A NEW CAREER IN SOCIO-PSYCHIATRIC NURSING
by HARRY A. GRAHAM
A special word must be given here to the way in which the problem of the attendant* is discussed among psychiatrists at technical meetings. Pleas are made for better education, making him feel a part of the group, and recognition that he also has a part in the treatment of the patient. Such analyses overlook the fact that an aide is not paid enough to consider his position a possible career, is often prevented from expressing his opinion about patients, and, when he does, is often not taken seriously. When his problems (including that of advancement) are considered, administrators often try to solve them for him rather than to work them out with him seriously and matter-of-fact1y.l
PPROXIMATELY 682,129 people A in the United States, or about one person out of 350, were hospi- talized in psychiatric facilities in 1964. At the same time, about 444,978 pa- tients were admitted or readmitted to psychiatric hospitals.a Caring for these patients were approximately 101,000 psychiatric aides, 16,300 registered nurses, and 9,600 licensed practical nurses. These figures illustrate the fact that there are not nearly enough trained personnel to adequately treat our men- tally ill and that the brunt of the psychiatric load is being borne by the psychiatric aide. The gravity with which the dedicated psychiatrist views this problem is substantiated by the open- ing quote.
Before the psychiatric nurse came into being, psychiatric wards were en- tirely stded by attendants, and many of the techniques now expected of,
* The tsnn aide and attendant am used synonymously in this p@w.
and exercised by, the good nurse were formulated from the practice of the ward attendant working in our early mental hospitals. It is interesting to note that a paper entitled Directions for Attendants was prepared in 1830 by McLean Hospital, Belmont, Massa- chusetts, which later, in 1882. estab lished the first school of nursing in a psychiatric setting. In September of 1965, the last class of this school of nursing was enrolled and will be re- placed by college-affiliated psychiatric nursing programs.
With the advent of collegiate pro- grams in nursing, psychiatric orientation has become of increasing importance and supportive, supervised training in the one-to-one therapeutic nurse-patient relationship has become an integral part of the curriculum. The increased em- phasis placed upon the collegiate train- ing of graduate nulses working in psychiatry points toward a future in which the highly trained nurse might become the $5.00 therapist urgently proposed by Hollingshead and Redlich.
At this time, I would refer you to the exciting work of June Mellow, R.N., Ed.D. and the article published in this journal by Margaret A. Colliton, R.N., D.Sc.N., The History of Nursing Ther- apy: A Reactionnaire to the Work of June Mellow.
In addition to the psychiatric nurse, the potential of the psychiatric aide also has been the topic of much research by all of the psychiatric disciplines,
but as yet, the aide remains the ugly stepchild of the psychiatric team. Part of this problem stems from the lack of supportive recognition given to the aide within the psychiatric com- munity.
The nursing profession, while con- stantly bemoaning the fact that there are not enough people entering psy- chiatric nursing today, although wages, educational advantages and job oppor- tunities have been steadily increasing, generally fails to utilize and respect the capabilities and opinions of the psychiatric aide concerning patient be- havior and patient care, thereby depriv- ing itself of this untapped potential. However, the federal government has currently invested through the USPHS, over 5 million dollars in inservice edu- cation for psychiatric aides in 1965,2 in an attempt to remedy this situation.
The value of the academic training of the graduate nurse, while not dis- puted, is in many cases, at least open to question when weighed against the practical experience of the dedicated aide who handles the problem, both minor and severe, which arise daily in the care of the disturbed patient.
The aide enjoys few of the benefits now accorded the professional mem-
7. 8 , 0 , 10, 11
bers of the psychiatric team. The pro- fessionals, although dependent upon the observations, skills and insights of the aide, refuse to afford him any status. Today, while nurses salaries have in- creased, the aide is still underpaid and, according to studies, tends to under- estimate his own importance. While the demands upon the psychiatric team have increased, his relatively unchanged position on todays economic scales has caused otherwise dedicated men and women to seek other fields of employ- ment, as evidenced by the rapid turn- over of aides today. With the low sal- aries and lack of status, the attendant currently has several choices: to leave the job, to withdraw his investment, or to continue struggling for change. It becomes increasingly apparent that a valuable member of the psychiatric team, while being exploited, unfortu- nately, is not being utilized to his full therapeutic potential.
How can we best solve this problem and utilize the aide so as to realize more of his potential? A new subspe- cialty in psychiatry is needed, with training programs and adequate com- pensation, concurrent with a standard- ized licensing program to be inaugu. rated for this group; that is, men and women trained in psychiatric technol- ogy. Upon completion of an accredited training program, they would be reg- istered as psychiatric technicians, qual- ified to work with psychiatric as well as mentally retarded patients, in a skilled therapeutic manner, thus in- creasing the quality and scope of patient care.
Psychiatric technicians would have as their role the social therapy of the
Perspectives in Psychiatric Care Volume IV Number 4 1966 35
ward milieu, which would include in- teracting with small groups of patients and utilizing supportive therapy in crisis situations in the ward community. This increased reliance on, and con- fidence in, the preservice trained tech- nician not only would benefit the em- ploying institution by saving valuable time now needed for on-the-job train- ing, but would also raise the quality of nursing care offered. The therapeutic team could truly function as a team.
The following is a quotation from the Governor's Council on Mental Health for the State of Minnesota, presented in 195 1 : .
