‘Caught in the middle’? Mental nurse training in England 1919–51

The early history of mental health nurse training is one that has only been partially researched. While some writers have discussed the content and impact of training on the development of mental health nursing, little has been written on the professional and institutional factors that influenced this development. The medical profession, psychiatry, was to play an important role in the development of training and regulation of nursing staff in the large Victorian asylums and was an important influence on the knowledge base of mental health nursing. Their professional organization, the Medico-Psychological Association (the Royal Medico-Psychological Association after 1926 when they acquired a royal prefix) produced the first textbook for asylum nurses in 1885 and established a national training scheme for them 4 years later. However, in 1919 the Nurses Registration Act established the General Nursing Council for England and Wales and this body was given statutory responsibility for the training and registration of nurses, including 'mental' nurses. They were soon to be in conflict with the Medico-Psychological Association. The two organizations continued to run their own rival training schemes for mental health nurses for over 30 years, the Royal Medico-Psychological Association finally relinquishing their role in 1951. The Royal Medico-Psychological Association scheme proved far more popular than the General Nursing Councils, with significantly more nurses participating in it. This paper discusses these organizational influences on the development of 'mental nurse' training and discusses the possible impact that they have had on the knowledge base of mental health nursing.     

The therapeutic relationship: historical development and contemporary significance

The therapeutic relationship is a concept held by many to be fundamental to the identity of mental health nurses. While the therapeutic relationship was given formal expression in nursing theory in the middle of the last century, its origins can be traced to attendants' interpersonal practices in the asylum era. The dominance of medical understandings of mental distress, and the working-class status of asylum attendants, prevented the development of an account of mental health nursing based on attendants' relationships with asylum inmates. It was left to Peplau and other nursing theorists to describe mental health nursing as a therapeutic relationship in the 1940s and later. Some distinctive features of colonial life in New Zealand suggest that the ideal of the attendant as the embodiment of bourgeoisie values seems particularly unlikely to have been realized in the New Zealand context. However, New Zealand literature from the 20th century shows that the therapeutic relationship, as part of a general development of a therapeutic discourse, came to assume a central place in conceptualizations of mental health nursing. While the therapeutic relationship is not by itself a sufficient basis for professional continuity, it continues to play a fundamental role in mental health nurses' professional identity. The way in which the therapeutic relationship is articulated in the future will determine the meaning of the therapeutic relationship for future generations of mental health nurses.     

Counselling and mental health nursing: a qualitative study

The author draws upon his experience of training, practising and teaching both counselling and mental health nursing in order to examine the relevance of counselling skills training to mental health nurses. The qualitative study reported in this paper elicits the feelings and thoughts of five mental health nurses about their attitude towards individual counselling work with mental health clients. It is asserted that newly qualified mental health nurses may feel inadequately prepared for this aspect of their work and they may also feel inadequately supported. Additional counselling training may help equip mental health nurses for the skills they need to work within the therapeutic relationship. By not providing adequate counselling skills training, mental health nurse educators may contribute to a cycle of incompetence. Training methods are identified that may enhance nurse training and help promote competence and confidence for the newly qualified nurse.     

Asylum nursing in the UK at the end of the Victorian era: Hill End Asylum

This paper explores aspects of asylum care at the beginning of the 20th century. Archival materials from Hill End, the Hertford County Asylum, provide a single historical case study. The study focuses on the methods and standards by which asylum nursing was monitored and also examines aspects of the origins and work life of the nursing staff. Standards of care were monitored by a number of official bodies visiting the asylum, whilst the medical superintendent's role focused on the supervision and disciplinary control of nursing staff. Evaluation reports at the time were largely favourable in relation to the care given in Hill End Asylum. However, the reports were based on the relatively limited expectations of the time: primarily relating to the cleanliness, quietness and lack of overt complaints regarding care from patients. Further measures reported related to: death rates, wet beds, numbers of staff dismissed, together with the use of mechanical restraints and seclusion. Nursing staff in the asylum were not normally recruited locally and frequently stayed for only short periods of time. Training provided was very limited at Hill End although a national nurse training scheme was well established by this time. The nursing issues important within the asylum were common to all asylums at the time, and some are still significant today. This paper provides an insight into the historical development of the mental health nursing profession in the UK and its relationship with the medical profession. It also provides evidence that current attempts to monitor the quality of care through clinical governance processes are far from new.     

