psychiatric-mental-health-nursing

Preface to Section 1 Phil Barker 2 1 The nature of nursing 3 Phil Barker 2 Getting personal: being human in mental health care 12 Phil Barker and Poppy Buchanan-Barker 3 The care and confinement of the mentally ill 21 Liam Clarke 4 Evidence-based practice in mental health 30 Hugh McKenna 5 The craft of psychiatric–mental health nursing practice 37 Peter Wilkin 6 Leading developments in the craft of caring 45 Angela Simpson 7 Recovery: a personal perspective Irene Whitehill 51 8 Recovery and reclamation: a pilgrimage in understanding who and what we are 58 Anne Helm Preface to Section 1 When one isn’t dominated by feelings of separateness from what he’s working on, then one can be said to ‘care’ about what he is doing. That is what caring really is, a feeling of identification with what one’s doing. Robert Pirsig The practice of nursing involves doing something that appears quite ‘ordinary’, in highly extraordinary settings and circumstances. Nurses care for people who, for different reasons, are unable or unwilling to care for themselves. In one sense, caring is hardly ‘rocket science’. ‘Anyone could do it’ has become an increasingly popular cry, especially among economists and bureaucrats anxious to reduce the financial cost of caring. There is some truth in this. At least in principle, anyone could care for someone else. This often involves nothing more complex than giving one’s time, sitting and talking with the person, sharing some of the load of the person’s life. What could be simpler? Like many things in life, the simple stuff often turns out to be the most complex. Nursing, as a professional discipline, differs greatly from the ‘ordinary caring’ provided by a friend or a relative. The difference is in the context. Caring for a friend or a relative is a moral duty or obligation, where the carer and the cared for are united by blood ties or the loyalty of love. Nurses often are required to care for people who have been abandoned by everyone else, or who may, for one reason or another, be difficult to care for, far less care about. Usually, nurses care for more than one person at a time, dealing with competing demands and often rapidly changing priorities. Such contextual challenges transform the ordinary act of human kindness into the extraordinary discipline of human caring. In this section we begin with a consideration of the nature of nursing itself; how its meaning has changed over the years; and what is special about psychiatric and mental health nursing. This leads, naturally, to a reflection on the challenges of ‘getting personal’. How do nurses go about getting close to people in their care, getting to know them as persons and the nature of their unique human needs? The profession of nursing, known by different names around the world, did not emerge out of a vacuum, but is merely the latest stage in the history of caring, which dates back centuries.We shall consider how things have changed down the years and what caring values remain intact. Understanding the value of nursing, and the evidence that signals an appreciation of its worth, is central to current developments in the field. However, the nature of evidence has become a vexed issue, often confused by ideology or political bias. A careful consideration of what evidence is and is not, will help the discipline clarify further its caring focus. Debate has raged for at least a generation over whether nursing is an art or a science. This book raises an alternative perspective, the concept of nursing as craft is considered, and some critical thought is given to how we might manage the development of this craft in the complex world of practice. Finally, we turn full circle to connect again with the people who might need nursing and who, given their status, might help nurses clarify the proper focus of their craft. These contributions are framed positively, emphasizing how nurses might aid and abet the recovery process, helping people to reclaim ownership of lives blighted or overtaken by mental distress. The last two contributions in this section are the most important – reminding us of the genuine purpose of nursing. What – ultimately – is nursing for, if not to enable people to take back ownership of their lives and bid farewell to their professional carers? CHAPTER 1 The nature of nursing Phil Barker* Why nursing? 3 Nurses: still invisible after all these years 3 What is psychiatric and mental health nursing? 4 Psychiatric–mental health nursing: a definition 5 What is the purpose of nursing? 5 Back to basics: the nature of nursing 6 The craft of caring 7 The purpose of nursing 8 Nursing the world 9 References 10 WHY NURSING? This is the most important chapter of all the chapters in this book. Not because it is the opening chapter, providing a ‘way in’ to the rest of the text, but because it invites you – the reader – to think about nursing. • What is nursing? • How do nurses do nursing? • Why do they do this rather than anything else? • How important is nursing to the welfare and recovery of people with any serious problem in human living?a The answer to this last question is straightforward, if confusing. • Psychiatric–mental health nursing is the mostimportant discipline in mental health care worldwide. • However, it is also the least important. • Why the paradox? NURSES: STILL INVISIBLE AFTER ALL THESE YEARS When people have a ‘mental breakdown’, the Hollywood film drops them into the arms of a brilliant, humane