Community Psychiatric Nursing

Community Psychiatric Nursing

Coßlßlunity Psychiatrie Nursing A research perspective Volume 2 Edited by CHARLES BROOKER BA(Hons), MSc, RMN, DipNEd, RNT Regional Nurse - Research Trent Regional Health Authority Formerly Senior Research Fellow University of Manchester and EDW ARD WHITE MSc(SocPol), MSc(SocRes), RMN, DipCPN, PGCEA, RNT Senior Research Fellow University of Manchester Presently seconded to University of London SPRINGER-SCIENCE+BUSINESS MEDIA B.V.

First edition 1993 1993 Springer Science+Business Media Dordrecht Originally published by Chapman and Hall in 1993 Typeset in 10/12 Times by Mews Photosetting, Beckenham, Kent ISBN 978-0-412-43600-0 ISBN 978-1-4899-6888-3 (ebook) DOI 10.1007/978-1-4899-6888-3 Apart from any fair dealing for the purposes of research or private study, or criticism or review, as permitted under the UK Copyright Designs and Patents Act, 1988, this publication may not be reproduced, stored, or transmitted, in any form or by any means, without the prior permission in writing of the publishers, or in the case of reprographic reproduction only in accordance with the terms of the licences issued by the Copyright Licensing Agency in the UK, or in accordance with the terms of licences issued by the appropriate Reproduction Rights Organization outside the UK. Enquiries concerning reproduction outside the terms stated here should be sent to the publishers at the London address printed on this page. The publisher makes no representation, express or implied, with regard to the accuracy of the information contained in this book and cannot accept any legal responsibility or liability for any errors or omissions that may be made. A catalogue record for this book is available from the British Library Library of Congress Cataloging-in-Publication data available

Contents Contributors Foreword Christine Hancock General Secretary, Royal College of Nursing Introduction Charles Brooker and Edward White vii x xiii 1 Community psychiatric nursing 1980 to 1990: a review of organization, education and practice 1 Edward White 2 A study to investigate the views of patients and their carers on the work undertaken by nurses to prepare the patient for discharge from hospital 27 Katharine Ferguson 3 Skills for CPNs working with seriously mentally ill people: the outcome of a trial of psychosocial intervention 46 Charles Brooker, Niebolas Tarrier, Christine Barrowclough, Anthony Butterworth and David Goldberg 4 Client/CPN contact during the administration of depot medications: implications for practice 71 Gordon Turner 5 Human immunodeficiency virus (HIV) disease and drug misuse - research issues for CPNs 101 jean Faugier

vi Contents 6 A review of a psychological intervention for depression in elderly people 117 Colin Hughes 7 The CPN and depression in elderly people living in the community 134 Anna Waterreus 8 The CPN in primary care: a pilot study of the process of assessment 147 Kevin Gournay, Grant Devilly and Charles Brooker 9 Failure and dissatisfaction 164 Kevin Gournay and ]ulia Brooking 10 Patients' and CPNs' views of a CPN service 180 Ray Field 11 Clinical audit and CPN services 197 Patricia Harrigan, ]an Sorensen and Steve Ryder 12 Attitudes towards supervision: a comparison of CPNs and managers 219 Susan Major Index 239

Contributors Christine Barrowclough Charles Brooker ]ulia Brooking Anthony Butterworth Grant Devilly ]ean Faugier Consultant Clinical Psychologist Department of Clinical Psychology Withington Hospital Manchester Regional Nurse - Research Trent Regional Health Authority Fulwood House Sheffield Professor of Nursing The Medical School University of Birmingham Birmingham Professor of Community Nursing Department of Nursing University of Manchester Manchester Research Assistant Institute of Psychiatry University of London London Senior Research Fellow Department of Nursing University of Manchester Manchester

viii Katharine Ferguson Ray Field David Goldberg Kevin Gournay Patricia Harrigan Colin Hughes Susan Major Steve Ryder ]an Sorensen Contributors Lecturer Department of Nursing University of Manchester Manchester Senior Nurse - Education SW Thames Regional Health Authority London Professor of Psychiatry Academic Department of Psychiatry Withington Hospital Manchester Deputy Director Health Research Centre University of Middlesex Enfield Director, Non-Statutory Programmes West Yorkshire College of Health Sturlies Northowram Hall Halifax CPN for the Elderly The Dales Community Mental Health Team for the Elderly North Derbyshire Health Authority Senior Nurse (Community) Kidderminster and District Health Authority Worcestershire Senior Research Fellow York Health Economics Consortium University of York York Research Fellow York Health Economics Consortium University of York York

Gontributars ix Niebolas Tarrier Gordon Turner Anna Waterreus Edward White Professor of Clinical Psychology Department of Clinical Psychology Withington Hospital Manchester Postgraduate Student Department of Nursing Studies University of Edinburgh Edinburgh Research Nurse Epidemiology and General Practice Institute of Psychiatry London Senior Research Fellow University of Manchester Presently seconded to University of London

