mental health nursing

mental health nursing

Inr. J. Nurs. Stud., Vol. 32, No. 4, pp. 353-365. 1995 CopyrIght c 1995 Elsevm Science Ltd Printed in Great Britain. All rights reserved 002&7489*95 $...

1MB Sizes 7 Downloads 625 Views

Inr. J. Nurs. Stud., Vol. 32, No. 4, pp. 353-365. 1995 CopyrIght c 1995 Elsevm Science Ltd Printed in Great Britain. All rights reserved 002&7489*95 $9.50+0.00

Pergamon 0020-7489(95)00027-5

The current status andfuture

challenges ofpsychiatric/men tal health nursing TONY BUTTERWORTH” Profksor

of Community Nursing. University of Manchester, Manchester,

U.K.

Abstract-To obtain a global picture of the current status of nursing education and nursing practice in the mental health/psychiatric field, the International Council of Nurses (ICN) sent a questionnaire to 23 of its 101 member associations.? The basis for the selection was to obtain information from a broad spectrum of different associations, e.g. state of development-economic and political, language, and geographical region. Of these, 16 (or 69%) returned completed questionnaires, often accompanied by extensive supporting documentation. In addition, four nurses’ associations in Africa completed the questionnaire during staff field visits in that region. This paper makes reference to the responses received to the questionnaire and some verbatim quotes are included.

Introduction

Until more recent times, the role of nursing in psychiatric/mental health care was predominantly linked to conditions and attitudes prevailing in psychiatric/mental institutions. For the most part, nurses worked in settings where they had received their training and consequently had an institutionalised perspective of patient care. Patients’ human needs-those of self-respect, quest for independence, and self esteem were often ignored. Although significant changes in models of care have occurred during the intervening

* To whom all correspondence should be addressed. t This paper is reproduced with the kind permission of the International 353

Council of Nurses, Geneva, Switzerland.

354

A. BUTTER WORTH

years, two major relatively new developments have dramatically altered the psychiatric/mental health field this past decade, including the roles and functions of psychiatric/mental health personnel. These concern the major advances in all fields of basic and clinical neuroscience and thus approaches used to diagnose and treat mentally ill people, and the influence of social, economic and political factors on patient care such as the deinstitutionalisation of people with mental disorders. As the majority of patients move out into the community, some nurses are positive, perceiving this development as a way to improve standards by exerting more nursing influence on patient care and treatment possibilities, while others feel threatened fearing “loss of control” and “diffusion of responsibilities”. Thus, nurses, along with other mental health workers, are going through a period of role re-definition. Mental health and human rights

The Preamble of the Declaration of Luxor on Human Rights For The Mentally Ill adopted by the World Federation for Mental Health (1989) on 27 January 1989, upholds the inalienable rights of people “publicly labelled or professionally diagnosed, treated or confined as mentally ill, or suffering from emotional distress”. It states that “difficulty in adapting to moral, social, political or other values in itself should not be considered a mental illness” and regrets that people inappropriately labelled continue to be confined as mentally ill. The Declaration stressesthat “the fundamental rights of mentally ill persons shall be the same as those of all other citizens and that these include, among others, the right to dignified, humane and qualified treatment....” (WHO, 1990).

For patients with mental disorders it was not the 1989 Declaration but the recent media expose(London Observer, 10 and 24 September, 1989),that shocked the public’s conscience about society’s abandonment of such people. Although the international psychiatric community and the European Commission had been aware of the inhuman conditions, the major reform began only after wide press coverage created an international outcry. Yet numbers of mentally ill or handicapped people continue to live under subhuman conditions. The slow public and professional response to instigate change in the treatment and care of patients with mental disorders can be attributed to many cultural, social and physical factors (Nursing Times, 1985). In some countries, this neglect is an inheritance from the days when social deviance was thought to be a natural outgrowth of innate depravity, deserving punishment and discipline (McCausland, 1987). Around the turn of the century in the United Kingdom, the medical practitioner’s assumption about mental illness was that it was worse than disease and “that people who were seen to be disordered were dangerous” (Curran and Harding, 1978). Laws, even up to 1955,were mainly designed for the protection of society in that they reflected the belief that mental patients were dangerous (Lemmer and Smits, 1989). It was not until the late 40s when the United Nations Universal Declaration of Human Rights was passed that a wider public debate began on the rights of people with mental disorders and their institutional care. Although attitudes of both the public and health professionals have begun to change, there still remains an underlying entrenched prejudice against mental illness. Even the Alma Ata Declaration on primary health care, although perhaps implied, does not explicitly include mental health care as one of its essential elements (WHO & UNICEF, 1978).

