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The in and out nurse: Thoughts on the role of the psychiatric nurse in the community and the preparation required
fn/. J. Nurs. Stud. Vol. 4, pp. 225-231, Pergamon
Press, 1967.
Printed in Great kritam
The In and Out Nurse: Thoughts on the Role of the Psychiatric N urse in the Community and the Preparation Required W. J. A. KIRKPATRICK 28 GranlsClose, Mill Hill, London, N, W.7
THE AIM of psychiatric care and treatment is to return the patient to his family, social, and work setting as soon as possible. This in some instances will mean being discharged from hospital before a full recovery has occurred. The growth towards wholeness is to be completed within the patient’s normal surroundings in the community from which he was formally or informally withdrawn during the acute phase of illness. Therefore this implies a definite need and a logic for a domiciliary psychiatric nursing service. Is it not logical to assume further that the hospitalbased nurse should retain the central position of care for the patient in the community, as a guide, teacher and friend towards the patient’s full integration into his home and community? Furman (1) informs us that “The more community-minded psychiatrists in Britain expressed in diRerent ways their desire to involve mental hospital nurses more in the work outsidr the hospital. “A typical opinion was that nurses are most useful in follow-up programs when assigned to geriatric cases and in situations calling for close observation of psychotic processes . . . . that nurses with special social work training are most useful for all types of field work in community programs”. If the psychiatrically orientated nurse is to be effective in the community, we are bound to ask many questions, such as:
1.
What are the different developed ?
skills, if any, that are needed,
2.
How should such nurses be prepared by whom?
3.
Do we understand how the nurse is to fulfil this role in the preventive, and post-care areas of concern? 225
for nursing
and how arc these to be
within
the community,
and
in-care
226
W. J. A. KfRKPATRICK
4.
If we tentatively agree that the psychiatric nurse has a functional role within the community health services, are we aware of the expectations which the other disciplines (including other branches of nursing) and the community as a whole may have of this nurse?
5.
How are we to prepare a sufficient number of nurses for nursing in the community with the same confidence and ease as in the ward situation, realizing that nursing is nursing irrespective of the milieu of care?
There is no doubt that the nursing profession has been and is central in the caring for the mentally ill within the hospital, in conjunction with the many other caring personnel. One may also assume that the nurse should retain this position of care for the patient in the communitya continuation of the relatively intimate but disciplined contact the nurse has already established with the patient in hospital. Therefore could not the hospital ward doors swing out as well as in, with the nurse ideally arriving with the patient from the community, caring for him in hospital and following this up with supportive care for the patient in the community? This interaction in the community on behalf of the patient will require new techniques of care, in which it is important that the human function of the nurse as an expert in personal care be maintained. Nurses must not leave the bedside or the side of the patient simply to become a filler-out of forms. The nurse must remain essentially a nurse, the common core of competence for all the professional workers in the community mental health services, whether in the hospital or in the community. Such a nurse has been designated in Holland as a “social-psychiatric nurse.” This suggests that the nurse must have a basic working knowledge in the behavioural, social, political, economic, cultural and religious resources within the area in which the patient lives and the nurse is practising. Behind this kind of basic knowledge it is essential for the nurse to have a sound background in psychiatric nursing, as obtained whilst preparing for State Registration for the Mental Register. It is imperative that a nurse have a clear conception and understanding of the nurse’s role within the community’s mental health services. This role, as in any other profession, will depend upon the function one serves. The functions of a psychiatric nurse are extremely difficult to define, simply because many of these are intuitive responses, effective to the extent one is listening to the whole persondity of the patient, within the patient/nurse situational encountering of each other. However, I shall attempt to define these through my own limited experience and reading. 1.
To have a clear concept of health and the dynamics involved in the development and the maintenance of a healthy personality, including the recognition of healthy coping mechanisms, particularly in the time of crisis and stress.
2.
To have a well-formulated concept of the dynamics ment of illness and the treatment process.
3.
To have a basic understanding of the dynamics involved and family interactions, healthy and pathological.
4.
To have knowledge and understanding of the social and administrative cesses within the mental health services, the Mental Health Act.
involved
in the develop-
in individual,
group pro-
THE IN AND OUT NURSE
227
TO have a respect and understanding of the roles of the other caring disciplines involved in the care of the mentally ill. The World Health Organization Reportt2) The Nurse in Mental Health Practice states “It seems that the nurse in mental health practice regardless of where she works and often of what she is called, is required to carry out duties which are fundamentally the same, and which require the same sort of skills. The main differences in function spring from a shift in emphasis according to the patient’s predominant needs at any one time.” It lists seven types of skill needed: 5.
