Institutionalisation

Following the industrial revolution and the relocation of the population in towns and cities, there was a growth in poverty and ill health (Nolan 1993). This represented an increasing problem for those experiencing mental health problems who were unable to afford the private asylums in operation at the time. Within England, concern over the conditions and treatment within private asylums facilitated a drive for lunacy reform (Porter 2002). Subsequent legislation between 1809 and 1845 allowed for the allocation of funds to build public asylums. This reflects a period of the growth of institutions across Europe and Western societies (Wright 1997). It represented a marked optimism for the benefits of the asylum, underpinned by the growing psychiatric profession and the commitment to institutional care as the vehicle to provide a cure for insanity (Rogers & Pilgrim 2001).

Throughout the history of mental health care, the beliefs and understanding of professionals and the public on the causation of mental health problems have influenced the manner in which people have been treated and the drive for “cures”. In the early days of asylums, treatments were defined by a need for physical restraint on patients. During this period, in the eighteenth and early nineteenth centuries, individuals caring for the inmates of the asylum were termed ‘keepers’. The implications of such a title suggest that those individuals had a role in restricting and controlling the movements of those admitted to the asylum (Nolan 1993).

The optimism for the benefits of a new public asylum system during the mid nineteenth century supported opportunity for the development of pioneering approaches to the management of mental illness developed within the UK and across Europe (Digby 1985, Porter 2002). This included attempts to abandon and reduce the use of physical restraint, examples of which can be seen in the work of Pinel in France, Chiaguri in Italy and Hill and Connelly in England (Porter 2002). 1796 also witnessed the establishment of the York retreat, a Quaker institution founded on the principles of Christian humanism which recognised the humanity of those experiencing mental health problems and promoted moral therapy which attempted to enable individuals to remain included within society (Digby 1985, Nolan 1993).

Within the new public system, after the 1845 Lunacy Act, the role of keeper emerged into one of attendant. The attendant's role was one that involved the most daily contact with people admitted to asylums and they were responsible for their day-to-day care and engagement in work within the asylum. Attendants worked under the direction of the medical superintendent (Nolan 1993). Nolan (1993) notes some early examples of individual superintendents and institutions providing training for attendants but it was not until the very end of the nineteenth century that formalised training was introduced. During this time problems were experienced with the recruitment and conduct of attendants, though pay and conditions were very poor. Pessimism in the asylum system began to spread in the late nineteenth century as asylums became overcrowded and did not deliver the cure for insanity initially hoped for (Porter 2002).

If the history of mental health services and psychiatric hospitals is an area that you are interested in, here is a list of resources that you might find helpful. They include fiction books, video clips and Websites.

At the turn of the twentieth century, attendants had become known as nurses and the term “mental nurse” was officially instigated on the nursing register in 1923. This reflected the increasing role of psychiatry and the medical approach to understanding mental health problems and therefore nursing was the most appropriate way to care for and treat the mentally ill. During the early part of the century, asylums became known as hospitals. The introduction of the Mental Treatment Act in 1930 represented some attempt to challenge the stigma associated with mental illness that was perpetuated by compulsory treatment through the introduction of voluntary admission. This was underpinned by a desire to treat mental illness within a public health framework (Freeman 1998).

During the twentieth century, further developments in the treatment of mental illness occurred. This included the evolution of a psychodynamic theory pioneered by Freud. However, alongside such developments, treatments were advocated such as psychosurgery which involved removal of parts of the brain thought to be implicated in the symptoms of mental illness. Insulin therapy was also used which involved administering large doses of insulin to cause a coma. These types of treatment, among others, have been heavily criticised as highly dangerous and abusing a population perceived as vulnerable within society. Ion and Beer (2003) warn of the need for us to avoid naively criticising the past without questioning how our own practices may be perceived through the lens of history.

This is particularly poignant given the ethical debates concerning the use of electroconvulsive therapy (ECT) and the damaging impact of psychiatric medication. While there are different perspectives among professionals, service users and families about the use of these interventions today, they are regularly employed to treat mental health problems. The controversies surrounding the use of ECT and psychiatric medication could suggest that their use as treatment may be perceived differently in years to come.

Antipsychotic medication was introduced in the 1950s at a time when the physical state of Victorian asylums was deteriorating and changes in mental health legislation allowed for a more open-door policy within psychiatric hospitals. Public faith in the psychiatric hospital system was diminished through a series of public inquiries and published stories concerning ill treatment, abuse and neglect in hospitals (e.g. Robb 1967). This also occurred within the context of the development of the “antipsychiatry” movement. Key thinkers, such as RD Laing and T Szasz, some of whom were trained psychiatrists, challenged some of the assumptions that mental health problems were a distinct mental illness. A number of antipsychiatrists proposed that mental illness does not exist at all and that people's experiences were the product of an “insane” society. These, combined with other factors, culminated in an announcement by Enoch Powell, in the famous water tower speech, that psychiatric hospitals were consigned to the past and the future of mental healthcare delivery lay in the community. It was also during this time that a humanistic understanding of mental health problems was advocated by Carl Rogers (1967) and the interpersonal nature of nursing was emphasised by the work of Hildegard Peplau (1952).