and invariably caring psychiatrist.1 Nurses, by contrast are invisible or, as de Carlo2 noted,they occupy an ‘aberrant, secret, and dangerous world’ where their role is mainly that of ‘custodial companionship’. If Nightingale was the icon for physical care nursing then, Nurse Ratched, from ‘One flew over the cuckoo’s nest’, has become the mental health nursing icon (see Real life tells a different story. In hospital or community care, psychiatrists are few in number, and only fleetingly present at the care face.b In the ‘real world’ nurses are a I use the term ‘problem in living’ since all forms of ‘mental illness’, ‘psychiatric disorder’ or other ‘mental health problems’ either involve or result from the person’s problem in living with themselves, other people or life in general. b Nurses often talk about the ‘realities’ of their everyday work as the ‘coal face’, implying that this is hard and dirty work. However, nurses have to ‘get close’ to the people in their care, becoming a recognizable face that the person comes to trust. In that sense, it might be more realistic to talk about the ‘front line’ of nursing as the care face. *Phil Barker is a psychotherapist and Honorary Professor at the University of Dundee, UK. If you are a psychiatric or mental health nurse or are studying to become one, ask yourself : • Why did I want to become a psychiatric–mental health (PMH) nurse? • What did I expect that I would do for or with people as a nurse? • To what extent are my original expectations of nursing, proving to be a reality? If you are a member of another health or social care discipline, or someone with experience of mental health services, either as a ‘patient’, family member or friend, ask yourself: • What is psychiatric–mental health nursing? • What do these nurses do with or for the people in their care? • In your experience, what do they not do that they should be doing? Reflection 4 The need for nursing • How would you explain psychiatric–mental health nursing to a member of the public? • Which of the two groups described above do you belong to? Reflection the only caring constant.3,c Despite the media hype, when people talk about their ‘recovery’ from mental illness, they rarely name doctors, psychotherapy or even drugs. Instead, they talk about support, comfort, presence and other ‘human’ stuff,4 which they believe sustained them on their recovery journey. They thank people who offered extraordinary human support, who nourished their souls. Apart from friends, families and other ‘patients’, invariably they thank nurses. This should not surprise us since ‘psychotherapy’ originally meant the ‘healing of the soul (or spirit)’, and nursing, originally meant ‘to nourish’. Some years ago, I had the privilege of spending time with Pat Deegan,d the famous American psychologist, survivor and key proponent of ‘recovery’ in mental health. We discussed her original ‘breakdown’, when she was diagnosed as a ‘chronic schizophrenic’ at 20 years of age and told ‘not to hope for much’. Her recovery really began when she was discharged from hospital to a boarding house, where she roomed with ‘a bunch of hippies’. This ‘assortment of oddballs’ supported her as she wrestled with her demons.‘They treated me like a person, not a patient’, Pat recalled. Their caring acceptance appeared to kick start a process in which Pat began to care for, and also accept herself, for who she was. Although she went on to become a psychologist, rather than a nurse, her work emphasizes the social construct of nursing:5 how to support people in facing life’s challenges; how to help them grow and develop as people. For Pat Deegan, what ‘made a difference’ was being accepted as ‘just another human being’, albeit with some problems in living. Those around her ‘nursed’ her in the most traditional manner, helping her to live and grow, from day to day. Ironically, this caring attitude was miles away from the kind of ‘care’ she had known as a hospital ‘patient’. There are, however, many encouraging signs that nurses are beginning to reclaim ‘genuine nursing’ with all its human and social values. WHAT IS PSYCHIATRIC AND MENTAL HEALTH NURSING? In 2007, my colleague Poppy Buchanan-Barker and I tried to clarify the concept of psychiatric–mental health nursing and what it involved in practice.6 We asked nurses from different countries: ‘what is psychiatric and mental health nursing?’ and ‘how do PMH nurses do nursing?’ To help them provide a brief answer we supplied examples of two-line definitions of medicine, psychology and social work, drawn from the Internet, and asked a range of practitioners, leaders, researchers and professors – to define and describe their discipline in simple language. Most replied saying that they needed ‘time to think about this’. Some needed weeks, others needed months, to come up with an answer. A few said such a definition couldn’t be done, or, for various philosophical reasons, shouldn’t be done. Almost all admitted that these were difficult questions.e However, lay people were more forthcoming: • Nurses help people; • Nurses relieve a person’s distress; • Nurses help people get through the day, and through the night. • Nurses help people ‘deal with stuff … all sorts of stuff ’.f However, behind these obvious, if not commonsense descriptions, lies a wealth of hotly disputed debate concerning what is (or is not) nursing; the proper focus of nursing;7 and the often subtle difference between care and treatment. Maybe the nurses we involved in our study were trying to define psychiatric–mental health nursing as a professional idea, whereas the lay people described this as a human or social service. Few of the nurses in our study referred to caring or care, except in very general terms – such as ‘nurses give nursing care’, which is rather like saying ‘doctors practise medicine’. However, one professor of nursing from the USA said that the field was divided into two ‘camps’. 