CURRENT

STATUS AND FUTURE

CHALLENGES

355

The international nursing community adopted its first Code of Ethics in 1953 at the time when the Grand Council of the International Council of Nurses met in Brazil (Bridges, 1967). This Code, which was revised in 1973 and reaffirmed by the Council of National Representatives in 1989, has been translated into many languages and speaks of the four fundamental responsibilities of the nurse: to promote health, to prevent illness, to restore health and to alleviate suffering. Furthermore it states that the need for nursing is universal, and that inherent in that is respect for life, dignity and rights of man, unrestricted by consideration of nationality, race, creed, colour, age, sex, politics or social status. Although the Code for Nurses holds no judiciary power, it does provide nurses with a guide for action based on the fundamental values and needs of society. Extent of the problem

Mental illness takes an enormous toll. According to a World Health Organization (WHO) report on 48 of the world’s most prevalent diseases, mental disorders affect approximately 200 million people (WHO, 1990). It is unlikely that the extent of the problem is accurately reflected in this figure, as, for example, mental illness caused by episodic or insidious abuse of women and children often goes unreported. Armed conflict, violence, and displacement are other situations which have lasting detrimental effects on its victims, especially children. A study of children living in Northern Ireland found that psychological disorders and mental illness increased considerably among children and adults during the 1968 riots and violence in Belfast (Fraser, 1986). Considering that there are, world-wide, approximately 25-30 million refugees and internally displaced people, exclusive of those affected by armed conflict, the magnitude of the actual number of people who might be suffering from some form of mental disorder becomes staggering. Impact of social and scientific developments

From small beginnings in the 1950s deinstitutionalisation has brought increasing numbers of chronically mentally ill people out of hospitals and into communities. Many factors have contributed to this revolution in the care of the mentally ill, among which was the human rights concern to release institutionalised patients from their often enforced confinement. Deinstitutionalisation has been variously described as a “process that grew directly from society’s disenchantment with centralized authority in general and with institutions in particular” (Slavinsky, 1984) to a movement that was facilitated by the advent of psychotropic drugs (McCausland, op. cit.). Others believe that the impetus came with efforts to contain health care costs (Peplau, 1987), or that it was a result of entrenched vested interest, e.g. institutions, drug companies and professional groups. Whatever the underlying factors, deinstitutionalisation-with both its positive and negative consequences-is a reality that will continue to have a profound impact on psychiatric/mental health nursing education and practice. In communities where deinstitutionalisation has been carefully planned, benefits have been substantial and individuals previously committed to long-term in-patient care have been successfully integrated back into society. But this has not been done without costs. In New South Wales, it was recognised early that increased levels of training and retraining were needed for all staff involved in the development of community-based mental health

356

A. BUTTER WORTH

services.Implementation of the programme included the upgrading of existing community mental health services and provision of a variety of different living arrangements, e.g. hostels and group homes. Rehabilitation (living skills centres, activity centres) and community support teams were also provided to assist both the clients and their families. Other groups that have alleviated the burden of care for families are self-help organizations and concerned citizens groups. However, deinstitutionalisation can lead to great human suffering if ill conceived and poorly supported. In some industrialised countries, large numbers of people with chronic mental disorders have been thrust into unprepared communities. Financial constraints, lack of political commitment and professional inertia have led to: inadequate numbers of appropriate alternative care facilities; mosaic staffing patterns and inconsistent qualifications of staff; sporadic linkages and referrals for care and treatment; and poor continuity of care. Consequently, readmissions are high in New South Wales, in 1984more than twothirds of all admissions to psychiatric hospitals were readmissions (Breust, 1989) and the number of homelesschronically mentally ill people has increased. Among these are young people addicted to alcohol or other drugs who cannot be engaged or are hard to engage with traditional health care and community services. McBride (1990) notes that there is a shift away from the behaviourial sciencesto the neurosciencesin the organizing frameworks of psychiatry. “Imaging techniques now permit looking into the living human brain to identify structural defects in specific regions. New drugs are being developed to correct biochemical imbalances. The study of genetics is moving away from a focus on rare disorders to common ones with growing attention to enzyme deficiencies.”

