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The rise of public sector psychosocial nursing
The Rise of Public Sector Psychosocial Nursing Oliver H. Osborne, R. Jalane Hagerott, Illa Hilliard, and Mary Durand Thomas
For a number of years, the Department of Psychosocial Nursing, University of Washington, engaged in a region-wide State-University collaboration with the Division of Mental Health authorities in states of the Pacific Northwest. This collaboration provided the basis for another 12 years of a Washington State Division of Mental Health-Department of Psychosocial Nursing contract to improve nursing in the state’s two mental hospitals. This article describes the history, contractual relationships, and components of these projects. It concludes with a discussion of the consequences of these years of State-University cooperation. including conceptual issues, and the generation of the psychosocial nursing subspeciafty, public sector psychosocial nursing.
Copyright 0 1993 by W.B. Saunders Company
T
HIS ARTICLE describes more than 18 years of collaboration between the University of Washington Department of Psychosocial Nursing and Division of Mental Health authorities in states of the Pacific Northwest. It summarizes the basis for the Department’s engagement in these StateUniversity collaborations, discusses an early interstate State-University collaboration, and concludes with an assessment of the State-University collaborations as a strategy for social change and a factor in the development of the emerging psychosocial nursing specialty, public sector nursing. The history of care of the mentally ill includes such stages as the premoral, moral, institutionalization, mental health, medical, psychodynamic, reinstitutionalization, and other eras (Osborne, 1987). A contemporary focus is cooperation between clinical settings and educational institutions, that is, State-University collaboration. The StateUniversity collaboration is a programmatic effort to orient university mental health education and research programs toward the needs of the most severely psychosocially disabled who are the primary consumers of public mental health services (Special Section on State-University Collaboration, 1991). This movement represents a program of planned social change and, as such, is an attempt to use the university to achieve mental health policy objectives. Archives of Psychiatric Nursing, Vol. VII, No. 3 (June), 1993:
Collaboration between government and academia for social change is not new. The first serious and sustained mental health collaborative effort came with the creation of the National Institute of Mental Health (NIMH) in 1946. Using the mechanism of grants and contracts, the federal government engaged universities in mental health research and the education of mental health professionals. The collaborative approach to change was reincarnated in the form of the federal government mental health policy change programs of the late 1960s and early 1970s. Then, the concern was that community mental health centers were serving people who complained of minor emotional and social difficulties and neglecting the needs of the recently deinstitutionalized severely mentally ill.
From the Department of Psychosocial Nursing, Department of Anthropology, University of Washington, Seattle, WA Western State Hospital, Ft. Steilacoom, WA and Eastem State Hospital, Medical Lake, WA This article is an expanded version of an article published in Hospital & Community Psychiatry in October 1992. Address reprint requests to Mary Durand Thomas, RN, CS, PhD, Associate Professor, Department of Psychosocial Nursing, SC-76, University of Washington School of Nursing, Seattle, WA 98195. Copyright 0 1993 by W.B. Saunders Company 0883-9417/93/0703-0003$3.0000/0
pp. 133-138
133
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Using a wide variety of mechanisms, the federal government progressively refocused the programs of these community agencies toward the needs of underserved racial minorities, children, aged, and deinstitutionalized patients. NIMH funding priorities for university programs reflected these emphases. THE BASES FOR PARTICIPATION
In the early 1970s the Department of Psychosocial Nursing enlarged its traditional focus on individuals and families to include social-cultural curriculum components. These new components emphasized facilitating change in systems, particularly mental health systems. This work was articulated through the NIMH-funded SystemsOriented Community Mental Health Program (SOCMHP). THE SOCMHP
In 1974, building on two existing community mental health courses, the Department developed and implemented the five-quarter SOCMHP. SOCMHP was designed to prepare psychosocial nursing graduates to plan, administer, and evaluate mental health programs. Additional goals were to introduce state mental health administrators to psychosocial nursing faculty and students and to infuse psychosocial nursing knowledge and perspectives into state planning processes. Acceptance of the program was gratifying. Students quickly gained access to internships in state mental health administrative offices in Idaho, Washington, Alaska, and Oregon. As the number of SOCMHP students grew, placements were developed in regional community mental health centers. Increasing demands for their services soon outstripped the number of student applicants. By the late 197Os, direct NIMH support for mental health education was declining. Instead, states received federally funded block grants. Although portions of this money could be used for the preparation of mental health personnel, Idaho, Oregon, and Alaska could not justify allocating these funds to a Washington educational program. The SOCMHP was terminated. Attention focused on establishing stronger relationships between the Department and the Washington State Division of Mental Health.