1.
Basic nursing skills,
2.
technical,
3.
occupational
4.
organizational,
5.
interpersonal,
6.
observational,
7.
skills of communication.
and recreational,
The acquisition of these skills is the key to much of the future success of the developing-flexible (in and out) psychiatric nurse, irrespective of the nurse’s milieu of care. The security of knowledge will enable the nurse to share ideas and concerns with other professional persons, to initiate new ways of caring, and to help with the solution of old problems. The nurse, through guidance in the tutorial and field learning situations, should develop many of the following skills-listed, not necessarily in order of appearance, as individual skills to be used in conjunction with each other in response to the unique individual crisis of the person for whom the nurse and the whole of the mental health services of this country are continually evolving. 1.
Knowledge
2.
To be able to accept what appears to be unacceptable.
3.
To be able to listen with the whole personality person.
4.
To communicate
5.
To know how to make effective patient.
6.
To sense the area of hurt,
7.
To share one’s strength.
8. 9. 10. 11. 12. 13.
and respect for oneself as a person.
via written,
To be able to recognize
verbal
to the other whole significant
and non-verbal
use of self through
methods. active concern
for the
and to soothe the patient.
early signs of return of mental illness.
To be able to reduce conflict, by improving the self-image of the patient. To make constructive use of anxiety, tension and other emotions. To exploit constructively one’s status as a respected and familiar member of the Mental Health Service. To be able to make over-all observations on the immediate crisis. To provide under supervision, crisis or supportive orientated psychotherapy.
W.
220
3. A. KIRKPATRICK
14. 15.
To have a basic knowledge of drugs used in psychiatry and their side affects. To assist the family to retain or to re-establish family stability and concern for each other.
16.
To be able to understand something of the various national, cultural backgrounds of our immigrant population.
17.
To be an effective liaison officer between the family, medical, social, religious, hospital and community services.
18.
To know the resources of the community.
19.
To be able to assess and to analyse the situational psychological, social and religious factors.
20.
To have teaching,
21.
To be able to engage in unprejudiced of care.
leadership,
planning
crisis on the basis of physical,
and policy-making examination
racial, social and
abilities.
of new ideas and methods
denominator of all these skills would appear to be that of knowing The bridge between all the varying disciplines is the use of the self as an instrument of care in each nurse/patient encounter, and as an aid towards the creative resolution of the crisis situation in the patient’s life. It would appear that the skills required of the psychiatric nurse in the community are similar to those required of the same nurse practising in the hospital or other clinical situations. This would imply that there is no real reason why all psychiatric nurses should not work with the same ease within the pre-admission, admission and post-admission stages of care. It further implies that basic clinical nursing skills are essential to community nursing. The effectiveness of the “in and out” nurse is based on the integrity of purpose, as each individual nurse constantly questions the depth of knowledge and skill required in any specific area of concern. Psychiatric nursing is both an art and a science irrespective of the nurse’s area of concern, for it is grounded in the understanding of the individual whether in the clinical or community setting. In both of these situations the nurse must observe, interpret and intervene creatively, recognising the essential fact that nursing is nursing, wherever and whenever it is practised, though certain modes or methods of practice may differ; yet the purpose of the profession is to care always. Nursing is a profession and a science. Therefore training in the logic and methods of science should lie behind and become the framework, an integral part of the preparation of all students at all levels, including the post-graduate. In a world of constantly changing values it is necessary to revise our popular (mis)conage nursing must be presented and ception of the nurse. In the technological seen to be a challenge, a scientific act expressed through a shared responsible concern for another individual. One feels that the skills and knowledge required for the effective development of a comprehensive community mental health nursing service cannot and must not be rationally or irrationally determined or isolated within the enclosed walls of a psychiatric hospital or localized cells of care in the community. The nurse working in the community or the hospital soon realises that the community mental health services cannot be developed by the professional alone. Rather it is a collaborative, co-ordinated effort with other caring-members of the community, often beginning The common
and of being oneself.