More Satisfying Than Factory Work: An Analysis of Mental Health Nursing Using a Print Media Archive

The move towards comprehensive nurse training in Australia thirty years ago continues to trouble many of its mental health nurses. It has been viewed as a failure by many and the profession has been judged by some commentators to have lost its preparedness for specialist care. Discourse put forward to support this negative evaluation usually centres on the recruitment of mental health nurses and a limited interest among student nurses to undertake mental health nursing because of their negative opinions towards it. Emerging from a larger ethnographic research project focused on mental health nursing practice in Australia, this article presents an analysis of the profession's current circumstances using historical print media. As we move further from the era of direct entry, specialist training, the article notes the development of assumptions within the profession. These include the idea that mental health nurses received better training in direct entry, specialist programs, and therefore were better prepared for their specialist roles. The article puts forward a critique that challenges this. The article argues the most profound change faced by the profession is the erosion of the mental health nursing identity in Australia. The loss of the stand-alone hospital system, direct entry specialist training, and specialist professional registration have left mental health nursing with a growing uncertainty about itself as the profession evolves into its (mostly) post-mental institution world. At a time when the specialty of mental health nursing is experiencing serious staff shortages throughout the developed world, the article points to the importance of using historical sources to contextualize our present circumstances.     

The remarkable (Disappearing Act of the) mental health nurse psychotherapist

The aim of this Australian based qualitative study was to better understand key drivers for mental health nurses to undertake training in psychotherapy, and how these capabilities are integrated into their clinical practice. Open ended reposes from a national survey of 153 mental health nurses were supplemented with data from 12 semi‐structured interviews of nurses with rich experience of integrating psychotherapy and mental health nursing capabilities. Key findings emerging from the thematic analysis were that mental health nurses are providing uniquely holistic psychotherapeutic services to consumers with often complex conditions, despite overtly hostile clinical and policy contexts. These often very well qualified mental health nurse psychotherapists are different to the traditional identity of either a nurse or psychotherapist. Recommendations from the findings of this study are that where appropriately qualified, mental health nurses be granted eligible provider status for existing Medicare funding items. Finally, training and building foundational capabilities in psychotherapy is highly recommended for all mental health nurses.     

Reflective practice and its role in mental health nurses' practice development: a year-long study

The study reported in this paper lasted over a year, and identifies a conceptual framework of nursing practice based upon a relationship-building process. It also identifies six characteristics of nursing roles inherent within the practice of mental health nurses on a Nursing Development Unit. The paper presents a structure and process of reflection for nursing practice as illustrated by the work of a group of nurses working in a NDU. The purpose of the study was to help them better understand their work with patients. The findings from the study are used to explore how the nurses described and implemented individualized, patient-focused care. This care was based upon the ability of the nurse to communicate well and to build a relationship with a patient, bound within a context of change.     

Theatrical entertainments and kind words: nursing the insane in Western North Carolina, 1882-1907

This paper argues that at the turn of the 19th century, nurses at the State Hospital in Morganton, North Carolina (now called Broughton Hospital) played critical roles in successfully implementing the best-known therapeutic methods of the time. They were also instrumental in developing the hospital's visibility and acceptance in rural western North Carolina. When the Hospital established its first nurse training school in 1895, this corps of first-generation western North Carolinians practising institutional nursing was highly esteemed in their field. Their skills not only served the community outside of the Hospital's walls, but were also sought out by other private and state asylums.     

Liaison mental health nursing: origins, definition and prospects

Liaison mental health nursing is an evolving specialist area of mental health nursing in the United Kingdom (UK). It has many similarities with 'psychiatric consultation liaison nursing' practiced in the United States of America (USA), but there have been differences in its development. It is well established in general health settings where psychological problems are most apparent, such as accident and emergency services and oncology. However, it lacks clear developed, and how it is currently described. The position of liaison mental health practice within nursing is discussed, and also its relationship to liaison psychiatry. The theoretical base of this specialty may be seen as an integration of biological, psychological and sociological perspectives. There is no current programme of training for liaison mental health nurses, and this is likely to inhibit its recognition as a specialty in the UK. As interest grows in psychosocial aspects of physical health, liaison mental health nursing has the potential to provide a focus for research within nursing. Areas for further development are reviewed, and a research agenda is proposed.     

Early 20th century untrained nursing staff in the Rockhampton district: a necessary evil?