THE CONTRACT PROJECT
In that time period, despite successful collaborations, the leadership of the State Division of Mental Health harbored doubts about its relationships with the University. A succession of Division directors argued that the University was a state agency and, therefore, its social work, psychosocial nursing, psychology, psychiatry, and other mental health programs should dedicate much of their effort to the state’s official mental health mission. Yet they resisted involvement with the University, fearing that it might overwhelm their scarce resources. This fear was not entirely unfounded because the reduction of NIMH funding for University programs had forced University departments to aggressively search for alternative resources. State officials also believed the University was primarily interested in research and teaching rather than providing clinical services. Finally, they believed that faculty and students lacked interest in the severely mentally and socially disabled populations that were the state’s primary responsibility. These fears were resolved in 1979 when the division hired a former faculty member of the University of Washington Department of Psychiatry as director of the Division of Mental Health. This director understood the culture and unique mission of the University. She and faculty of the Department of Psychosocial Nursing entered into discussions that resulted in a Division-Department contract designed to improve the quality of nursing in the state hospitals (Osborne, 1986; Thomas, 1987; Osborne, Hagerott, Hilliard, & Thomas, 1992). The exact meaning of quality was not defined. However, it was agreed that the department would provide a variety of programs designed to increase the number of psychosocial nurses employed in the state hospitals and to raise their level of education, clinical abilities, and professionalism. There are two state psychiatric hospitals in Washington. Western State Hospital is located in the Puget Sound region, a 60-minute drive from the University. The smaller Eastern State Hospital is located across the Cascade Mountains, 350 miles to the east. Both the Division and the Department agreed that equivalent programs would be provided to each hospital. Initially, the contract allowed for a full-time lecturer and a half-time program assistant, with funding for travel to Eastern
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State Hospital. Resources have increased as the project matured: funding now includes the salary of a full-time associate professor, consultants, and a project coordinator. The Department has consistently allocated more than 30% time of a senior faculty member as Principal Investigator. This group comprises the contract faculty and staff. In addition, the contract supports travel, communications, equipment, supplies, and other project activities. These activities include graduate study, appointment of clinical faculty, seminars, certification study, research, a fellowship program, conferences , and enhancement of communication. Graduate Study
One of the more challenging components of the project has been recruiting baccalaureate-prepared nurses into graduate school. The first mechanism used was a state-sponsored tuition program coupled with a state hospital service-payback agreement. The goal of this program was to attract students with advanced preparation to state hospital employment. This program did not thrive, and after 3 years it was dropped. Even the neediest students resisted the requirement for state hospital employment that made them feel like indentured servants. A service-payback strategy can only work if the service requirement is seen as desirable. The second and more productive approach was aimed at attracting the increasing number of baccalaureate-prepared nurses who, as a result of improved salaries, have entered state hospital employment. These students are enrolled in contractsupported graduate-extension courses held on-site at the hospitals. After successful participation in this program, students are encouraged to enter the regular graduate program. Clinical Faculty
State hospital nurses with masters degrees and a demonstrated interest in the contract project are invited to apply for clinical faculty status in the department. Currently, 12 state-hospital nurses are members of the clinical faculty. They form the leadership group that makes the project work on a daily basis. Their faculty activities include informing their colleagues of the contract project and encouraging their participation, acting as clinical consultants to the faculty, engaging in state hospital-department
research projects, offering seminars, and teaching undergraduate and graduate classes in areas of their expertise. Based on their specialization and the needs of the hospitals, a clinical specialist from one hospital may act as consultant to the other hospital. Seminars
Each year, the project faculty and hospital leadership staff design a year-long seminar program for registered nurses. These popular seminars are frequently attended by nonnurse professionals and paraprofessionals as well as nurses. Seminar presentations may be given by faculty, clinical faculty, or other community experts, who are paid as consultants to the project. Certification Study Groups
One means of achieving the development of clinical expertise among the nurses is to facilitate their certification as psychiatric-mental health nurse generalists or specialists. This has been done through sponsoring and leading certification study groups, and the provision of resource materials. This project component has been extremely successful and is increasingly managed by members of the clinical faculty. Research
Collaborative staff-faculty research projects are designed and implemented to achieve two major goals: (1) research training, and (2) development of knowledge of state hospital nursing practice. Two projects have been completed and published (Osborne, Murphy, Leichman, Hagerott, Griffin, Ekland, et al., 1990; Thomas, Ekland, Griffin, Hagerott, Leichman, Murphy, et al., 1990). Two other projects are nearing completion (Ray & Hilliard 1992; Thomas, Osborne, Beaven, Blacksmith, Ekland, Hagerott, et al., 1992). The Fellowship Program
In 1990, a State Hospital Nursing Fellowship program designed to develop advanced management and clinical leadership skills was initiated. This program encourages the exchange of nurses between hospitals and provides opportunities for nurses from other state hospital systems to study aspects of the Washington system and to complete a special project.
