health nursing comment
the giant of mental health nursing woke up
of mental health nurses are markedly absent from clinical guidelines
produced by The National Institute for Clinical Excellence, say
Phil Barker and Poppy Buchanan-Barker. Mental health
nurses, it seems, just don't count. So, argue Barker and
Buchanan-Barker, it's time mental health nurses had their
own representative body to stand up for them.
lot has happened in nursing over the past 35 years that we have
been in the mental health field. At the end of the 1960s nurses
were 'trained' in a highly institutional fashion. As Steve Wright
has observed, then there were a couple of weekly nursing journals
and "not enough nursing books by nurses to fill a shoebox"
(Wright, 2004). If anyone had told us that 35 years later, huge
numbers of mental health nurses would be graduates - many with Master's
degrees and even some staff nurses with doctorates - we would have
laughed. In those days, nurse tutors recycled, uncritically, the
medical wisdom of the day and practising nurses focused on 'fitting
in' - avoiding rocking the institutional boat, at all costs. By
the early 1970's this changed dramatically as nursing was redefined
as a 'research-based profession' and the 'training' of nurses turned
slowly into proper 'education'.
mental health nursing is a remarkably diverse discipline, led by
an increasingly well-qualified group of teachers, many of whom also
conduct research and a few of whom also find time to practice. Mental
health nurses now fulfill a wider range of responsibilities than
ever before. Nursing is more important than ever, and those who
are being prepared to practice nursing are - at least in principle
- better prepared than ever (Wilshaw, 2004).
when was the last time a mental health nurse appeared on radio or
television, discussing the importance of caring (Barker, 2000)?
When was the last time a newspaper or popular magazine described
how nurses rise to the challenge of caring for people across the
psychiatric lifespan? However nurses do make media appearances whenever
someone wants to blame them for some failing in service delivery.
By contrast, radio programmes like 'All in the Mind' or 'In the
Psychiatrist's Chair' perpetuate the myth of the highly-accessible,
all-seeing, all-knowing, psychiatrist. Nurses - who are the font-line
of almost every aspect of psychiatric practice - remain largely
are surprised that nurses are not incensed by this state of affairs,
especially since the public face of any professional discipline
is the key to recruitment. We suspect, however, that mental health
nursing has something of a professional esteem problem.
find it hard to believe that they are that important. In a sense,
they remain the children of the psychiatric family, allowing their
parents - psychiatric medicine and psychology - to do most of the
concrete example of this low professional esteem is provided by
the National Institute for Clinical Excellence (NICE). This important
body was established by the government to make recommendations on
treatments and care using the best available evidence.
its brief, one would have expected that NICE would recognise the
central role of nursing in mental health service delivery, and nurses
would be fully represented in the various NICE Guideline Development
Groups or Review Panels.
compared to the prominent positions adopted by psychiatric medicine,
psychology, social work and even the voluntary sector groups - like
Mind or Rethink - mental health nursing is pitifully represented,
if not absent altogether.
each mental health guideline published to date, the Guideline Development
Groups (GDG) and Guideline Review Panels (GRP) have included several
high-ranking professorial and research psychiatrists, GPs, psychologists
and social workers.
GDG for the schizophrenia guidelines (NICE, 2002) included no less
than five doctors - one consultant psychiatrist from practice, two
professors of psychiatry, one professor of primary care and the
deputy director of the Royal College of Psychiatrists Research Unit.
The GDG also included two psychologists. One was a professor of
clinical psychology and the other the director of the Centre for
Outcomes Research and Effectiveness. Despite the fact that the care
and ongoing management of people with a diagnosis of schizophrenia
almost always is a nursing responsibility, NICE chose not to enlist
any distinguished or high ranking mental health nurses, as they
had done with medicine and psychology. Instead, a solitary nursing
lecturer-practitioner was included in the GDG, but seemed unable
to convince the elite forces of psychiatry and psychology, of the
importance of nursing for the care of this vulnerable group. The
resulting guidelines - most of which were based on nothing more
than the evidence of 'expert opinion'- focused exclusively on medical
and psychological issues.
our view, the guidelines marginalised the nursing voice (Barker
and Buchanan-Barker, 2003), illustrating the highly political nature
of the power games in health care (Hart, 2003).
year NICE published its self-harm guidelines, focused on a clinical
population that presents considerable challenges for mental health
nurses working with younger people, adults and the prison population.
