- Email: [email protected]
THE MENTAL NURSE IN THE COMMUNITY
213
all surgical wounds in an aseptic dressing-room wound cross-infection could be eliminated. Administratively, greater use could be made of hospital beds. Instead of a fixed number of beds being allotted to each consultant to be filled at his discretion, he would receive beds as needed for the treatment of his patients. Under the present system, with the inflexible fixed number of beds per specialist, many beds remain unoccupied in some specialties which could well be filled by other specialties; but this is seldom done. The hospital building programme for the next ten years gives us an opportunity to improve the living conditions of patients and the working conditions of hospital staff. The money for the programme has been promised; what we need now is imagination.
AVERAGE MONTHLY RETURN OF A
*
e.g.,
NURSE’S
WORK
assisting M.w.o., seeking absconded patients, moving patients’ contacting (L.H.A. welfare services).
property,
THE MENTAL NURSE IN THE COMMUNITY A. R. MAY M.B. Lond., M.R.C.P.E., D.P.M. CONSULTANT PSYCHIATRIST
S. MOORE S.R.N., R.M.N., S.T.D. CHIEF MALE NURSE
WARLINGHAM PARK
HOSPITAL,
SURREY
THE Mental Health Act of 1959 directed attention to the possibilities of treatment outside the mental hospital, and the new policy of extramural care is to be reinforced by a drastic reduction in hospital beds. Many centres of progressive psychiatry had anticipated these trends, and it is already clear that the shift of emphasis from hospital to community will mean a redistribution of medical and nursing staff as well as closer integration with local health authorities. Successful physical methods of treatment, new and potent drugs, and the increased tolerance of mental illness by the public at large have made community care feasible on a large scale. But it cannot work without staff, and the coordination of this new kind of therapeutic team presents problems unfamiliar to a hospital. From a practical viewpoint, the new policy means that extramural care must now be provided for a group of mainly psychotic patients who would previously have been treated in hospital. This group includes convalescent patients discharged from hospital earlier than hitherto, patients who may have relapsed after previous remission, and new patients who are not thought to need inpatient care.1 Most of the group will probably be cared for in dayhospitals or outpatient clinics, or by their family doctors, with specialist advice where necessary. But in some the disability mainly reflects social maladjustment, and these may be helped by psychiatric social workers (P.s.w.s), or mental welfare officers (M.w.o.s) under psychiatric supervision. Ultimately successful management of these patients depends on having adequate staff of all grades, and deploying it efficiently and economically. OUTPATIENT
Since 1954
NURSES
Warlingham Park Hospital
has seconded
qualified mental nurses to extramural duties in the borough of Croydon, whose population of 250,000 is served by the hospital. We began doing this because of the shortage of P.s.w.s and because
recognised the need for condischarged patients. These outpatient nurses ", who were based on the hospital, we
tinued supervision of 1.
our
May, A. R. Lancet, 1961, i, 760.
between the hospital and the patient when discharged and helped him to reestablish himself community. At first two nurses (a man and a woman) were allocated; but, as the work grew, two more were seconded, and the total of four has remained fairly constant, subject to demands on staff for new developments within the hospital. During the past few years, the role of these outpatient nurses has been modified in the light of experience, and they are now an important part of Croydon’s integrated district psychiatric service.2 We believe we can now formulate the following principles:
kept
contact
he was in the
1. Though the nurses are in close contact with P.s.w.s, M.w.o.s, and other local health authority agencies, and though the greater part of their work lies outside the hospital, they should remain on the nursing establishment of the hospital and within its medico-nursing administrative framework. Not only does this arrangement avoid conflict with traditional loyalties,
but it also facilitates
interchange with other nursing staff and secondment of trainees. 2. Because of her training, the qualified mental nurse is well fitted to assess the mental state of a patient, especially if she already knows the patient. It is in this nurse-patient relation that the real value of the outpatient nurse is most clearly seen. 3. The outpatient nurse can reassure and encourage patients, supervise the medication prescribed by the doctor, detect deficiencies in personal habits and care and often remedy them, and relieve the anxieties of relatives by timely explanation. regular
HOW
The
THE
SCHEME
WORKS
work exclusively with outpatients, and have no hospital duties. Though some may live in the hospital, they work from an office in the mental health centre which is attached to our day hospital in Croydon. It is an advantage for a nurse to be able to drive a car or scooter. We have one hospital car for the service, but nurses are encouraged to use their own vehicles and are nurses
paid mileage. Each nurse is given a number of regular patients. We try to give her patients she already knows; but geographical proximity, sex, and total case-load have also to be considered. Occasional work is distributed as convenient. " Each nurse’s regular patients constitute a ward ", and a formal " ward round " is held weekly in the centre under Other the psychiatrist coordinating community care. interested doctors and a P.s.w. come to this meeting; and each nurse reviews the patients in her ward. Decisions about further action are taken where necessary. Thus a patient may be brought to see the psychiatrist, or the P.s.w. may be asked to help in some complex social problem beyond the scope of the nurse. 2.
