist in the community mental health programme. J. psychiat. Nurs.,b, lo-23,26. Moore, J. H. (1973). Planning comprehensive care. Practice Team 30-31,2-5. Moore, S. (1961). A psychiatric outpatient nursing service (Warlingham Park Hospital). Menr. Hlth 20, 51-54. Moore. S. (1964). Mental nursing in the community. Nurs. Times60,467-470. Morgan, A. J. and Moreno, J. W. (1973). The Practice of Mental Health Nursing: A Community Approach. Lippincott, Philadelphia. Moss, A. C. (1972). Nursing care study. Community psychiatric nursing. Nurs. Mirror 135,26-29. Murphy, M. (1977). Community links. Nurs. Mirror 144.55-56. Nickerson, A. (1972). Psychiatric community nurses in Edinburgh. NWS. Times 68,289-291. Parnell, J. W. (1977). Psychiatric nursing in the community. University of Surrey Thesis, Ph.D. Parnell, J. W. (1978). Community psychiatric nursing. A descriptive Study. Queen’s Nursing Institute, London. Passermanick, B., Scarpitti, F. R., Lefton, M., Dinitz, S. W., Warnert, J. L. and McPharters, H. (1964). home vs hospital care for schizophrenics. J. Am. Med. Ass. 187,177-181. Popkin, D. R. (1969). Co-ordination of field work experience in the course of community mental health. Nurs. Outlook 17,41-43. Rawlings, J. A. (1970). Course in community psychiatry. Nurs. Mirror 130, June 26. Richards, H. and Smith Hargrave (1970). Nursing in response to social crisis: what is community mental health Nurs. C/in. N. Am. 5,647-655. in a black community? Roberts, L. A. M. (1976). The community psychiatric nurse (Early development and current role). Nurs. Times 72,2020-202 1. Roberts, L. A. M. (1978). Community nursing care study. Nurs. Times 74, 141-146. Robinson, 1. D. (1972). Description and evaluation of a psychiatric home visiting service. N.Z. med. J. 75, 15-19. Ryce, S. W. (1978). Psychiatric nursing-from a health centre. Nurs. Mirror 147,35-36. Santos, J. A. J. (1975). Community mental health nursing. The ANPI Papers, Jan.-Mar., 3-7. Scarpitti, F., Lefton, M., Dinitz, S. and Passamanick, B. (1964). Problems in a home care study of schizophrenics. Archsgen. Psychiat. 10, 143-154. Scott, E., Sharma, S. K. and Temple, K. (1977). Care of schizophrenic patients (beginning research). Nurs. Times 73,740-74 1. Sharpe, D. (1966). The psychiatric nurse as a social visitor. Nurs. Times62, 1578-1580. Sharpe, D. (1975). Role of the community psychiatric nurse. Nurs. Mirror 141,60-62. Shaw, A. (1975). CPN attachment in a group practice. Nurs. Times 73, Health Centre Supplement, 9-14. Singer, P., Holloway, B. and Kolb, L. C. (1970). The psychiatric team and home care in Soviet Union and Amsterdam. J. psychiat. Nurs. ment. Hlth Serv. 8,4&U. Sladden, S. (1975). Hospital based community psychiatry nursing service. Nurs. Mirror 141,56. Sladden, S. (1977). The work of community psychiatric nurses in a hospital based community service. Unpublished University of Edinburgh Thesis, Ph.D. Smith, B. S. (1970a). Mental illness and the district nurse. Organic and neurotic reactions. Nurs. Times 66, 1329-1330. Smith, B. S. (19706). Mental illness and the district nurse. Depression, psychosis and mental deficiency. Nurs. Times 66, 1363-l 364. Smith, B. S. (1970~). Mental illness and the district nurse. Preventive measures. Nurs. Times 66, 1395-1396. Stanford, J. (1976). Schizophrenia. An end to relapse. Nurs. Times 72,418-420. Stewart, M., Kerr, B. and Dunlop, W. (1974). Psychiatric nurse in the community. Nurs. Mirror 139,84. Stickle, B. A. (1974). The district nursing sister and community psychiatry. Nurs. Mirror 139,63-65.