1 A subservient discipline and an extension of psychiatry’s social control mechanism(s), for the policing, containment and correction of already marginalized people, which carried out a number of defensive, custodial, uncritical and often iatrogenic practices and treatments, based on a false epistemology and misrepresentation of what are, by and large, human problems of being, rather than so-called ‘mental illnesses’. 2 A specialty craft that operates primarily by working alongside people with mental health problems; helping individuals and their families find ways of coping with the here and now (and past); helping people discover and ascribe individual meaning to their experiences; and exploring opportunities for recovery, reclamation and personal growth – all through the medium of the ‘therapeutic relationship’. c The British psychiatrist, Albert Kushlick, once described everyone except nurses, as ‘DC10s – offering direct care (DC) for only 10 minutes’, before ‘flying off’ somewhere else. d All the quotes here are taken from an interview with Pat Deegan, recorded in England in 1997. Available at: . e Further details of this study are available from the author at: . f These are some of the replies we received when we asked a group of lay people ‘what do nurses do? The nature of nursing 5 PSYCHIATRIC–MENTAL HEALTH NURSING: A DEFINITION Of course, nursing was adequately defined over 50 years ago.8 Nursing is a significant, therapeutic, interpersonal process. It functions cooperatively with other human processes that make health possible for individuals in communities … Nursing is an educative instrument, a maturing force, that aims to promote forward movement of personality in the direction of creative, constructive, productive, personal and community living.9 Peplau was defining what nurses focus on doing, and further developed this definition to represent nursing’s unique focus: Nursing can take as its unique focus the reactions of the patient or client to the circumstances of his illness or health problem.9 Peplau was highly influential in the development of the American Nurses Association’s definition of nursing: Nursing is the diagnosis and treatment of human responses to actual or potential health problems.10 The distinction between psychiatric nursing and psychiatric medicine was clear-cut for Peplau. The nurse’s primary responsibility was to nurture and aid patients in their personal development through nursing services; helping ‘guide patients in the direction of understanding and resolving their human dilemmas’.11 The nurse’s secondary responsibilities include cooperating with physicians who prescribe psychiatric treatments for patients.11 Regrettably, in recent years, many PMH nurses have focused their attention on these secondary responsibilities. Some even assume that by emulating the work of their medical colleagues – e.g. by increasing their involvement in psychiatric diagnosis or prescribing of medication – they are ‘advancing’ the practice of nursing. WHAT IS THE PURPOSE OF NURSING? I have, for many years endorsed both the American Nursing Association (ANA) definition of nursing and Peplau’s description of the ‘proper focus’ of psychiatric nursing. However, although the focus of nursing is clear, its purpose – what it was for – appeared less clear. Almost 20 years ago I tried to extend Peplau’s original definition, by defining the purpose of nursing as trephotaxis – from the Greek, meaning ‘the provision of the necessary conditions for the promotion of growth and development’. • When nurses help people explore their distress in an attempt to discover ways of remedying or ameliorating it, they are practising psychiatric nursing. • When nurses help the same people explore ways of growing and developing, as persons, exploring how they presently live with and might move beyond, their problems of living, they are practising mental health nursing. These two forms of caring practice are closely related, with a highly fluid border separating them. The former might be seen as problem focused or situation specific, whereas the latter is more holistic: concerned with the person’s life – how it is lived, along with its many inherent meanings. By emphasizing the purpose of nursing, rather than its many different processes, more emphasis is given to the developmental and educative aspects of nursing, first described by Peplau. However, nurses do not ‘make’ people develop, far less ‘change’ them; neither do they ‘teach’ them anything directly. Instead, they provide the conditions necessary for the person to experience growth, development and change, and to learn something of significance from their own experience.12 Emotional rescue and psychiatric nursing When people are acutely distressed, under threat – whether physical, psychological or spiritual – or presenting a risk to themselves or others, the high drama of the situation requires an equally dramatic nursing response. Here, the nurse might need to make the person and the environment as physically safe and emotionally secure