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© Springer International Publishing Switzerland 2018
J.C. Santos, J.R. Cutcliffe (eds.), European Psychiatric/Mental Health Nursing in the 21st Century, Principles of Specialty Nursing,
https://doi.org/10.1007/978-3-319-31772-4_14 S. Hemingway (*)
University of Huddersfield, Huddersfield, UK e-mail: [email protected]
N. Brimblecombe
South London and Maudsley NHS Foundation Trust, London, UK
14
Community Psychiatric/Mental Health
The medicalisation of asylums created a powerful lobby expounding the neces- sity of ‘medical care’ which excluded non-medics from authority in talking about so-called mental illness (and running asylums). Medicalisation ultimately led to
‘therapeutic nihilism’ when the physical interventions that were increasingly emphasised over the earlier ‘moral’ (psychological and social) treatments achieved so little. The occasional spectacular biomedical success, such as that of the treat- ment of general paralysis of the insane (GPI) (Braslow 1995), encouraged otherwise unsuccessful physical treatments to be pursued.
14.2 The Shift to Deinstitutionalisation
Community psychiatric/mental health nursing in Europe developed as a result of changes in the approach to psychiatric healthcare, with a shift away from institu- tionally based care and an overall expansion in the number of people seen by mental health services. There were a range of factors driving this change:
• Psychiatric institutions had grown larger, and were no longer perceived as thera- peutic in themselves,
• New anti-psychotic drugs introduced in the early 1950s potentially made liv- ing outside the hospitals possible for many patients. However, in reality this was not always closely correlated with reducing bed numbers. In England, there were significant reductions in the numbers of inpatients prior to the rou- tine introduction of the new medications (reference), whilst in Norway reduc- tion in hospital beds only started in the early 1970s (Pedersen and Kolstad 2009)
• A combination of scandals regarding ill treatment in institutions and evidence of the ill effects of prolonged hospital stays created a general rejection of large scale institutions (Goffman 1968),
• Increased professional focus on active and acute treatment and less emphasis on long-term care of the chronically ill,
• From the 1960s onwards, consumer and social rights campaigner movements challenged the status quo (Brown 1981),
• Not only was the detention of large numbers of individuals, who could have potentially been cared for at home, increasingly seen as morally undesirable, there were also questions as to the financial costs of such systems (Knapp et al.
2011).
Across Europe the speed and degree of the shift from institutional to community focused care has varied considerably, as has the role of P/MH nurses in such moves.
Local factors, such as financial resources and social acceptance of deinstitutionali- sation, have led to marked variation in the quality of the community mental care systems (Fakhoury and Priebe 2002) even when ministers of health from all the European World Health Organisation states have publicly committed to developing community based services to replace care in large institutions.
14.3 The Shift to Community-Focused Care and Nursing:
The Development of Community Mental Health Nursing in the UK
The variation in approach to deinstitutionalisation and the varying roles of P/MH nurses in different healthcare systems have both influenced the major shift/no shift of nurses to work in community settings across Europe. For example, very early approaches to community care in the Netherlands involved P/MH nurses (Koekkoek et al. 2009), whilst in Germany, the role of P/MH nurses has remained predominantly one of inpatient care, with other professions taking on community roles. In many countries, national plans for major community based develop- ments have simply not been delivered in practice (Brimblecombe and Nolan 2012).
In the United Kingdom (UK) the inpatient population in the hospitals peaked in 1954/55, and was from then on rapidly reduced. To support this change, staff from psychiatric hospitals began to work the community with the first ‘commu- nity mental health nurse’ (CPMHN) posts in England being established at Warlingham Park Hospital during the 1950s (May 1965). The subsequent growth in community P/MH nursing roles was gradual with only 1000 CPMHNs by 1977 and 2000 by 1980. It was, however, a catalyst for change amongst P/MH nurses, as those working in the community were working outside of the direct supervisory influence of psychiatry (Brimblecombe 2005), and this gave an opportunity for P/
MH nurses to develop an agenda of professionalisation and independence (Godin 1996) and to become more recognised as a professional group in their own right (Brimblecombe 2005).
Hunter (1974) describes the early development of the role of the CPMHN as having two phases—the first being concerned with what has come to be known as the after-care or continuing care stage, and the second of more diverse func- tions. These include the incorporation of skills gradually being developed by some P/MH nurses in the more progressive services, particularly psychothera- peutic and behavioral treatment methods. For the first 20 years of the develop- ment of community care services, CPMHNs worked almost exclusively with people suffering from schizophrenia or older people with mental health prob- lems. The P/MH nursing role being, largely, to prevent relapse or readmission.
From the 1980s onwards, this changed with P/MH nurses increasingly working in primary health-care settings (rather than focusing on work with people in specialist mental health services with severe and enduring mental health prob- lems). By the mid-1990s, there was a strong policy push back against this trend, as there was little evidence that much of this primary care work was clinically effective and that people with so-called severe mental illness were often not receiving adequate services (Gournay 1994; Department of Health 1994). A similar change of emphasis also took place in the Netherlands (Koekkoek et al.
2009).
In 2006 in England, a government-led review of P/MH nursing was undertaken.
Its first recommendation was that the ‘principles and values of the Recovery
Approach will inform P/MH nursing practice in all areas of care and inform service structures, individual practice and educational preparation’.
Accordingly nurses were to:
• Value the aims of service users.
• Work in partnership and offer meaningful choice.
• Be optimistic about the possibilities of positive change.
• Value social inclusion.
The focus on a recovery model was a confirmation (if one was needed) that nurses were not to pursue a narrow ‘medicalised’ model of care, focusing on symp- tom reduction, but should be working in partnership to meet the service users’ own goals wherever possible.
14.4 Nurse Prescribing in Mental Health
Historically, the professional demarcations for providing medication were that the doctor prescribed, the pharmacist dispensed and the nurse administered (Hemingway and Ely 2009). The idea of CPMHNs extending their role into prescribing was intro- duced late in the last century (Hemingway and Flowers 2000). There were a series of arguments as to why this was both logical and was potentially in the best interests of service users. Firstly, P/MHNs were undeniably already heavily involved with medications related issues, with an estimated 22% of the inpatient P/MHNs’ time being spent on medicines related interventions (Whittington and McLaughlin 2000), and a significant amount of time also spent on medication related issues in commu- nity settings (Hemingway 2016). Nurses also reported that they often ‘defacto’ pre- scribed, by explicitly advising doctors on exactly what to actually prescribe (Ramcharan et al. 2001). The potential benefits of P/MHNs prescribing were set out by the National Prescribing Centre ( 2005):
• To allow service users quicker access to medication
• To provide services more efficiently and effectively
• To increase service user choice
• To make better use of nurses’ skills and knowledge
14.5 Becoming a Nurse Prescriber
In the UK, since 2003 P/MH nurses have potentially been able to prescribe, initially from a plan drawn up by a medical practitioner and more recently independently, i.e. the nurse diagnoses and can prescribe any drug within their area of competence and the limits of their knowledge (Hemingway and Ely 2009). Take up of the pre- scribing role is, therefore, dependent on organisational governance ownership and support (Hemingway and Ely 2009). In order to be able to legally register as