THE IN AJVD OUT MJHSE
229
with the patient’s relatives, friends and workmates-effective in their caring to the extent to which the nurse has assisted them towards the understanding of the situation and towards the developing of a relationship of concern. By offering each nurse candidate a planned clinical experience, situated within a variety of settings in the hospital and the community, we are preparing a nurse in depth of understanding and concern, able to function as the “in and out” nurse with an ultimate concern for each patient under care. In this field of human relations, I have tried to establish that there is a basic core of knowledge, understanding and skill shared by all caring persons. One then queries whether or not the psychiatric community nurse should retain the basic psychiatric nurse-training as laid down by the General Nursing Council or whether the curriculum should be designed and determined by the educational needs of the individual student. Should the psychiatrically trained nurse in the community have a further basic training in the social sciences during the basic training period, followed by a year as a Staff nurse and a following year as a Sister or Chargenurse within the clinical situation of the hospital. Approximately half of this time would be spent in the care of the chronically ill and geriatric patient, and the course would finish with a further year’s training in the skills outlined earlier, i.e. the social skills. Or again should we outline a course similar to that used for training the social-psychiatric nurse in Holland-three years’ general nurse training, two years in mental hospital work and two years of social work training. What is needed is a University of Care enabling us to expand our knowledge, deepen our insights, sharpen our skills, and broaden our understanding and compassion. The role of the community psychiatric nurse, like the role of any other practitioner of care, will be defined in any specific situation through a process of reciprocal communication in trust. It will also be defined in the specific situation in the terms of the requirements of the number of patients carried and the nurse’s individual competence in meeting the patient’s needs; and also through the nurse’s integrity as a member of an inter-disciplinary team, as a synthesizer, interpreter and coordinator of all the care directed towards the patient. There is no doubt that nurses in the community can be effective channels of care in or out of the clinical situation, in or out of uniform. However, the current situation in nursing is so fluid and yet at the same time so starched that firm predictions of the value of training or how the nurse should be trained for the “in and out” community nursing role is almost nil. Yet we have one firmly established starting point, and that is that in all ages nurses have been and are being consecrated by their own desire to the relief of suffering. The nurse is, I suggest, the pivot of health around which suffering humanity revolves, whether in the clinical situation or in the community, as long as we remain aware that nursing is a career of compassion for men and women by men and women, whether or not the nurse is Auxiliary, Enrolled or Registered, whether or not the nurse regards it as a career or a vocation, and whether or not the nurse considers it an act of love-“the accurate estimate and supply of someone else’s need.” In being prepared to meet the conscious and unconscious demands of the patient, whether in the clinical situation or in the community, the nurse offers a personal service unique to each individual patient.
230
W.
3.
A. KIRKPATRICK
All the foregoing comments suggest that within the discipline of psychiatric nursing the nurse with additional training could very well become the “in and out” nurse of the future. References 1. S. S. FURMAN,Community Mental Education and Welfare ( 1966).
Health
Service in Northern
Europe,
US.
Department of Health,
2. World Health Organisation, Technical Conference, The nurse in mental healthpractice.Public Health Paper No. 22, (1963). 3. Report of Work Conference, Graduate Education in Psychiatric Mental Health Nursing, University of Pittsburgh, U.S.A. (1965). (Although I have not quoted directly from this report, I have been stimulated and encouraged by it to formulate my own thoughts, which has resulted in this article.)
RCsum&-L’object fondamental des soins psychiatriques est de replacer le malade dans son milieu “normal,” et ceci souvent m&me avant qu’un rttablissement complet soit possible. Ceci implique done la Claire necessite d’un service de soins a domicile. On peut bien s’imaginer que c’est l’infirmiere rayonnant de l’hopital qui gardera la position centrale dam la mise en oeuvre de ce service et agira en tant que guide, institutrice et amie afin que puisse s’effectuer l’integration totale du malade dans son milieu domestique et dans sa communaute. 11 est essentiel que de telles infirmitres congoivent et comprennent parfaitement le role que joue l’infirmi&e dans le service public de santt mentale. Ceci ne devrait pas etre determine isolement par un organisme sit& a l’inttrieur de l’hopital psychiatrique ou des cellules localistes fournissant les soins au sein de la communautt. Cette fonction sera, comme celle de tous ceux qui dispensent des soins, dtterminee dans une situation particulitre don&e par un pro&de d’tchange rtciproque de confiance. Beaucoup depend de la competence personnelle dont l’infirmitre donne preuve en repondant aux besoins du malade et de son inttgrite en tant que membre d’une tquipe mutuellement disciplinte, synthttisant, interpretant et coordonnant tous les soins dirigts vers l’individu en question. Ceci signifie que, dans le cadre des soins pyschiatriques, l’infirmiere possedant une formation suppltmentaire pourrait tres bien devenir un canal effectif de ces soins, soit a l’interieur, soit a l’exterieur de l’ambiance clinicale, soit en portant, soit en ne portant pas l’uniforme. Ce sera l’infirmitre interne-externe de i’avenir. Nous devons souligner le seul point de depart qui reste fermement ttabli, a savoir que les infirm&es de toutes les Cpoques ont tte, et sont encore consacrtes per leur propre d&r de participer a l’alltgement de la souffrance.