May,
A.
R., Sheldon, A.P., MacKeith, S. A. ibid. (1962), ii, 1319.
214
The function of the nurse is of course different from P.S.W. Her approach is primarily clinical. Detailed investigation of the patient’s family or modification of his environment, is not expected. Often nurse, P.s.w., and M.w.o. may all be helping a single " problem case ". Informal contact between these groups is easy and frequent, but the weekly meeting coordinates the work, and overlap is avoided because each is responsible to the
Medical Education
that of the
AN EXPERIMENT IN
THE TEACHING OF PSYCHOTHERAPY TO MEDICAL STUDENTS DOROTHEA H, BALL
psychiatrist. Patients
M.B.
referred to the service from among those the mental hospital, from the psychiatric from discharged unit in the local general hospital, from the day hospital, and from outpatient clinics. Exceptionally, the nurse’s visit may supplement routine attendance at a clinic. 60-70 patients are seen at present for routine clinical assessment. 25-30 will be visited at least once a week and the rest less often. Nurses make a monthly return of all visits, indicating the reason for each, and an average monthly return, based on three months ending Jan. 31, 1962, is shown in the accompanying table. Most of the patients seen on routine visits have been in hospital before and are known to be prone to relapse. Of 72 patients on the " ward " list on Jan. 31, 1962, 27 had one previous admission to Warlingham Park Hospital, and 37 had been admitted more than once. Of these 64 patients, 48 had been discharged within the past year. The diagnostic are
were schizophrenia 29; affective disorders 23; longstanding neurotic illness 11; and senile dementia 9. Regular supervision of patients makes up the bulk of visits, but there are a good many personal inquiries to discover why patients have not kept appointments at clinics. Nearly always these are schizophrenic patients;
categories .
they fail to continue with phenothiazine drugs the relapse-rate is high. and if
One
also attends each of five afternoon outpatient clinics (each with 2-3 doctors) four evening aftercare groups for long-term patients, and three evening social clubs. nurse
DISCUSSION
Nurses have taken part in this work voluntarily, and, while some were uncertain about it at first, the experience has clearly given them all great personal and professional satisfaction. As members of a larger team they have benefited from closer contact with all the services sharing in community care, while the novel experience of visiting patients in their homes has shown the importance of environmental stress and social factors in psychiatric illness. The help given by the service is freely acknowledged by the psychiatrists who use it, particularly for geriatric patients. The acute pressure on these beds can often be alleviated by regular home visits which relieve the anxiety of relatives and encourage them to accept responsibility-even if only temporarily-for elderly people. The trend towards extramural management of psychiatric patients needs more than an increase in outpatient clinics and domiciliary visits by a consultant. Many patients are more or less chronically disabled, and their care and
supervision outside hospital would overtax already overcrowded clinics. Yet some provision must be made for them. The possibility of relapse in recently discharged patients, especially schizophrenics, poses similar problems in supervision. Yet we believe that these patients are properly the responsibility of a comprehensive community psychiatric service, and, judging from our seven years’ experience, an outpatient nursing service can make a valuable contribution
to
their
care.
Glasg.
CLINICAL ASSISTANT, DEPARTMENT OF PSYCHOLOGICAL UNIVERSITY COLLEGE
MEDICINE, HOSPITAL, LONDON, W.C.I
H. H. WOLFF Cantab., M.R.C.P.
M.D.