AIM: This paper explores the role of untrained nursing staff within the nursing services of the Rockhampton region, Queensland, Australia, throughout the early 20th century. It details who these nurses were, where they worked and how their work was affected by factors such as legislation and social changes. BACKGROUND: Despite the increasing prevalence of trained nurses from the late 19th century, nurses who had never undergone any formal training continued to gain work in hospitals, institutions and their local communities. METHOD: This paper is an historical analysis of a wide range of primary source material relating to untrained nursing staff. The primary source material used related specifically to a limited geographical region in Australia. FINDINGS: Untrained nursing staff primarily worked as private duty nurses at the beginning of the 20th century. However, as the century progressed, their opportunities to work as untrained nursing staff tended towards institutions dealing with the chronically ill and the aged. As a result of this transition, their profile altered from that of a married/widowed woman living at home with dependents to one who could live on-site at the institution with no dependents. Furthermore, the level of autonomy of the untrained nurse decreased dramatically throughout this period from being relatively independent to being under the control of a trained nurse within the institution. CONCLUSION: Consideration of the historical evolution of untrained nursing staff challenges some of the assumptions made about this category of nurse, assumptions that can affect current relationships between professional nurses and others who undertake nursing work.     

Quantitative analysis of mental health nurse prescribers in Scotland

The UK parliament approved legislation expanding prescribing rights for all registered nurses in 2006. Mental health nurses do not appear to be embracing prescribing to the same degree as their colleagues. For example, mental health nurses represent 14% of the UK nursing population, but only 3% nurse prescribing population. In order to explore this disparity, the paper discusses quantitative analysis of the following objectives: (1) describe the impact of nurse prescribing on nurse prescribers in NHS Greater Glasgow and Clyde; and (2) identify differences between mental health nurse prescribers and other nurse prescribers in NHS Greater Glasgow and Clyde. Following online pilot study, a 26-item questionnaire was posted to 668 nurse prescribers in NHS Greater Glasgow and Clyde. A total of 365 questionnaires were returned (55.4%). Significant differences were found between mental health nurse prescribers and others in terms of age, gender, prescribing practice, academic achievement, method of prescribing, workplace, experience and attitude to prescribing. Possible reasons for these differences are suggested and form the basis of further planned research.     

21st century nursing practice in Ghana: challenges and opportunities

DONKOR N.T. & ANDREWS L.D. (2011) 21st century nursing practice in Ghana: challenges and opportunities. International Nursing Review 58 , 218–224 Aim: This article is intended to stimulate critical thinking and generate fruitful discussion on nursing practice in Ghana as experienced by the authors. Its rationale is to promote exchange of ideas and creative partnerships to ensure that right decisions are made in preparing competent, adaptable and resourceful nurses who can contribute to health for all in the 21st century. The problem: The challenges of nursing education, practice and migration in Ghana seem grim. There is inadequate capacity of training institutions, low staff morale, poor distribution and serious workforce shortages. Methods: Government reports and policy documents on nursing were sourced from official websites and reviewed and discussed in the context of the international scholarly published literature. Opportunities: The authors note that despite the severe crises, a number of opportunities such as improved home‐based training, international nursing education partnerships and welfare and human resource development could foster effective nurse retention and managed migration. Conclusions: To address the issues with nursing health service delivery and nursing shortages in Ghana requires all stakeholders to move beyond the traditional stereotypes and be flexible and forward‐looking. Needed policy options include expansion of local nursing education and training capacity, collaborative training opportunities, improving the welfare and retention rates of current staff and international exchange of nurse resources that is mutually beneficial to both source and sink countries.     

The education and training needs of qualified mental health nurses working in acute adult mental health services

This paper presents findings from a research study that investigated the education and training needs of qualified mental health nurses who work in acute adult mental health services in the UK. The study aimed to address a key knowledge 'gap' highlighted by recent Department of Health reports () that suggest that little is known regarding the education and training expectations, priorities and needs of mental health nurses who work in acute adult mental health services. This study aimed to identify (i) what type of post-registration education and training mental health nurses working in acute settings need; (ii) how the nurses want education and training to be delivered; and (iii) what qualifications and accreditation the nurses want to receive? The research consisted of two methods: focus groups and a questionnaire survey. This paper reports on the findings from the questionnaire survey. The results of the survey demonstrate that there is a real need for post-registration education and training for this group of nurses; to equip them with the relevant knowledge and skills to nurse people in the acute phase of their mental illness in acute inpatient settings.     