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Stobie, E. G. and Hopkins, D. H. G. (1972). Crisis intervention. A psychiatric community nurse in a rural area-Part 1. Nurs. Times 68, Occasional Paper, 165-168. Stobie, E. G. and Hopkins, D. H. G. (1972). Crisis intervention. A psychiatric community nurse in a rural areaPart 2. Nun. Times68, Occasional Paper, 269-170. Strong, P. G. and Sandland, E. T. (1974). Subnormality in the community. Nun. Times 70,354-356. Tippings, R. and White, D. M. D. (1978). New community nursing service for the elderly mentally ill. Nun. Times74,1719-1720.
Todd, J. (1978). CPN-a lifeline keeping psychiatric patients at home. Nurs. Mirror 147,46-48. Tumilty, E. M. (1969). Community psychiatric nursing. Nurs. Times65. Occasional Papers, 157-160. Wallace, J. G., Robinson, A., McPherson, I. and Martin, I. C. A. (1972). The Darlington experiment: By, wtth and for the community. Nurs. Times 68, Occasional Papers, 185-188. Warren, J. (1971). Long-acting phenothiazine injections given by psychiatric nurses in the community. Nurs. Times67, Occasional Paper, 141-143. Whitehead, J. A. (1974). Community orientated services for old people with psychiatric symptoms. Modern Geriufrics 4,214-218. Willey, R. (1969). Nursing after-care in psychiatry. Nun. Times%, 1629. Williams, R. (1974). Teamwork. The key to community psychiatric nursing. Can. J. psychiat. Nurs. 15, 15-17. Wood, C. (1978). What kind of maintenance therapy for schizophrenic patients in the community? J. Commun. Nurs. 2,1 l-13. (Received 20 November
1979; acceptedforpublication
18 December 1979)
Stud. Vol. 17, pp. 197-210. Press Ltd., 1980. Printed in Great
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Community psychiatric nursinga literature review J. H. GRIFFITH* and S. P. MANGEN Department of Psychiatry, St. George’s Hospital Medical School, Blackshaw Road, Tooting, London S. W. 17, England.
In the last 25 years, the management of psychiatric patients has changed from a hospitalbased to a community-centred policy. The availability of psychotropic drugs, the overcrowding of hospitals, and the recommendations in the 1959 Mental Health Act to promote community care were some of the important factors influencing change in attitude towards psychiatric illness. One of the recent innovations in the area of mental health is Community Psychiatric Nursing. As with any new approach, the early development of community psychiatric nursing was slow and limited but increased in momentum over the last 5 years. As a consequence, an increasing volume of literature has started to appear. Much of it comprises descriptions of services, of goals, patterns of care and special aspects. There have been few evaluative studies. One hundred and twenty-nine articles covering aspects of community psychiatric nursing were extracted from the Nursing Times, Nursing Mirror, The International Journal of Nursing, Health and Social Service Journal and other journal sources which dealt with mental health. Very few attempts have been made at a comprehensive review of the literature published in this area; therefore, the purpose of this article is to bring them together. One such attempt was made by Hunter (1974) who published an historical review of community psychiatric nursing in Britain up to 1974. Community psychiatric nursing originated in Britain at Warlingham Park Hospital in the early 1950s. This was recognised by Hunter, who saw this and the development of subsequent psychiatric nursing services as being concerned with “after care or continuing care stage” and, more generally, with the enormous diversification of skills acquired by the psychiatric nurse within the developing services. At that time, the nursing staff of 42 hospitals in Britain were involved in community care. By 1979, this number had not only increased, but there had been significant developments in community based services. *To whom reprint
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Types of services
The literature reveals several perspectives in community care: the extending of services, crisis intervention, community-based after-care services, observation and assessment, and behavioural psychotherapy. The extension of care was a significant feature of the,earlier hospital-based services, as Maisley (1975) pointed out in her survey of the participation of hospital-based nurses in an after-care programme. She found that, although nurses spent a quarter of their working week in the community, the standard of their inpatient care was not affected. The community approach was also recognised as advantageous since it greatly enhanced relations and communications between hospital and community. Moore (1961, 1964), Mandleson and Stevens (1972), Nickerson (1972), Wallace, Robinson, McPherson and Martin (1972), Llewellyn (1974), Stewart, Kerr and Dunlop (1974), Williams (1974), Sladden (1977), Hildebrandt and Davis (1975), Kelly (1976), Barker (1977), Manning (1978) and Todd (1978) describe similar schemes in other hospital-based services designed to rehabilitate patients into the community. Home visits were