PHYSICIAN, BETHLEM ROYAL AND MAUDSLEY HOSPITALS; ASSISTANT, DEPARTMENT OF PSYCHOLOGICAL MEDICINE,
CLINICAL
UNIVERSITY COLLEGE HOSPITAL
IN this country very little has so far been done to prepare the medical student for the psychotherapeutic aspects of his future work. O’Neillhas described a scheme in which students allowed to take on psychiatric patients for psychotherapy under supervision; and for the past three years we have been working on a similar scheme at University
were
College Hospital. It was started in order to teach students something about simpler forms of psychotherapy; but an added reason was our students’ frequent complaint that they were told a good deal about psychotherapy but never saw it in action. The psychotherapeutic relationship is so delicate that attempts at demonstrating it to students are not easy. To have students sitting in during a session is liable to disturb both patient and therapist. On the other hand we felt that students would gain much if they could have some personal experience. PRELIMINARY TRAINING
give all the students in our school some understanding of the relationship between the patient and his doctor and of the patient’s reaction to his illness. As Tredgold2 has explained, this teaching begins even before the students come into the psychiatric department. In the introductory course there are psychiatric lectures, demonstrations, and group discussions. While the students are clerking in the medical and obstetric wards, members of the psychiatric department teach them by interviewing patients in their presence, using a psychodynamic interview technique and making a number of simple interpretations. Afterwards these interviews are We try
to
discussed with the students so as to make them aware of what was going on between the patient and psychiatrist and to give them some idea of psychopathology. We do the same again later, while the students are clerking in the psychiatric department, by conducting diagnostic interviews of outpatients with the students present and by giving them the opportunity of taking psychiatric histories themselves. Students are also seen in small groups for detailed discussion of case-histories. METHOD
When all the students have thus gained some theoretical concept of psychotherapy and seen it in action, albeit superficially, they may volunteer to take on a patient themselves for treatment. Because of the time and energy demanded of them, 1. 2.
we
felt that such work
L., O’Neill, Davies, T. T., Davies, Tredgold, R. F. ibid. 1962, i, 1344. E. T.
D.
must
Lancet, 1958, ii,
34.
be
all surgical wounds in an aseptic dressing-room wound cross-infection could be eliminated. Administratively, greater use could be made of hospital beds. Instead of a fixed number of beds being allotted to each consultant to be filled at his discretion, he would receive beds as needed for the treatment of his patients. Under the present system, with the inflexible fixed number of beds per specialist, many beds remain unoccupied in some specialties which could well be filled by other specialties; but this is seldom done. The hospital building programme for the next ten years gives us an opportunity to improve the living conditions of patients and the working conditions of hospital staff. The money for the programme has been promised; what we need now is imagination.
AVERAGE MONTHLY RETURN OF A
*
e.g.,
NURSE’S
WORK
assisting M.w.o., seeking absconded patients, moving patients’ contacting (L.H.A. welfare services).
property,
THE MENTAL NURSE IN THE COMMUNITY A. R. MAY M.B. Lond., M.R.C.P.E., D.P.M. CONSULTANT PSYCHIATRIST
S. MOORE S.R.N., R.M.N., S.T.D. CHIEF MALE NURSE
WARLINGHAM PARK
HOSPITAL,
SURREY
THE Mental Health Act of 1959 directed attention to the possibilities of treatment outside the mental hospital, and the new policy of extramural care is to be reinforced by a drastic reduction in hospital beds. Many centres of progressive psychiatry had anticipated these trends, and it is already clear that the shift of emphasis from hospital to community will mean a redistribution of medical and nursing staff as well as closer integration with local health authorities. Successful physical methods of treatment, new and potent drugs, and the increased tolerance of mental illness by the public at large have made community care feasible on a large scale. But it cannot work without staff, and the coordination of this new kind of therapeutic team presents problems unfamiliar to a hospital. From a practical viewpoint, the new policy means that extramural care must now be provided for a group of mainly psychotic patients who would previously have been treated in hospital. This group includes convalescent patients discharged from hospital earlier than hitherto, patients who may have relapsed after previous remission, and new patients who are not thought to need inpatient care.1 Most of the group will probably be cared for in dayhospitals or outpatient clinics, or by their family doctors, with specialist advice where necessary. But in some the disability mainly reflects social maladjustment, and these may be helped by psychiatric social workers (P.s.w.s), or mental welfare officers (M.w.o.s) under psychiatric supervision. Ultimately successful management of these patients depends on having adequate staff of all grades, and deploying it efficiently and economically. OUTPATIENT
Since 1954
NURSES
Warlingham Park Hospital
has seconded
qualified mental nurses to extramural duties in the borough of Croydon, whose population of 250,000 is served by the hospital. We began doing this because of the shortage of P.s.w.s and because
recognised the need for condischarged patients. These outpatient nurses ", who were based on the hospital, we
tinued supervision of 1.
