Date: Sun, 26 Oct 1997 08:14:16 +0000 From: Chris Burford <cburford-AT-gn.apc.org> Subject: M-PSY: PSYCHIATRIC NURSING I would like to comment on the opening point in the notice Ben Davidson forwarded about the book he has just published with Phil Barker. [PSYCHIATRIC NURSING - ETHICAL STRIFE Edited by Phil Barker and Ben Davidson Published by Arnold, London] >Although the popular view is that care and treatment of people with mental >illness rests in the hands of psychiatrists, in reality psychiatric nurses >are by far the biggest group of mental health professionals; spend the most >time with people experiencing mental illness; and dispense the great >majority of psychiatric care and treatment. While some of the strife may be ethical, and I welcome increased sharing of the ethical issues involved in risk management, which today feel very burdensome to me as a psychiatrist, I would like to reframe the question in terms of the skill mix needed to provide good quality and efficient mental health systems. Rather than too much professional strife, I would suggest that there is an open debate and constructive competition about which roles are needed and which filled by which profession, with which training, to meet the increasing demands for mental health care. I support the view that psychiatric, or mental health, nurses, are the key professional group whose role needs to be clarified and enhanced as a way forward. At the moment in England they seem to me to play three or perhaps four roles, which do not always come together with other professionals in the best manner. 1) Staff on busy acute admission wards, almost always on a rota, unable therefore to give the real continuity of care together with the patient and the ward psychiatrists, and burdened down with monitoring, which may not always reduce the risks it is supposed to do. 2) Community Mental Health Nurses who have evolved over 25 years from giving depot injections for schizophrenia, to almost a profession in their own right, using their initiative much more than a ward based nurse can. The downside was that they are recognised to have expanded into filling a need for the neurotically ill, but nationwide to have surprisingly low proportions of people with psychosis on their caseload. General psychiatrists came to feel they were left monitoring people with psychosis who were vulnerable to relapse and readmission, while CMHN's (CPN's) were doing counselling work. 3) Some CMHN's have increasingly been attached directly to general practices for counselling work largely unsupported by psychiatrists. Half of all GP practices have some counselling time, but this is a minute fraction of the potential that GP's might wish to refer for counselling if the resources were there. 4) To try to remedy these discrepancies, the last Conservative government put great pressure under a policy document called The Care Programme Approach, that no one should be discharged from hospital without a key worker, and the assumption was that this key worker often should be a community mental health nurse. Whether nurses are essentially good at, or are trained to be key workers or "case managers" is a further question. This mixture has not overcome the discrepancies whereby about 90% of the mental health budget is devoted to managing expensive hospital admissions, with comparatively inadequate mental health services in the community, able among other things to prevent admissions, the majority of which are readmissions. In fact psychiatric admissions have gone up in the last five years. I think the role of psychiatric nursing will be shaped about how well its skills, or its skills with new training, can answer these needs, and what division of labour is most efficient between psychiatry, nursing and social work, in assisting people with the sort of break-downs that fill the expensive hospital beds. Chris Burford London. --- from list marxism-psych-AT-lists.village.virginia.edu ---
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