made by ward-based nurses who were allocated specific responsibility for the community. At that time, the extension of care was mainly through the use of long acting phenothiazines which reduced the relapse rate amongst schizophrenic patients (Passamanik et al., 1964); Scarpitti, Lefton, Dinitz and Passamanick, 1964; Warren, 1971; Keener, 1975; Stanford, 1976; Scott, Sharma and Temple, 1977; Hunter, 1978). Furthermore, their use in conjunction with the development of therapeutic relationships within their own environment demonstrated that the majority of these patients can be treated without admission to hospital. That this is so, has been shown by Greenblatt, Moore, Albert and Solomon (1963) in a project in which 128 patients referred for admission were allocated to a community extension service. They reported that 52% of these patients remained out of hospital a year after referral in comparison with 18% of these patients who were not in contact with the service. The sample was equally divided into schizophrenics, depressives and neurotic/personality disorders. The work of the nurse concentrated on the alleviation of illness, care of the ill and practical help.
Crisis intervention
Crisis intervention and other forms of group-oriented therapy have been one area in which psychiatric nurses have become involved in the community. Farewell (1976) and Hopkins (1972) described the work of psychiatric nurses through the crisis theory model. They showed that crises ranging from normal developmental situations, e.g. adolescence, to acute crises experienced by most psychiatric patients can be effectively dealt with through such intervention. In such situations, the psychiatric nurse works in conjunction with other professionals from the health and social services. The crisis scheme operates on a 24-hr basis, and members of the team effectively deal with crises within the patients’ own environment. This progressive approach diverges from the disease process adumbrated through the medical model in the treatment of psychiatric illness. Crisis theory is seen in terms of a complex dynamic process involving the patient, his environment and significant others. Resolution of crises through chemotherapeutic agents and hospitalisation are regarded as maladaptive since these present problem-solving through suppression of symptomatology. Crisis theory advocates confrontation with traumatic events of life since these are unavoidable. Since environmental factors are main precipitants, proponents of crisis theory emphasise
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that resources should be readily available to deal with these problems in the community.
In this manner, potential crises such as alienation from families and fantasies activated by hospitalisation can be avoided. The model, however, does not conceptualise all disruptive elements in terms of family disorders or an impoverished, unsupporting environment. It is perceived more in terms of a living and learning situation whereby individual and group ties are strengthened, rather than dispersed as inevitably results through hospitalisation. Intervening in the environmental context also helps to desensitise the community from the stigma surrounding mental illness. Psychogeriatric services Psychiatric morbidity in elderly patients involves organisational and clinical problems which have been reduced significantly through the introduction of these new trends. The development of community psychogeriatric services partially reflected this, as less emphasis was being placed on isolated and segregated methods of care which were characteristic of the previous approaches to treatment. Aire and Isaacs (1978) give a comprehensive account of community intervention through a multidisciplinary team based at Goodmayes Hospital and in the community. The hospital-based team operates through a crisis theory method which is in operation on a 24-hr basis, and gives practical nursing care and psychological support to patients and their families. In addition to this, community psychiatric nurses based at a health centre take referrals not only from the hospital, but also from general practitioners. Health visitors and district nurses liaise with this system, and through their methods of surveillance, are able to report any psychiatric disturbance observed or reported during the course of their duties. Barker and Black (1971) described an experiment in which hospital-based community psychiatric nurses managed psychogeriatric patients in a day hospital setting as well as in their homes. They found that their work consisted mainly of counselling and advising relatives on problems concerning management. The majority of their patients were demented with concomitant psychiatric conditions, but some were manic depressives or in confusional states. A significant number of these patients lived with elderly relatives or friends, but a large proportion lived by themselves. They reported that liaising with general practitioners, geriatricians, psychiatric nurses, health visitors and district nurses was valuable and helpful since all