our
May, A. R. Lancet, 1961, i, 760.
between the hospital and the patient when discharged and helped him to reestablish himself community. At first two nurses (a man and a woman) were allocated; but, as the work grew, two more were seconded, and the total of four has remained fairly constant, subject to demands on staff for new developments within the hospital. During the past few years, the role of these outpatient nurses has been modified in the light of experience, and they are now an important part of Croydon’s integrated district psychiatric service.2 We believe we can now formulate the following principles:
kept
contact
he was in the
1. Though the nurses are in close contact with P.s.w.s, M.w.o.s, and other local health authority agencies, and though the greater part of their work lies outside the hospital, they should remain on the nursing establishment of the hospital and within its medico-nursing administrative framework. Not only does this arrangement avoid conflict with traditional loyalties,
but it also facilitates
interchange with other nursing staff and secondment of trainees. 2. Because of her training, the qualified mental nurse is well fitted to assess the mental state of a patient, especially if she already knows the patient. It is in this nurse-patient relation that the real value of the outpatient nurse is most clearly seen. 3. The outpatient nurse can reassure and encourage patients, supervise the medication prescribed by the doctor, detect deficiencies in personal habits and care and often remedy them, and relieve the anxieties of relatives by timely explanation. regular
HOW
The
THE
SCHEME
WORKS
work exclusively with outpatients, and have no hospital duties. Though some may live in the hospital, they work from an office in the mental health centre which is attached to our day hospital in Croydon. It is an advantage for a nurse to be able to drive a car or scooter. We have one hospital car for the service, but nurses are encouraged to use their own vehicles and are nurses
paid mileage. Each nurse is given a number of regular patients. We try to give her patients she already knows; but geographical proximity, sex, and total case-load have also to be considered. Occasional work is distributed as convenient. " Each nurse’s regular patients constitute a ward ", and a formal " ward round " is held weekly in the centre under Other the psychiatrist coordinating community care. interested doctors and a P.s.w. come to this meeting; and each nurse reviews the patients in her ward. Decisions about further action are taken where necessary. Thus a patient may be brought to see the psychiatrist, or the P.s.w. may be asked to help in some complex social problem beyond the scope of the nurse. 2.
May,
A.
R., Sheldon, A.P., MacKeith, S. A. ibid. (1962), ii, 1319.
214
The function of the nurse is of course different from P.S.W. Her approach is primarily clinical. Detailed investigation of the patient’s family or modification of his environment, is not expected. Often nurse, P.s.w., and M.w.o. may all be helping a single " problem case ". Informal contact between these groups is easy and frequent, but the weekly meeting coordinates the work, and overlap is avoided because each is responsible to the
Medical Education
that of the
AN EXPERIMENT IN
THE TEACHING OF PSYCHOTHERAPY TO MEDICAL STUDENTS DOROTHEA H, BALL
psychiatrist. Patients
M.B.
referred to the service from among those the mental hospital, from the psychiatric from discharged unit in the local general hospital, from the day hospital, and from outpatient clinics. Exceptionally, the nurse’s visit may supplement routine attendance at a clinic. 60-70 patients are seen at present for routine clinical assessment. 25-30 will be visited at least once a week and the rest less often. Nurses make a monthly return of all visits, indicating the reason for each, and an average monthly return, based on three months ending Jan. 31, 1962, is shown in the accompanying table. Most of the patients seen on routine visits have been in hospital before and are known to be prone to relapse. Of 72 patients on the " ward " list on Jan. 31, 1962, 27 had one previous admission to Warlingham Park Hospital, and 37 had been admitted more than once. Of these 64 patients, 48 had been discharged within the past year. The diagnostic are
were schizophrenia 29; affective disorders 23; longstanding neurotic illness 11; and senile dementia 9. Regular supervision of patients makes up the bulk of visits, but there are a good many personal inquiries to discover why patients have not kept appointments at clinics. Nearly always these are schizophrenic patients;
categories .
