A challenge for community psychiatric nursing: is there a future in primary health care?

The growing debate surrounding the role of the community psychiatric nurse (CPN) in the United Kingdom is reviewed. Issues which have attracted significant interest and which form the focus of this paper are the prioritization of CPN services, CPN attachment to primary health care (PHC), and the effectiveness of clinical interventions. The requirement for CPNs is now to concentrate services on people experiencing severe and enduring mental health problems. Innovative and effective clinical and social interventions for this client group are beginning to disseminate into everyday CPN practice. Problem-solving family interventions, cognitive therapies and case management are three such examples. The past, present and possible future role for CPNs working in primary health care settings with people experiencing nonpsychotic mental health problems is a particular focus in this paper. Drawing on the relevant literature, central issues addressed are the process and outcome of CPN work with nonpsychotic service users, reasons for the growth of CPN involvement in PHC, and the overall expansion of interest in mental health interventions within the primary health care environment. The literature suggests that this expansion has been strategically unplanned, but that mental health need amongst primary health care service users is significant. The concluding contention of this paper is that a future role for CPNs in primary care does exist.     

The required role of the psychiatric-mental health nurse in primary health-care: an augmented Delphi study

An augmented Delphi study was employed to elicit the perceptions of CPNs, GPs, social workers, managers of psychiatric nursing services and health service purchasers in England, on the role required of a psychiatric (mental health) nurse in primary health care. In the final stage of the study, users of mental health service were enlisted in a verification study of the emergent findings. A broad consensus emerged that a gap existed in mental health services in primary care. This was perceived as placing a large burden on GPs, which might be reduced by the appropriate development of community psychiatric-mental health nursing. The study suggested the possibilities for development of a 'mental health nurse consultant' role, which might augment the current CPN role, within which the nurse might offer not only direct patient care, but also support to members of the primary care team.     

Mental health in the community: roles,responsibilities and organisation of primary care and specialist services

UK health policy embodies two opposing trends affecting mental health care in the community: a move towards a primary care-led NHS which inevitably reflects the concern of GPs with 'milder' mental illness, and specific mental health policies intended to refocus the specialist services on people with 'serious' mental illness. A training needs assessment study undertaken with primary care staff and community psychiatric nurses revealed the problems created on the ground by these opposing trends. This paper describes these problems from the perspectives of three groups: primary care nurses, general practitioners (GPs) and community psychiatric nurses (CPNs). The overall impression was of primary care teams encountering high levels of need for which they felt unprepared, and of a CPN service torn in two by the opposing demands of GPs and their employing trust. The discussion section of the paper compares the findings of the study with a model for reorganisation put forward in the literature and highlights the obstacles to be overcome in bridging the policy gap.     

An investigation into the factors influencing variation in the growth of community psychiatric nursing services

During the last 30 years community psychiatric nursing (CPN) services have become an established feature of mental health provision throughout the United Kingdom. The creation of new services peaked in the mid 1970s; however, the rate of individual service growth during the last 5 years has been variable. In 1980, the first national survey of community psychiatric nurses was carried out; 5 years later, in 1985, the survey was repeated by the author. A comparative analysis of the manpower data reveals interesting regional differences and these findings are presented. Using quantitative methods, five district health authorities were identified as extreme examples of variability in CPN team growth. The CPN service managers in these five health authorities were interviewed in depth using a semi-structured interview guide. The data produced help to illuminate factors that are involved in the widely differing rates of growth in CPN teams.     

Working with families caring for a relative with schizophrenia: the evolving role of the community psychiatric nurse

