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A personal reflection on my experience as a Mental Health Nurse in New Zealand

By Richard Lakeman (1995) This year I have had the opportunity to reflect on my practice as a New Zealand nurse who has worked in various mental health settings. The question "What differentiates the practice of psychiatric nurses from other disciplines working in mental health settings?" was high on my agenda of questions to explore, largely because I had noticed a blurring of roles assumed by nurses and other disciplines in the areas in which I have worked. In my quest to answer the question I read widely on the nature of nursing and posed my question to whomever would listen. A definitive answer continues to elude me but through the process of inquiry, other questions to do with philosophy, values, power and oppression, have arisen which inform the original question. The question posed reflects a quest for personal meaning in relation to my practice. Personal meaning is not formed and shaped in isolation from our sociocultural context (Street, 1991). I originally prepared the following brief account of some of my work experiences in order to identify my motivations for asking the question. For me the account has become a further source of reflection. Street (1991) states that we make choices from a multiplicity of choices. What we write or record may begin in an arbitrary fashion, but as questions emerge we may begin to focus on specific incidents for a more detailed analysis. The following account includes a number of value judgements about practices and processes which I have been involved in. What I have chosen to omit or include reflects my values, tensions and contradictions in practice at least as much as it serves the purpose of identifying why I have chosen to ask the question "What differentiates the practice of psychiatric nurses from other disciplines?" My entry into the world of psychiatric nursing followed what was once a typical course for many nurses. Having had my grounding in medical and surgical nursing I obtained employment in a large, rural psychiatric hospital as a registered nurse. Talk of deinstitutionalisation and a shift to a community focus had been going on for over fifteen years but at this time the talk had not yet become reality. It took me many months to become clear about the role of the registered nurse in the areas in which I worked but my identity as a nurse always remained intact. Registered nurses, enrolled nurses and psychiatric assistants outnumbered the other disciplines who had direct patient contact. The nursing staff cared for patients twenty four hours a day. There was a clear hierarchy of power, various designations of nursing staff, charge nurses, nursing supervisors and head nurse. If ones professional identity became shaky then one could always wear the uniform and medals as a reminder of who you were and what you represented. A comfortable but distant relationship existed between nurses and other disciplines. Everyday those patients that were able, would migrate to the occupational therapy department or recreational hall where occupational therapists and recreation officers would engage them in interesting art, craft and recreational activities. This provided welcome respite for the remaining patients and nurses who enjoyed the extra space in an otherwise claustrophobic and emotionally charged environment. A privileged few would derive a sense of purpose and achievement from working in the canteen or on "activation gang", work duty supervised by nurses. The psychology, social work and Maori liaison departments were housed in separate parts of the hospital. Some patients would have appointments with these other professionals for a chat, therapy, psychological testing or family meetings. Occasionally they would visit the villas, or wards for team meetings, where treatment or management difficulties were discussed. Generally however, "the doing" of treatment was left to the nurses. Some nurses became particularly good at managing the inevitable conflict between patients arising from cramped living conditions and disturbed behaviour. This was a valued skill. In fact managing conflict was

seen as a fundamental skill of nursing. Soon after transferring to a locked admission ward of the hospital I was involved in a frightening confrontation with an acutely ill patient. The nursing supervisor of the time latter commented to me that this "was real nursing" and advised me "to get involved in conflict" and my discomfort would resolve. Nurses were expected to set and enforce limits on patients behaviour and back up the other members of the team. It was very clear that the environment, placing limits on peoples behaviour and sometimes the manner of the staff precipitated much unnecessary conflict but there were occasions where conflict was inevitable. I quickly learned that affecting change at any level in the institution was difficult. There was a unique and well established institutional culture. Apparently most things had been tried before and failed. Any initiative that conflicted with the status quo required the approval of several levels of senior staff and the endorsement of the entire team. There appeared to be an unspoken rule that you did what was expected, not make waves and that you take advantage of the many opportunities for overtime that were available. Good nursing and innovations did occur but these were largely due to the vision and tenacity of a few respected individuals. At this time loose primary nursing models were used in most parts of the hospital. This allowed nurses to have formally recognised, special relationships with patients. Staff had informal relationships with patients borne of sometimes many years of shared experience in the hospital. Nicknames for patients and chiding remarks reflected a friendly, paternalistic, parent like attitude of many staff towards patients. Nursing care plans were starting to become in vogue as the process of care came under increasing scrutiny from outside agencies involved in deinstitutionalisation and providing community care. As the villas of the "open side" of the hospital began to empty of patients, nursing staff took redundancy or moved on to other jobs. I moved on to an acute psychiatric unit attached to a general hospital. The physical layout and culture were very different from where I had come from. The clients (as they were now called) were somewhat different too, in that they tended to come from the community, and did not have a long history of containment in large institutions. At that time particularly difficult clients were transferred to other, more secure facilities. The atmosphere in this acute facility was more permissive and there appeared to be an emphasis on clients maintaining self-responsibility and control. An entire multi-disciplinary team consisting of doctors, nurses, psychologists, occupational therapists, social workers and latter Maori health workers were located in the one building. Other disciplines such as dietitians, pharmacists, physiotherapists and medical specialists were much more accessible. Management encouraged staff to utilise and develop their individually acquired skills. Thus some nurses practiced massage and aromatherapy, others group or family therapy and others were practicing and developing their skills in various counselling techniques. As well as specialising in these various activities, nurses continued to provide twenty four hour care. Nurses utilised their crisis management skills on the ward and by being accessible to clients outside the hospital by phone. The recent changes to the Mental Health Act acknowledged the skills of nurses in assessment and sanctioned another nursing role, that of designated authorised officer. Nurses provided physical nursing care when required and performed delegated medical tasks such as administering and assessing the efficacy of medication or assisting with ECT. Liaison with family members and community key workers was an important role for the nurse. Multidisciplinary meetings were held regularly to plan care and treatment. It is my opinion that an outside observer would have been hard pressed to discern who was what in a team meeting. The psychiatrist would have perhaps been the easiest to spot as he or she would have probably expressed a strong, and likely unchallenged opinion on the clients medical treatment or legal status under the Mental Health Act. The nurse may have been identified by his or her giving a rapid account of the clients presentation over the last twenty four hours and perhaps appearing a little edgy as she or he would have been mindful of ongoing responsibilities for clients while the meeting was going on.

