Reflections on Community Psychiatric Nursing

Tony Gillam

• Publisher: Routledge
• Year: 2003
• ISBN:
  9781134511457
• Edition: 1
• Topic: Médecine
• Subtopic: Prestation de soins de santé

Reflections on Community Psychiatric Nursing provides new insights into many aspects of the CPN's work. Written by a practising CPN, this is a lively and easy-to-read introduction to the key debates in community mental health, covering issues including: * professional identity
* the community and the role of the nurse
* teaching, assessment and clinical supervision
* good practice and the concept of risk
* mental health promotion
* user involvement
* treatment, from medication to psychosocial interventions.This text is essential reading for students and those undertaking further training as CPN's. In addition, practising nurses and other professionals will find it useful in developing their own reflective practice as well as offering a useful overview of an increasingly important area of nursing.

1   Who was that masked man?

The identity of the Community Psychiatric Nurse

Reflection

By the late 1980s I was living in an old hospital house in the grounds of a Victorian asylum – Powick Hospital in Worcester. I was working on nights as a newly qualified staff nurse at the city’s modern Newtown Hospital but the only accommodation my wife and I had been offered by my new employer was one of a row of unfurnished houses with no heating and a leaking roof. A few years later it was demolished, along with Powick Hospital itself.

In that first cold winter in Worcester, I had come across an article in the Nursing Standard on ‘How to write a book review’. The book reviews editor, Phyllis Holbrook, was – it seemed to me – trying to encourage readers to become book reviewers, so I tried my luck and began to have the first of many reviews published. Spurred on by this, I decided to try writing an article and, searching for ideas, came across something I had written in my final year as a student nurse.

While on student placement with the Community Psychiatric Nurses in Telford I had been asked to ‘give a little talk’ on an aspect of community psychiatric nursing. I read it through and it looked passable, so I typed it up on an ancient manual typewriter that my father-in-law had given me, and sent it off to Nursing Standard. By the time it was published (in October 1989) we had moved house and had a baby, and I had escaped from night duty by changing health authorities once again, this time taking a job as a staff nurse in an acute psychiatric day hospital in Kidderminster.

I felt I had been rehabilitated, moving from nights onto days, and from in-patient to day-patient services. There was a record in the charts at the time by Soul II Soul called Back to Life. The opening lines were, ‘Back to life, back to reality . . .’ I was delighted to be able to work in therapeutic groups and to do one-to-one counselling with day patients who lived in the community. After some time in day care, I had the opportunity of being completely rehabilitated into the community. I took the leap that several of those day patients were fearing and left the relative security of the day hospital team for the breathtaking freedom of becoming a Community Psychiatric Nurse (CPN) in my own right. It felt like an enormous privilege to have so much autonomy and so much responsibility.

Over the intervening years I have glanced at that first article from time to time and have felt a little embarrassed. Was it not a bit presumptuous of me to suggest how CPNs should work when, at the time of writing, I was not even a CPN? Was I not romanticising the job of the CPN, by making a CPN out to be some kind of Lone Ranger or a Philip Marlowe-style private investigator?

A while ago, re-reading it by way of preparation for this book, I decided I should stand by this first article. After all, it was written from the point of view of a student nurse and from the perspective of one who had spent more time working in hospital than working in the community. I think these are important viewpoints from which to comment upon what CPNs do and the article touches on some key concerns for CPNs then and now.

The blossoming of private-finance initiatives and public–private collaboration has meant that the centralisation of health services has continued despite the decentralising impulse of community care. It remains to be seen if any kind of National Service Framework can force providers to balance ‘economies of scale’ with the wishes of people to have a ‘local’ service. Over the past decade we have seen a resurgence in the debate about compulsory treatment in the community, so the concept of CPNs as ‘community custodians’, however distasteful, is relevant. The tension between autonomy and teamwork is as alive as ever, no less so with the emergence of community mental health teams. Plenty of CPNs continue to lead remarkably autonomous professional lives, some with a ‘take-it-or-leave-it’ attitude to clinical supervision and accountability. The idea of assertive leadership that promotes autonomy and teamwork seems even more imperative now that I am a practising CPN than it did when I looked on, admiringly, from the vantage point of the hospitaltrained student nurse.

Psychiatric nursing in the community – the Lone Ranger and the multi-disciplinary team

In the traditional psychiatric institution the services are centralised: all roads lead to hospital, so to speak. A patient is identified in the community, his or her illness becomes acute and the patient is admitted to the hospital where all the resources are concentrated in one place.

According to the more modern, patient-centred approach, services should be decentralised and, to avoid institutionalising patients, the services should come to the people. Those who see psychiatry as a means of social control might see this as a shift in the psychiatric nurse’s role from custodian/ warden to vigilante. The community nurse goes out in search of the problem people, in an attempt to ‘clean up the city’. The CPN seeks to eradicate psychiatric problems, to get to the root of the problem and thus to purge the community.