Over the next 30 years, psychiatric hospitals gradually closed. Historians suggest that care in the community for people with mental health problems has existed for many years including during the asylum era (Wright 1997). However, it is the closure of mental hospitals which contributed to the growth of community nursing and the significant expansion in community services that reflects the model of care delivery we see today. In-patient beds were concentrated in smaller units and district general hospitals rather than distinct large psychiatric hospitals. Many of the service users today who have had long-term needs may have experience of being admitted to an asylum, and this is an area that you might want to explore with them once you have established the therapeutic relationship; particularly considering narratives from people with experience of using services are fairly invisible within the history of mental health care.

This historical overview has given an indication of the negative problems associated with the asylum system which has also been criticised for perpetuating stigma and social exclusion through separating people with mental health problems from the remainder of society. However, it is essential to recognise some of the potential benefits of the asylum system, not least as it appeared to offer the best structure for treatment and support to people during their evolution in the Victorian era. Some who have experience of being admitted to psychiatric hospitals speak positively of the peace, quiet and space that were available in the institutions that often had sports grounds, farms and gardens. Social opportunities for connecting with others were also part of the structure of psychiatric hospitals which is important to bear in mind given that isolation remains a barrier to social inclusion and positive mental health for those living in the community.

The majority of mental health services are delivered in the community setting and as a student mental health nurse you will have the opportunity to work in these areas. The evolution of the community teams as the main structures of support for service users provided an important opportunity to challenge the segregation of people with mental health problems and enable people to continue relationships and roles in wider society. This continues to be one of the main areas in which mental health nurses provide support for service users. However, community care has not been without its critics. The closure of psychiatric hospitals and the establishment of community services were chronically underfunded. There was concern that people discharged from psychiatric hospitals were vulnerable to homelessness or ending up as part of the prison population due to a lack of adequate support available in the community setting. During the mid 1990s there were a small number of high-profile incidents of violence related to service users. This led to severe criticism from the press and some charities concerning the appropriateness of supporting people with experience of mental health problems in the community. These incidents and the media and public response to them have been suggested to have had a significant influence on governmental mental health policy at the time, in particular the development of the Care Programme Approach (Hannigan & Cutcliffe 2002). This is explored in more detail in Chapter 8.

The introduction of Modernising Mental Health Services (Department of Health (DH) 1998) and the National Service Framework for Mental Health (DH 1999) outlined the hopes of a new government in tackling these concerns regarding the provision of mental health services and for ensuring the care provided to service users was effective and of good quality. These documents had a significant impact on the structure and development of services and were designed to be underpinned by significant financial investment, though there remains concern that the funding imbalances have not been redressed and mental health care remains a “Cinderella service”.

Over the past 200 years the role of supporting people with mental health problems has evolved from one of keeper of the insane to one of a mental health nurse working alongside people experiencing mental distress. This overview has provided a very brief insight into some of the factors that have informed and shaped this development. An appreciation of the historical roots of the profession is important in order to understand the issues of power and control experienced within mental health services today. In particular, this concerns the contested nature of treatments in mental health alongside the stigma associated with being “consigned to an institution”. Many of these issues bear relevance to today and are picked up in different ways throughout the book. Chapter 3 deals with the philosophies and theories governing contemporary mental health care, some of which you will see have their origins in theories of Rogers and Peplau highlighted here. As you work through this chapter it would be beneficial to think about the similarities and differences between these and what you have read here. Chapter 9 also considers psychiatric medication and enabling people to make choices about their treatment, while Chapter 7 explores the therapeutic relationship and some of the barriers to this. Perhaps more importantly, it is through the professionals and service users that you work with in practice where the relevance of this history may become most apparent, particularly for those who have witnessed and been part of the changes discussed here.

What is a mental health nurse?

Mental health nurses work across many diverse settings including GP surgeries, accident and emergency departments, community teams and in-patient psychiatric wards, although there are core skills and values which are integral to this work whatever the setting. This book provides an overview of such capabilities and explores the theory and learning that underpin them in relation to the student practice experience. As you gain familiarity with the literature relating to mental health you may come across debates surrounding the focus and boundaries of the mental health nursing role. This has been influenced by the origin of mental health services, the rapidly changing context of health care over the past 50 years as well as the lack of agreement as to the exact cause and therefore best treatment of mental ill health. This culminates in a situation where it is perhaps more difficult to answer that important question,“what does a mental health nurse do?” than it initially seems.

The last statement has highlighted that it is sometimes difficult to define and identify what is involved in mental health nursing. Often it is a role that can be less visible within media and public information and therefore hard to recognise what it entails until there is the opportunity to gain experience. Some of you may have had this opportunity before starting your first mental health placement.

Where might a mental health nurse work?

A mental health nurse can work in a vast variety of different settings. Figure 1.1 is an overview of some of the areas where a mental health nurse may work. This provides some examples of the settings where you could be based (though there may be others that you come across in the course of your training). Chapter 5 goes into more specific detail about each of these areas.