Resumen-El objetivo basic0 de la atencion y tratamiento psiquiitricos es la vuelta de1 paciente a su medio “normal,” a menudo antes de la plena recuperaci&r, si es posible. Por lo tanto esto implica una Clara necesidad de un servicio domiciliario de enfermeras psiquiatras. Puede considerarse que la enfermera radicada en el hospital podria conservar la position central de la atencibn, coma guia, profesora y amiga, a fin de lograr la plena integraci6n de1 paciente a su hogar y comunidad. Es esencial que dichas enfermeras tengan una Clara conception y comprensi6n de1 papel de la enfermera dentro de 10s servicios sanitarios mentales de la comunidad. A semejanza de1 papel de cualquier otro profesional sanitario, t&e seri definido en cada situation especifica a travts de1 proceso de confiada comunicaci6n reciproca. Depende en gran manera de la competencia individual de la enfermera para hater frente a las necesidades de1 paciente, y de su integridad coma miembro de un equip0 interiormente disciplinado, sintetizando, interpretando y coordinando toda la atencion dirigida a la persona de que se trate.
THE IN A.ND OUT NURSE Esto implica que dentro de1 ejercicio de la enfermeria psiquibtrica, la enfermera con formacidn adicional puede muy bien ser un canal eficaz de atencion, dentro o fuera de la situation clinica, y dentro o fuera de la condition de la futura enfermera “interna y externa.” Debemos mantener la idea de que un punto de partida firmemente establecido radica en el hecho de que las enfermeras en todas las Cpocas han estado y siguen estendo consagradas a ayudar para alivio de1 sufrimiento, por propia vocation. Annoraunn -
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231
Press, 1967.
Printed in Great kritam
The In and Out Nurse: Thoughts on the Role of the Psychiatric N urse in the Community and the Preparation Required W. J. A. KIRKPATRICK 28 GranlsClose, Mill Hill, London, N, W.7
THE AIM of psychiatric care and treatment is to return the patient to his family, social, and work setting as soon as possible. This in some instances will mean being discharged from hospital before a full recovery has occurred. The growth towards wholeness is to be completed within the patient’s normal surroundings in the community from which he was formally or informally withdrawn during the acute phase of illness. Therefore this implies a definite need and a logic for a domiciliary psychiatric nursing service. Is it not logical to assume further that the hospitalbased nurse should retain the central position of care for the patient in the community, as a guide, teacher and friend towards the patient’s full integration into his home and community? Furman (1) informs us that “The more community-minded psychiatrists in Britain expressed in diRerent ways their desire to involve mental hospital nurses more in the work outsidr the hospital. “A typical opinion was that nurses are most useful in follow-up programs when assigned to geriatric cases and in situations calling for close observation of psychotic processes . . . . that nurses with special social work training are most useful for all types of field work in community programs”. If the psychiatrically orientated nurse is to be effective in the community, we are bound to ask many questions, such as:
1.
What are the different developed ?
skills, if any, that are needed,
2.
How should such nurses be prepared by whom?
3.
Do we understand how the nurse is to fulfil this role in the preventive, and post-care areas of concern? 225
for nursing
and how arc these to be
within
the community,
and
in-care
226
W. J. A. KfRKPATRICK
4.
If we tentatively agree that the psychiatric nurse has a functional role within the community health services, are we aware of the expectations which the other disciplines (including other branches of nursing) and the community as a whole may have of this nurse?
5.
How are we to prepare a sufficient number of nurses for nursing in the community with the same confidence and ease as in the ward situation, realizing that nursing is nursing irrespective of the milieu of care?