A team member might have expressed a conceptualisation of a client's problems in terms of family group dynamics, psychoanalytical, behavioural or developmental theory. Whether the perspective was accepted and used to direct therapy would depend on how forceful and articulate the person was and how congruent this perspective was with the world views of the rest of the team. Different disciplines appeared to share a common language in the conceptualising of problems according to the above theories, which was a good thing. However discerning a unique perspective arising from the various disciplines present would have been difficult. Notably absent was a perspective derived from nursing theory. The nursing process was vigorously pursued and numerous inventories of nursing diagnosis could be found in the staff room and nursing station. Some nurses appeared skilled in assessment and were able to undertake thorough mental status examinations and elicit insightful social histories. What is more they were able to rapidly discern what was immediately relevant in a situation and provide a tentative, often accurate guess at the medical diagnosis. However this embodied knowledge was not reflected in the written nursing care plans. The nursing care plan which was often synonymous with the treatment plan was in vogue. There was a requirement that the care plan reflected the teams wishes, was readily understandable to the team and client, involved the client in its formulation and reflected the clients goals. There was no universally accepted theoretical or philosophical basis for the care plans. Clearly identified nursing models were not used to guide the gathering of data, identification of problems and implementation of the plan. So care plans, tended to be either a team treatment plan, a client's list of goals, a list of things to do, or an impersonal entity borrowed heavily from the text books available on the ward with vague, non-specific interventions. Not surprisingly care plans were often a source of conflict, or a focus for criticism, as it was not possible that they could, simultaneously be all that people wished of them. While useful for communicating the limits required to be imposed on client's behaviour or listing tasks to be accomplished, they appeared to lack utility in the basic function of guiding nursing care and affecting positive outcomes for the client. Rather than being a means to and end, the care plan appeared to be pursued as an end in its own right. It was clear that the quality of nursing was judged on the care plan which made it an anathema to those that held nursing to be primarily an interpersonal process or other than a list of tasks to complete. What appeared to be missing was a glue, in the form of a coherent and shared framework to bind the care plan or the phases of the nursing process together. The progress notes reflected the same difficulty that nurses had in communicating what it was they did as nurses. The understanding was that notes were to be kept to a minimum, should be concise and relevant. The problem being that what was relevant for one team member or nurses in general was irrelevant to others. What might otherwise have been a useful forum to chronicle the development and phases of a therapeutic relationship inevitably became a list of tasks completed and a brief outline of observed behaviour and current symptoms. The problem arising for me from these observations is describing and prescribing what nurses do, and particularly what they do differently from others. In this workplace at least, nurses appeared to lack a common or possibly a concise language with which to describe what they did as nurses with clients that made a difference. In practice there was little dilemma, as nurses were developing and using generic mental health skills such as counselling, massage and group facilitation, to good effect. What is more they shared a common language with medicine and other disciplines with a shared social science background. So therapy was described and prescribed in terms of medicine, behaviour modification, cognitive therapy, family therapy etc. What appeared unique to nursing as workers in the context of this workplace was the provision of a twenty four hour service and the responsibilities entailed in running a psychiatric ward, administering medication, attending to physical care, being accessible to clients and managing the many crises that tended to arise. Implicit in the role of nurse was the ability to calm, counsel and allay anxiety in the client.