these worked towards a common goal of keeping the patient at home. They further described a ‘relative relief scheme’ which was implemented as a relief of family burden in situations where family life was restricted as a result of the patient. Similar schemes for the after-care of psychogeriatrics (Moore, 1973; Goldstein, 1973; Whitehead, 1974; Leopoldt and Robinson, 1975; Brown, 1976; Ainsworth and Jolley, 1978; and Tipping and White, 1978), have been outlined, and provided encouraging evidence of their effectiveness in managing such patients in the community. The general approach is a multidisciplinary one which incorporates psychiatrists, general practitioners, geriatricians, psychiatric nurses, health visitors and district nurses. The needs of patients are assessed at domiciliary visits, and intensive preventive measures are adopted so as to avoid hospitalisation. However, if admission to hospital becomes a necessity, most patients are rehabilitated to the community at the earliest opportunity. Mental handicap services The mentally handicapped represent a large subdivision of mental patients, and the literature cited indicated that limited care and after-care facilities exist in the community for these patients. The needs of these patients present unusual difficulties when con-
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sidered, and demand special nursing skills for a community service to be effective. In discussing mental illness and the district nurse, Smith (1970~) highlighted one fundamental management problem-the psychological strain imposed on families by such patients. This was particularly evident as district nurses and health visitors were not sufficiently equipped to deal with the care of the mentally handicapped. Strong and Sandland (1974) carried out a survey to assess the need for nurses in the community to care for the mentally handicapped. Questionnaires were sent to principal and senior nursing officers of 53 mental handicap hospitals, together with an outline of aims and objectives of the survey. They found that there was a need for a better supportive service for the mentally handicapped in the community, and that this service could be effectively provided by trained and experienced nurses in mental handicap. These views are supported by Marchant (1978) following a survey carried out with the aim of establishing a community psychiatric service for the mentally handicapped. In this survey, the role of the nurse was examined and perceived as supporting and advising families and relatives, giving instructions and training through the promotion of self help skills, and the management of behavioural problems associated with the mentally handicapped. The location of this service was envisaged as being hospital based or community based, with the nurse functioning as part of a multidisciplinary team. Interest in community schemes for the mentally handicapped is belated, but the implementation of behavioural principles into the training programme of psychiatric nurses have created a new therapeutic dimension through which operant techniques buttressed with a good nurse/patient relationship can be applied successfully in the care and management of the mentally handicapped.
Child and adolescence services The provision of community nursing services in child and adolescence psychiatry is increasing as a clinical speciality. Studies reporting on this service in Britain indicate that provisions for child and adolescence community care/after-care is an integral part of the existing psychiatric domiciliary service. The communication system with hospital and community resources involves the nurse in professional liaison with schools, the probation services, the clergy and youth clubs. Through these contacts, the nurse plays a vital role in preventing, supervising and supporting adolescents exposed to emotionally stressful situations. MacDonald (1972) provides evidence from two case histories in which the Dingleton Hospital team were involved. Two adolescents were referred by their general practitioners to this service for psychiatric advice. The Dingleton team demonstrated the effectiveness of the community-integrated nature of their service in dealing with these situations through the therapeutic mode of family therapy. American studies reported in the literature indicate that some psychiatric nurses care predominantly for children and adolescents as part of their mental health schemes. Birenbaum (1974) describes such a service in which paediatric nurses are trained and utilised to work with familes under stress, either from having a child in the process of recovery from severe illness requiring hospitalisation or from social and emotional stress experienced from members of the family. Parental compliance, psychological preparation for medical procedures, parental anxieties about their children and child abuse and neglect were some of the areas in which the nurses were professionally involved. He concluded that the utilisation of nursing skills in primary health care not only enables