There is no doubt that the nursing profession has been and is central in the caring for the mentally ill within the hospital, in conjunction with the many other caring personnel. One may also assume that the nurse should retain this position of care for the patient in the communitya continuation of the relatively intimate but disciplined contact the nurse has already established with the patient in hospital. Therefore could not the hospital ward doors swing out as well as in, with the nurse ideally arriving with the patient from the community, caring for him in hospital and following this up with supportive care for the patient in the community? This interaction in the community on behalf of the patient will require new techniques of care, in which it is important that the human function of the nurse as an expert in personal care be maintained. Nurses must not leave the bedside or the side of the patient simply to become a filler-out of forms. The nurse must remain essentially a nurse, the common core of competence for all the professional workers in the community mental health services, whether in the hospital or in the community. Such a nurse has been designated in Holland as a “social-psychiatric nurse.” This suggests that the nurse must have a basic working knowledge in the behavioural, social, political, economic, cultural and religious resources within the area in which the patient lives and the nurse is practising. Behind this kind of basic knowledge it is essential for the nurse to have a sound background in psychiatric nursing, as obtained whilst preparing for State Registration for the Mental Register. It is imperative that a nurse have a clear conception and understanding of the nurse’s role within the community’s mental health services. This role, as in any other profession, will depend upon the function one serves. The functions of a psychiatric nurse are extremely difficult to define, simply because many of these are intuitive responses, effective to the extent one is listening to the whole persondity of the patient, within the patient/nurse situational encountering of each other. However, I shall attempt to define these through my own limited experience and reading. 1.
To have a clear concept of health and the dynamics involved in the development and the maintenance of a healthy personality, including the recognition of healthy coping mechanisms, particularly in the time of crisis and stress.
2.
To have a well-formulated concept of the dynamics ment of illness and the treatment process.
3.
To have a basic understanding of the dynamics involved and family interactions, healthy and pathological.
4.
To have knowledge and understanding of the social and administrative cesses within the mental health services, the Mental Health Act.
involved
in the develop-
in individual,
group pro-
THE IN AND OUT NURSE
227
TO have a respect and understanding of the roles of the other caring disciplines involved in the care of the mentally ill. The World Health Organization Reportt2) The Nurse in Mental Health Practice states “It seems that the nurse in mental health practice regardless of where she works and often of what she is called, is required to carry out duties which are fundamentally the same, and which require the same sort of skills. The main differences in function spring from a shift in emphasis according to the patient’s predominant needs at any one time.” It lists seven types of skill needed: 5.
1.
Basic nursing skills,
2.
technical,
3.
occupational
4.
organizational,
5.
interpersonal,
6.
observational,
7.
skills of communication.
and recreational,
The acquisition of these skills is the key to much of the future success of the developing-flexible (in and out) psychiatric nurse, irrespective of the nurse’s milieu of care. The security of knowledge will enable the nurse to share ideas and concerns with other professional persons, to initiate new ways of caring, and to help with the solution of old problems. The nurse, through guidance in the tutorial and field learning situations, should develop many of the following skills-listed, not necessarily in order of appearance, as individual skills to be used in conjunction with each other in response to the unique individual crisis of the person for whom the nurse and the whole of the mental health services of this country are continually evolving. 1.
Knowledge
2.
To be able to accept what appears to be unacceptable.
3.
To be able to listen with the whole personality person.
4.
To communicate
5.
To know how to make effective patient.
6.
To sense the area of hurt,
7.
To share one’s strength.
8. 9. 10. 11. 12. 13.
and respect for oneself as a person.
via written,
To be able to recognize
verbal
to the other whole significant
and non-verbal
use of self through
methods. active concern
for the
and to soothe the patient.
early signs of return of mental illness.
To be able to reduce conflict, by improving the self-image of the patient. To make constructive use of anxiety, tension and other emotions. To exploit constructively one’s status as a respected and familiar member of the Mental Health Service. To be able to make over-all observations on the immediate crisis. To provide under supervision, crisis or supportive orientated psychotherapy.
W.
220
3. A. KIRKPATRICK
14. 15.
To have a basic knowledge of drugs used in psychiatry and their side affects. To assist the family to retain or to re-establish family stability and concern for each other.
16.
To be able to understand something of the various national, cultural backgrounds of our immigrant population.
17.
To be an effective liaison officer between the family, medical, social, religious, hospital and community services.
18.
To know the resources of the community.
19.
To be able to assess and to analyse the situational psychological, social and religious factors.
20.
To have teaching,
21.