136
Conferences
In 1986, the successes of the project provided the stimulus for the Western Interstate Commission for Higher Education (WICHE) conference, The Changing Role of Nurses in State Hospitals (Davis & Sanchez, 1987). In 1990, the contract project sponsored the first national conference on Public Sector Psychosocial Nursing in Institutions: Formulating the Subspecialty (Special Issue: Public Sector Psychosocial Nursing, 1991). This conference was designed to identify the need and specify the research, education, and clinical practice parameters of public sector nursing. A second national conference held in 1992, Public Sector Psychosocial Nursing: Empowering for Patient Care, focused on ways to further clarify the specialty and to release the potential of public-sector nurses. Enhancement of Communications
Throughout the years, the greatest difficulty confronting the project has been maintenance of good communications between the administrators of the division, hospital superintendents, nursing service directors, clinical faculty, the many nurses on each shift at each hospital, and the department faculty. Memos, letters, telephone calls, and hospital newsletters were the communication tools used during the early years of the project. As the complexity of the project has increased, additional means have been used. A project brochure, “Nursing Excellence: Pathways to Professionalism,” describes the components of the contract project and how nurses can participate in them. This brochure is also used by the hospital nursing departments in recruitment. In addition, a newsletter published by the Public Sector Project keeps the staff updated on upcoming seminars, courses, and other project events, and recognizes achievements such as certification. There is also a yearly meeting of nurse leaders that has been dubbed “The Middle Earth Conference” because it is held half-way between the hospitals. This meeting allows the participants to share information about their hospitals and communities , discuss past and future project activities, meet with state hospital and community mental health leaders, develop their professional relationships, act as role models, solve difficult clinical
OSBORNE ET AL
problems, dispel false rumors, and generally improve intrahospital and interhospital communications . STATE-UNIVERSITY COLLABORATION RECONSIDERED
A Strategy For Social Change
Popular mental health political advocacy suggests that, in contrast to the past when they were situated in remote settings, contemporary state hospitals are an integral part of the community and community health services. Numerous barriers to the full integration of state hospitals into communities still exist. The control of politicians and government bureaucrats prevails. They remain large, formidable institutions, usually surrounded by small towns or suburban communities. The numerous people they employ often have few ties to the local community. Their mission to accept and treat the committed severely mentally ill carries with it the corollary of protecting the public from the presumed and real dangers of this population. These are some of the factors that continue to make state hospitals, their patients, and employees feel isolated and embattled. The State-University collaboration experience exposed this sense of isolation and embattlement as a primary barrier to the development of professionalism among state hospital nurses. Study of both the failures and successes of the contract project showed that the most potent project activities were those that required individual nurses to surmount such formidable barriers as their different work shifts, doors of their wards, gates of their hospitals, real and imagined restrictions upon their behavior, entrenched status differences, and invidious public stereotypes of them, their patients, and their place of work. Without deprecating their inherent value, analysis of the meaning of each project component clearly indicated that their most powerful combined effect was to facilitate the nurses’ interactions with each other, the faculty, nurses in the other hospital, their clinical specialists, directors, and superintendents, University graduate students, and a wide variety of other people. In addition, the project called on participants to travel to other hospitals, present papers and lectures, engage in research programs, and plan and administer projects. Before the institution of the
PUBLIC SECTOR PSYCHOSOCIAL
NURSING
contract project there was virtually no discourse between the nurses of the two hospitals. Only rumors and a sense of competition prevailed about imagined and actual practices in these different places. Today, there are strong collegial relationships between the different hospital staffs and between the hospital staffs and the university faculty. Individual nurses freely call on each other for support and information about a wide range of clinical, administrative, educational, research, and other matters. The Directors of Nursing affirm that the collaboration has not only proved a vital contribution to the recruitment and retention of staff, it has also motivated them to reach out beyond the contract project for other knowledge-building opportunities. It is this social intercourse with other groups that has been the most potent tool of social change. These new and challenging experiences combined to stimulate the nurses’ intellect, sense of adventure, and self-confidence. A general heightening of joie de vivre and a view of their specialty as exciting has been a most important, albeit serendipitous, result of the project. The workings of the State-University collaboration as shown by this contract also needs to be considered. It has been noted that the contemporary State-University collaboration initiative is reminiscent of such mental health system programs of planned change as the initiation of the NIMH and the policy changes of the late 1960s and early 1970s. The many different mental health epochs have also been noted. All of these changes testify to a unique volatility in mental health legislation, legislative oversight, programs, and administrative personnel at both the federal and local levels. Each new hospital administrator comes with a different policy mandate and personal view of the hospital’s mission and how to achieve it. All this instability results in the development of organizational rigidities and creates a free-floating fear and loathing of any change on the part of many employees. In addition, hospital administrators are not always tolerant of the differences in culture and mission between the service delivery and university systems. Moreover, it is the service agency that controls the money, contains the programs, has primary responsibility for the patients, and defines the ultimate terms of the contracts. Consequently, there is an imbalance of power. In comparison, the mission, internal dynamics,
