The changing face of psychiatric nursing

6 Advances in Psychiatric Treatment (2005), vol. 11. http://apt.rcpsych.org/

Gournay Advances in Psychiatric Treatment (2005), vol. 11, 6–11

This is the first of a new series planned for 2005 (see also Cowen,2005, this issue) that will revisit articles published in the earlyvolumes of APT. Kevin Gournay’s original article is available on ourwebsite (http://apt.rcpsych.org), as a data supplement to the onlineversion of the present article.

In 1996, APT published an article with much thesame title and by the same author. The article, whichI wrote during 1995, examined the key issuesconcerning psychiatric nursing (Gournay, 1996). Thearticle began by describing the rationale for returningthe focus of nursing to serious mental illness, citingthe problems associated with the interventions ofcommunity psychiatric nurses (CPNs),1 during the1980s and early 1990s, working with people withcommon mental disorders in primary care. I arguedthat, in order to be effective, nurses needed to acquireclinical skills in the management of people withschizophrenia and other serious and enduringillnesses. In particular, I argued that, unless nursesreceived appropriate training in these clinical skills,merely shifting the focus of their work from insti-tutions to the community, and the patient focus from

those with common mental disorders to those withschizophrenia, would prove inadequate. I alsoadvanced the argument that the problems of peoplewith dual diagnosis, i.e. substance misuse andserious mental illness, needed particular attention. Idrew attention to the neglected nursing roles ofphysical healthcare and medication management,and set out a range of areas in which education andtraining could be improved. The training prioritiesincluded the expansion of the Thorn Programme fortraining nurses in psychosocial interventions, andthe continuing need to train a relatively smallernumber of nurses in cognitive–behavioural therapyfor common mental disorders. I concluded the articleby arguing for a strengthening of evidence-basedapproaches to nurse education and suggesting thedevelopment of research in psychiatric nursingwithin the context of multidisciplinary investigationsusing randomised controlled trials and economicanalyses.

In the 9 years that have passed since that articlewas written we have seen major changes in theNational Health Service and in mental health policy.In this revisitation article I examine what has actuallyhappened, in this intervening period, to the topicsdescribed above, and consider other topics thathave since become important.

The changing face of psychiatric nursingREVISITING... MENTAL HEALTH NURSING

Kevin Gournay

Abstract Psychiatric nursing has changed significantly since I wrote a similar article almost 10 years ago.Community psychiatric nurses now focus their attentions almost entirely on people with serious andenduring mental illnesses and undertake case management roles in community teams. Many nurseshave now been trained in the use of psychosocial interventions and there have been particular advancesin the training of nurses in medication management. In turn, prescribing by nurses has become a realityand this role will expand rapidly over the next few years. Unfortunately, the potential for nurses todeliver cognitive–behavioural therapy to those with common mental disorders has not been realisedand it is unlikely that this situation will change. Psychiatric nursing roles have increased in the forensicsystem and nurses are now working with people with dangerous and severe personality disorders andwithin prison healthcare. The education and training of nurses has undergone a fundamental shift andnurses of the future are likely to be graduates. Here I discuss the implications of these changes.

Kevin Gournay is Professor of Psychiatric Nursing at the Institute of Psychiatry (De Crespigny Park, Denmark Hill, London SE58AF, UK. Tel.: 020 7848 0139; fax: 020 7848 0458; e-mail: [email protected]) and is a chartered psychologist and aregistered nurse. He has extensive clinical experience in the treatment of anxiety disorders and has a large and wide-rangingresearch portfolio. He supervises several Medical Research Council research training fellows and sees this area as a priority. Hemanages research and training projects overseas, and his other widespread interests in mental health include policy work for theDepartment of Health. In 2004 he was elected Psychiatric Nurse of the Year by the American Psychiatric Nurses Association.

1. Throughout this article I refer to community psychiatricnurses (CPNs) or psychiatric nurses. I acknowledge thatsome prefer to use the term mental health nurses.

The changing face of psychiatric nursing

7Advances in Psychiatric Treatment (2005), vol. 11. http://apt.rcpsych.org/

Serious mental illness

In 1990, a quinquennial review of communitypsychiatric nursing (White, 1990) showed that 27%of the patients on CPN case-loads had a principaldiagnosis of schizophrenia and a quarter of CPNsin the UK had no people with schizophrenia on theircase-loads. Although there have been no furthercomprehensive surveys of community psychiatricnursing, it is clear that the vast majority of psychiatricnurses now work with people with schizophreniawithin the context of the community mental healthteams and the assertive outreach and crisis resol-ution services. Thus, the pendulum has indeedswung in the direction that was desired by so manycommunity psychiatrists, and some nurses, in theearly 1990s. However, there is now some concernthat this shift has caused problems for people withcommon mental disorders.