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the children and their parents to benefit from mental health care, but also provides a model for other health practitioners. Hilderbrandt and Davis (1975) described a study designed to lower the drop-out rate of initial outpatient attenders. Patients were randomly assigned to a home visit and nonhome visit group. They found that 33% of the patients in the non-home visit group failed to keep their appointments in comparison with 10% of the home visit group. The low drop-out rate in the home visit group was seen as a result of a form of ‘crisis intervention’ as patients felt that ‘significant others’ were concerned enough to offer immediate help. In other U.S. studies, Drake (1970) reported that the staff of a community mental health centre found schools to be a strategic social unit for the effective provision of mental health services. He concluded that teachers and counsellors should be involved in community mental health programmes since they are vital in terms of prevention, detection and treatment of emotionally disturbed behaviour. McElroy and Narciso (1971) are in agreement with this conclusion as they see the school as one of the main agencies for the socialisation of the young. Consequently, mental health programmes should be designed so as to strengthen healthy development and prevent emotional problems which are located in schools. In comparison with their British counterparts, training programmes for American psychiatric nurses working in child and adolescent services seem to be more specific and goal directed towards preventive methods. Haldane, Smith and Henderson (1971) discussed this issue when they examined training programmes for nurses in child, adolescent and family psychiatry. They described the nature of the work involved and pointed to the emotional and moral demands which adolescents made on the existing services. They emphasised the need for special training, the nature of which involves a change in orientation towards a more unified system. Through this approach, psychiatric nurses in this speciality would provide a more comprehensive service in the community. Community- and family practitioner-based services The positive effects of extending psychiatric care to the community were emphasised by Marais (1976) who defined community psychiatric nursing as an alternative to hospitalisation. He described the service as one which “seeks to identify and develop the potential of a person to solve problems within the framework of tradition and culture in a particular community”. Parnell (1978), in a descriptive study of community psychiatric nursing, concluded that a community-based service offering ‘specialist’ primary care in the community can be beneficial to the mental health service. Community nurses are involved in the understanding of relationships and psychiatric community care involves cooperating with those who, by reason of work, vocation, interest or relationship, come into contact with the mentally ill person. Corser and Ryce (1977) showed that a community-based scheme can be effectively implemented by a multidisciplinary team. They described a scheme which employed a community psychiatric nurse as a member of a multidisciplinary team. From 1974 to 1976, 189 patients were assigned to the psychiatrist and 100 to the community psychiatric nurse. They found that the nurse had observed and reported more problems than the psychiatrist, but symptoms of anxiety and depression were the most common in both treatment groups. The overall attendance rate was 97%, which suggested that patients found this system of care beneficial and without stigma. Communication between team members was efficient and the presence of the nurse was welcomed by other team members because they were able to deal more confidently with emotionally disturbed
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people. Harker, Leopoldt and Robinson (1976) described a scheme in which a psychiatric nurse was attached to a general practice serving a catchment area of 18,ooO in Oxford. Psychiatric advice and guidance were readily available. Consequently, the quality of patient care was enhanced with a reduction in the degree of stigma reported. Group attachment schemes have been implemented elsewhere (Leopoldt and Hurn, 1973; Leopoldt, Hopkins and Overall, 1974; Shaw, 1975; Marks, 1977) and reports indicate that they are equally as effective. Success of these community based schemes have been reported in Great Britain (Hunter, 1962; Brooke and Cooper, 1973; Berry and Gordon, 1976; Dobson, Floyd and Gregory, 1976; Parnell, 1977; Griffith, 1978; Ryce, 1978; Wood, 1978) and overseas (Fried and Fried, 1976; Singer, Holloway and Kolb, 1970; Morgan and Moreno, 1973; Santos, 1975; Garrison, Kulp and Rosen, 1977). Together, these reports suggest that the skills of the nurse have been considerably developed in terms of supportive and preventive methods, family therapy, and more recently, behavioural psychotherapy. The overall view which emerges is that the hospital is gradually becoming one source of treatment, rather than the sole locus of treatment.