as possible. This requires great skill and composure on the nurse’s part. Such dramatic help is akin to the work of the lifesaver rescuing someone from drowning, or the fire-fighter delivering a person from a burning building. When people are suicidal or tormented by ‘voices’ they require just this kind of ‘emotional rescue’. In such a situation the nurse provides the kind of supportive conditions that will reduce the experience of distress and prepare the way for a more detailed examination of what needs to be done next. When nurses respond to people’s distress by helping to contain it, delimit it or otherwise fix it, they are practising psychiatric nursing. Both the nurse and the person are locked in the present. The emphasis is on stemming the flow of distress, or keeping a watchful eye out for any signs of exacerbation of the original problem of living. Growth and mental health nursing As soon as the ‘crisis’ has passed, and the person – or their circumstances – appears to have calmed down, the focus turns to something more constructive and developmental. Once the ‘drowning’ person has been dragged ashore and is judged to be ‘safe’ the emphasis switches to 6 The need for nursing ‘rehabilitation’: what needs to happen now to help the person return to normal living. If the person appears to have played a part in their own crisis – whether by accidentally falling or intentionally jumping into the river – the focus turns to an examination of the person’s motives, or understanding of the risks involved. Of necessity, this will involve a more detailed, longer term enquiry, which aims to ensure the person’s safety and well-being in the future. In such a situation: The nurse tries to foster active collaboration – ‘caring with’ the person,13 developing an active alliance, so that together they might develop an understanding of the problem, its personal meanings and relationship to the overall life of the person. Such a careful, paced, developmental approach to clarifying the person’s understanding of the function and meaning of her or his problems of living, and their possible solutions, is the substance of mental health nursing (). Nursing as a social activity However, even if ‘professional nursing’ did not exist, people would still find ‘ordinary nursing’ in different areas of everyday life. People have been ‘nursing’ one another long before the birth of nursing, as a professional discipline. The most enduring example is the supportive care offered by parents to their children, which spans nations and cultures and is largely indistinguishable from the parenting found in the animal kingdom. Being responsible for their offspring, parents shape the immediate physical environment of their young, ensuring that the ‘space’ is safe and will provide adequate room for growth. In the early stages of development, parental support is intimate and often very directive. As the child grows, the parents step back, allowing the child more opportunity to make decisions, and mistakes; helping the child towards autonomy and personal determination. If parents do not foster autonomy, they risk ‘smothering’ the child, suffocating its natural development. The ultimate aim of parenthood is redundancy: parents want their children to be able to survive without them. Nursing should embrace a similar ambition for redundancy. Similar forms of ‘ordinary nursing’ are to be found in a variety of formal and loose-knit social groups, where members engage in mutual support, in an effort to develop resilience and encourage growth. The ‘buddy system’, made famous by Alcoholics Anonymous over 70 years ago,14 inspired a range of other mutual-support and selfhelp groups. These do not try to control people, but to provide the kind of social support that might help members ‘grow and develop’, through and beyond their immediate problems. In many cases, the aim is to ‘learn to live with’ some problem, demonstrating that a full life is possible, despite the presence of a disability. BACK TO BASICS: THE NATURE OF NURSING The ‘postmodern’ problem PMH nurses have struggled to define themselves and their work.15 Some argue that the question of what nursing is ‘has been “done to death” over the years, and we are no closer to a definition than we were fifty years ago’.16 Other experienced and senior figures even question whether their discipline ‘should be called “nursing” at all’.17 Such comments are typical of the tortured selfexamination found in the PMH nursing literature. Indeed, some contemporary authorities would argue that it is impossible to define PMH nursing as it involves a ‘spectrum of roles, responsibilities and practices, defined by the economics, institutions and policies of the day’.6 However, if nursing is simply to be whatever the ‘economic, institutional and political’ influences of the day demand, how do we avoid a repeat of the kind of ‘nursing’ that developed during the Third Reich.18 In these ‘postmodern’ times it has become unfashionable to attempt to ‘define’ things explicitly.19 Some nursing academics argue that ‘postmodernism considers reality to be subjective, not fixed or true and immutable’20 and that ‘postmodernism defies absolute definition because the words we use to describe it (or anything else) cannot be separated from the context in which those words are used’.21 If we offer a definitive answer to a question, such as ‘what is nursing?’ we risk presenting our view as ‘something special … another authorised version (grand narrative) of the nature of knowledge, from the academy’.22 The problem with such postmodern debates, as Burnard argued, is that: while they undermine any strong position, they also leave the commentator (or reader) unable to take any strong position for him or herself. Or, rather oddly, the reader can take any view. The writer’s own view can, of course, always be undermined by another reading of that view. And so it all goes on, in a never-ending spiral that ultimately takes us nowhere particularly useful.23 Burnard seemed to be frustrated by relativism, which has been around for at least 2500 years.24 However, when people say that their beliefs are ‘true’, do they mean ‘just for me’? The philosopher, A. C. Grayling, does not think so, and offers a graphic example: • What groups have influenced how you think and feel about yourself and your life problems? • How did the other group members influence you? Reflection The nature of nursing 7 (Relativism may apply) in cases of taste or preference, and sometimes when there is known to be no way to settle a choice of view. But if I say that camels have humps, I do not mean to imply that it is simultaneously the case that camels have no humps just because someone else believes as much.24 This is the problem with so much ‘philosophizing’ in PMH nursing: it addresses ‘things’ in the abstract, but pays no attention to ‘real things’. I am uncomfortable with ‘sitting on the fence’ positions. I like to take a ‘strong position’ on issues that I consider to be important. In taking such a strong position, I have often found myself in conflict with received opinion, with traditional values and practices, and also with colleagues. So be it. If we believe that something needs changing, then discomfort may need to be part of the process of change. Over a decade ago I wrote: we need to forget how once we valued: competitiveness, domination, exploitation, fragmentation, blind reason and detached objectivity. (However) In these postmodern times, I remain comfortable declaring myself a humanist.25 It may be interesting, amusing and sometimes enlightening to see how people disagree about the nature of reality. However, if I was asked whether I could take a relativist view of nursing and say that everyone’s viewwas true, my answer would be no. • The people who sit in corridors, observing distressed people in their bedrooms, from a distance, may be called ‘nurses’ but are not practising nursing. • The people who tell anguished people what is ‘wrong with them’ and then lecture them, however kindly, about the nature of their ‘symptoms’ may be called ‘nurses’, but are not practising nursing. • The people who helped frail and disabled people to the gas chambers at Auschwitz may have been called ‘nurses’ but were not practising nursing. One of my mentors (Annie Altschul) once said that ‘a nurse is a person registered with the appropriate nursing council – there is no other definition’. This was, and still is accurate, but not particularly helpful. I want a definition of nursing that ‘works’, that is more than just a label. Does it do what it says on the tin? If nurses do not ‘provide the conditions necessary for growth and development’, they may be doing something that is valued or approved by some professional body, but they are not practising nursing – as I understand it. The nurses at Auschwitz were ‘nurses’. We might excuse their actions on the grounds of ‘just following orders’, but could you describe their actions as ‘nursing’?g Common denominators To gain any ‘real’ sense of ‘nursing we need to deal with more basic issues. We need to grasp some fundamentals. Of course, ‘nursing’ will be different in different situations, for different people, under different circumstances, at different times. However, we need to put these ‘differences’ to one side and ask – what do these ‘different’ contexts have in common? Despite the many different ways that nursing might be defined, there are some ‘common denominators’, which the philosopher might say represents some ‘universal truths’. • People look after themselves, their family members and friends, animals, the environment, their prized possessions and a range of other ‘things’, in a way that might be called ‘nursing’. They provide the conditions, under which the kinship, friendship, welfare or value of the person or thing will grow, develop or prosper. • The athlete who sustains damage to a tendon or ligament is often said to be ‘nursing an injury’ – acting in such a way as to prevent the injury getting worse trying to promote healing. • The seasoned drinker is often described as ‘nursing a pint’ – taking time over the consumption of a beer, savouring each mouthful, in a vain effort to prolong this enjoyable experience. • The nurseryman, responsible for planting and overseeing a new forest, ‘nurses’ his new shoots. The fragile new growth is sheltered from strong winds, and adequate drainage, irrigation and – most of all – space is made available, all of which are necessary if growth and development are to take place.26 In English, the words nurse and nursing have been used to represent fostering, tending or cherishing ‘things’ at least since the Middle Ages. PMH nursing stands in the shadow of those dictionary definitions, owing its very existence to ancient notions of the human value of tending, and cherishing things, as part of our hopes to foster their growth and development. THE CRAFT OF CARING Blending art and science Nurses have also debated whether nursing is an art or a science.27 I believe that the practice of nursing requires both knowledge (science) and aesthetics (art), however these are blended to form a craft. Craft workers use their skills and knowledge to satisfy the demands or expectations of patrons or customers while satisfying their own aesthetic and technical ambitions. g I chose this example for my mentor, Annie Altschul, was Jewish and a refugee from Nazi Germany. 