This paper describes the effect on the role and function of the community psychiatric nurse (CPN) after training to deliver psychosocial intervention to families caring for a relative with schizophrenia living at home. The study was undertaken as part of a larger investigation, commissioned by the Department of Health, which is examining outcome in families after CPNs have received training in psychosocial intervention strategies. In the last decade four major controlled studies have shown that relapse in schizophrenia can be improved if families receive; detailed assessments of individual need, health education about schizophrenia, and family stress management programmes, often defined as "psychosocial intervention". Whilst these research programmes have been underway, CPN services have been developing closer links with Primary Health Care and individual CPN's work with clients with severe and long-term mental illness has, as a consequence, been reducing. This trend has been rightly criticized, as has the tendency for CPN work to focus on the individual rather than the family with whom the client often lives. Informal carers willingly accept the burden of care for their relatives but their own needs are all too often neglected. The pilot phase of the outcome study demonstrated that after CPNs had received experimental training in psychosocial intervention, families reported a number of positive benefits when followed up for 12 months. First, for the clients there were improvements in the symptoms of their illness and in their social functioning. Second, carers' satisfaction with the service received showed a marked improvement as did their estimates of minor psychiatric morbidity. These changes in outcome entailed a cost. Experimental CPNs reported that undertaking family intervention was more time-consuming than "traditional" CPN care of the client with schizophrenia. Further, the data reveal that the training led to CPNs extending their role in a variety of other ways even though they received only a modicum of support from colleagues within their own health authorities. This preliminary paper concludes that although family work undertaken by CPNs should be seen as an important priority, problems may arise as services attempt to juggle finite resources with ever growing demands. Guidance on the future role of the CPN from the Department of Health is essential and would greatly enable planners and managers alike to rank order service priorities.     

An extra pair of hands? A case study of the introduction of support workers in community mental health teams for older adults

Background Despite the expanding deployment of support workers in mental health services, little evidence exists on what managers and professional practitioners should expect of such staff in community settings. Aims This case study evaluated the introduction of support workers in community mental health teams for older adults. Method A multiple method design engaged support workers and professional colleagues in individual interviews, a focus group and a work satisfaction survey. Results While the new resource boosted service provision, disparity between the intended role and the assumptions of professional practitioners caused confusion and dissatisfaction. Conclusions The study highlights the need for managers to ensure role clarity when non‐professional workers are introduced into multidisciplinary community teams. Implications for nursing management Promoting diversity of skills in the mental health workforce is a progressive move in tuning services to the heterogenous needs of clients in the community. However, introducing unqualified workers into multi‐disciplinary teams necessitates clear guidance to prevent their activity being confined within existing professional models. Support workers offer much potential in innovative service delivery.     

Mental health service users' and practitioners' experiences of engagement in assertive outreach: a qualitative study

Assertive outreach services have been central to community mental health policy within the UK. These multidisciplinary teams were established to engage with service users who have severe and enduring mental health problems and have found traditional community services unable to meet their needs. Mental health nurses have a pivotal role in these multidisciplinary teams, yet the nature of these relationships from the perspective of those who work in and receive care is poorly understood. This study set out to explore the nature and meaning of engagement for practitioners and service users within assertive outreach services. A qualitative approach, informed by philosophical hermeneutics, underpinned the study. Participants were recruited from a single assertive outreach team in the UK. To be eligible for the study, mental health practitioners needed to be employed within the assertive outreach team. All service users residing in the community and receiving care from the team were also eligible for inclusion. In total 14 interviews were conducted with mental health practitioners and 13 with service users. Data analysis was informed by Turner's method. Four themes emerged from the data; contact, dialogue, transformation and shared understanding. Meaningful engagement was found to manifest itself through experiences such as providing and receiving practical assistance, having a genuine two-way conversation and valuing the experiences and personal attributes of the other person. The findings indicate that engagement is an active, dynamic and skilled process, which leads practitioners and service users to transform together to create a new relationship.     

A national survey of community psychiatric nurses and their client care activities in Ireland

Increasingly, people with mental health problems in Ireland and in the UK are receiving mental health services in the community. The aim of this study was to identify the predominant approaches to care used by community psychiatric nurses (CPNs) and the theoretical bases of their practice. One hundred and sixteen questionnaires out of 203 sent to CPNs throughout Ireland were returned, giving a response rate of 57.1%. In addition, 33 home visits by 13 CPNs were observed. The findings showed that over 96% of the sample were in full-time employment; most (71.4%) worked a 9-5 weekday shift; 31% had a postregistration counselling qualification, and about a quarter were based in hospitals. The average caseload size was 61 and the service was predominantly a closed referral one. The main client care activities were: assessment of clients, medication management, health promotion, and client and family support. From the observations, there was no evidence of CPNs practising cognitive, behaviour therapy or family therapies to any great extent. This study provides baseline data for monitoring trends in community mental health nursing in Ireland, and for informing future policy regarding service provision and training of CPNs.     