These new developments have revolutionised the management of patients with mental disorders, especially in countries with easy accessibility to psychotropic drugs. In many developing countries improvement in the care and treatment of patients with mental disorders has been negligible, because of traditional concepts surrounding mental illness. In some societies “bizarre” individuals are thought to be cursed, while in others they are worshipped since they are believed to represent spirits or are messengersof God. Many of these societies reject modern concepts of psychiatric and mental health, as they do not relate culturally relevant alternative approaches to traditional beliefs (Asuni, 1973). It is especially in this domain that more research and resourcesare needed. Psychiatric versus mental health nursing

The distinction between psychiatric disorders and mental health problems is vague. This confusion is reflected in the various names used to describe the field, e.g. psychiatric and mental health nursing, psychiatric nursing, mental health nursing, or psychosocial nursing and a reason for the use of “psychiatric/mental health” in this paper. According to McBride (op. cit.), the “name problem was itself connected with existing conceptualizations both of whether mental illness and mental health exist on the same continuum and whether psychiatric nurses have a distinct role to play in treatment of brain disorders”. Current emphasis on mental health rather than on psychiatric care, she notes, “may have been prompted by the wish of practitioners to identify with nursing’s health-orientated perspective rather than with the medical model...” on psychiatric care. “Psychiatric nursing is dead, long live mental health nursing!“, a quote recently reported in a nursing journal from the U.K. (Nursing Standard, 1989) supports McBride’s assump-

CURRENT

STATUS AND FUTURE

CHALLENGES

351

tion. The change in emphasis reflects the way in which the philosophy of nursing itself has changed, according to the article. In the United Kingdom the Royal College of Nursing’s Society of Psychiatric Nursing has changed its name to the Society of Mental Health Nursing. The core of the issue concerns nursing’s quest to establish its own identity relative to patient or client care. In the past, psychiatric nursing’s identity, particularly in psychiatric/mental health institutions, has been strongly influenced by whatever model of patient care was practised in the setting. The four main models were: the medical, psychotherapeutic, behaviourial and socio-therapeutic models. Each model, which formed the basis for professional practice, attempted to explain psychiatric disorders based on its own narrow conceptual framework (McKenna, 1990). Although no universal model of psychiatric/mental health nursing has yet emerged, the core of what constitutes nursing can be found in ICN’s definition of nursing. “Nursing.... encompasses the promotion of health, prevention of illness, and care of physically ill, mentally ill, and disabled people of all ages, in all health care and other community settings... the phenomenon of particular concern to nurses is individual, family and group responses to actual or potential health problems. The unique function of nurses in caring for individuals, sick or well, is to assess their responses to their health status and to assist them in the performance of those activities contributing to health, recovery, or to dignified death, that they would perform unaided if they had the necessary strength, will, or knowledge and to do this in such a way as to help them gain full or partial independence as rapidly as possible...” (ICN, 1987).

Psychiatric/mental

health nursing education

Historical perspectives

Early psychiatric/mental health training schools prepared direct entrance nursing personnel, i.e. students did not receive a basic education in general nursing. Such schools were placed within psychiatric hospital settings to ensure a steady supply of nursing personnel conforming with institutional needs. Their numbers, however, are steadily declining. Psychiatric/mental health nursing subjects as part of a general nursing syllabus is a relatively new phenomenon. In 1933, for example when the ICN Board of Directors and the Grand Council met in Paris and Brussels for the Quadrennial Congress, a resolution was passed by delegates from 30 countries to endorse the principle that Mental Nursing and Hygiene be included in the general curriculum of all Schools of Nursing (Bridges, 1967). In the U.S., it was not until 1937 that the body responsible for accrediting schools of nursing considered psychiatric nursing to be an essentialcomponent of general basic nursing education, and even in the 1950sit was still not generally recognised that psychiatric nursing content was helpful for the entire spectrum of nursing practice (Slavinsky, 1984).

Basic specialisation versus post-basic speciality preparation

The governing body of the ICN, the Council of National Representatives(CNR) accepted as a policy in 1985 “The Report on the Regulation of Nursing”. The policy the CNR approved is that programmes of nursing education should generally parallel those for other professions as to setting, level, academic credentials, control and general standards and that one of those standards should be

358

A. BUTTER WORTH “liberal and professional education preparing for the general practice of nursing in all settings, primary, secondary and tertiary” (Murphy and Hoeffer, 1987).