8 The need for nursing Craftwork blends aesthetics and technique with the expectations of the patron. The craftsperson needs to know how to weave, dye or cut cloth; how much pressure silver will take without breaking; how high a temperature is needed to fire a piece of clay. This craft– science is augmented by some aesthetic – marrying shape, form and colour to suggest an unspoken, often culturally embedded message. The meaning and value attached to a wedding dress, a talismanic piece of jewellery or a pot, however, comes from the owner not the maker. Such value-making is invisible but transformative. Through such attribution, the crafted object becomes unique, if not magical; like no other, despite possible surface similarities. The proper focus of nursing is the craft of caring. The value of care is defined by those who receive it.13 How could it be otherwise? Yet, the nurse also brings value, expressed through carefulness and expertise. Knowing when to talk, what to say and when to remain silent while nursing a depressed, distressed or dying person takes great skill. This is not something that can be learned on a course, far less from books. It requires a lifelong apprenticeship, where the human tools of the trade are sharpened with every encounter. The traditional image shows the craftsperson hunched quietly over the work, carefully, attentively and sensitively transforming the base material into something worthy of value. Genuine caring needs the same intimacy, quiet, care, attention and sensitivity to create the conditions under which the patient might begin to experience healing and recovery. In the clamour of the ward or clinic, nurses make a space – however metaphorical – for this to happen by being creative and resourceful, not by following protocols or national guidelines. However, as health and social care has become increasingly organized, and subject to the influences of economics and the political philosophy of the day, this fundamental appreciation of nursing can become lost in a morass of policies, protocols and legislation. However, although the term ‘care’ may have lost some of its original currency in nursing, ‘caring’ remains the universal, common denominator of PMH nursing. In the late twentieth century, many nurses grew dissatisfied with caring, exploring instead the idea of nursing as a therapeutic activity – in particular a behaviour change or psychotherapeutic activity. Of course, when nurses care effectively, what they do will be therapeutic – it will begin to provide the conditions under which the person can begin to be healed. As Nightingale observed: ‘It is often thought that medicine is the curative process. It is no such thing; … nature alone cures. … And what [true] nursing has to do … is to put the patient in the best condition for nature to act upon him.’28 Psychotherapy originally meant the ‘healing of the soul (or spirit)’. When nurses organize the kind of conditions that help alleviate distress and begin the longer term process of recuperation, resolution and recovery, those activities become therapeutic, engendering the potential for healing. Caring, sensitivity, attention to detail and respect We should also value caring because it emphasizes the caution, attention to detail and sensitivity necessary when handling something precious. The archaeologist who seeks some long-lost treasure, may begin his work with strenuous and dramatic digging – excavating the site until there are signs that something of value might lie somewhere just below the surface. Then the powerful tools of excavation are exchanged for smaller tools, which can be used more sensitively. Finally, when a ‘find’ begins to emerge, these small tools are exchanged for brushes, used even more carefully to remove the earth and dust that hides the treasure. The archaeologist’s careful approach to unearthing and finally revealing a possible find suggests a concern and respect for the treasure. The team may have unearthed a relic from a bygone age, or they may simply have uncovered another stone. Either way, their work is characterized by care, sensitivity and attention to detail. These ‘finds’ are priceless – whatever their market value. If a piece of pottery, buried in the earth a thousand years ago, is considered ‘priceless’, a person who is by definition unique should also be viewed as priceless. Respect for the person – irrespective of age, class, nationality, creed or colour, or the presumed nature or origins of their problems – lies at the heart of all the contributions in this book. If this is not a universal, defining characteristic of nursing, it should be.29 THE PURPOSE OF NURSING This book considers the highly contested notion of ‘mental health, which lacks any single, official definition.30 However, this book is about nursing not about ‘mental health’. In this sense, I hope that readers will discover in this book many examples of how, by caring for people diagnosed with one ‘mental disorder’ or another, they help those people to reclaim or attain the mercurial state known as ‘mental