A discourse analysis of debates surrounding the entry of nursing into higher education in Ireland

BACKGROUND: It was only at the start of the 21st century that the nursing profession in Ireland gained full entry to the academy, joining the ranks of the graduate professions in healthcare. Up to that time, the system of professional training of nurses in Ireland was based on the apprenticeship-training model. AIM: This paper critically analyses discourses opposing advanced educational preparation for nurses and the entry of nursing to higher education in order to reveal the discursive work they perform. METHODS: The study analyses historical and contemporary texts using a critical discursive approach. FINDINGS: The study uncovers common themes and continuities embedded in discourses concerning the role of the nurse and nurses' professional training. Through professional and popular debate, a particular and enduring set of images of the nurse was constructed, which was antithetical to the idea of a nurse receiving professional training in the academy. The debate was conducted by doctors, journalists, public officials, and by nurses, some of whom were ambivalent or even hostile to the notion of the educated nurse. Much of the debate concerned the role of the nurse and the relationship between knowledge/intelligence and practice/caring. CONCLUSIONS: As outsiders looking into the academy, nurses were required to justify their case for entry into higher education against a discursive backcloth that constructed a dichotomy between the mental and the manual and positioned nursing as a practical and commonsense occupation unworthy of academic study. In consequence, nursing was and continues to be challenged to expose, resist and counter the values and assumptions embedded in this backcloth as they strive to establish, maintain and consolidate their foothold in academia.     

The nurse as a social worker

In the early twentieth century the role of the public health nurse (PHN) was expanding to meet the needs of individuals, families, and communities. Among the ideas discussed in the early nursing literature was that of the social nurse. This role was conceptualized as a combined nurse and social worker. Much of the PHNs work was with people of the poorer classes who needed assistance with both the medical aspects of their disease, as well as help with social needs such as food, rent money, and bedding. In this reprint from The Visiting Nurse Quarterly (1911), Ellen La Motte, Nurse-in-Chief with the Tuberculosis Division of the Baltimore Health Department, argued for this combined role based on economic efficiency. As she pointed out, it was "economic waste" to have two sets of workers going into homes when the nurse was capable, with additional education, of carrying out both roles. Additionally, from La Motte's perspective the only way the nurse could move beyond her role as the "physician's handmaiden" was through "social training" that prepared her for a broader scope of practice than that received in the hospital-based nursing schools. In the end, however, she left it open to nurses as "reasonable beings" to determine the direction the profession would take on this issue. La Motte's words provide historical context for issues contemporary public health nursing leaders are addressing, such as inter-professional boundaries between nurses and public health workers, reductions in the public health workforce, and economic constraints faced by the healthcare system. The Institute of Medicine mandate for inter-professional practice within the healthcare system, however, presents opportunities for exploring new roles and practice models for nurses in conjunction with our partners in public health.     

Nurses are the key to improving mental health services in low‐ and middle‐income countries

Mental health nursing is a critical issue for most countries. Nurses in low‐ and middle‐income countries are often the primary providers of care for people with mental disorders. Some are highly qualified professionals who train other providers to identify and treat mental disorders. However, in other instances, particularly in low‐income countries, nurses have had very little or no mental health training and receive no support from mental health professionals. The lack of sufficient mental health professionals in these countries creates an environment where nurses without training are often the only providers available to care for people with mental disorders. In September 2007 the World Health Organization and the International Council of Nurses produced a report summarizing the responses to some of the questions on a survey of nursing mental health practices in 177 countries and territories. The summary of the open‐ended questions (e.g. what are the key issues for nurses providing mental health care in your country?) is reported for the first time in this article. Subsequent to the release of the Nurses in Mental Health Atlas, an online forum was held. There were 615 subscribers to this forum from over 80 countries. This article summarizes the rich insights and recommendations from both the survey's open‐ended comments and the online forum. The issues discussed include: the varied and complex roles for nurses in mental health care; nursing education; prescribing practices; nurse recruitment and retention; human rights; research; and technical expertise.     

Perceptions of training for care attendants employed in the care of older people

BACKGROUND: Care attendants, have long assisted nurses in the provision of care for older people in a variety of care settings in Ireland. While there has been recent interest in the provision of formal training for this grade of health care worker the majority remain untrained and unregulated. AIM: This paper describes a study undertaken to explore the perceptions of nurses and care attendants regarding the provision of formal training for care attendants employed in the care of the older people in southern Ireland. The aim was to identify through empirical research, the perceived implications of this training on the role of both nurses and care attendants. RESEARCH METHODOLOGY: A qualitative research design was used to afford each set of respondents the opportunity to express their thoughts and concerns. The research sites were two settings providing long-term care for older people. The research sample nurses (n = 40) and care attendants (n = 40). Data was derived through the use of two research instruments, focus group discussion and a questionnaire containing open-ended questions. Themes were extracted from the data using content analysis. RESULTS: The study identifies positive attitudes towards training for care attendants by both nurses and care attendants but also a perceived link between the provision of training and a blurring of role boundaries. In addition, findings disclose that although nurses are positively disposed to the training of care attendants, this is not accompanied by a desire to become actively involved. CONCLUSIONS: The study indicates a positive view of training for care attendants, also highlighting the importance of role clarification. Results are particularly relevant in the present climate of demographic change, changes in nurse education and staff shortages in Ireland.     