Once again, distinguished professors of psychiatry and psychology
were prominently represented at both guideline development and guideline
review level, supported by other senior medical and psychology clinical
and research staff.
solitary charge nurse from accident and emergency was included,
who doubtless provided a vital view from A&E.
the guideline was focused on primary and secondary care, acknowledging
that the problem of self-harm extends way beyond the beleaguered
confines of emergency room.
a bevy of highly experienced doctors and psychologists, was needed
to join with GPs, representatives of the Samaritans and a local
Mind group, and various 'research assistants', surely the inclusion
of one highly experienced mental health nurse could have been justified?
has been our privilege to work with, teach or supervise, nurses
with an enviable knowledge of self-harm. Some of these nurses have
written dissertations at Master's and even doctoral level, thereby
breaking new academic and clinical ground. Why were some of these
nurses not represented on both the Guideline Development and Guideline
Review Panel's? Again, Chris Hart's (2004) recent book appears to
offer the unspoken answer is - nurses don't count.
had hoped that mental health nurses would create some kind of a
fuss about their exclusion from core membership of this important
body (Barker and Buchanan-Barker, 2004), but again, the silence
has been deafening.
if to add insult to injury, NICE excluded mental health nursing
entirely from the Guideline Development and Guideline Review Groups
for its work on depression. We were astonished that NICE could so
casually ignore nursing, which is patently a vital part of the therapeutic
process for people with depression. Again, we know many clinical
and academic nurses who could have brought their expertise from
research and practice to bear on the NICE considerations.
observation of the nursing journals and nursing internet sites suggests
that there has been virtually no protest from mental health nursing
over its marginalisation from NICE. We would have thought that groups
like the Mental Health Nurses Association and the Royal College
of Nursing's mental health nursing forum, would have vigorously
challenged this state of affairs. However - at least so far - nothing.
mental health nursing needs is a dedicated organisation to represent
its interests; to provide leadership; and to ensure that its voice
is heard alongside the other key players in the field.
have the Royal College of Psychiatrists. Psychologists have their
specific branches of the British Psychological Society. Social Workers
have BASW. In other countries, like Australia and New Zealand, mental
health nursing has dedicated leadership and a dedicated 'college'.
Although the existence of such a college would not resolve all the
problems that nursing faces, it might at least help provide some
sorely-needed public profile.
the UK, there exist a number of competing organisations - the Mental
Health Nurses Association, the Forensic Nurses Association, the
Royal College of Nursing and Unison - which risk spreading the power
base of the discipline too widely. The Royal College of Nursing
(RCN) is led by an American former psychiatric nurse, but her brief
as general secretary means that her influence in mental health nursing
is virtually non-existent.
have met thousands of mental health nurses who are rightly proud
of the work that they do. Invariably, this is a private expression
of pride. These nurses have precious little in the way of organisational
means to bring their understanding of nursing's importance to a
wider, public audience. Presently, mental health nursing is like
a sleeping giant - awaiting some magical event to rouse it from
its slumbers. If the awful sound of 'exclusion' and 'marginalisation'
made by NICE is not enough to waken it, one wonders what actually
* Barker P (2000) The virtue of caring. International Journal of
Nursing Studies 37, 329-336
Barker P and Buchanan-Barker P (2003) NICE: Does the gold standard
have feet of clay? Mental Health Nursing 23, 9-11
Barker P and Buchanan-Barker P (2004) Experts without a voice Nursing
Standard 18(50) 22-23
Hart C (2004) Nurses and Politics: The impact of power and practice.
Basingstoke, Palgrave Macmillan.