health’. I hope that they will also discover how nurses might become social agents, in a much broader sense, helping families, communities and society at large to grow and develop, so that they might become healthy, meaningful and productive. Most of all, I hope that you will understand better what it is that nurses do in the name of nursing care, and why they do this rather than anything else.31 The nature of nursing 9 • What does ‘caring’ mean to you? • How important is ‘caring’ to PMH nursing? Reflection The progress of psychiatric and mental health nursing In 2006 ‘reviews’ of mental health nursing were published in England and Scotland.32,33 One might have expected these reviews to talk, enthusiastically, about ‘care’ and ‘caring’. Instead, the focus was on ‘interventions’, ‘evidence’ and ‘technology’. Perhaps caring is no longer considered sexy, but science and technology is exciting! If the craft of caring is to make a difference in the world of mental health then nurses will need to embrace, carefully, both science and art, blending these together, to form a meaningful, practical reality – the craft of caring. However, if a mental health ‘revolution’ is needed today, we need to ask to what extent science – in any form – will help make a significant contribution. History suggests that, however useful science in its various forms might be, it is not a necessary part of the ‘mental health revolution’. • Two hundred years ago, when the abolition of slavery began, this movement was not based on science or ‘evidence’ regarding the ‘rights’ or ‘wrongs’ of slavery, but on a particular set of human values. • One hundred years ago, when the emancipation of women began, this movement was not based on science or ‘evidence’ regarding the ‘rights’ or ‘wrongs’ of votes for women, but on a particular set of human values. • Fifty years ago, when the civil rights movement began in the USA, this was not based on science or ‘evidence’ regarding the ‘rights’ or ‘wrongs’ of racial equality, but on a particular set of human values. • Thirty years ago, when the gay rights movement began to be taken seriously, this movement was not based on science or ‘evidence’ regarding the ‘rights’ or ‘wrongs’ of freedom of sexual expression, but on a particular set of human values. 34,35,h As Burnard36 eloquently said, caring can give unselfish and even ‘unrewarded’ pleasure. Perhaps, the countless numbers of people who participated in the four ‘revolutions’ noted above, cared sufficiently to commit themselves – many at the expense of their health if not their lives – to make a change in their social world. It is difficult to imagine how those revolutions could have come about in the absence of caring. Despite the absence of any solid ‘scientific evidence’, the significance of caring is obvious. However it is viewed, it would seem that caring is an almost universal phenomenon and one linked to the very process of becoming and being a person … caring remains at the centre of the process of nursing, for whatever it is not, nursing is ultimately bound up with all aspects of the person.36 NURSING THE WORLD In 2007, the WHO and the International Council of Nurses published Atlas: nurses in mental health. 37 This reported that the number of skilled nurses was far too small to meet mental health service needs worldwide, and that basic and specialist training in mental health nursing was often absent or seriously deficient, even in more developed regions such as the European Union. In all continents, except Europe, there are fewer than three nurses in MH settings per 100 000 people. Reporting these sobering statistics, Salvage38 cited international mental health nursing expert, Ian Norman, as saying: ‘the evidence base for MH nursing interventions is at its strongest for decades. Yet it is alarming that these interventions are not being delivered to patients in many parts of the globe because of inadequate training’. Professor Norman listed prescription and collaborative medication management; education and training of service-users to manage their illness; family psychosocial education; assertive community treatment; supported employment; and integrated treatment for people with mental illness and co-occurring substance use disorders as examples of the kind of ‘evidence-based interventions’ to which he was referring (I Norman, personal communication). All these interventions are covered in later chapters, and may be good examples of mental illness services. However, if people in the more troubled and disadvantaged parts of the world are to realize their ‘mental health’ then something more radical will be necessary. They will need something more like the social actions that brought an end to slavery, opened the door to the emancipation of women, and guaranteed rights for ‘people of colour’ and gay and lesbian people. If we are to ‘make a difference’ for people across the world, first of all, we need to care deeply about them and their plight. This intangible human value will fuel our advocacy, will sustain our interest in them and their problems of human living, and will foster the development of the range of innovative projects needed to h Indeed, quite the reverse. Most ‘contemporary science’ supported slavery, the subjugation of women, segregation of ‘coloured’ people and the persecution of gay and lesbian people. 10 The need for nursing address the wide range of uniquely different social contexts. 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