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and programs of the University are relatively stable, despite the sometimes barbaric consequences of its publish-or-perish ethic. Most university health science faculty, especially nurse faculty, often have years of service-provider experience in health agencies. It is important that faculty engaged in long-term relationships with public agencies do not abandon their scholarly responsibilities. They must avoid being co-opted by the service priorities of the clinical agency, continuing flow of State-University collaboration money, and their reluctance to upset hard-won relationships. They must remind themselves that their unique contribution to the State-University collaboration is not their uncritical melding with the ideology, structure, politics, and economics of public institutions. Rather, they must maintain a certain strategic, intellectual, investigative, and moral distance. This reserve will allow them to develop, advocate, and test theories that challenge it-rationalities in the system and inpatient care traditions. For the Department, perhaps the most profound understanding derived from the State-University collaboration is that an impressively large, but undetermined, measure of state hospital nursing practice is determined by the history, culture, social organization, economics, politics, and physical environment in which it is practiced. Further, the social facts discerned from the State-University collaboration experience forces the conclusion that these undetermined conditions apply to nursing practice in most public-supported institutions. Years of exposure to these collaboration conditions resulted in the identification of the psychosocial nursing subspecialty of public sector psychosocial Nursing which is conceived as nursing practice in tax-supported environments. Such nursing is more than a social good. That is, it is more than caring for the unwell. Equally, it is a social necessity and an instrument of social, political, and economic policy, as much driven by the demands of the environments in which it is practiced as by the needs of patients. As a social necessity it is practiced in tax-supported institutions that are subject to changing public ideologies about sickness, populations that are sick, financing for their care, and the types of care they must receive (Osborne & Thomas,1991). The Department’s long engagement in StateUniversity collaboration has not only benefitted the service agencies. It has provided significant
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insights into long-overlooked, little-understood, and significant aspects of psychosocial nursing practice. It has generated the notion that the almost exclusive traditional focus on the nurse-patient relationship must be re-examined. If accepted by the profession, these insights have the potential for redefining the parameters of psychosocial nursing and, by extension, significantly improving state hospital nursing. ACKNOWLEDGMENT The authors acknowledge the support received from the interagency agreement between the Division of Mental Health of the Washington State Department of Social and Health Services and the Department of Psychosocial Nursing, University of Washington. REFERENCES Davis, M., & Sanchez, M. (Eds.). (1987). The changing role of nurses in state hospitals: Problems and solutions.
Boulder, Co: WICHE. Osborne, O.H. (1986). Problems and solutions: Hospitaluniversity nursing collaboration. In The Changing role of the state hospital. Boulder, Co: WICHE. Osborne, O.H. (1987). The changing role of nurses in state hospitals: Problems and solutions. In M. Davis & M. Sanchez (Eds.), The changing role of nurses in state hospitals: Problems and solutions. Boulder, Co: WICHE. Osborne, O.H., Hagerott, R. J., Hilliard, I., & Thomas, M.D. (1992). A state-university collaboration to improve state hospital nursing care. Hospital Community Psychiatry, 43, 1040-1041.
ET AL
Osborne, O.H., Murphy, H., Leichman, S. S., Hagerott, R.J., Griffin, M., Ekland, E.S., & Thomas, M.D. (1990). Forced relocation of hospitalized psychiatric patients. Archives of Psychiatric Nursing, 4, 221-227.
Osborne, O.H., & Thomas, M.D. (1991). On public sector psychosocial nursing: A conceptual framework. Journal of Psychosocial Nursing and Mental Health Services, 29, 13-18.
Ray G.J., & Hilliard, I. (1992, May). Caringforpersons
with
schizophrenia: Implications of nursing diagnoses and nursing dependency. Paper presented at Public Sector
Psychosocial Nursing National Conference II: Empowering for Patient Care, Seattle, Washington. Special issue: Public sector psychosocial nursing. (1991). Journal of Psychosocial Nursing and Mental Health Services, 29, 4-47.
Special section on state-university collaboration. (1991). Hospital & Community Psychiatry, 42, 39-73.
Thomas, M.D. (1987). Improving state psychiatric hospital nursing care: the Washington experience. In M. Davis & M. Sanchez (Eds.), The changing role of nurses in state hospitals: Problems and solutions. Boulder, Co: WICHE. Thomas, M.D., EkIand, E.S., Griffin, M., Hagerott, R.J., Leichman, S.S., Murphy, H., Osborne, O.H. (1990). Intrahospital relocation of psychiatric patients and effects on patient aggression. Archives of Psychiatric Nursing. 4, 154-160.
Thomas, M.D., Osborne, O.H., Beaven, J., Blacksmith, J.M., Ekland, E., Hagerott, R.J., Hilliard, I., Kelly, J.T., Kennedy, M., Leichman, S., & Thurston, J. W. (1992, May). Meanings of State Hospital Psychosocial Nursing. Paper presented at Public Sector Psychosocial Nursing Conference II: Empowering for Patient Care, Seattle, Washington.