At this time the health system and mental health services in particular was undergoing an unprecedented rate of change. Community, day hospital and forensic services were expanding and new roles for nurses were developing. I had the privileged opportunity of working as a coordinator and facilitator of therapeutic groups in the inpatient unit. It was in this role that I first seriously considered the question of what differentiated the work of nurses from others. In this role I was required to view the client in terms of the group. I no longer had responsibility for coordinating overall "care" for the client and I worked ordinary working hours. I looked to occupational therapists and a few nurses, who were skilled and committed to group work as a therapeutic modality for supervision and guidance. I have no doubt that participation in groups had a positive impact on the wellbeing of clients. Groups provided a cost-effective way to provide education and experiential learning in coping strategies, as well as having a therapeutic value much more readily gained from participation in a group eg. a sense of universality. Was group facilitation really nursing? I had my doubts when on a few occasions that I worked as a nurse on the ward my colleagues would make comments such as "You're doing some real work today!". With a few exceptions, participation in and facilitation of group therapy was shunned by nurses. Motivating nursing staff to be involved in participation or facilitation and presenting the program in a positive light to their clients was an ongoing challenge. Other disciplines were enthusiastic and required little encouragement in participating. A number of reasons were cited by nurses for their lack of enthusiasm for groups. some did not see it as their role; were too busy and groups were low priority tasks; fear of making mistakes; and probably most significantly group facilitation was a public task and nurses felt uncomfortable having their practice under public scrutiny. My next role was in a day hospital setting. Group therapy was valued by the nurses, occupational therapist and activities officer who worked in this facility. Considerable autonomy was afforded to the staff in this unit in terms of assessment, planning care and providing therapy. The nurses and occupational therapist assumed key worker roles, and utilised the small team for problem solving and sharing ideas. Members of the team had different strengths and approaches to care. One might take a Rogerian approach to counselling while another might take a cognitive approach. All utilised a standard assessment format and formulated a plan of care and therapy based on identified problems as well as identifying clear discharge criteria. The nurses acted as resource persons regarding medications and the occupational therapist made it clear that functional assessments were her domain, however there the difference in roles ended. A close working relationship developed between day hospital and health workers in the community. A key worker system operated in my area where by a key person was associated with each client of the mental health services in the community. Previously the exclusive domain of nurses, this role was now being filled by social workers, psychologists, occupational therapists and lay people. The key workers were grouped in teams, with a psychiatrist in each team, who assumed responsibility for the medical management of each individual. Individual's various areas of expertise were acknowledged and utilised by the team eg. a client might be referred to the psychologist for psychometric testing, or the OT for functional assessments. Nurses were rostered on depot medication clinics. The key worker role however was fairly homogenous. On reflection it appears difficult to identify commonalities in what psychiatric nurses do in the many different contexts in which they work. There is an obvious body of knowledge allied to medicine such as psychopharmacology which nurses draw on and which entails certain responsibilities in some contexts. Some nurses I have spoken to, view application of the nursing process as a unifying activity in nursing. However most health professionals use a problem solving process of assessment, identification of problems, planning, implementation and evaluation in their work. Nurses may claim that they view problems differently eg. in terms of human responses but in reality this approach often leads to interventions, which are the same as those used by other health professionals.

Conspicuously absent from my account thus far, has been any personalised account of practice or interaction with clients. In the course of recounting some experiences of working in a large psychiatric hospital with colleagues, we entered into a long discussion about the many different characters we had met. What struck me was how, even years latter, we were able to remember names, idiosyncrasies, family details and what worked effectively in our dealings with these individuals. We had come to know our clients so well they had left a lasting impression on us. One colleague commented that nursing is all about getting to know someone, establishing a relationship. Even armed with a piece of paper outlining a persons entire life history, effective nursing would be impossible without establishing a relationship. In all the contexts of nursing described, the nurse attempted to meet the needs of the client in the context of a relationship, this is perhaps a defining characteristic of nursing. However nursings' hegemony in developing relationships with the clients of mental health services is under challenge. Caring for the chronically mentally ill, once the domain of nurses is rapidly being usurped by community trusts and lay care givers with minimal training and little compulsion to adhere to codes of ethics. Although these clients may be cared for intermittently by nurses when they are admitted with a relapse for treatment in an acute unit. Occupational therapists and social workers now fill the roll of keyworker along side nurses in some areas. The warnings of Hughes and Hennessy (1994), that nurses will become generic health workers may well be coming to fruition. I am aware that in some areas other disciplines are claiming the keyworker or case manager role as their exclusive domain. So much for the collegiality that might be traded for a generic role in a multidisciplinary team. A colleague of mine suggested to me that nurses are not the ones who are losing their identities or being forced to become generic health workers. Other disciplines are the ones who are changing to be more like nurses, in recognition that the continuity of care and therapeutic potential inherent in developing one key relationship with a mental health worker is the most cost effective and therapeutically effective way of providing care. Arguably nurses have always been the generic health worker. They have traditionally done what ever has needed to be done to ensure peoples health needs were met. Many disciplines such as occupational therapy, physical therapy and social work have evolved as a result of health professionals claiming and developing specialised knowledge related to traditional nursing activities (Smith, 1992). This has often been good for the client but has done little for the nursing profession. I wonder what nursing will claim for its own. There is a great depth of expertise and experience amongst nurses who have worked with mentally ill clients for many years. It is only too apparent that nursing has not always provided a good service but it is unfair to judge past practices out of historical context. Is this knowledge about nursing care to be lost in favour of generic mental health skills? Are we to become undifferentiated in our practice from other disciplines? The answers to these questions are in our hands