According to the Report, the scopeof preparation and practice of a nurse is: the capacity and authority to practise primary, secondary, and tertiary health care competently as a generalist in all settings and branches of nursing, and the capability and legal responsibility to superviseand direct auxiliaries. The scopeof preparation and practice of a nurse specialist is defined as: advanced education and expertise in a branch of nursing, built upon the nurse base of competence and authority for generalist practice in all settings and branches of nursing. The fundamental question of what it means to be a “nurse” and the related issue-the merits of basic specialisation versus general nursing education-are still, however, being debated by nurse leaders. As pointed out by Butterworth, there “is a common level which all nurses should and could attain if they all have “caring” of their interpersonal dealing with patients” (Butterworth, 1984).

at the centre

It is not the intent of this paper to go into details of the debate or to discuss an explicit nursing model, but to present one of the central principles upon which the position taken by the CNR is based. This relates to the development of the nursing profession and its potential social contribution, and setsforth that increasesin the complexities of health care and its social milieu call for the heightened capabilities of nurses,ascitizens and practitioners to meet new challenges. To encourage the development of nursing’s potential, educational requirements should include liberal, social, scientific and technical education; and nursing service standards should reflect the changing health care needs and enhanced professional capacities (ICN, 1986). Such a foundation, ICN believes, is laid during the generalist preparation for practice. The debate is how to develop post-basic specialist programmes which arise from a model of generalist nursing practice, and yet expand the nurses’ role into the speciality domain in a way that builds and develops nursing skills, provides quality care controls, assurescredibility to the consumer, as well as meeting the particular needs of that speciality. In transition

A major development in nursing education as discerned from responses to a questionnaire, is the turning away from traditional “medical models” of care to a “nursing” focus, particularly in countries where deinstitutionalisation is well established. Basically, a traditional medical model views psychiatric illnesses as having a specific physical cause related to the functional anatomy of the brain over which patients have little or no control. Control, either through drugs and physical treatment or of the external environment, has to be supplied from outside (Barratt, 1989). On the other hand, a nursing focus stresses interpersonal relationships, behaviourial concepts and holistic responsesto identified problems. Comments from respondents to the questionnaires in this survey suggestthat “The teaching of subjects in mental health/psychiatric nursing has been predominantly affected by the changes in the service and the attitudes to psychiatric illness... Now our curriculum model focuses on the human experience of psychiatric illness in any setting and there is a renewed emphasis on the issue of mental health at community and at individual level,”

and “more humanistic and social components more marked and evident”,

CURRENT

STATUS AND FUTURE

CHALLENGES

359

and “emphasis put on communication

and relationships

as a therapeutic tool”

This change in curriculum orientation contradicts, at least for mental health/psychiatric nursing, the observations made in the Report by the Director General to the WHO Executive Board in 1989, which stated the “main developments in nursing over recent decades have been in response to sophisticated medical technology, neglecting preventive strategies, knowledge and skills” (ICN, 1988). All nursing students in basic general nursing programmes apparently now study mental health/psychiatric subjects, although the length of the study, its placement within the curriculum and the intensity of clinical experiences vary considerably from country to country and even from province to province or city to city within a country. Mental health/psychiatric subjects are either taught as individual courses or integrated with other themes throughout the curriculum. For example, under a course heading “Health Promotion”, the psycho-social needs of people in different age groups may be identified and, using the nursing process, students learn about such problems as addiction, depression, child abuse or stress. The skills, knowledge and attitude that nursing students are expected to demonstrate at the end of such a programme allow them to assess an individual’s psychological state and, within a general nursing framework, to plan and implement nursing interventions. Without further preparation or supervision, however, the roles of graduates of basic comprehensive or traditional nursing programmes in relation to caring for mentally ill people are necessarily limited. Such roles may include: assessing the individual and his/her immediate environment and planning therapeutic nursing interventions; providing direct care, including medication distribution and monitoring for their effects; teaching individuals and families skills, e.g. daily living and educating them on preventive mental health measures; interacting and liaising on the individual’s and family’s behalf with other care providers or services; consulting with other team members, both inside and outside institutions on continuity and coordination of care and its overall management; acting as the patient’s and family advocate to influence decisions; evaluating and revising treatment plans and schedules. Speciality education at the post-basic and graduate levels builds upon basic nursing competencies and stresses the interdependent roles of other psychiatric/mental health team members. Such programmes prepare nurses to apply a broad array of intellectual and interpersonal skills to change in some beneficial way the lives of people in both institutional and community settings (Peplau, 1987) for example, in caring for children and adolescents, elderly mentally ill.