Foreword Christine Hancock BSc(Econ), RGN General Secretary of the Royal College of Nursing The move towards a comprehensive and local mental health service, which gathered pace in the 1970s, has been one of the most profound changes in psychiatric nursing. In 1968, because of the scarcity of services, there were very few community mental health nurses. In 1990 the figure was 4990. At the sametime the number ofpeople in United Kingdom psychiatric hospitals and units feil from 132 000 in 1968 to 60 000 in 1989. A number of important developments underpinned this shift. For instance, significant pharmaceutical advances and the abandoning of some of the treatments favoured in the past have given nurses an important role in the administration of new treatment as weil as in monitoring. Behavioural, psychodynamic and cognitive psychotherapies - traditionaily associated with psychologists - are ail areas in which nurses have a significant input, or take the Iead. The growth of user organizations in mental health care has increased the opportunities for patients and clients to participate in their own care. Meanwhile, a vast array of legislative change has greatly affected the way in which mental health nurses now practise in this country. In 1983, the Mental Health Act changed the role of the mental health nurse, and this, along with other Acts including the Sex Discrimination Act, the Race Relations Act, the Disabled Persons Act and the NHS and Community Care Act, has influenced the nurse-patient relationship by focusing on the rights of individuals. Today's community mental health nurses face a number ofnew and difficult chailenges. No part of society is untouched by mental illness, and anyone may at some time require the services of a mental health nurse. Poverty, unemployment, homelessness and pressures on families as weil as demographic factors such as the increasing numbers of elderly people impact on the

Foreward xi mental health of the nation. Multiracial and multicultural communities present new areas of need. The Health and Safety Executive believes that 40 million working days are lost to stress alone every year. So something like 30 days are lost to stress and subsequent mental illness for every single day that is lost to industrial disputes. The nature of community health services varies considerably from region to region in terms of referral systems, case Ioad sizes and profiles. There is a very real concern about the split between health care and social care. This is an unreal dichotomy for many people with long-term problems where needs can be interdependent and may fluctuate considerably within a short time span. Evidence from RCN members indicates that this causes problems about which authority will purchase the services needed. The knowledge of how to care for distressed people is central to psychiatric nursing. But today's nurse has to combine that with an imaginative approach, intelligence and self-awareness. Mental health nurses do not simply follow rcgulations anymore. For people with a mental health problem, the most important need is appropriate assessment followed by effective care. Mental health nurses can provide information about options for care and potential outcomes, assess the need for care and, within a nursing framework, provide that care. They can be skilled in psychological interventions, aid rehabilitation and be involved in the promotion of mental health. As a group, community mental health nurses call upon the knowledge derived from medicine, social and behavioural science and physiological sc1ences. In short, the community psychiatric nurse is an autonomaus practitioner who works with a multidisciplinary and multiprofessional approach to provide care and prepare support staff to alleviate the problems of people who are mentally ill. Although mental health nursing is essentially practical, it must be founded on a theoretical base. The increasing amount of mental health research must be welcomed, as is the increasing influence of mental health nurses in academic departments. Their influence is also helping to promote the educational objectives of the Strategy for Nursing document (DoH, 1989) and the relevant mental health components in the other activities of their departments. The mental health nurse has a unique contribution to make in so many areas of nursing pracice and in so many settings. And for the whole family of nursing, it is essential that mental health nurses attempt to demoostrate and communicate the value of their branch of nursing. We live in a culture in which nurses and nursing are too often undervalued, and it is the continuing objective of the Royal College of Nursing to change this perception.

xii Foreward Many people have an unclear idea about what nurses do and it is quite common to hear people say, 'I couldn't do your job'. Often their reason for saying this is related to the fact that nurses are involved in so much intimate care and work which is perceived to be repetitive and somehow distasteful. This is illustrated by the following example which was studied by the RCN as part of the work undertaken to demoostrate that nursing really does make a difference to patient outcomes. A community psychiatric nurse daily visited an elderly Iady who lived with her sister. The patient would hide in the bedroom for most of the time while the CPN played drafts and had tea with her sister. Without the visits, the patient would rapidly become ill and need tobe admitted to hospital. Meanwhile, the daily visits, chats and cups of tea enabled her sister to cope. All the time the CPN was assessing this fragile situation. This second volume of Community Psychiatrie Nursing: A Research Perspective is another welcome addition to the increasing amount of mental health nursing research, and it is an essential demonstration of the cost effectiveness and value of this branch of nursing. REFERENCE Department of Health ( 1989) A Strategy for Nursing: A Report of a Steering Committee, HMSO, London.