To be able to engage in unprejudiced of care.
leadership,
planning
crisis on the basis of physical,
and policy-making examination
racial, social and
abilities.
of new ideas and methods
denominator of all these skills would appear to be that of knowing The bridge between all the varying disciplines is the use of the self as an instrument of care in each nurse/patient encounter, and as an aid towards the creative resolution of the crisis situation in the patient’s life. It would appear that the skills required of the psychiatric nurse in the community are similar to those required of the same nurse practising in the hospital or other clinical situations. This would imply that there is no real reason why all psychiatric nurses should not work with the same ease within the pre-admission, admission and post-admission stages of care. It further implies that basic clinical nursing skills are essential to community nursing. The effectiveness of the “in and out” nurse is based on the integrity of purpose, as each individual nurse constantly questions the depth of knowledge and skill required in any specific area of concern. Psychiatric nursing is both an art and a science irrespective of the nurse’s area of concern, for it is grounded in the understanding of the individual whether in the clinical or community setting. In both of these situations the nurse must observe, interpret and intervene creatively, recognising the essential fact that nursing is nursing, wherever and whenever it is practised, though certain modes or methods of practice may differ; yet the purpose of the profession is to care always. Nursing is a profession and a science. Therefore training in the logic and methods of science should lie behind and become the framework, an integral part of the preparation of all students at all levels, including the post-graduate. In a world of constantly changing values it is necessary to revise our popular (mis)conage nursing must be presented and ception of the nurse. In the technological seen to be a challenge, a scientific act expressed through a shared responsible concern for another individual. One feels that the skills and knowledge required for the effective development of a comprehensive community mental health nursing service cannot and must not be rationally or irrationally determined or isolated within the enclosed walls of a psychiatric hospital or localized cells of care in the community. The nurse working in the community or the hospital soon realises that the community mental health services cannot be developed by the professional alone. Rather it is a collaborative, co-ordinated effort with other caring-members of the community, often beginning The common
and of being oneself.
THE IN AJVD OUT MJHSE
229
with the patient’s relatives, friends and workmates-effective in their caring to the extent to which the nurse has assisted them towards the understanding of the situation and towards the developing of a relationship of concern. By offering each nurse candidate a planned clinical experience, situated within a variety of settings in the hospital and the community, we are preparing a nurse in depth of understanding and concern, able to function as the “in and out” nurse with an ultimate concern for each patient under care. In this field of human relations, I have tried to establish that there is a basic core of knowledge, understanding and skill shared by all caring persons. One then queries whether or not the psychiatric community nurse should retain the basic psychiatric nurse-training as laid down by the General Nursing Council or whether the curriculum should be designed and determined by the educational needs of the individual student. Should the psychiatrically trained nurse in the community have a further basic training in the social sciences during the basic training period, followed by a year as a Staff nurse and a following year as a Sister or Chargenurse within the clinical situation of the hospital. Approximately half of this time would be spent in the care of the chronically ill and geriatric patient, and the course would finish with a further year’s training in the skills outlined earlier, i.e. the social skills. Or again should we outline a course similar to that used for training the social-psychiatric nurse in Holland-three years’ general nurse training, two years in mental hospital work and two years of social work training. What is needed is a University of Care enabling us to expand our knowledge, deepen our insights, sharpen our skills, and broaden our understanding and compassion. The role of the community psychiatric nurse, like the role of any other practitioner of care, will be defined in any specific situation through a process of reciprocal communication in trust. It will also be defined in the specific situation in the terms of the requirements of the number of patients carried and the nurse’s individual competence in meeting the patient’s needs; and also through the nurse’s integrity as a member of an inter-disciplinary team, as a synthesizer, interpreter and coordinator of all the care directed towards the patient. There is no doubt that nurses in the community can be effective channels of care in or out of the clinical situation, in or out of uniform. However, the current situation in nursing is so fluid and yet at the same time so starched that firm predictions of the value of training or how the nurse should be trained for the “in and out” community nursing role is almost nil. Yet we have one firmly established starting point, and that is that in all ages nurses have been and are being consecrated by their own desire to the relief of suffering. The nurse is, I suggest, the pivot of health around which suffering humanity revolves, whether in the clinical situation or in the community, as long as we remain aware that nursing is a career of compassion for men and women by men and women, whether or not the nurse is Auxiliary, Enrolled or Registered, whether or not the nurse regards it as a career or a vocation, and whether or not the nurse considers it an act of love-“the accurate estimate and supply of someone else’s need.” In being prepared to meet the conscious and unconscious demands of the patient, whether in the clinical situation or in the community, the nurse offers a personal service unique to each individual patient.