Exploring the role of the mental health nurse in community mental health care for the aged

There is currently considerable discussion about the impact of the aging population on the demand for health care services, however there is considerably less attention paid to the impact of mental health issues on the needs of the aged population. Nurses comprise the largest professional group within the mental health workforce in Australia. The availability of a high quality mental health nursing workforce will therefore be crucial to meeting the health needs of aging clients in the future, accompanied by an increased pressure to increase the proportion of care delivered in the community. There is however, a paucity of literature on the role and contribution of community mental health nurses specialising in the aged care field. The aim of this paper is to present the findings of a project designed to examine the role of mental health nursing within aged persons' community mental health teams in Victoria, Australia, with particular emphasis on the biopsychosocial interventions used. Fifteen participants from three community mental health services in Victoria participated in a focus group interview to share their insights and experiences. Data analysis revealed two main themes, the role of the nurse, and the specific functions of the nurse. This data is presented as a beginning contribution to the paucity of literature currently available in this important area.     

A description of clients nursed by community psychiatric nurses whilst attending English National Board Clinical Course No. 811: clarification of current role?

The English National Board Clinical Course No. 811 is a 36-week preparation for community psychiatric nurses (CPNs). Unlike health visiting or district nursing the course is not yet a mandatory prerequisite for practice and it has been estimated that, nationally, 23% of all CPNs have been awarded the certificate to date. There are currently 24 course centres in England, offering 420 places annually. The completion of a care study by the course student is a curriculum requirement. The present study aimed to establish the characteristics of clients chosen by course students for such work whilst attending the course in an attempt to obtain a 'proxy' measure of the current CPN role nationally. A stratified random sample of eight course centres was selected--four based in schools of nursing, and a further four located in establishments of higher education. Then within each course centre a stratified random sample of students was selected, who each completed a postal questionnaire. A 79% response was obtained. The results are described and discussed within the context of the CPN's developing role. The findings suggest that many CPNs conceptualize their role and function, to use Caplan's terminology, at the primary prevention level, and see their work as being located firmly in primary health care settings. The desirability of this orientation to CPN intervention is examined, acknowledging both mental health service developments and the wider educational implications.     

The effects of student nurse community mental health placements on sufferers of mental health problems in the community

The effects which student nurses have on the care of clients with mental health problems in the community is an area which has seldom been studied With the closure of large psychiatric hospitals and the rise in community placements as part of Project 2000, an increasing number of students are being placed in the community The study gathers data from clients attending five self-help/support groups in the North Derbyshire area of England Analysis of the data challenges assumptions generally held by community psychiatric nurses (CPNs) that the presence of a third person, e g student/visitor, during a CPN home visit to the client is detrimental to the therapeutic interaction between the CPN and the client The findings are inconclusive but suggest that some client groups (possibly those with long-term mental health problems) may find the presence of a student during a CPN visit facilitative The study raises the issue of the student nurse/patient power relationship within a support group Findings suggest that membership of a support group is empowering to the client and illustrates that clients in the community have greater control over the involvement of student nurses in their care than patients in hospital Groups within the sample expressed a unanimous view that student nurse placements should be long enough to allow therapeutic nurse/client relationships to develop This is in direct contrast to the current Project 2000 Common Foundation Programme approach of short observational non-institutional placements     

Perceptions of the role of the community psychiatric nurse

AIM: This small-scale study explores the self-perceived differences between the contributions of community psychiatric nurses (CPNs) and other members of a multidisciplinary community mental health team for older people. METHOD: Four CPNs and five other professionals completed questionnaires consisting of a series of open-ended questions (initially designed for a semistructured interview) in order to collect qualitative responses. The questionnaires were analysed on a thematic basis. RESULTS: CPNs' skills seemed to be recognised and valued by their multidisciplinary colleagues. However, the CPNs did not always appear to appreciate this, while the attributes identified by CPNs were not always the same as those identified by their colleagues. There did not appear to be any consensus among the CPNs yet their colleagues seemed to feel the CPN role was reasonably clear. CONCLUSION: This study suggests the CPN role involves taking a relationship-based, person-centred approach in which adaptability and flexibility are key characteristics. The results are largely consistent with other findings and demonstrate the need to nurture the contributions made by CPNs as autonomous practitioners in multidisciplinary settings providing care for older people with dementia.     