Neuropharmacology and mental health nurse prescribers

Aims and objectives. To outline the development and content of a ‘top‐up’ neuropharmacology module for mental health nurse prescribers and consider how much pharmacology training is required to ensure effective mental health prescribing practice. Background. Debate about the content of prescribing training courses has persisted within the United Kingdom since the mid‐1980s. In early 2003 supplementary prescribing was introduced and gave mental health nurses the opportunity to become prescribers. The challenge of the nurse prescribing curriculum for universities is that they have only a short time to provide nurses from a range of backgrounds with enough knowledge to ensure that they meet agreed levels of competency for safe prescribing. There is growing concern within mental health care that the prescribing of medication in mental health services falls short of what would be deemed good practice. Over the past two decades, nurse training has increasingly adopted a psychosocial approach to nursing care raising concerns that, although nurses attending prescribing training may be able to communicate effectively with service users, they may lack the basic knowledge of biology and pharmacology to make effective decisions about medication. Methods. Following the completion of a general nurse prescribing course, mental health nurses who attended were asked to identify their specific needs during the evaluation phase. Although they had covered basic pharmacological principles in their training, they stated that they needed more specific information about drugs used in mental health; particularly how to select appropriate drug treatments for mental health conditions. This paper describes how the nurses were involved in the design of a specific module which would enable them to transfer their theoretical leaning to practice and in so doing increase their confidence in their new roles. Results. The findings of this study suggest that the understanding and confidence of mental health nurse prescribers about the drugs they prescribe coupled with the information they provide to service users can be improved as a result of specific educational support. It would appear that adopting a prescribing dimension to one's role requires nurses to revisit a number of skills that are integral to the work of the mental health nurse, e.g. good communication, establishing empathy, listening to what clients say, responding to what is required and involving clients in their own care. Conclusion. Mental health nurses from one particular Trust in the West Midlands were provided with a ‘top‐up’ course in neuropharmacology and, although they found this challenging, ultimately they found this to be helpful. As nurse prescribing is ‘rolled out’ to other nursing specialities it is important that local Trusts and Workforce Development Directorates maintain a dialogue about nurse prescriber training to ensure that nurse prescribers receive the appropriate time and support for their ongoing Continued Professional Development. Relevance to clinical practice. As increasing numbers of nurses from different specialities qualify as nurse prescribers it is vital that they are supported by their employing organizations and given the opportunity to maintain their competency and confidence in their prescribing practice.     

Passive patient or engaged expert? Using a Ptolemaic approach to enhance mental health nurse education and practice

This discussion paper seeks to explore an approach that metal health nurses can adopt that ensures the patient is at the centre of training and professional development opportunities. Although nurse training and education is shaped by practice and theory, the lived experiences of the patients as an educational resource often become lost in the milieu of 'doing' nursing. We argue that in addition to theoretical knowledge and practice knowledge, there is the need to harness the equally important patient experience knowledge. Drawing upon Ptolemaic concepts, this paper explores the potential tensions for mental health nurses resulting from the imbalance in power when engaging in therapeutic relationships with patients. It is argued that in order for mental health nurses to become more effective, they need to learn how to relinquish some of their power, even where this gives rise to uncomfortable tensions for the nurse. Such tensions result from the centrality afforded to theoretical knowledge and ritualized practice that underpins nursing and the difficulties this may cause for many nurses in accepting the value of patient experience as a primary source of knowledge. The difficulties of adopting this approach point to a need for mental health nurses and nurse educationalists to take a more reflexive approach to their patient encounters and within their encounters with each other.     

Nurse prescribing: implications for the life sciences in nursing curricula

The development of new roles, over recent years, for health care professionals, has meant that the boundaries between the different occupations are no longer as clear as they were in the past. For example, the reduction in junior doctors' hours in the United Kingdom (UK), has meant that nurses have had the opportunity to expand their practice into a variety of areas which were once exclusively the responsibility of doctors. One area in which nurses (in the UK) have expanded their practice is prescribing. This paper commences with an overview of the development of nurse prescribing and highlights the important role of the life sciences in the education and training of nurse prescribers. The major findings from studies examining the teaching and learning of these sciences in nursing curricula are presented, and the implications for post-qualifying courses enabling nurses to prescribe, and pre-registration nurse education programmes are discussed.