The constraints

Major economic, social and political constraints hinder the development of nursing education in general and psychiatric/mental health nursing education in particular. The 1989 Report of the Director General of WHO noted, for example that “All develop-

360

A. BUTTER WORTH

ing countries report that only very meagre financial resources are allotted to nursing education” and that “many nurse teachers... have no teaching qualifications”. Furthermore, according to the Report, “even when community experience is indicated in the syllabus, often in practice it is not provided, or the hours are drastically reduced...” (Peplau, 1987). As one respondent to the ICN questionnaire observed, “our students have not been able to do their psychiatric/mental not had any transport”.

health practicum because we have

(The country has one centralised psychiatric hospital where all basic nursing students receive their practical training.) Economic constraints and lack of political will have kept educational opportunities and salaries for nurses at a minimum. Few countries have continuing education programmes available for nurses. Low salaries also affect mental health/psychiatric nursing education. One country reported that all well qualified nurses had left the country for better paying jobs elsewhere and that this had created a critical situation, as most colleges of nursing had no qualified psychiatric instructors left to teach the students. Such personnel shortages also cause a great void of leaders in the clinical area, limiting improvement of nursing services for mentally ill people. A further complicating element in the educational sphere is the preparation of many different levels and categories of nursing personnel, whose functions upon graduation are more closely linked with the absence or presence of other mental health professionals, nurses may be thrust into positions of making clinical decisions concerning individual patients for which they have not been adequately prepared. In countries where symbols of mental illness are still closely linked with cultural taboos, beliefs and superstitions, a mental health/psychiatric curriculum based on Western ideas is at times used for lack of an alternative. Often, such curricula are disease-orientated, hospital-based, overspecialised and out of line with the mental health needs of the people (Wankiri, 1984). Unfortunately, not enough research has been carried out in the socioanthropological sphere to determine which traditional approaches to care and treatment of mentally ill people are effective. It is not surprising, therefore, that many people in those countries prefer the services of traditional healers over those of “modern” medical care which, at times, constitutes prison-like conditions with only minimally trained personnel to provide custodial care. Many countries are reporting a drop in enrolment of students at the basic level and an even greater reduction in the number of students indicating a preference for psychiatric nursing either immediately upon graduating from a basic programme or choosing to study it at higher level following basic nursing education (Breust, 1989). Specific reasons for this decline were not given. Nevertheless, from available information certain assumptions can be made: -

changes in mental health services and treatment and the placement of patients in community settings has led to role diffusion, creating uncertainty about what the future for psychiatric/mental health nurses will hold; unpleasant student experiences in clinical settings, remaining prejudice and fear, and lack of psychiatric/mental health nurse role models are discouraging students from choosing the field; health personnel shortages resulting in understaffed units in institutions and large client

CURRENT

STATUS AND FUTURE

CHALLENGES

361

load in community settings-standards of nursing care are difficult, if not impossible to maintain, leading to professional frustration and “burn-out”; - students are aware that a career structure and other incentives in the field are inadequate or lacking; --- continuing education opportunities are limited. Redressing some of these problems requires strong nursing leadership, political commitment and an infusion of funds. The future of mental health/psychiatric services will continue to depend to a large extent on the functions and roles carried out by nursing personnel. In turn, the quality of those serviceswill be greatly influenced by the educational preparation of its practitioners and their living and working conditions. Culturally appropriate basic and continuing education, based on national needsand resources,and adequate remuneration and opportunities for career advancement are necessaryfor nursing personnel to perform at the standards of mental health nursing practice that the profession has set for itself. Mental health/psychiatric