For a number of years, the Department of Psychosocial Nursing, University of Washington, engaged in a region-wide State-University collaboration with the Division of Mental Health authorities in states of the Pacific Northwest. This collaboration provided the basis for another 12 years of a Washington State Division of Mental Health-Department of Psychosocial Nursing contract to improve nursing in the state’s two mental hospitals. This article describes the history, contractual relationships, and components of these projects. It concludes with a discussion of the consequences of these years of State-University cooperation. including conceptual issues, and the generation of the psychosocial nursing subspeciafty, public sector psychosocial nursing.
Copyright 0 1993 by W.B. Saunders Company
T
HIS ARTICLE describes more than 18 years of collaboration between the University of Washington Department of Psychosocial Nursing and Division of Mental Health authorities in states of the Pacific Northwest. It summarizes the basis for the Department’s engagement in these StateUniversity collaborations, discusses an early interstate State-University collaboration, and concludes with an assessment of the State-University collaborations as a strategy for social change and a factor in the development of the emerging psychosocial nursing specialty, public sector nursing. The history of care of the mentally ill includes such stages as the premoral, moral, institutionalization, mental health, medical, psychodynamic, reinstitutionalization, and other eras (Osborne, 1987). A contemporary focus is cooperation between clinical settings and educational institutions, that is, State-University collaboration. The StateUniversity collaboration is a programmatic effort to orient university mental health education and research programs toward the needs of the most severely psychosocially disabled who are the primary consumers of public mental health services (Special Section on State-University Collaboration, 1991). This movement represents a program of planned social change and, as such, is an attempt to use the university to achieve mental health policy objectives. Archives of Psychiatric Nursing, Vol. VII, No. 3 (June), 1993:
Collaboration between government and academia for social change is not new. The first serious and sustained mental health collaborative effort came with the creation of the National Institute of Mental Health (NIMH) in 1946. Using the mechanism of grants and contracts, the federal government engaged universities in mental health research and the education of mental health professionals. The collaborative approach to change was reincarnated in the form of the federal government mental health policy change programs of the late 1960s and early 1970s. Then, the concern was that community mental health centers were serving people who complained of minor emotional and social difficulties and neglecting the needs of the recently deinstitutionalized severely mentally ill.
From the Department of Psychosocial Nursing, Department of Anthropology, University of Washington, Seattle, WA Western State Hospital, Ft. Steilacoom, WA and Eastem State Hospital, Medical Lake, WA This article is an expanded version of an article published in Hospital & Community Psychiatry in October 1992. Address reprint requests to Mary Durand Thomas, RN, CS, PhD, Associate Professor, Department of Psychosocial Nursing, SC-76, University of Washington School of Nursing, Seattle, WA 98195. Copyright 0 1993 by W.B. Saunders Company 0883-9417/93/0703-0003$3.0000/0
pp. 133-138
133
134
OSBORNE ET AL
Using a wide variety of mechanisms, the federal government progressively refocused the programs of these community agencies toward the needs of underserved racial minorities, children, aged, and deinstitutionalized patients. NIMH funding priorities for university programs reflected these emphases. THE BASES FOR PARTICIPATION
In the early 1970s the Department of Psychosocial Nursing enlarged its traditional focus on individuals and families to include social-cultural curriculum components. These new components emphasized facilitating change in systems, particularly mental health systems. This work was articulated through the NIMH-funded SystemsOriented Community Mental Health Program (SOCMHP). THE SOCMHP
In 1974, building on two existing community mental health courses, the Department developed and implemented the five-quarter SOCMHP. SOCMHP was designed to prepare psychosocial nursing graduates to plan, administer, and evaluate mental health programs. Additional goals were to introduce state mental health administrators to psychosocial nursing faculty and students and to infuse psychosocial nursing knowledge and perspectives into state planning processes. Acceptance of the program was gratifying. Students quickly gained access to internships in state mental health administrative offices in Idaho, Washington, Alaska, and Oregon. As the number of SOCMHP students grew, placements were developed in regional community mental health centers. Increasing demands for their services soon outstripped the number of student applicants. By the late 197Os, direct NIMH support for mental health education was declining. Instead, states received federally funded block grants. Although portions of this money could be used for the preparation of mental health personnel, Idaho, Oregon, and Alaska could not justify allocating these funds to a Washington educational program. The SOCMHP was terminated. Attention focused on establishing stronger relationships between the Department and the Washington State Division of Mental Health.