As is noted below, there have been very substantialchanges in the training provided to CPNs, with anemphasis on psychosocial interventions in seriousmental illness (Box 1). However, there is very littletraining available to them in managing conditionssuch as obsessive–compulsive disorder, post-traumatic stress disorder, severe panic disorder andagoraphobia, and so on. It is now clear that the focusof CPNs on people with serious mental illness hasconsumed the CPN workforce entirely. Even so, thereis a shortage of CPNs to provide skilled nursing carefor people with serious and enduring mental illness.The reality is that several thousand more CPNs areneeded to provide a reasonable standard of care forpatients on community case-loads. Even if the moneyto do this were immediately available, it would notsolve the problem. It takes several years to train anurse and several years more to train them to a levelwhere they may carry out effective community roles.Thus, it would be many years before the workforcewould be sizeable enough to meet the needs ofservices. Furthermore, there are currently enormousdifficulties in recruiting and retaining nurses in manyparts of the UK and the problem is compounded bythe well-acknowledged demographic time bomb,

wherein disproportionate numbers of CPNs willretire over the next few years. Pay, conditions ofservice and the problem of house prices furtherexacerbate the problem. Given all of the difficultiesin meeting the needs of people with serious andenduring mental illness, there seems little prospectthat CPNs will have a significant role in the care ofpeople with common mental disorders.

Contemporary nursing servicesand nursing roles

As noted above, the nature of community psychiatricnursing has changed considerably in the past decadeor so, and the CPN may differ little in function fromtheir case manager colleagues from other professionsin the community teams. Certainly, the professionaldistinctions between nurses, social workers andoccupational therapists have blurred somewhat,and the overlap of roles and the sharing of casemanagement tasks seems to be to the advantage ofpatients.

By contrast, nurses in in-patient services continuein a custodial role. However, the nature of this rolehas changed. In-patient care has become one of themost difficult (and undervalued) areas of psychiatry.In my 1996 article, dual diagnosis was highlightedas an increasing problem, and there is little doubtthat it still provides one of the single largestchallenges in services. A number of recent studies(e.g. Wright et al, 2002) demonstrate the risingprevalence of this problem, particularly in innercities. It is likely that, on the average acute ward,there are more people with a dual diagnosis thanwithout. This, of course, has brought additionalproblems, and dual diagnosis is arguably a signi-ficant factor in the increasing levels of violence onesees in in-patient services. In turn, the in-patientpopulation is increasingly likely to be sectionedunder the Mental Health Act and to be non-compliant (non-concordant) with treatment. Thus,nurses in in-patient services have a more difficultjob than in the asylum days.

The difficulties of the in-patient environment leadto problems of recruitment and retention to whichno one really has a solution. The background workto the National Institute for Clinical Excellence(NICE) guidance on the short-term management ofviolent behaviour in psychiatric in-patient settings(National Institute for Clinical Excellence, 2005)emphasises the problem by citing the very high ratesof injury to staff and patients during restraintepisodes, and identifies a wide range of problemsconcerning the use of seclusion and training incontrol and restraint.

Box 1 Important roles of nurses in seriousmental illness

• Family interventions• Physical healthcare• Medication management• Working with dual diagnosis patients• Cognitive–behavioural therapy for delusions

and hallucinations


Gournay

Neglected nursing roles

My 1996 article identified two areas as beingparticularly important: the physical health of peoplewith serious mental illness and the managment ofmedication.

Physical health

The first, physical health in serious mental illness,remains a problem. However, my department at theInstitute of Psychiatry has recently begun to developmodules of training for nurses working in both in-patient and community settings to deal with a verywide range of physical health issues that are ofparticular relevance for those with mental illness.This training includes health education and takesaccount of the difficulties of delivering interventionsto people who may have cognitive deficits or verypoor levels of motivation. The training emphasisesthe need to target areas such as cardiovascular andrespiratory disease and sexual health and alsorecognises that this population may need active helpto access an appropriate range of health services.There is no doubt that all those involved in nurseeducation must make major efforts to continuetraining initiatives, so that the physical health needsof those with serious and enduring mental illnessesare adequately met.