nursing practice

In transition

In developed countries, the care of people with mental illness was, up to the mid-20th century, largely provided in public psychiatric institutions staffed predominantly by aides (Mechanic, 1982). Much of the care in these institutions was custodial and trained nursing personnel performed traditional roles-e.g. bathing, feeding, toileting and dressing, and preventing patients from harming themselves and others. In subsequent years, other functions were added, such as assisting with hydrotherapy, electroshock or insulin coma, while counselling patients only recently emerged as a role. Today, in many countries, psychiatric/mental health nurses are the only mental health professionals to have the 24 h responsibility for patients in the in-patient or institutional settings, and therefore, are the prime care givers and monitors of patient progress. With refinement of clinical skills through ongoing supervision of practice, a generalist nurse should be able to assume,among other roles, the following [adapted from American Nurses’ Association Standards of Child and Adolescent Psychiatric and Mental Health Nursing Practice (ANA, 1985)]: therapist who sharesthe responsibility for providing an atmosphere in which all activities and behaviours are focused on the therapeutic care of the individual; counsellor or teacher; collaborator with other mental health and psychiatric professionals in assessingthe needsand planning for the care of the individual and family; advocate and change agent who provides for the physical, mental health and other needs of the individual; promoter of mental health with individuals, families, groups and communities; participant in the research process and implementor of research findings. In addition to the roles of a generalist nurse, graduates of speciality programmes who have had supervised clinical experiencesmay be expected to assumethe following roles, among others [adapted from American Nurses’ Association Standards of Child and Adolescent Psychiatric and Mental Health Nursing Practice (ANA, 1985)]:

362

A. BUTTER WORTH

~ -

therapist, e.g. psycho, play, drama for individuals, groups and families; clinical supervisor of patient care staff and graduate nursing students; administrator of psychiatric and mental health nursing services; educator of nurses and other care personnel in a variety of institutional and community settings; - consultant to professional and nonprofessional people or groups concerned with the general welfare, education and care of individuals; ~ researcher who contributes to the theory and practice of psychiatric and mental health nursing through research in this field or a related field. Mental health/psychiatric nurses have been in the vanguard as positive agents for changes in many countries. For example in Uganda, psychiatric clinical officers-nurses who have received advanced training at Makerere University-are highly respected mental health practitioners who are fully responsible for psychiatric/mental health services, particularly in rural areas. Similar advanced educational programmes for nurses have been developed in Botswana, Lesotho and Zambia (Wankiri, 1984). In the U.K., nurses launched a rehabilitation centre to help mentally disturbed patients learn many of the skills neededto move towards lessrestricted life-styles in the community or in institutions. Based on research findings, the rehabilitation programmes help people to lead a better quality of life, for example through learning “living skills” (Carlisle, 1985). In many countries, nurses are conducting research and demonstrating patient outcome related to nursing care, such as studies on sleepdeprivation, effectsof homelessness,aspects of addictive cycle and high risk pregnancy. Innovative mental health/psychiatric programmes initiated by nurses can probably be found in every country; however, major constraints impede their widespread development.

Constraints

It appears that some mental health/psychiatric nurses have not easily adapted to the deinstitutionalisation of the mentally ill, possibly because psychiatric nursing has not identified its unique professional perspective (Nolan, 1989). Nurses, according to Nolan, have adopted a “lay” or “common senseapproach” which prevents them from realising their full therapeutic potential. He claims that training has not helped since it has failed to provide nurseswith the skills neededto engagepatients in therapeutic relationships. Pollock, using a small sample for a study on the work of community psychiatric nursing, found that nurses with limited resources and lack of direction were establishing their own modus operandi and defining their own work practices while trying to produce the best match of needs to resources (Pollock, 1988). Barnum calls this the “nursing’s angel complex”: the notion that no matter what pittance of support nurses get, they can fly (Barnum, 1989). Simpson (1989), having examined selected research reports on community psychiatric nursing (CPNs), noted that “on the one hand... CPNs are enthusiastically embracing a new role with a client group not appropriate for psychiatric (medical) intervention, and on the other..... they are not equipped to do so”. He claims that there “appears to be no research at all indicating whether community psychiatric nursing interventions are, in fact, systematic and rooted in sound theoretical and research-basedpractice”. Barratt (1989) notes that CPNs are a relatively new group of carers and are still experimenting with their role within

CURRENT

STATUS AND FUTURE

CHALLENGES

363

society while, as Brooker (1987) reports, they are in a rapidly developing area of mental health nursing. In many developing nations, where there is usually one psychiatric hospital for the entire country, problems of mental health and psychiatric nursing are closely linked to other problems of general health and socioeconomic origin, but above all, according to Wankiri (1984) to inappropriate organization, inappropriate curricula and manpower shortages. The author states: “The few existing psychiatric hospitals are for the most part old custodial institutions-overcrowded, understaffed and rarely able to provide more than just chemical therapy and electroconvulsive therapy. Their forbidding appearance also greatly contributes to the negative image of psychiatric nursing among the public...” “The isolation of the mentally sick in uncongenial surroundings has led to a situation in which most African health workers in the rural areas are unwilling or unable to follow up such patients. They do not regard the promotion of community mental health, the prevention of mental illness, and the identification and management of mentally sick patients as their responsibility.”