. . , The psychiatric aide would pro- vide services for the patients not re- quired of the present attendants and must be compensated accordingly. . . The psychiatric aide would be ex- pected to establish and maintain a therapeutic relationship with the pa- tients assigned to his care. Through daily companionship, he would be responsible for encouraging patients to participate in ward activities as prescribed by the physician, and as- sume wholesome emotional attitudes. By providing personalized attention, he would attempt to identify with his patients in order to emphasize what- ever therapy is planned for them.. . One of the most important employees in a state mental hospital is the person whose duty is the constant care of the patient. That employee is now desig- nated as an attendant, which is all too synonymous with the concept of custo- dial care. Properly trained and com- petent psychiatric aides,, who would be able to carry out the treatment program for each individual patient
Prsftwaldy called psychiatric techricims - The Aujbor.
must be substituted as rapidly as pos- sible for the present hospital at- tendant?."
The formal training of attendants and their use in the ward community in the role described in this paper is not a new idea. Harry Stack Sullivan, M.D.,lfi recognized the therapeutic value of trained attendants and wrote of his success with them at Shepard and Enoch Pratt Hospital, Towson, Mary- land, 1926-1931. His beliefs were further supported by William Silvers- burg, M.D., who followed him as director of his ward from June 1930, to June 1931, where he continued most of his (Sullivan's) administrative policies. In 1950-1951, Dr. Kaldeck, clinical director of Medfield State Hos- pital, Medfield, Massachusetts, recog- nized some of the potential of the attendants by training them as group therapy leaders.''
In 1953, the state of Texas took a progressive step by establishing its psy- chiatric nurse technician program, un- der the auspices of the Board for State Hospital and Special Schools, in co- operation with the Texas junior col- leges. This program consists of 37 lecture hours, 10 laboratory hours, and a 30-hour experience block and leads to the Associate Degree in Science. One of the aims of the broad program, of which this education program is a part, is the licensing of the psychiatric nurse technician. This aim is opposed by the Texas professional nurses, possibly because they fear a competitive or sep- arate group and do not recognize the fact that the licensed psychiatric nurse technician would be a nursing tech-
nician, supported and supervised by professional nurse.
It is my belief that part of the solution to the problem of securing more and better qualified psychiatric personnel could be initiated by the following program:
1 ) Educational preparation which is preservice in nature, taught on the junior college level, including as part of the curriculum related work in the social sciences, communication skills and, at least, some exposure to the humanities; 2 ) preparation which com- bines classroom instruction with clin- ical practice and provides individual as well as group supervision of the clinical experience. Experience should be pro- vided in group dynamics, whether re- lated to the clinical experience or as a separate entity.
Upon completion of the program, an Associate Degree in Science would be conferred. I would suggest that some type of reciprocal licensing system, such as is now operative in nursing, would further serve to bring dignity and rec- ognition to the psychiatric technician. As a final step, I would hope for the emergence of some type of organiza- tion, such as the health professions have brought into being, which would help the psychiatric technician to set standards of practice, encourage growth by intra-professional recognition and, generally from within the group, chart the psychiatric technicians future course.
It is the responsibility of all in the psychiatric profession to examine these issues and to support both the further development of the collegiate nursing programs and the initiation and devel-
opment of qualified training schools for psychiatric technicians. Recognition of the potential of each of these groups, plus clear understanding and adherence to the definition of their respective roles within the structure of the ward community and the social hierarchy of the entire psychiatric profession, are of the utmost importance at this time.
REFERENCES 1 Stanton, A., Schwanz M., The Mental Hospitd,
New York: Basic Books, 1955. 2 Hospitals Guideline Issue, J o d of tbe
American Hospital Association, August 1, 1965, Chicago, Ill.
:I Public Health Service Publication No. 992, Toward Quality in Nursing Needs and Go&: Report o f the Surgeon Generals Consultant Group On Nursing, Washington, D. C.: U. S. Government Printing Office, 1963.
* Hollingshead, A. B., Redlich, F. C., Socid C h s and Mental Illness, London: J. Wiley Sons, 1958.
jMellow, June, The Evolution of Nvssing Therapy and Its Imp/ications for Education, unpublished Ed.D. dissertation, Boston Uni- versity, 1964. Available through intralibrary loan. This is a synthesis of all of Mellows previous works.
fl Colliton, M. A., The History of Nursing Therapy: A reactionmire to the work of June Mellow Perspectives in Psychiatric Care, Vol. 111 No. 2, 1965.
7 Hollingshead, op. czt. 8Greenblatt. M., e; d, Prom Gustodid to Tber-
ripentic Patient Care in Mental Hospitals, New York: Russell Sage Foundation, 1955.
9 Hyde, R. W., Experiencing the Patients Day, New York: G. P. Putnam & Sons, 1952.
10 Kaldeck, W., Gfoup Psychotherapy by Nvssos and Attendants, Diseases of ;he Nervous Systern, New York, New York, 1952.
11 Sullivan, H. S. , Schizophrenia as a H S M Process, New York: W. W. Norton GI., 1962.
12 Mental health training grant awards, fiscal year 1965. U. S. Department of Health Education and Welfare, Public Health Service publication, 1965.
1 5 Meeta1 Hospi;&, September, 1964. 14The Psychiatric Aide, Vol. IX, No. 1, New
York, N. Y. 1952. l G SUUiVM, Op. C k 1~Kalde& op. cit.
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