The management of medication

Medication management (Box 2) is an area inwhich there has been significant success. At thetime of writing the 1996 article, I had begundeveloping educational materials for nurses on thistopic. By 2004, a medication management trainingpackage for nurses had been subject to a randomisedtrial (Gray et al, 2004). The programme allocated1 day a week for 10 weeks to teaching nurses toimprove compliance in the manner described byKemp et al (1998). The training also includedmeasures to improve nurses’ skills in using stan-dardised instruments to assess mental state and the

side-effects of medication and also to deal withpatients’ beliefs and feelings about treatments.Nurses were provided with a range of otherskills necessary to improve compliance. These skillscentred on using a non-confrontational approach,based on the principles of motivational interviewing,and emphasised listening to the reasons whypatients had difficulty complying and then negotia-ting compromise solutions.

The trial demonstrated not only that nursestrained in these methods improved their skills andknowledge but, most importantly, that theirintervention led to very significant changes in patientpsychopathology, with a 17 point difference on thePositive and Negative Syndrome Scale (PANSS) scorebetween the treatment and the control group.

This training package has now been disseminatedto more than 1000 nurses across the UK, followinganother Institute of Psychiatry initiative to traintrainers in all regions to deliver the trainingprogramme locally. At the time of writing, thepackage has also been disseminated across the statesof Australia and there are similar training pro-grammes planned for other European countries. TheGray et al (2004) study is now being replicated withfunding from the Medical Research Council.

Nurse prescribing

Although this training innovation should lead tomajor improvements in patients’ compliance withdrug regimens, nurse prescribing is arguably a moreimportant development. The arguments for nurseprescribing are set out in detail in Gournay & Gray(2001). Nurse prescribing is now a reality and,although psychiatric nurses are somewhat behindtheir general nursing counterparts in obtainingprescriptive authority, training programmes inprescribing are being set up at a number of univer-sities across England. Within a few years it isenvisaged that thousands of psychiatric nurses willbe carrying out a range of prescribing tasks up toand including prescribing new psychiatric drugsindependently (albeit under the overall supervisionof a consultant psychiatrist). The principal advantageof nurse prescribing is that it will free up thepsychiatrist to deal with the complex and difficultcases, leaving the routine to experienced nurses. Toensure that this development is both safe andeffective, we need to ensure that the training andsupervision of nurses are adequate and that thenecessary resources are released to continue fundingthe initiative appropriately. Furthermore, providingnurses with prescriptive authority is clearly animportant topic for evaluation and there is anobvious need to assess clinical and economicoutcomes of nurse prescribing.

Box 2 Components of medication manage-ment training for nurses

• Knowledge of psychopharmacology• Mental state assessments• Assessment of medication side effects• Motivational interviewing skills• Strategies to improve adherence



The nurse cognitive–behaviouraltherapist

The 1996 article argued for the further developmentof training programmes for nurses in cognitive–behavioural therapy. Regrettably, this expansion hasnot come to fruition, and although there are afew hundred such qualified nurses, cognitive–behavioural therapy for people with common mentaldisorders is scarce, to say the least, outside ofspecialist centres. There has been a modest increasein the number of clinical psychology training places,but the expansion of the cognitive–behaviouraltherapy workforce has been completely overwhelmedby a widening of the evidence base for the efficacy ofthis approach. This has been emphasised evenfurther by the NICE guidance on schizophrenia,which recommends the provision of cognitive–behavioural therapy to deal with hallucinations anddelusions (National Institute for Clinical Excellence,2002). It seems obvious that nurses are in an idealposition to become the agents for the delivery ofcognitive–behavioural therapy. However, they willneed a more intensive training than that currentlyoffered on psychosocial intervention programmes(see below). Realistically, such intensive training willnot be available for some time to come, as trainingproviders are still dealing with the backlog causedby the absence of appropriate basic training for CPNsover a number of years.

Education and training

The 1996 article set out the background to the ThornNurse Initiative (Gournay & Birley, 1998), which atthat time had delivered training to a few dozen CPNs.The Thorn Programme has now been replicated inmany universities across the UK, and similar trainingprogrammes in psychosocial intervention have beendeveloped at various educational levels, up to andincluding master’s degree, by other universities andthe Sainsbury Centre for Mental Health. We now havethousands of mental health professionals trained inpsychosocial interventions, and most communitymental health teams include several workers whohave received basic training in assertive communitytreatment methods, basic cognitive–behaviouraltherapy techniques for dealing with hallucinationsand delusions, and family interventions.