Role definition
The extension of care from hospital to community, together with the acquisition of new skills, is leading to the rejection of ancillary and custodial roles for the psychiatric nurse. John (1961), in discussing the role of the psychiatric nurse, judges that in the early 195Os, inadequate nursing care was given to patients. This she claimed arose out of role conflict between trained psychiatric nurses and those untrained. There was an intrinsic need for nurses in training to develop further professional skills, but this was obstructed by the domestic nature of their duties. Cleaning and bed making drastically restricted patient contact; liaison with medical staff was kept at a minimum, Moreover, the nurse was not perceived as part of a team. Decision making was centralised under the aegis of matrons who had restricted communication with ward staff. In the 196Os, many writers (May and Moore, 1963; May, 1965; Sharpe, 1966; Kirkpatrick, 1967; Greene, 1968; Tumilty, 1969; Leininger-Madeleine, 1969; Popkin, 1969) outlined the role of the community psychiatric nurse, and from these several composite functions emerged: (1) Following up patients on discharge from hospital so as to assist them in settling into the community. This sometimes involved assistance with employment and accommodation; (2) Attending mainly to the psychiatric needs of chronic schizophrenic patients by administering phenothiazine injections, supervising medication, monitoring sideeffects and taking appropriate action when necessary;, (3) Attending to practical needs, such as personal hygiene; (4) Giving support and advice to families, particularly in crisis situations, as well as in general management of patients; (5) Co-ordinating between hospital, community and other health caring agencies; (6) Promoting socialisation for patients in the community. These represent a distinct departure from their previous role since empathy was established through formation of relationships not only with the patient, but also with
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his family and those directly concerned with his care. There was considerable overlap in performance with district nurses, health visitors and social workers. Roles were undifferentiated since they were all working towards the common goal of helping patients with emotional difficulties. In outlining their respective roles, Maxwell (1974), Gunn (1969), Hudson (1976), Smith (197Ob, c) and Stickle (1974) have acknowledged the fact that psychiatric nurses had a distinct advantage in dealing with the mentally ill in the community. These workers frequently encountered a wide range of mental illness while caring for patients with a variety of physical illnesses in the community. Because of their basic psychiatric skills, psychiatric nurses were better prepared to identify and deal with psychiatric syndromes at the acute stage. Further elaboration of the community psychiatric nurses’ role is evident in the 1970s. This is reflected in a proliferating literature; a significant departure from their established role is not indicated, but rather a broader and clearer definition of their role in the community (Willey, 1969; Moss, 1972; Richards and Smith Hargrave, 1970; Crow, 1971; Bell, 1970; Duran, 1970; Bryant and Sandford, 1972; Frank, 1974; Forrest, 1974; Bell and Tarnopolski, 1975; Bijman and Van Het Erve, 1975; Copping, 1975, 1976; Sharpe, 1975: Roberts, 1976; Charnock, 1977; Corrigan and Soni, 1977; Kelly, 1976; Harris and Solomon, 1977; Lewis, 1977; Clarke 1978, 1979; Donnelly, 19780, b, c; Green, 1978; Iveson-Iveson, 1978; Martin and Kenny, 1979). The general approach seems to be more social, environmental and interpersonal in nature within a framework of objectives. These have been outlined by Murphy (1977) as follows: (1) (2) (3) (4)
effective and total patient care in the community; a service which gives support to the patient and his family in the times of crisis; to reduce or prevent the effects of institutionalisation on the patient and his family; to promote positive health in the community.
In addition, Murphy outlined a variety of roles which the community psychiatric nurse performs: (1) support-day-to-day care and after-care; (2) primary prevention-the prevention of actual mental illness by the alleviation of common psychological stress; (3) secondary prevention-the prevention of recurrence of illness or accelerating its remission; (4) tertiary prevention-the de-institutionalisation of patients at high risk of institutionalisation; (5) advice and guidance. Two fundamental reasons underly the role changes in recent years: the burgeoning of opportunities in nurse education, the changes in health and social services policy and administration culminating in National Health service reorganisation in 1974. The abolition of the role of psychiatric social workers to generic social workers as recommended in the Home Department (1968) (Seebohm Report) resulted in increased contributions of psychiatric nurses to the domiciliary treatment service. Psychiatric nursing began to adopt a more differentiated role in terms of making definite contributions to the treatment of patients in the community. Education
and training
Social science research has validated and attracted attention to the role of environmental factors in the aetiology of psychiatric illness. Community psychiatry aims to