Fig 1.1 Areas of mental health nursing practice. (A) Points of access to service. (B) Community support. (C) In-patient care

The following section defines the nature of mental health nursing work in more detail, aiming to help you begin to answer ‘so what does a mental health nurse do?’

What does a mental health nurse do?

It is important to recognise that the role of a mental health nurse is not a static one and will be developing and changing in response to new healthcare structures, service user and workforce needs alongside new opportunities. In recent years, these changes have included the introduction of mental health nurse prescribers, nurse consultants and the possibility of nurses being involved in the act of sectioning as approved mental health practitioners (explained in more detail in Ch. 4). A key nursing theorist, Altschul (1972), described therapeutic relationships as the core of mental health nursing. In this respect the main tool that the mental health nurse has at his or her disposal to impact positively on an individual's health is his or her self. The relationship that a nurse and service user establish is, therefore, central. This means that communicating effectively and learning to really listen and understand another is one of the most important aspects of being a mental health nurse. Without this, the support a nurse is able to provide is limited.

The contemporary mental health nursing role is a complex one. Mental health nurses are involved in working directly with individuals and families to provide support and deal with the impact of being diagnosed with a mental health problem. They will be involved in promoting the health of the individual, but also increasingly working with schools, colleges and communities to promote mental health and enable people to access opportunities outside mental health services to maximise their potential. Mental health nurses are also involved in managing and leading care (examined in Chs 8 and 14) and contributing to the improvement of health care through research and the development and implementation of strategies for enhancing quality.

Through the therapeutic relationship, mental health nurses assess, plan, implement and evaluate care. This is structured through individual time spent with the person.

An introduction to the care programme approach and joint working

One of the main frameworks in the UK, in which this care process is structured in mental health services for adults, is through the Care Programme Approach (CPA). Essentially, this framework was developed to support the increasing amount of care that was delivered in the community in people's own homes. It also aimed to enhance closer working between health and social care services. The CPA sets out the entitlements for the person to have an up-to-date assessment, a care plan that is regularly reviewed and a care coordinator. Mental health nurses are commonly care coordinators although these can also be social workers, psychiatrists and occupational therapists. The role of the care coordinator is to liaise with other professionals to ensure the action in the care plan is being carried out. Mental health services providing care for children and adolescents and older adults (over the age of 65) follow similar processes although they use different terms for these and are being encouraged by the government to introduce the CPA (DH 2008). Refer to Chapter 9 for more detail about using the CPA.

Paperwork and administration are part of a contemporary mental health nurse's role. They are an important part of communication and working effectively in partnership with others. However, it is difficult to achieve the right balance between the requirements of paperwork and the delivery of direct care. It can be frustrating for a nurse as demands of paperwork feel like they may be getting in the way of direct time with service users. A study by the Sainsbury Centre showed that between 27% and 30% of nurses' time was spent on administration and this was the highest of the mental health professions included (Garcia 2006). They also reported too much time doing paperwork contributed to practitioner stress. It is essential that administration systems are not too complex and bureaucratic leading to high demands on resources being concentrated towards paperwork. It is also important that as practitioners we maintain reflective practice in this area to promote efficient working and help avoid paperwork becoming a barrier to spending quality time with services users.

Multidisciplinary team

Within modern healthcare systems, professionals work within multidisciplinary teams. This is perceived as the most effective structure to coordinate the delivery of care and ensures the optimum experience for a service user. Within mental health care, multidisciplinary teams are essential for delivering holistic care which meets the diverse needs and wishes of people with experience of mental distress. It also recognises that the impact of mental health problems can be complex where individuals may benefit from support in a number of areas in their life and that different professionals can offer varied skills and knowledge in these areas.

In response to developing knowledge in mental health care, changing policy and rapidly developing health care, the boundaries of this multidisciplinary team can shift as new roles evolve and change. Figure 1.2 outlines the core roles and professions that you might come across during your mental health placements.

Fig 1.2 Common roles within a mental health multidisciplinary team

The following discussion considers these roles as they will impact on your experience in placements and the service users you will be working with.

The mental health charity, Mind, have also produced a comprehensive overview of roles in mental health care which can be viewed at: http://www.mind.org.uk/help/research_and_policy/whos_who_in_mental_health_a_brief_guide (accessed June 2011).

Partnership organisations

The complexity of the impact that mental health problems can have on people's lives has already been highlighted. This can mean that input is provided by organisations outside of mental health services. This will clearly depend on the individuals' situation and the nature of their needs. However, it is possible that an individual may be receiving support from general healthcare services, from housing, charitable or advocacy organisations. Some people in distress may need ongoing or intensive input with some of these issues and may therefore live in supported accommodation or hostels provided by such organisations. The changing context of healthcare services suggests that these organisations outside of the NHS, in the voluntary or third sector, are likely to take on an increasing role in providing support across care settings, but in particular to individuals who experience mental health problems or who have learning disabilities (Longley et al 2007). Developing relationships and working in partnership with these organisations is an important area for mental health nurses (explored in more detail in Ch. 15). In this respect, as a mental health nurse you may be working as part of a multidisciplinary and interagency team as well as collaboratively with service users and their loved ones. This contributes to the role of a mental health nurse being a complex yet rewarding one.