Whether or not we subscribe to this anti-psychiatry view of community nursing it cannot be denied that a major source of satisfaction for the CPN is going out there and doing the job on his or her own. The CPNs are lone rangers, their own boss, and any successes are entirely to their personal credit.

CPNs seem to take pride in the fact that they dispense with their colleagues’ opinions, they are freethinkers, private investigators trying to get a lead to solve the mystery of mental illness, shunning interference from other agencies.

The difficulty with this attitude is that it is hard to reconcile it with the ‘team approach’. The concept of working as a member of a multi-disciplinary team, pooling skills and resources, has become central to modern hospital nursing. It has many advantages for both patients and staff. From the staff point of view it means shared responsibility and shared accountability, and helps to avoid the disillusionment and exhaustion that contribute to burnout. From the patient’s viewpoint there is the benefit of specialised help from a number of different perspectives. A second opinion is not something that has to be sought but something offered automatically.

Perhaps an ideal combination, then, would be a fusion of the independent worker approach with the team approach. This would mean a commitment on the part of the CPN to build up group cohesion with his colleagues.

Regular and frequent meetings are one way of ensuring continuity of care but also improve communication and, at best, should reassure nurses of the mutual support they can offer one another. It should not be thought of as a weakness to admit difficulties and to seek practical help and moral support. On the contrary, to be able to discuss freely in this way is a hallmark of professionalism.

Meetings should be equally concerned with sorting out business and building group cohesion. Important as it is, making time for meetings will not on its own guarantee group cohesion or ensure that CPNs work as a team. It is essential that the team has firm leadership to keep it together.

The question of leadership is not clear cut in community nursing. In a hospital ward the structured hierarchy means that everyone knows where they stand. But if it is desirable for each member of the team to have an equal say, for one opinion to be as valid as any other, then the most senior cannot afford to pull rank and the most junior cannot afford to abdicate their share of responsibility.

What is called for is a flattening of the hierarchy. There is a boss, but not a bossy boss, there are junior nurses but they are not mere errand-runners, tea-makers, yes men or scapegoats. A flattened hierarchy seems the ideal framework for a team approach, where everyone listens to and respects everybody else. Although people are accountable for their own actions, the team still needs to be overseen and directed if it is not to disintegrate at times.

The senior nurse’s responsibility is to ensure that rifts are healed, communication lines are kept open, ideas are exchanged, feelings expressed, and grievances aired freely and constructively. As team leaders, it is their job to encourage people to work together and look after one another.

Bearing in mind that, from what has already been discussed, CPNs are notorious for going their own way, it will be clear that at times this ‘encouragement’ will need to be quite forceful. They may need to be chased and cajoled into making time for meetings. Once captured, CPNs may need to be probed and prompted to discuss things and, in sharing difficulties, protected against feeling that they are admitting failure and defeat. If nurses and services are not to break down and burn out then these solitary, pioneering creatures somehow need their independence respected and their professionalism shared.

2 No such thing as society

Sociological aspects of community psychiatric nursing

Reflection

Any discussion about what job title best describes the CPN these days seems to centre on whether we are Community Psychiatric Nurses or Community Mental Health Nurses. Do we want to continue to be associated with psychiatry, and would it not be better if we focused on mental health rather than mental illness? This is a debate taken up by Liam Clarke in his book Challenging Ideas in Psychiatric Nursing. Clarke describes the recommendation that all psychiatric nurses should be awarded the title ‘mental health nurse’ as ‘quite astonishing for whatever chance one might have of defining mental illness, defining mental health . . . would be a formidable task indeed’ (Clarke 1999: 9). He suggests that, given that all three terms (‘community’, ‘psychiatric’ and ‘nurse’) are ‘problematic’, any analysis of community psychiatric nursing must deal with the meanings to which these words give rise.

When I first became a CPN I was less concerned about the ‘P’ and the ‘N’ and more interested in the ‘C’. I was curious about the community I was serving. Where was it? What was it? The first of these questions might be solved with a good street map, but the second was more philosophical. I commuted each day to work and, at the end of the afternoon, would return to my own ‘community’ – an area called St John’s in Worcester. Except, I was not sure if this really was my community. I lived there, I was registered with a doctor there, I used the local post office and bakery, but I did not know my neighbours, I knew nothing of the history of the area and was unsure whether I would stay there for the rest of my life.

In TV soaps, like EastEnders and Coronation Street, everybody seems to use the same pub, the same café. I did not. I discovered one pub in St John’s where I felt very welcome. This was the Brunswick Arms, where they had folk music every Sunday night. I think I felt so comfortable there, not because it was a stone’s throw from my house and not because it was in my part of town, but because other musicians went there. I had found my community. A community of musicians, many of whom did not live in the neighbourhood at all.