they fail to continue with phenothiazine drugs the relapse-rate is high. and if
One
also attends each of five afternoon outpatient clinics (each with 2-3 doctors) four evening aftercare groups for long-term patients, and three evening social clubs. nurse
DISCUSSION
Nurses have taken part in this work voluntarily, and, while some were uncertain about it at first, the experience has clearly given them all great personal and professional satisfaction. As members of a larger team they have benefited from closer contact with all the services sharing in community care, while the novel experience of visiting patients in their homes has shown the importance of environmental stress and social factors in psychiatric illness. The help given by the service is freely acknowledged by the psychiatrists who use it, particularly for geriatric patients. The acute pressure on these beds can often be alleviated by regular home visits which relieve the anxiety of relatives and encourage them to accept responsibility-even if only temporarily-for elderly people. The trend towards extramural management of psychiatric patients needs more than an increase in outpatient clinics and domiciliary visits by a consultant. Many patients are more or less chronically disabled, and their care and
supervision outside hospital would overtax already overcrowded clinics. Yet some provision must be made for them. The possibility of relapse in recently discharged patients, especially schizophrenics, poses similar problems in supervision. Yet we believe that these patients are properly the responsibility of a comprehensive community psychiatric service, and, judging from our seven years’ experience, an outpatient nursing service can make a valuable contribution
to
their
care.
Glasg.
CLINICAL ASSISTANT, DEPARTMENT OF PSYCHOLOGICAL UNIVERSITY COLLEGE
MEDICINE, HOSPITAL, LONDON, W.C.I
H. H. WOLFF Cantab., M.R.C.P.
M.D.
PHYSICIAN, BETHLEM ROYAL AND MAUDSLEY HOSPITALS; ASSISTANT, DEPARTMENT OF PSYCHOLOGICAL MEDICINE,
CLINICAL
UNIVERSITY COLLEGE HOSPITAL
IN this country very little has so far been done to prepare the medical student for the psychotherapeutic aspects of his future work. O’Neillhas described a scheme in which students allowed to take on psychiatric patients for psychotherapy under supervision; and for the past three years we have been working on a similar scheme at University
were
College Hospital. It was started in order to teach students something about simpler forms of psychotherapy; but an added reason was our students’ frequent complaint that they were told a good deal about psychotherapy but never saw it in action. The psychotherapeutic relationship is so delicate that attempts at demonstrating it to students are not easy. To have students sitting in during a session is liable to disturb both patient and therapist. On the other hand we felt that students would gain much if they could have some personal experience. PRELIMINARY TRAINING
give all the students in our school some understanding of the relationship between the patient and his doctor and of the patient’s reaction to his illness. As Tredgold2 has explained, this teaching begins even before the students come into the psychiatric department. In the introductory course there are psychiatric lectures, demonstrations, and group discussions. While the students are clerking in the medical and obstetric wards, members of the psychiatric department teach them by interviewing patients in their presence, using a psychodynamic interview technique and making a number of simple interpretations. Afterwards these interviews are We try
to
discussed with the students so as to make them aware of what was going on between the patient and psychiatrist and to give them some idea of psychopathology. We do the same again later, while the students are clerking in the psychiatric department, by conducting diagnostic interviews of outpatients with the students present and by giving them the opportunity of taking psychiatric histories themselves. Students are also seen in small groups for detailed discussion of case-histories. METHOD
When all the students have thus gained some theoretical concept of psychotherapy and seen it in action, albeit superficially, they may volunteer to take on a patient themselves for treatment. Because of the time and energy demanded of them, 1. 2.
we
felt that such work
L., O’Neill, Davies, T. T., Davies, Tredgold, R. F. ibid. 1962, i, 1344. E. T.
D.
must
Lancet, 1958, ii,
34.
be