The Thorn Programme opened its doors to otherprofessionals several years ago and now nursesoccupy about two-thirds of course places. However,while all this is very welcome, the limitations of suchtraining need to be emphasised. What these pro-grammes have done is to provide mental healthprofessionals with basic skills across a number of

areas. There is still a need, as with cognitive–behavioural therapy, to equip more professionalswith more advanced skills in family interventionsfor those with schizophrenia and their carers, andalso to develop specialist programmes for othergroups, including those with personality disordersand the increasing community population who havefallen foul of the criminal justice system.

Undergraduate nurse education

In 1995 I highlighted some of the shortcomings ofundergraduate nurse education, including theproblems of teachers being located in universitiesrather than in clinical centres. Many departmentsof nursing in universities were then characterisedby a preponderance of anti-psychiatric philosophyin many programmes, and lack of importantinformation in training courses regarding thebiological aspects of mental illness and psycho-pharmacology. There has been progress in some ofthese areas, although clinically focused training isprobably an ideal rather than a reality.

The 1996 article also identified the problems ofnurses who had been trained in large institutionsand needed an updating in their skills. There havebeen several recent initiatives, including efforts bythe National Institute for Mental Health (England)to improve the skills of nurses working in in-patientsettings, and these are to be welcomed. However,there are now some ominous signs that, followingthe moves to make nursing an all-graduate pro-fession, psychiatric and, indeed, learning disabilitiesnursing may disappear in their present form. Formany years it has been possible to train and registeras a psychiatric, rather than a general or learningdisabilities nurse. However, there are moves afoot toset up generic training, so that one has to qualify asa generic registered nurse before moving on totraining in psychiatric nursing as a post-qualifyingspecialty. In my opinion, this would compromise anumber of the aforementioned initiatives. However,in the wider circles of nursing, the debate continuesand it may yet be several years before any resolution,one way or the other, is achieved.

Other areasHigh secure hospitals

Two areas that were not discussed in any detail inmy 1996 article have now become prominentin psychiatric nursing. The first is the issue of theexpansion of forensic services. Nursing in the highsecure hospitals has been beset by problems overthe years and these have, of course, been raised in


Gournay

the two notorious reports into care and treatment atAshworth Hospital (Department of Health, 1992,1999). One positive effect of these scandals has beenthe investment in nursing in these institutions.Nevertheless, it must be said that this work isextremely demanding, with nurses (and indeed otherstaff) trying to balance the needs of the patient againstpublic safety. In turn, attempting to provide thera-peutic interventions within a custodial environmentpresents enormous challenges.

Although there are very welcome initiatives aimedat transferring many of the female patients to lessintimidating environments, forensic services as awhole continue to expand. Indeed, because of theshortage of beds, forensic populations frequentlyoverspill into local mental health services and themixed custodial/care role of nurses is now muchmore mainstream than a decade ago. This is reflectedin the new NICE guidelines (National Institute forClinical Excellence, 2005) that set out guidance andmethods to improve security (such as closed-circuittelevision) and place an understandable emphasison searching, restraint, seclusion and the use of rapidtranquillisation. While this guidance will be veryuseful, it none the less emphasises the changingnature of psychiatric care.

Prisons

Yet another area of expansion of mental healthservices is prison healthcare. From 2005, prisonhealthcare becomes the responsibility of the NHSand prisoners should expect the same standard ofmental healthcare as patients in local services. Atthe time of writing, there are no fewer than 60 prisonswith in-reach programmes, i.e. nurses, doctors andother health professionals, employed by localservices, are spending part or all of their workingday delivering mental healthcare and treatment toprisoners in our overcrowded jails. Nurses, andindeed other professionals, may now be party to whatLen Stein, the pioneer of assertive communitytreatment, once called ‘transinstitutionalisation’, asthe care and treatment of mentally ill individualspasses gradually from hospital to prison. The role ofthe psychiatric nurse in this respect has undergonea fundamental shift.

Care or custody?