Introduction The idea for this, the second volume of the series, was conceived during conversations we had when we shared a room in the Department of Nursing at the University of Manchester. We were both employed there as contract researchers and knew that we had shared a very similar career path, including previous posts as community psychiatric nurses (CPNs), as service planners and as senior lecturers in higher education. Similarly, we had both held the post of research officer to the Community Psychiatrie Nurses Association (CPNA), at different times, continuously from 1984 to 1992. It was as CPNA research officers that we undertook the Second and Third National Quinquennial Community Psychiatrie Nursing Surveys. In our view, these additions to this longitudinal data set have contributed to the environment in which many important debates have begun. These relate to the organization of CPN services and the individual work practices and educational preparation of CPNs. The information provided by the three sturlies has not only described but also helped to explain these trends over time. These data have continued to be interrogated for service and educational personnel in the National Health Service and by other researchers. The third survey differed from the other two by obtaining a substantial external research grant from a concerned national agency. The success of such funding provided an indication of the growing interest in this substantive area. Volumes 1 and 2 of this series have contained 24 contributions and it is of interest to reflect on the sources of funding for these. Central government has played a significant role in underwriting the costs of CPN research, both through commissioned projects and research studentships. We are pleased that this present volume has been able to present the findings from much of this work. Community psychiatric nursing research has not only been funded by the Department of Health (DoH), of course, and monies have been forthcoming

xiv Introduction from a wide variety of other sources, including the English National Board for Nursing, Midwifery and Health Visiting (ENB) and from district health authorities (DHAs). Suchfunding has allowed individuals to undertake research for awards at Diploma, Baccalaureate and higher degree Ievel. Examples of this work have also been able to enter the public dornain through both volumes and have so helped to inform the policy debate. However, in the past, a tension has arisen between customers (Department of Health) and contractors (academic researchers) about the areas of research deemed worthy of attention. For, as the former chief scientist to the Department of Health recently commented, policy makers are:... less likely to welcome agencies who want to debate the policy and its development, or the credibility of the proposals to advance it, than research which illuminates and propels the policy development in band... given the pressure of government business they are also unlikely to want to devote much time to developing a long-term research strategy, or contemplating questions for the future. Researchers, however, do want to develop long-term plans and to have time to speculate and innovate. (O'Grady, 1990) O'Grady concluded that the relative strengths ofthese positions could not continue to co-exist without modification. As we write, new arrangements are being developed in which the relationship between research and the policymaking process will be made more explicit (Department of Health, 1991a). The formation of the Central Research and Development Committee (CRDC) at the DoH has a mental health sub-group and both benefit from nursing representation, which may bode weil for the future. This innovation will Strengtben the position of regional health authorities (RHAs); indeed, most NHS research and development activity will become their responsibility in the future (Department of Health, 199lb). The recent establishment of the CentreforMental Health Service Development (CMHSD) at King's College, University of London, could complement these initiatives by acting as a broker between funding agencies and RHAs. This, in addition to their direct consultancy services. Thus, it behoves CPN practitioners, managers, researchers and educationalists to feed into the systems which will be designed to identify, at RHA Ievel, the research needs of specific populations. Such activity might bebest advanced by appropriate service-based personnel and academics working in close alliance. However, we would wish to temper any optimism about the new procedures by which research priorities are being determined. If CPN research is to continue to command a market share of financial resources, a number of preconditions will need to be met. These will include:

Introduction XV 1. An equitable nursing voice being heard in both the Central Research and Development Committee and Advisory Group on Practices for Mental Health. 2. Mental health nursing research expertise being utilized at RHA Ievel to ensure methodological rigour, as priorities are set. 3. Concomitant work being undertaken by responsible national agencies to articulate the strategic policy position of community psychiatric nursing organization and education. Several initiatives have already begun to address the third point above, which is arguably the most pressing for community psychiatric nurses. For example, the Royal College of Nursing (RCN) recently hosted a symposium in London, at which national figures in psychiatric nursing urged the RCN to publish a paper identifying the need for a national review of psychiatric nursing. Indeed, as we write, such a document is in the process ofbeing drafted. lndependently, the English National Board has also pressed the Department of Health to undertake just such an exercise, based on the findings of research it bad commissioned to help set the agenda for the future of psychiatric nursing over the next decade (White, 1991). When the last nationalreviewwas undertaken 24 years ago, community psychiatric nursing fell outside the terms of reference and has yet to be scrutinized systematically. While we both acknowledge that research is but one contribution to knowledge, we also believe it tobe a crucially important activity in a cash-lirnited National Health Service. We offer the contents of this book, therefore, written by a cross-section of authors, as evidence of the increasingly respectable nature of CPN research and the role such work should play in helping to shape the future of community psychiatric nursing service and education. We are pleased to offer our gratitude to all those who contributed to this second volume. We arealso indebted to Rosernary Morris, our Senior Editor at Chapman & Hall, for her vision and support. REFERENCES Department of Health (1991a) Research for Health: A Research and Development Strategy for the NHS, HMSO, London. Department of Health (1991b) NHS Research and Development Strategy: Guidance for Regions, HMSO, London. O'Grady, F. (1990) Valediction, Department of Health Yearbook of Research and Development, HMSO, London. White, E. (1991) Thefuture ofpsychiatric nursing by the year 2000: a Deiphi study. Research Monograph, Department of Nursing, University of Manchester. Charles Brooker Trent Regional Health Authority Edward White University of London