According to Peplau (1987), what is most “needed now are psychiatric nurses within the profession to track research findings, coming from all sciences, and to serve as interpreters of those findings for the nursing profession”. Psychiatric/mental health nursing practice cannot be viewed in its entirety without looking at the issues that influence its practitioners. In most countries, there are widely reported shortages of nursing personnel. Many studies have shown reasons for this: poor working conditions, low salaries and limited career opportunities, increased demand for highly trained nurses but a decreased pool from which to recruit young people, lack of professional autonomy and low image of the profession. Improving the educational preparation of psychiatric/mental health nurses, and developing a research data bank and a solid theoretical foundation on which to base their practices, must go hand in hand with better working conditions (e.g. salary and remuneration), greater autonomy within an interdisciplinary setting, opportunities for further educational advances and career development, and participation in policy-making. In addition, needs and resources studies must be conducted to provide valid data on nursing personnel, to be used with some consistency in staffing services.

Nursing legislation

Of the 20 national nurses’ associations that responded to the questionnaire, eight reported that their country’s legislation did not meet present day needs, three that no such legislation existed, and two that some aspects of the laws were relevant while others were not. Only five noted that nursing legislation was up-to-date. These responses reflect the findings of the ICN Regulation of Nursing Study that in a large majority of countries the regulations governing nursing practice are inadequate for dealing with the complexity and expansion of the nursing role to meet today’s health care needs (ICN, 1984). However, there seemed to be no problems for nurses to practise at the level for which they were prepared-which could be inconsistent with the above finding that legislation is outdated or absent. As pointed out in this document, “the central purpose of statutory regulation of nursing should be to protect the public by ensuring competent, accessible nursing care”. Based on the findings of the Regulation Study and recognising the world-wide nature of

364

A. BUTTER WORTH

the problem, the International Council of Nurses launched a global project to involve national nurses’ associations and senior nurses in the ministry of health in the critical examination of national nursing legislation and regulations with the aim to bring about necessarychanges. As a result, many NNAs are now more acutely aware of the actions that need to be taken to redress the problem and have begun the initiatives. National Nurses Associations (NNAs)

Severalpsychiatric/mental health speciality branches within national nurses’ associations have developed standards for practice and for education that spell out desired levels of performance, situations or conditions and criteria-which can be used for comparison. Furthermore, NNAs and their speciality groups have made submissions to government authorities on such issuesas: -

the delivery of servicesto mental clients as a priority in 1990; the legal status of mentally ill people; proposals for new mental health legislation; statement of nursing needs to increase appropriations for psychiatric/mental health care; sale of liquor bill; standards for informed consent; safe staffing levels; changesin levels of education; upgrading of physical facilities; proposals concerning community care for adult mentally ill and mentally disabled people and the health of those in prison; substance abuse.

The NNA high responserate (69%) to ICN’s questionnaire demonstrates their concern for psychiatric/mental health nursing issuesand their desire to seeinternational health bodies take a leadership role to reduce the inequities and improve conditions, both for the recipients of care and the care givers. Future developments

Looking into the future, mental health/psychiatric nursing education at the general basic level will focus largely on prevention and concepts of healthy living, and will include theory and clinical experience in public policy, biological-psychological basis of behaviour, social psychology, sociology, normal physiology, and will be based on “humanistic-holistic caring” as the central core of all nursing practice. The generalist nurse will be mainly concerned with preventive and promotive aspectsof mental health in all settings4.g. homes, schools, clinics, hospitals, factories. The nursing care of mentally ill people both in institutions and in the community will be provided by nurses prepared at the post-basic or graduate level, working individually and within interdisciplinary mental health teams. Using an integrated theoretical perspective, their approach to care will provide for “a range of services including supportive care, rehabilitative care and crisis intervention as well as more traditional forms of psychotherapeutic interventions” (Slavinsky, 1984). In addition, mental health/psychiatric