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3.
A. KIRKPATRICK
All the foregoing comments suggest that within the discipline of psychiatric nursing the nurse with additional training could very well become the “in and out” nurse of the future. References 1. S. S. FURMAN,Community Mental Education and Welfare ( 1966).
Health
Service in Northern
Europe,
US.
Department of Health,
2. World Health Organisation, Technical Conference, The nurse in mental healthpractice.Public Health Paper No. 22, (1963). 3. Report of Work Conference, Graduate Education in Psychiatric Mental Health Nursing, University of Pittsburgh, U.S.A. (1965). (Although I have not quoted directly from this report, I have been stimulated and encouraged by it to formulate my own thoughts, which has resulted in this article.)
RCsum&-L’object fondamental des soins psychiatriques est de replacer le malade dans son milieu “normal,” et ceci souvent m&me avant qu’un rttablissement complet soit possible. Ceci implique done la Claire necessite d’un service de soins a domicile. On peut bien s’imaginer que c’est l’infirmiere rayonnant de l’hopital qui gardera la position centrale dam la mise en oeuvre de ce service et agira en tant que guide, institutrice et amie afin que puisse s’effectuer l’integration totale du malade dans son milieu domestique et dans sa communaute. 11 est essentiel que de telles infirmitres congoivent et comprennent parfaitement le role que joue l’infirmi&e dans le service public de santt mentale. Ceci ne devrait pas etre determine isolement par un organisme sit& a l’inttrieur de l’hopital psychiatrique ou des cellules localistes fournissant les soins au sein de la communautt. Cette fonction sera, comme celle de tous ceux qui dispensent des soins, dtterminee dans une situation particulitre don&e par un pro&de d’tchange rtciproque de confiance. Beaucoup depend de la competence personnelle dont l’infirmitre donne preuve en repondant aux besoins du malade et de son inttgrite en tant que membre d’une tquipe mutuellement disciplinte, synthttisant, interpretant et coordonnant tous les soins dirigts vers l’individu en question. Ceci signifie que, dans le cadre des soins pyschiatriques, l’infirmiere possedant une formation suppltmentaire pourrait tres bien devenir un canal effectif de ces soins, soit a l’interieur, soit a l’exterieur de l’ambiance clinicale, soit en portant, soit en ne portant pas l’uniforme. Ce sera l’infirmitre interne-externe de i’avenir. Nous devons souligner le seul point de depart qui reste fermement ttabli, a savoir que les infirm&es de toutes les Cpoques ont tte, et sont encore consacrtes per leur propre d&r de participer a l’alltgement de la souffrance.
Resumen-El objetivo basic0 de la atencion y tratamiento psiquiitricos es la vuelta de1 paciente a su medio “normal,” a menudo antes de la plena recuperaci&r, si es posible. Por lo tanto esto implica una Clara necesidad de un servicio domiciliario de enfermeras psiquiatras. Puede considerarse que la enfermera radicada en el hospital podria conservar la position central de la atencibn, coma guia, profesora y amiga, a fin de lograr la plena integraci6n de1 paciente a su hogar y comunidad. Es esencial que dichas enfermeras tengan una Clara conception y comprensi6n de1 papel de la enfermera dentro de 10s servicios sanitarios mentales de la comunidad. A semejanza de1 papel de cualquier otro profesional sanitario, t&e seri definido en cada situation especifica a travts de1 proceso de confiada comunicaci6n reciproca. Depende en gran manera de la competencia individual de la enfermera para hater frente a las necesidades de1 paciente, y de su integridad coma miembro de un equip0 interiormente disciplinado, sintetizando, interpretando y coordinando toda la atencion dirigida a la persona de que se trate.
THE IN A.ND OUT NURSE Esto implica que dentro de1 ejercicio de la enfermeria psiquibtrica, la enfermera con formacidn adicional puede muy bien ser un canal eficaz de atencion, dentro o fuera de la situation clinica, y dentro o fuera de la condition de la futura enfermera “interna y externa.” Debemos mantener la idea de que un punto de partida firmemente establecido radica en el hecho de que las enfermeras en todas las Cpocas han estado y siguen estendo consagradas a ayudar para alivio de1 sufrimiento, por propia vocation. Annoraunn -
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