THE CONTRACT PROJECT
In that time period, despite successful collaborations, the leadership of the State Division of Mental Health harbored doubts about its relationships with the University. A succession of Division directors argued that the University was a state agency and, therefore, its social work, psychosocial nursing, psychology, psychiatry, and other mental health programs should dedicate much of their effort to the state’s official mental health mission. Yet they resisted involvement with the University, fearing that it might overwhelm their scarce resources. This fear was not entirely unfounded because the reduction of NIMH funding for University programs had forced University departments to aggressively search for alternative resources. State officials also believed the University was primarily interested in research and teaching rather than providing clinical services. Finally, they believed that faculty and students lacked interest in the severely mentally and socially disabled populations that were the state’s primary responsibility. These fears were resolved in 1979 when the division hired a former faculty member of the University of Washington Department of Psychiatry as director of the Division of Mental Health. This director understood the culture and unique mission of the University. She and faculty of the Department of Psychosocial Nursing entered into discussions that resulted in a Division-Department contract designed to improve the quality of nursing in the state hospitals (Osborne, 1986; Thomas, 1987; Osborne, Hagerott, Hilliard, & Thomas, 1992). The exact meaning of quality was not defined. However, it was agreed that the department would provide a variety of programs designed to increase the number of psychosocial nurses employed in the state hospitals and to raise their level of education, clinical abilities, and professionalism. There are two state psychiatric hospitals in Washington. Western State Hospital is located in the Puget Sound region, a 60-minute drive from the University. The smaller Eastern State Hospital is located across the Cascade Mountains, 350 miles to the east. Both the Division and the Department agreed that equivalent programs would be provided to each hospital. Initially, the contract allowed for a full-time lecturer and a half-time program assistant, with funding for travel to Eastern
PUBLIC SECTOR PSYCHOSOCIAL
135
NURSING
State Hospital. Resources have increased as the project matured: funding now includes the salary of a full-time associate professor, consultants, and a project coordinator. The Department has consistently allocated more than 30% time of a senior faculty member as Principal Investigator. This group comprises the contract faculty and staff. In addition, the contract supports travel, communications, equipment, supplies, and other project activities. These activities include graduate study, appointment of clinical faculty, seminars, certification study, research, a fellowship program, conferences , and enhancement of communication. Graduate Study
One of the more challenging components of the project has been recruiting baccalaureate-prepared nurses into graduate school. The first mechanism used was a state-sponsored tuition program coupled with a state hospital service-payback agreement. The goal of this program was to attract students with advanced preparation to state hospital employment. This program did not thrive, and after 3 years it was dropped. Even the neediest students resisted the requirement for state hospital employment that made them feel like indentured servants. A service-payback strategy can only work if the service requirement is seen as desirable. The second and more productive approach was aimed at attracting the increasing number of baccalaureate-prepared nurses who, as a result of improved salaries, have entered state hospital employment. These students are enrolled in contractsupported graduate-extension courses held on-site at the hospitals. After successful participation in this program, students are encouraged to enter the regular graduate program. Clinical Faculty
State hospital nurses with masters degrees and a demonstrated interest in the contract project are invited to apply for clinical faculty status in the department. Currently, 12 state-hospital nurses are members of the clinical faculty. They form the leadership group that makes the project work on a daily basis. Their faculty activities include informing their colleagues of the contract project and encouraging their participation, acting as clinical consultants to the faculty, engaging in state hospital-department
research projects, offering seminars, and teaching undergraduate and graduate classes in areas of their expertise. Based on their specialization and the needs of the hospitals, a clinical specialist from one hospital may act as consultant to the other hospital. Seminars
Each year, the project faculty and hospital leadership staff design a year-long seminar program for registered nurses. These popular seminars are frequently attended by nonnurse professionals and paraprofessionals as well as nurses. Seminar presentations may be given by faculty, clinical faculty, or other community experts, who are paid as consultants to the project. Certification Study Groups
One means of achieving the development of clinical expertise among the nurses is to facilitate their certification as psychiatric-mental health nurse generalists or specialists. This has been done through sponsoring and leading certification study groups, and the provision of resource materials. This project component has been extremely successful and is increasingly managed by members of the clinical faculty. Research
Collaborative staff-faculty research projects are designed and implemented to achieve two major goals: (1) research training, and (2) development of knowledge of state hospital nursing practice. Two projects have been completed and published (Osborne, Murphy, Leichman, Hagerott, Griffin, Ekland, et al., 1990; Thomas, Ekland, Griffin, Hagerott, Leichman, Murphy, et al., 1990). Two other projects are nearing completion (Ray & Hilliard 1992; Thomas, Osborne, Beaven, Blacksmith, Ekland, Hagerott, et al., 1992). The Fellowship Program
In 1990, a State Hospital Nursing Fellowship program designed to develop advanced management and clinical leadership skills was initiated. This program encourages the exchange of nurses between hospitals and provides opportunities for nurses from other state hospital systems to study aspects of the Washington system and to complete a special project.
