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OF mental health care and mentally ill

Development of community mental health nursing

Closure of the large mental hospitals and their replacement by smaller units attached to local district hospitals, and the development of day hospitals and community-care facilities had a marked impact on the practice of mental health nursing from the 1960s. May and Moore (1963) describe the work of two (later four) nurses seconded from Warlingham Park Hospital in 1954 to visit patients discharged from hospital and now living in Croydon. These ‘outpatient’ nurses saw ex-patients suffering from schizophrenia and depression, and their duties were to:

monitor their compliance with medication and attendance at outpatient clinics;

assess and monitor their mental state;

monitor difficulties in their personal habits and seek to improve these and;

reassure relatives. Their role was clinical and investigation and reporting patients’ family and social circumstances was not expected; this was the remit of the psychiatric social worker. Each nurse was responsible for a ward of patients. They attended a weekly ward round, and also outpatient clinics and evening aftercare groups. McNamee (1993) reports that Moorhaven Hospital established what was known as a ‘Nursing After-Care’ service in 1957. This differed from the Warlingham Park Hospital service in that it involved nurses working both in the wards as well as with patients who had been discharged. It is ironic that more than 40 years later this flexible model of working which offers one approach to bridging the gap between inpatient and community care is rarely seen in practice. Moorhaven Hospital community psychiatric nurses (CPNs) were expected to build relationships with their patients and to use this as a medium for care delivery and for helping patients to cope with the effects of their illness. Thus, the nurse was envisaged as a therapeutic agent, a role that served also to enhance the status of nursing at the time. The CPN role continued to develop. According to Hunter (1974) their functions in the 1960s included:

providing practical assistance to patients and their families (for example, help bathing and shaving patients);

giving advice particularly to patients’ families on medication, monitoring its side effects and cooperating with general practitioners and psychiatrists to reduce these;

acting as a link between the ward and community and facilitating admission in the event of relapse;

ensuring continuity of care for designated groups of patients (including those with schizophrenia, recurrent depression and organic psychosis);

supervising patients in outpatient clinics;

assisting in running social clubs and work groups; and

assisting patients to gain employment and accommodation on discharge from hospital.

The CPN role expanded to assume social and rehabilitative functions particularly from the 1970s following the Local Authority Social Services Act, which abolished specialist social workers for people with mental health problems. CPNs began to offer crisis intervention, group work, psychotherapy and behaviour therapy. However, in the 1960s and 1970s CPNs worked primarily within hospital treatment teams, received all referrals from hospital consultants and carried out care programmes that were medically oriented. A change of emphasis away from medical domination towards a more autonomous social model of care followed attachment of CPNs to general practice in Oxford and elsewhere in the 1970s. These CPNs accepted referrals from many sources (open referral system), including each other, and developed into far more independent practitioners responsible for patient assessment, and also planning and implementing an appropriate care package. Later, though, attachment of CPNs to primary-care teams was criticized  for deflecting the attention of nurses towards the so-called ‘worried well’ and away from the needs of people with serious mental illness who are a government priority for mental health care. Thus the trend has been towards CPNs operating in secondary mental health services based in community mental health teams. In the early 1970s, and particularly following the White Paper, Better Services for the Mentally Ill, there was a growing lobby for specialist community training for mental health nurses. The Joint Board of Clinical Nursing Studies (JBCNS) established a committee to examine requirements for an approved community psychiatric nurse (CPN) course that did not overlap with the requirements for district nurses or health visitors. It was agreed that a separate course was needed to produce highly trained nurses who could meet the specific needs of mentally ill people. In 1974 the JBCNS published the Outline Curriculum in Community Psychiatric Nursing for Registered Nurses. This 36–39 week course was designed to prepare Registered Mental Nurses (RMNs) to work in multiprofessional environments and to give both rehabilitative and therapeutic care in the community. A major element of the course was community placement, particularly with the community psychiatric service, which the student would join following qualification (White 1990a). The first CPN course was started by Chiswick College in 1973 (White 1990a) and, by the end of the 1970s, CPNs had achieved independent recognition and other colleges and polytechnics were running courses. CPNs worked from general practice clinics or accepted referrals from other agencies, and developed specialist skills to assist and work with care groups and organizations. Increased specialization of CPNs and other mental health nurses from the 1970s mirrored and was sometimes forced by increased specialization by their medical colleagues.

An important example was the development of training for nurses in behaviour therapy by Isaac Marks at the Maudsley Hospital from 1972. This led to the English National Board (ENB) course 650 – ‘Short-term Adult Behavioural Psychotherapy’, which was the first of a series of post-registration courses to provide community mental health nurses with specialist skills and a specific therapeutic orientation. A more recent example is the Thorn Programme developed and disseminated from the Institute of Psychiatry, King’s College London, and the University of Manchester, which trains mental health nurses and other professionals to deliver research-based care and treatment programmes to people suffering from severe and enduring mental illness.

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