The role of the mental health nurse in clinical governance
It is clear, then, that we now face a primary question: does clinical govern-ance provide greater scope for stories like the one Cochrane hid? Does it project the voice of the lifeworld, as well as the voice of medicine, and set both in the context of the wider culture sustaining health and healthcare?
Mental health nursing literature has not adequately resolved the tensions imposed by mental health nurses’ dual obligations as both whole per-sons /members of community and agencies of effective intervention. Writers increasingly propose versions of both and solutions to practising in light of those tensions (e.g. Repper, 2000). Some, however, emphasise one register over the other. Thus Newell & Gournay see three interrelated needs:
• a ‘need within mental health nursing . . . for appropriate evidence upon which to base our clinical practice as nurses’
• a need to participate in research and practice in multidisciplinary teams
• a need, to ‘have a coherent, authoritative voice within the discipline of mental healthcare . . . through participation in the National Health Ser-vice’s evidence-based practice, clinical effectiveness, and clinical
govern-ance agendas’ (Newell & Gournay, 2000)
While some contributors to their text speak more obviously in the voice of the lifeworld (e.g. Campbell, 2000), the hierarchy-of-evidence warrants are those associated with the voice of medicine (see the quotation from Goldberg, above). More recently, Gournay (2003) notes the continuing
‘need to emphasise a starting point for everyone involved in health services research to listen to what users have to say about what is important to them’, and that: ‘although this rhetoric has been sounded for more than a decade . . . true central consumer involvement in health services research is still a dream’ (Gournay, 2003, p. 248). Gournay follows this claim for the value of the consumer’s view with an assertion that ‘mental health nursing is poorly served by its academic infrastructure’ and that:
very few professors of mental health nursing have any formal training in health services research methods and most are largely ignorant of basic topics such as epidemiology, quantitative methodologies and the realistic application of power calculations for the purposes of determining reasonable
sample sizes. (Gournay, 2003, p. 249)
How emphasis on these methodologies (and the implied hierarchy of evid-ence) squares with giving priority to ‘what users have to say is important to them’ is not addressed. By contrast, Barker’s account of the Tidal Model as a ‘discrete’ nursing contribution to ‘a multidisciplinary care and treatment process’ (Barker, 2001, p. 234) warrants a narrative-based methodology in terms redolent of the lifeworld. In giving precedence to the person’s story the Tidal Model acknowledges that the narrative is the location for the person’s enactment of life (p. 236).
168 Clinical Governance, Accountability and Mental Health Nursing
Barker stresses the need to avoid ‘stifling the continued search for true under-standing of . . . problems of human living’ (p. 233), and to promote instead a ‘human living’ approach grounded in nursing’s ‘longstanding attachment to the concept of caring through interpersonal relationships’ (p. 237).
We can hear in these texts mental health nursing versions of the voice of medicine and the voice of the lifeworld8, and of the corresponding criteria for judging the adequacy of care: effectiveness and humaneness (Mishler, 1984, p. 63). What is at stake is the possibility of what Mishler called ‘humane care’:
A serious problem arises when these two criteria, humaneness and effect-iveness, are placed in opposition. . . . [Humane] care is effective care and, to be effective care must be humane. . . . [Humane] care refers to the primacy accorded to patients’ lifeworld contexts of meaning as the basis for understanding, diagnosing, and treating their problems. . . . A discourse dominated by the voice of medicine represents a practice that is not humane . . . such a practice is also an ineffective practice.
(Mishler, 1984, pp. 191–2) He argues further that ‘strengthening the voice of the lifeworld promotes both humaneness and effectiveness of care’, and that:
Given that current forms of clinical practice are based on and incorpor-ate an asymmetical power relationship between patients and healthcare workers . . . achieving humane care is dependent upon empowering
patients. (Mishler, 1984, p. 193)
Following Mishler’s argument, we can draw implications for mental health nurses in the context of clinical governance sketched in this chapter.
Nurses should resist participation in a clinical governance language game ruled by the ‘delivery of interventions’ metaphor; resist reduction to the role of deliverers of effective interventions. Obligations to fulfil contracts to
‘deliver’ effective care are subordinate to the covenantal obligation to sustain the person who is ill in his or her participation in community.9
As individuals, mental health nurses have limited capacity to order the voices of medicine and the lifeworld appropriately, and to manage the tensions of practice for the benefit of those persons/patients with whom they have obligations of both covenant and contract. They could be empowered to do so if policy, at trust and national level, articulated more clearly the values base for mental health care grounded in the voice of the lifeworld and the voice of medicine rightly ordered.
Assertive policies, addressing the relationship between the voice of the life-world and the voice of medicine, have been put into practice in New Zealand
8 I note the contrast, but also that both Gournay and Barker have acknowledged the rela-tive value of the respecrela-tive ‘other’ voice.
9 For elaboration on the contract /covenant distinction see Tilley & Pollock (1999).
The role of the mental health nurse in clinical governance 169 and in Ontario, Canada. The New Framework for Support (Trainor et al., 1999) in Ontario proposes reconceptualisation of mental health and illness, based on a ‘balanced knowledge base’ incorporating medical /clinical, social science, experiential, and customary traditional knowledge. It provides a model of how to order clinical knowledge in a wider context of knowledge governance. Both the Ontario Framework and the New Zealand Blueprint for Mental Health (Mental Health Commission, 1998; cf. Mental Health Commission, 2002) promote ‘recovery’ as a central principle. The New Framework cites Anthony’s definition of ‘recovery’:
Recovery is described as a deeply personal, unique process of changing one’s attitudes, values, feelings, goals, skills, and/or roles. It is a way of living a satisfying, hopeful, and contributing life even with limitations caused by an illness. Recovery involves the development of new meaning and purpose in one’s life as one grows beyond the catastrophic effects of mental illness.
Recovery from mental illness involves much more than recovery from the illness itself. People with mental illness may have to recover from the stigma they have incorporated into their very being; from the iatrogenic effects of treatment settings; from lack of recent opportunities for self-determination; from the negative side effects of unemployment; and from
crushed dreams. (Anthony, 1993, p. 15)
We can learn from these models as we seek, in both practice and policy, to realise the significance of clinical governance, and the contemporary implications of Cochrane’s secret story. Necessarily amphibians10 as we participate in systems of accountability and clinical governance, we are called to order and integrate two voices, two modes of caring. We can do so more effectively, in the interests of humane care, if able to justify our prac-tice by reference to trust and national policies on clinical governance. These policies should set our effectiveness-directed, contract-mediated clinical roles in the context of covenantal, persons-in-relationship-in-community-grounded governance. The emerging story of humane care can best develop if policy enriches the language game, and furnishes a more congenial
‘dwelling’ for those who participate in systems of clinical accountability for mental health care, and human relations.
10 This account poses a different role for the clinical governance-environment version of the
‘amphibian’ nurse described by Ryan (1997) and sketched in Tilley (1995). In this version, we amphibians must now embody the tensions of the coexistence of modernity and its anti-thesis; with the general manager logically the Big Amphibian incorporating the tensions of all in the trust, to fulfil his/her responsibility of ensuring the quality of covenant while delivering on contract. See also Ryan & Mowat (2003).