General practitioners' views of community mental health services: A survey in one London borough

Community mental health teams are increasingly focusing their activities on people with severe mental illnesses. At the same time, the overall extent of mental health need in primary care ensures general practitioners (GPs) remain key professionals in the co-ordination and provision of mental health services to a wide range of patients. This study sought to establish the views of GPs working in one London borough on community mental health services, and to establish what they believed were appropriate services for community mental health professionals to provide. A postal questionnaire sent to all 104 GPs working in the borough produced a 48% response rate. GPs believed community mental health teams were useful, and effective in dealing with patients presenting with a variety of mental health problems. Many believed that enhanced primary health care teams, adequately resourced and staffed with attached mental health professionals, could provide a wide range of mental health interventions. Dissatisfaction appeared to be related to the evolving focus of community mental health teams. Many GPs believed that they had lost a valuable service for people with less severe mental health needs.     

Assessing the side-effects of antipsychotic drugs: a survey of CPN practice

Assessing the side-effects of antipsychotic drugs: a survey of CPN practice
The provision of community-based care for people with serious and enduring mental health problems requires an approach that combines drug therapy, psychological interventions and skills training. Mental health nurses are being required to place more emphasis on their work with this client group. It has been suggested that community psychiatric nurses (CPNs) will require training in appropriate skills to work with the seriously mentally ill. While the training of CPNs to use psychological intervention strategies has received limited attention, the area of medication management, including the detection of side-effects, is relatively unexplored. Community psychiatric nurses' practice with clients on antipsychotic medication was investigated. This paper reports selected findings on the assessment of medication side-effects and CPNs' attitude to this aspect of their role. Fifty CPNs in three health districts completed a self-administered questionnaire. The results showed that the CPNs were supervising the medication of large numbers of clients. They reported that their training had adequately prepared them to assess clients for medication side-effects and that this was being done frequently. They also felt that their reports of side-effects influence the pre-scribers' decisions on medication when clients are reviewed. However, the data also suggested that CPNs were only monitoring their clients for three to four side-effects and that they held an unfavourable attitude towards their involvement with medication.     

Group processes in a case discussion workshop for community psychiatric nurses

This paper describes a case discussion workshop with a team of hospital-based community psychiatric nurses (CPNs). After describing the growth of the CPN movement in Britain and the conflicting ideas surrounding the professional role of CPNs, some of the group processes within a particular group of CPNs will be illustrated. Particular attention is paid to the way in which reading material distributed to the group may reflect group processes, and the way in which institutional factors impinge on case discussions. The case for various forms of psychodynamic input into community psychiatric teams is also made.     

Mental health nurses’ contributions to community mental health care: An Australian study

Australian mental health policy is focused on providing mental health care in the community setting and community mental health teams provide services to clients in a shared model with primary care. The historical literature reports that community mental health nurses’ experience high levels of stress and are often allocated the most complex and challenging clients managed by the team. Yet information on their specific roles remains limited. This paper reports on research conducted at one Australian public mental health service to identify the components of the community mental health nursing role and to quantify the time nurses spent in each component during the study period. Six focus groups were conducted with community mental health nurses to identify their perceived role within the team. Data analysis identified 18 components of which 10 were related to direct clinical contact with clients and eight covered administrative and care coordination activities. A data collection tool based on the findings of the focus groups was designed and nurses recorded workload data on the tool in 15‐min intervals over a 4‐week period. Seventeen nurses collected 1528 hours of data. Internal coordination of care was identified as the top workload item followed by clinical documentation and national data collection responsibilities supporting the complexity of the community mental health nursing role. The high rating attached to the internal coordination of care role demonstrates an important contribution that community mental health nurses make to the functioning of the team and the delivery of quality mental health care.     

Education for community psychiatric nurses: content, structure and trends in recruitment

Under the auspices of the Standing Advisory Group for Community Psychiatric Nursing Education, annual surveys of the leaders of the UK's post-registration courses for community psychiatric nurses (CPNs) have taken place since the 1987-88 academic year. In this paper, findings are reported from the 1997-98 survey. Thirty-two of the 39 course leaders running post-qualifying programmes for CPNs (English National Board course 812 or equivalent, and Specialist Practitioner courses) in the 1997-98 academic year responded to a nine-page postal questionnaire. Responses suggested that the majority of courses for CPNs are now offered at first degree level, with most students completing their programmes of study and clinical practice in one full-time academic year. Most courses appeared to include education in key areas of specialist content pertinent to contemporary CPN practice. Examples included: evidence-based psychosocial interventions; collaborative working with users of mental health services; inter-professional issues; cognitive-behavioural interventions; reflective practice and clinical supervision; and medication-related issues. Overall, however, courses for CPNs appeared to be characterized by considerable variations in specialist content. Possible explanations for this are offered, along with suggestions for future research.