In addition to the increase in care for people withmental illness who have contact with the criminaljustice system, there are now growing numbers ofpeople with personality disorders being cared forwithin our services. The Government’s Dangerousand Severe Personality Disorder Initiative is nowbeing piloted in two high secure hospitals (Rampton

and Broadmoor) and in two prisons. There aresignificant numbers of nurses caring for thesepatients/prisoners, and they are in a very uneasyposition as both custodians and treatment agents.Nurses (and their colleagues in psychiatry), may bewondering exactly what their role is, as the patientpopulations differ considerably from people withidentifiable psychiatric illnesses. At present, somenurses are unhappy about the prospect of this morecustodial role and are understandably askingwhether this is part of a remit for a profession withprimary focus on caring for those who are unable tocare for themselves because of illness. As in the restof psychiatry, there are uneasy questions to be askedregarding the age-old topics of mad versus bad andcustodian versus carer.

Conclusions

In summary, the years since my original article haveseen many changes in mental healthcare, whichhave, to a greater or lesser extent, been mirroredwithin psychiatric nursing. There is no doubt thatthe skills of psychiatric nurses have improved inmany respects; in other areas, such as physicalhealthcare, there has been little change. Furthermore,the young (or indeed older) person entering thenursing profession will generally have a higherstandard of education than in previous generationsand the psychiatric nurses who qualify over the nextfew years will do so with an honours degree. Perhapsthis fact identifies the most important shift yet tocome. It seems extremely likely that the caring tasksundertaken by psychiatric nurses in years gone by,which included helping people with schizophreniain their activities of daily living, attending to theincontinence of elderly mentally ill patients andsimply looking after those who cannot care forthemselves, may no longer be the province of thenurse – these essential tasks may be delegated toother, less-well paid, individuals who are nowincreasingly populating our workforces.

ReferencesCowen, P. J. (2005) New drugs, old problems. Revisiting:

Pharmacological management of treatment-resistantdepression. Advances in Psychiatric Treatment, 11, 19–27.

Department of Health (1992) Report of the Committee of Inquiryinto Complaints about Ashworth Hospital. Cm 2028-1-2.London: HMSO.

Department of Health (1999) Report of the Committee of Inquiryinto the Personality Disorder Unit, Ashworth Hospital. London:Stationery Office.

Gournay, K. (1996) Mental health nursing: issues and roles.Advances in Psychiatric Treatment, 2, 103–108.

Gournay, K. J. M. & Birley, J. (1998) The Thorn Programme.Nursing Times, 94, 54–55.

Gournay, K. & Gray, R. (2001) Should Mental Health NursesPrescribe? (Maudsley Discussion Paper no. 11). London:Institute of Psychiatry.



Gray, R., Wykes. T., Edmonds, M., et al (2004) Effect of amedication management training package for nurses onclinical outcomes for patients with schizophrenia. Clusterrandomised controlled trial. British Journal of Psychiatry,185, 157–162.

Kemp, R., Kirov, G. & Everitt, B. (1998) Randomised controlledtrial of compliance therapy: 18-month follow-up. BritishJournal of Psychiatry, 172, 413–419.

National Institute for Clinical Excellence (2002) ClinicalGuideline 1. Schizophrenia: Core Interventions in the Treatmentand Management of Schizophrenia in Primary and SecondaryCare. London: NICE.

National Institute for Clinical Excellence (2005) Guidelines onLong-term Management of Disturbed/Violent Behaviour inPsychiatric In-patient Settings. London: NICE. In press.

White, E. (1990) A Quinquennial Survey of Community PsychiatricNursing. Manchester: University of Manchester, Departmentof Nursing.

Wright, S., Gournay, K., Glorney, E., et al (2002) Dual diagnosisin the suburbs: violence and offending. Journal of ForensicPsychiatry, 13, 35–52.

MCQs1 Psychiatric nursing is expanding into:a primary careb CBT for common mental disordersc forensic areasd general hospitals.

2 In 1990, the proportion of people with schizophreniaon CPN case-loads was:

a 87%b 67%c 47%d 27%.

3 One of the most important neglected nursing rolesis:

a public educationb GP liaisonc physical healthcared community team management.

4 Nurses working within the Dangerous and SeverePersonality Disorder Initiative are now located in:

a one prison and one high secure hospital settingb two prisons and two high secure hospital settingsc three prisons and three high secure hospital settingsd four prisons and four high secure hospital settings.

5 NICE guidance to be published early in 2005 ofrelevance to psychiatric nursing focuses on:

a schizophreniab depressionc disturbed/violent behaviourd computer-assisted treatments.

MCQ answers

1 2 3 4 5a F a F a F a F a Fb F b F b F b T b Fc T c F c T c F c Td F d T d F d F d F

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The changing face of psychiatric nursing