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mobilise resources within the patient’s social network and community. It is an area of specialisation which requires those working within it to gain new theoretical and practical knowledge and create new spheres of competence. One development of note has taken place in the Faculty of Health and Social Studies at Chiswick Polytechnic, London, which initiated an eight week course in community psychiatric nursing in 1970. This is now held in conjunction with The Joint Board of Clinical Nursing Studies, and has been extended to one year. Rawlings (1970) and Cole (197 1) give details of the 1970 course, the substance of which mainly dealt with the role of the psychiatric nurse in the community. The courses are for Registered Nurses of the Mentally Subnormal or Registered Mental Nurses (1979) and for State Enrolled Nurses (1977) working in the community. The main aim of the course is “to prepare a Registered Nurse of the Mentally Subnormal or a Registered Mental Nurse to work effectively in a multidisciplinary team in order to give appropriate nursing care, therapeutic, and rehabilitative support to the patient in the community, taking into account his family and all relevant social contacts”. The syllabus includes psychology, sociology and social administration as well as the principles and practice of community psychiatric nursing. Five objectives have been outlined: (1)
(2)
(3) (4) (5)
Assessing the needs of the mentally handicapped or mentally ill patient, the care, treatment, training and education leading to the optimum rehabilitation of the patient; Skills in developing therapeutic relationships with patients and their families, ability to promote cooperative relationships with colleagues and effective liaison with other relevant services in the patient’s and family’s interest; Skills in organising and assessing the priorities in the day-to-day management of work: ability to contribute to the planning and development of the service; Providing information to the patient and his family on health care and the social resources in the community; Teaching appropriate skills and principles to others.
This extensive and varied range of educational resources involves academic work and supervised clinical practice.
outlined
in the course objectives
Behaviour therapy
In addition to these training courses, principles of behaviour therapy have been incorporated into the therapeutic framework of the psychiatric nurse. Marks (1975) shows that nurses can play an important role in the treatment of behavioural disorders, and views this as “a new form of clinical nurse specialist”. Marks, Hallam, Philpott and Connolly (1975) have pointed out that training nurses in behavioural methods is less expensive and time consuming compared to training psychiatrists and psychologists, since less of the nurses’ education is redundant to the skills actually exploited. The nurse therapist, however, can be easily integrated into the treatment team. McDonald (1975) examined the effects of behavioural psychotherapy in a domiciliary setting and concluded that this form of treatment “is an important ingredient in a behavioural psychotherapeutic service”, but warned that it should be subjected to regular review. Roberts (1978), Lewis (1977) and McDonald (1975) have described case studies utilising this treatment technique and have shown that it can be successfully applied in a community setting.
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Psychotherapeutic techniques The nurse, in her therapeutic role, calls on various psychotherapeutic skills when dealing with emotionally sensitive situations. These skills are not pursued in depth, and therefore are not as intensive as formal methods of psychotherapy. Interpretations using defence mechanisms form an integral part of insight-oriented therapy often practiced by psychiatric nurses. Henderson, Leven and Cheyne (1973u, b, c) provided examples of this method in a pilot study describing a domiciliary treatment service. The therapeutic programme was carried out by State Enrolled psychiatric nurses at the Ross Clinic, and was implemented in 1969. The main objective was to equip the-nurse with the skills central to ‘the therapeutic process’. Emphasis is placed on the nurse/patient relationship through which the nurse is expected to discuss and deal with the positive and negative ‘transference’. The importance of communication with the family members and other therapeutic agents was also seen as vital in unravelling the dynamics of the patient in treatment. Several case histories are discussed by these authors in support of their claims. Personality factors played an important role in the selection of the nurses employed. Self-confidence and understanding of their defence mechanisms were seen as two of the basic components relevant to the psychotherapeutic process. Brooke and Haque (1972) and Haque (1973) have described therapy embracing a similar approach. They described a pilot experiment designed to investigate an interdisciplinary exercise involving a psychiatrist and a nursing sister. They were located at the Cassell Hospital, and worked with general practitioners and local authority personnel. The aim of this scheme was to assist professionals in increasing their understanding of psychodynamic issues when dealing with problem families. In so doing, they developed an increased capacity for coping with the anxieties which such patients aroused in them. Haque (1973) provided evidence from another pilot scheme implemented for counselling and helping problem families before a crisis point developed. A number of workers from different disciplines were involved in this community scheme, and it was concluded that this interdisciplinary approach played a significant part in the prevention of crises. The schemes described here are similar to those discussed earlier by Stobie and others at Dingleton. However, the approach adopted by