CURRENT

STATUS AND FUTURE

CHALLENGES

365

nurse specialists will carry out many functions related to the prevention of mental illness and the promotion of mental health in a broad variety of settings, across the age span, infant to geriatric. Post-basic and other graduate programmes will be able to attract an adequate number of well-qualified applicants because mental health/psychiatric nursing is respected for its special skills and knowledge, autonomy, opportunity for innovation, and availability of supportive supervision, as well as the opportunity it provides to influence policy decisions which both directly and indirectly affect mental health/psychiatric services. These services will be culturally relevant and integrated within the primary health care system of the nation. In addition, mental health/psychiatric nurses’ expertise is publically recognised and financially rewarded. References ANA (1985). Standard.7 of’ Child and Adolescent Psvchiatric and Mental Health Nursing Practice, p. 5. American Nurses’ Association, Kansas City. Asuni, T. (1973). Existing concepts of mental illness in different cultures and traditional forms of treatment. In: Mental Health Services in Developing Countries, Papers presented at a WHO Seminar on the Organization of Mental Health Services, Addis Ababa, 1973. World Health Organization, Geneva. Barnum, B. (1989). Nursing’s image and the future. Nurs. Hlth Care January, 19-21. Barratt, E. (1989). Community psychiatric nurses: their self-perceived roles. J. Adv. Nurs. 14,4248. Breust. M. (1989). Institutionalization versus living in the community: psychiatric deinstitutionalization and nursing in New South Wales. In: Issues in Australian Nursing 2 (G. Gray and R. Platt, Eds), p. 72. Churchill Livingstone, Melbourne. Bridges, D. C. (1967). A History of the InternationalCouncilofNurses 189991964. J.B. Lippincott Co., Philadelphia. Brooker, C. (1987). An investigation into the factors influencing variation in the growth of community psychiatric nursing services. J. Adv. Nurs. 12, 367-375. Butterworth, T. (1984). The future training of psychiatric and general nurses. Nurs. Times 80(30), 65-66. Carlisle, D. (1985). A school for normal living. Nurs. Times 85(41), 16-17. Curran, W. J. and Harding, T. W. (1978). The Law and Mental Health: Harmonizing Objectives, p. 10. World Health Organization, Geneva. Fraser, M. (1986). Children in Cony¶ict, p. 208. Penguin, London. In Children in Situations of Armed Conflict. p. 8. UNICEF (1986) No. E/JCEF/CRP 2, 10 March, 1986. ICN (1986). Report on the regulation of nursing. Prepared by Margretta M. Styles, ICN, Geneva, p. 49. ICN (1987). Definition of nursing. Approved by the CNR. ICN (1988). Report by the Director-General, The role of nursing and midwifery personnel in the strategy for health for all. Executive Board, EB83/6, 17 October, 1988, p. 10. Lemmer, B. and Smits, M. (1989). Facilitating Change in Mental Health. Chapman and Hall, London. McCausland. M. (1987). Deinstitutionalization of the mentally ill: oversimplification of complex issues. Adv. Nurs. Sci. 9(3), 24-33. McBride, A. B. (1990). Psychiatric nursing in the 1990s. Archs Psychiat. Nurs. 4(l), 21-28. McKenna, H. (1990). A pill for every ill. Nurs. Times 86(10), 28-30. Mechanic, D. (1982). Nursing and mental health care: expanding future possibilities for nursing services, In: Nursing in the 1980s (L. Aiken, Ed.), pp. 3433358. J.B. Lippincott Co., Philadelphia. Murphy, S. and Hoeffer, B. (1987). The evolution of subspecialities in psychiatric and mental health nursing. Archs Psychiat. Nurs. l(3), 1455154. Nolan, P. (1989). Face value. Nurs. Times 85(35). 62-65. Nursing Times (1985). News Focus. The hell called Leros. Nurs. Times 39, 18. Nursing Standard (1989). Focus on mental health nursing. Nurs. Stand. 25(4), 28-30. Peplau, H. (1987). Tomorrow’s world. Nurs. Times 7 January, 29-32. Pollock, L. (1988). The work of community psychiatric nursing. J. Adv. Nurs. 13, 537-545. Simpson, K. (1989). Community psychiatric nursing-a research based profession. J. Adv. Nurs. 14, 274280. Slavinsky, A. (1984). Psychiatric nursing in the year 2000: from a nonsystem of care to a caring system. Image--J. Nurs. Schol. 16(l), 17-20. World Federation for Mental Health (1989). The Declaration of Luxor-Human Rights for the Mentally 111, adopted 17 January 1989 by the Nile Congress at Luxor. Wankiri, V. (1984). Mental health and psychiatric nursing in Africa. World Hlth Forum 5, 334-337. WHO & UNICEF (1978). Primary health care. A joint report. Geneva. WHO (1990). WHO Features No. 140, April 1990.