136
Conferences
In 1986, the successes of the project provided the stimulus for the Western Interstate Commission for Higher Education (WICHE) conference, The Changing Role of Nurses in State Hospitals (Davis & Sanchez, 1987). In 1990, the contract project sponsored the first national conference on Public Sector Psychosocial Nursing in Institutions: Formulating the Subspecialty (Special Issue: Public Sector Psychosocial Nursing, 1991). This conference was designed to identify the need and specify the research, education, and clinical practice parameters of public sector nursing. A second national conference held in 1992, Public Sector Psychosocial Nursing: Empowering for Patient Care, focused on ways to further clarify the specialty and to release the potential of public-sector nurses. Enhancement of Communications
Throughout the years, the greatest difficulty confronting the project has been maintenance of good communications between the administrators of the division, hospital superintendents, nursing service directors, clinical faculty, the many nurses on each shift at each hospital, and the department faculty. Memos, letters, telephone calls, and hospital newsletters were the communication tools used during the early years of the project. As the complexity of the project has increased, additional means have been used. A project brochure, “Nursing Excellence: Pathways to Professionalism,” describes the components of the contract project and how nurses can participate in them. This brochure is also used by the hospital nursing departments in recruitment. In addition, a newsletter published by the Public Sector Project keeps the staff updated on upcoming seminars, courses, and other project events, and recognizes achievements such as certification. There is also a yearly meeting of nurse leaders that has been dubbed “The Middle Earth Conference” because it is held half-way between the hospitals. This meeting allows the participants to share information about their hospitals and communities , discuss past and future project activities, meet with state hospital and community mental health leaders, develop their professional relationships, act as role models, solve difficult clinical
OSBORNE ET AL
problems, dispel false rumors, and generally improve intrahospital and interhospital communications . STATE-UNIVERSITY COLLABORATION RECONSIDERED
A Strategy For Social Change
Popular mental health political advocacy suggests that, in contrast to the past when they were situated in remote settings, contemporary state hospitals are an integral part of the community and community health services. Numerous barriers to the full integration of state hospitals into communities still exist. The control of politicians and government bureaucrats prevails. They remain large, formidable institutions, usually surrounded by small towns or suburban communities. The numerous people they employ often have few ties to the local community. Their mission to accept and treat the committed severely mentally ill carries with it the corollary of protecting the public from the presumed and real dangers of this population. These are some of the factors that continue to make state hospitals, their patients, and employees feel isolated and embattled. The State-University collaboration experience exposed this sense of isolation and embattlement as a primary barrier to the development of professionalism among state hospital nurses. Study of both the failures and successes of the contract project showed that the most potent project activities were those that required individual nurses to surmount such formidable barriers as their different work shifts, doors of their wards, gates of their hospitals, real and imagined restrictions upon their behavior, entrenched status differences, and invidious public stereotypes of them, their patients, and their place of work. Without deprecating their inherent value, analysis of the meaning of each project component clearly indicated that their most powerful combined effect was to facilitate the nurses’ interactions with each other, the faculty, nurses in the other hospital, their clinical specialists, directors, and superintendents, University graduate students, and a wide variety of other people. In addition, the project called on participants to travel to other hospitals, present papers and lectures, engage in research programs, and plan and administer projects. Before the institution of the
PUBLIC SECTOR PSYCHOSOCIAL
NURSING
contract project there was virtually no discourse between the nurses of the two hospitals. Only rumors and a sense of competition prevailed about imagined and actual practices in these different places. Today, there are strong collegial relationships between the different hospital staffs and between the hospital staffs and the university faculty. Individual nurses freely call on each other for support and information about a wide range of clinical, administrative, educational, research, and other matters. The Directors of Nursing affirm that the collaboration has not only proved a vital contribution to the recruitment and retention of staff, it has also motivated them to reach out beyond the contract project for other knowledge-building opportunities. It is this social intercourse with other groups that has been the most potent tool of social change. These new and challenging experiences combined to stimulate the nurses’ intellect, sense of adventure, and self-confidence. A general heightening of joie de vivre and a view of their specialty as exciting has been a most important, albeit serendipitous, result of the project. The workings of the State-University collaboration as shown by this contract also needs to be considered. It has been noted that the contemporary State-University collaboration initiative is reminiscent of such mental health system programs of planned change as the initiation of the NIMH and the policy changes of the late 1960s and early 1970s. The many different mental health epochs have also been noted. All of these changes testify to a unique volatility in mental health legislation, legislative oversight, programs, and administrative personnel at both the federal and local levels. Each new hospital administrator comes with a different policy mandate and personal view of the hospital’s mission and how to achieve it. All this instability results in the development of organizational rigidities and creates a free-floating fear and loathing of any change on the part of many employees. In addition, hospital administrators are not always tolerant of the differences in culture and mission between the service delivery and university systems. Moreover, it is the service agency that controls the money, contains the programs, has primary responsibility for the patients, and defines the ultimate terms of the contracts. Consequently, there is an imbalance of power. In comparison, the mission, internal dynamics,