In the article, ‘“Community” and “neighbourhood”, I not only question these concepts but explore different ways of working for community nurses. At that time, our CPN team had a referral system that allowed each CPN to take on those referrals they found interesting. There was a weekly meeting in which all the referrals that had been received (probably between two and five) would be discussed. CPNs would then make bids for them, taking into account how busy they were, any annual leave coming up, any special interests in either the patients’ conditions or suggested approaches to dealing with these.

A number of things happened that changed this. One was a growing reluctance among some of the team members to take on referrals, forcing others to take them by default. This illustrates the potential for the abuse of autonomy in community psychiatric nursing. The second change was the introduction of GP-attachment, which meant that patients started to be allocated, not in terms of special interest, particular skills or caseload capacity, but according to whether the referral came from the practice to which you were attached. Inevitably, some practices refer more often than others, which creates inequalities within teams. Thirdly, when I reflect back to our old referral meetings, I realise that there were actually fewer referrals coming into the team in those days. This meant that we had the luxury (if that is what it was) of carefully considering the appropriateness of a handful of referrals each week and how best to allocate them. Finally, there was something introduced called ‘Patient’s Charter Standards’, which set similar standards for community nurses of all kinds, CPNs, district nurses and midwives, lumping us all together in a frenzy to meet the needs of ‘urgent’ and ‘non-urgent’ referrals. It seems to me that there is a difference between an emergency for a midwife and an emergency for a CPN but this was not taken into account. Thus, our calm, collected and delightfully civilised way of dealing with people in possible need of the skills of a CPN was replaced with the feast or famine that is the lot of a GP-attached CPN. The trend towards Community Mental Health Teams may well mean a move back to a more rational way of allocating referrals but it would seem that the community of people deemed to be in need of a CPN continues to grow.

‘Community’ and ‘neighbourhood’ – how concepts shape the provision of care

Phrases such as ‘community care’ and ‘neighbourhood watch’ have entered so much into common parlance in recent years that we have perhaps lost sight of the values implied. It has been said that the term ‘community’ has been used ‘with an abandon reminiscent of poetic licence’ (Wirth 1979). The words ‘community’ and ‘neighbourhood’ have an almost quaint connotation. They imply a return to a simpler way of life, where people cared for each other, far from the self-centred hustle and bustle of modern life. Dennis protests, however, that ‘the usefulness of the idea of the neighbourhood community is not commensurate with the kind of popularity . . . it enjoys’ (Dennis 1968). Dennis suggests that the words’ resurgence in the latter part of this century has not been accompanied by a resurgence in their concomitant values. This may constitute a form of what Piaget called ‘magical thinking’ on the part of planners and politicians, whereby simply using the words brings about a change in attitude (Piaget 1929). The same principle applies to the preference for the phrase ‘mental health’ over ‘mental illness’ – the aim is to shift the emphasis, to re-frame in a positive light. In this case, it could be that ‘mental health workers’, such as CPNs, are equally guilty of magical thinking – wishing we dealt in mental health, rather than with mental illness.

As CPNs we need to ask, ‘Where is the community in which we work?’ or, indeed, ‘What is the community?’ It is here that sociology can help us. Sociology has no shortage of definitions of the term. ‘At the minimum [community] . . . refers to a collection of people in a geographical area’ (Abercrombie et al. 1988). Many definitions extend to include concepts such as a sense of belonging and of self-containment. For example, MacIver and Page (1961) write that ‘the bases of community are locality and community sentiment’, whereas nowadays we find

people occupying specific local areas which lack the social coherence necessary to give them a community character. For example, the residents of a ward or district of a large city may lack sufficient contacts or common interests to instil conscious identification with the area. Such a ‘neighbourhood’ is not a community because it does not possess a feeling of belonging together. . . . There must be the common living with its awareness of sharing a way of life as well as the common earth.

(MacIver and Page 1961)

This insistence on identification and belongingness seems to have its origins in earlier concepts of Gemeinschaft and Gesellschaft (Toennies 1955). Toennies suggested that traditional/rural societies had a sense of community (Gemeinschaft), whereas modern/urban society (Gesellschaft) tended to be more individualistic and impersonal. Relationships in Gemeinschaft were seen as close, supportive and affective, whereas in Gesellschaft relationships were distanced and merely contractual. Gemeinschaft, then, implies collective identity and solidarity: ‘it is the lasting and genuine form of living together’, wrote Toennies, ‘in contrast to Gemeinschaft, Gesellschaft is transitory and superficial’ (Toennies 1955).

Few CPNs, I suggest, would describe the communities they serve as Gemeinschaften in Toennies’ sense. Some CPNs would concede that their community at least fits the minimal definition of a ‘collection of people in a geographical area’ (Abercrombie et al. 1988). I recently attended an event called a ‘Community Lunch’. A district nurse discovered ...