the latter differs in that crisis theory operates through all available therapeutic resources, while in Brooke and Haque’s study, the techniques are predominantly psychodynamic. As the authors have shown, comprehensive community psychiatric services represent a challenging medium for the management of some aspects of psychiatric illness. However, there have been few attempts to evaluate particular services. Those discussed below represent the most comprehensive attempts to date. Both Warren (1971) and Hunter (1978) have reported on schemes with schizophrenic patients. In Warren’s investigation, Medicate injections were administered to 130 schizophrenics by 10 community psychiatric nurses over a 6-month period. The author pays particular attention to an analysis of the overall cost of the service, and the assessment of the value of a psychiatric nurse giving these injections. He found that there was a great financial saving in the use of community psychiatric nurses. However, he emphasised that a good nurse/patient relationship must be established to ensure success. Hunter examined the practice of community psychiatric nursing over a 5-year period during which 94 schizophrenic patients were followed up by community psychiatric nurses. Hunter concluded that less emphasis should be placed on
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the patient-centred approach since social situations and interpersonal relationships play a more vital role for the future well-being of the patient. Coates (1976) and Robinson (1972) have reported on other evaluation studies in Canada and New Zealand, respectively. Coates described a Home Treatment study which investigated the relative effectiveness of community care vis-d-vis hospitalisation for unselected severely disturbed patients. Hospital care, home care and a combination of both were compared in a sample of 212 patients. The analysis indicated that evaluation in the mental health field requires multiple outcome measures to avoid the common assumption that change in one domain is accompanied by concomitant changes in another. Robinson examined the effects of community psychiatric nursing of patients on trial discharge from hospital. The results suggested that after-care by community psychiatric nurses was extremely effective in reducing the rate of readmission. It was concluded that the needs of patients progressed from those of a medical dependency to those which were fulfilled by social incentives, the longer the patient remained in the community. A controlled evaluation of community psychiatric nursing in severe neurotics is in progress at St. George’s Hospital, London. The aim of this study is to evaluate the efficacy of community psychiatric nursing in follow-up care of severe neurotics. Research of the interface between the roles of social workers and community psychiatric nurses is progressing at Glasgow University.
Summary and conclusions
The inchoate nature of much of the research covered in the literature mirrors that of the development of community psychiatric nursing services. There has been little in terms of evaluation and liaison of roles between community psychiatric nurses and psychiatrists, general practitioners and social workers. Nonetheless, the articles give a clear indication that community psychiatric nurses play an invaluable role in the community through a worthwhile and effective service. The literature reviewed supports this conclusion; nurses proved to be effective as part of a multi-disciplinary team as well as sole professionals contributing to the treatment of psychiatric patients in the community. Another trend evident in this area of professionalism is the autonomy in decision-making by community psychiatric nurses, and the fulfillment of responsiblities based on such decisions. The psychiatric nurse not only studies and assesses problems presented by patients but also makes decisions about treatment plans and after-care. This is of particular relevance when behavioural techniques are pursued. Economic analyses, moreover, have produced positive evaluation in terms of the costs and benefits to both patient and service, and more active steps should be taken to develop professionalism and this form of specialism. The implications are clear: increasing therapeutic responsibility qualify community psychiatric nurses as planners and decision makers both alongside and together with doctors and other agents in initiating and developing more community mental health schemes. This is one of the most effective ways in which these professionals can be of benefit to their patients. Despite this, however, more research in the area of community psychiatric nursing is clearly needed so as to establish this relatively new approach to treatment. For example, the overlapping of roles between community psychiatric nurses, psychiatrists, social workers, district nurses and other care-giving agents should be closely examined so as to eliminate role conflict which may result from duplication of roles. More training pro-
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grammes in community psychiatric nursing should be set up and examined in areas of forensic, child and adolescent psychiatry to assess the need for community intervention in these areas. Finally, with the predicted increase in numbers of psychogeriatric patients, research resources should be marshalled to provide adequate community care for the elderly. Acknowledgemenrs-The authors would like to thank their comments and helpful suggestions in the preparation
Professor E. S. Paykel of this review article.
and Dr. Peter
Sainsbury
for
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