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and programs of the University are relatively stable, despite the sometimes barbaric consequences of its publish-or-perish ethic. Most university health science faculty, especially nurse faculty, often have years of service-provider experience in health agencies. It is important that faculty engaged in long-term relationships with public agencies do not abandon their scholarly responsibilities. They must avoid being co-opted by the service priorities of the clinical agency, continuing flow of State-University collaboration money, and their reluctance to upset hard-won relationships. They must remind themselves that their unique contribution to the State-University collaboration is not their uncritical melding with the ideology, structure, politics, and economics of public institutions. Rather, they must maintain a certain strategic, intellectual, investigative, and moral distance. This reserve will allow them to develop, advocate, and test theories that challenge it-rationalities in the system and inpatient care traditions. For the Department, perhaps the most profound understanding derived from the State-University collaboration is that an impressively large, but undetermined, measure of state hospital nursing practice is determined by the history, culture, social organization, economics, politics, and physical environment in which it is practiced. Further, the social facts discerned from the State-University collaboration experience forces the conclusion that these undetermined conditions apply to nursing practice in most public-supported institutions. Years of exposure to these collaboration conditions resulted in the identification of the psychosocial nursing subspecialty of public sector psychosocial Nursing which is conceived as nursing practice in tax-supported environments. Such nursing is more than a social good. That is, it is more than caring for the unwell. Equally, it is a social necessity and an instrument of social, political, and economic policy, as much driven by the demands of the environments in which it is practiced as by the needs of patients. As a social necessity it is practiced in tax-supported institutions that are subject to changing public ideologies about sickness, populations that are sick, financing for their care, and the types of care they must receive (Osborne & Thomas,1991). The Department’s long engagement in StateUniversity collaboration has not only benefitted the service agencies. It has provided significant
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OSBORNE
insights into long-overlooked, little-understood, and significant aspects of psychosocial nursing practice. It has generated the notion that the almost exclusive traditional focus on the nurse-patient relationship must be re-examined. If accepted by the profession, these insights have the potential for redefining the parameters of psychosocial nursing and, by extension, significantly improving state hospital nursing. ACKNOWLEDGMENT The authors acknowledge the support received from the interagency agreement between the Division of Mental Health of the Washington State Department of Social and Health Services and the Department of Psychosocial Nursing, University of Washington. REFERENCES Davis, M., & Sanchez, M. (Eds.). (1987). The changing role of nurses in state hospitals: Problems and solutions.
Boulder, Co: WICHE. Osborne, O.H. (1986). Problems and solutions: Hospitaluniversity nursing collaboration. In The Changing role of the state hospital. Boulder, Co: WICHE. Osborne, O.H. (1987). The changing role of nurses in state hospitals: Problems and solutions. In M. Davis & M. Sanchez (Eds.), The changing role of nurses in state hospitals: Problems and solutions. Boulder, Co: WICHE. Osborne, O.H., Hagerott, R. J., Hilliard, I., & Thomas, M.D. (1992). A state-university collaboration to improve state hospital nursing care. Hospital Community Psychiatry, 43, 1040-1041.
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Osborne, O.H., Murphy, H., Leichman, S. S., Hagerott, R.J., Griffin, M., Ekland, E.S., & Thomas, M.D. (1990). Forced relocation of hospitalized psychiatric patients. Archives of Psychiatric Nursing, 4, 221-227.
Osborne, O.H., & Thomas, M.D. (1991). On public sector psychosocial nursing: A conceptual framework. Journal of Psychosocial Nursing and Mental Health Services, 29, 13-18.
Ray G.J., & Hilliard, I. (1992, May). Caringforpersons
with
schizophrenia: Implications of nursing diagnoses and nursing dependency. Paper presented at Public Sector
Psychosocial Nursing National Conference II: Empowering for Patient Care, Seattle, Washington. Special issue: Public sector psychosocial nursing. (1991). Journal of Psychosocial Nursing and Mental Health Services, 29, 4-47.
Special section on state-university collaboration. (1991). Hospital & Community Psychiatry, 42, 39-73.
Thomas, M.D. (1987). Improving state psychiatric hospital nursing care: the Washington experience. In M. Davis & M. Sanchez (Eds.), The changing role of nurses in state hospitals: Problems and solutions. Boulder, Co: WICHE. Thomas, M.D., EkIand, E.S., Griffin, M., Hagerott, R.J., Leichman, S.S., Murphy, H., Osborne, O.H. (1990). Intrahospital relocation of psychiatric patients and effects on patient aggression. Archives of Psychiatric Nursing. 4, 154-160.
Thomas, M.D., Osborne, O.H., Beaven, J., Blacksmith, J.M., Ekland, E., Hagerott, R.J., Hilliard, I., Kelly, J.T., Kennedy, M., Leichman, S., & Thurston, J. W. (1992, May). Meanings of State Hospital Psychosocial Nursing. Paper presented at Public Sector Psychosocial Nursing Conference II: Empowering for Patient Care, Seattle, Washington.