National Institute for Clinical Excellence (2002) Schizophrenia:
Core interventions in the treatment and management of schizophrenia
in primary and secondary care. NICE, London
National Institute for Clinical Excellence (2004) Self Harm: The
short-term physical and psychological management and secondary prevention
of self-harm in primary and secondary care. (Clinical Guideline
16). London: National Collaborating Centre for Mental Health, July
Wilshaw G (2004) Consultant Nursing in Mental Health Chichester:
Wright S (2004) The value of values. Nursing Standard 19(9) 15-16
* Phil Barker
is a psychotherapist in private practice and honorary professor
at the University of Dundee. He was a nurse for more than 35 years
and the UK's first professor of psychiatric nursing practice. He
is also professor
of health science, Trinity College, Dublin, Ireland
* Poppy Buchanan-Barker is a counsellor, advocate and director of
Clan Unity International,
between them, authored a number of books,
including The Tidal
Model: A guide for mental health professionals and
Spirituality and Mental Health: Breakthrough
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Jane Sedgewick, Child and Adolescent Mental Health Service Regional
Development Worker, Yorkshire and Humber.
Date: January 16, 2006
I do wonder why mental health nurses are so quiet, and what we can
do to raise the profile of their work.
wonder if the professional self-esteem problem is replicated in
general nursing? I believe that partly it could come from the perception
that nurses follow the 'medical model' (a left over from the 'training'
days outlined above) by those outside of ther profession. I also
feel nurses keep quiet because they don't have the power of the
medics if they want to challenge something.
nurses are non-thinking doers
cognitive therapist/supervisor, Staffordshire, UK
May 28, 2009
I agree with most of the comments made here. Unfortunately it feels
that despite a brief respite in the 90s - where mental health nursing
seemed to have finally clawed its way up in terms of its self esteem
and status in social rank - today mental health nursing has returned
to the lower ranks of the 'non-thinking doer', where the R.M.N seems
to follow blindly the all-knowing psychiatrist and psychologists.
Here the nurses role seemingly has returned to that of containing,
monitoring and reporting back.
feel the Nursing and Midwifery Council has not really promoted mental
health nursing in a way that other bodies such as the British Psychological
Society has done for psychologists. For those who don't understand
what I mean, take some time to visit their web
site and look at the mannner in which the psychologist is portrayed.
would seem absurd to even suggest using similar diaglogue to describe
the mental health nurse. Also the vast amount of nursing research
produced which, in its endeavours to struggle to become acknolwedged
as a serious academic discipline, often making reference to philosophic
traditions such as phenomenology, has, I fear back-fired on the
profession. Nursing education in mental heath only, appearing to
be a confused 'mis-mash' of social sciences and humanitities, indeed
many other professions appearing to see post-grad qualifications
in mental health nursing as a joke (I base this on some comments
I heard made from my psychology colleagues).
addition to this the recent Department of Health focus upon CBT
has also potential implications for the future status of the R.M.N.
The 'world of CBT' seems to be essentially led by psychologists
(despite a few 'high profile' nurses), psychology appearing to advocate
itself as the 'homeland' of all psychotherapy and everything else
to do with being human - their role appearing to be that of teaching
and leading all else who follow.
puts me in mind of Isaac Marks' (a psychiatrist not a psychologist)
apparent sentiment that anybody, 'even an RMN' can be trained up
to be therapist. This
I fear will not only be disastrous for the view of CBT in general
but once again say very little for the RMN, and more importantly,
sadly give the wrong message to the public that somehow they are
getting an inferior quality of therapy.
15, 2005: Mental health nursing to be overhauled by end of the year
- time for the country's 45,000 mental health nurses to adapt to
change in the NHS, says chief nursing officer Chris Beasley.
Jan 24, 2005: Psychiatric disorder
or spiritual misery? - People who've experienced madness have
later appreciated the spiritual insights of their distress. We should
do more to acknowledge this, argue Phil Barker and Poppy Buchanan-Barker
16, 2003: Pushing for compassionate and ethical psychiatric nursing
- Name an eminent thinker from 20th century psychiatry and mental
health, and a psychologist, psychiatrist or philosopher might spring
to mind. It's unlikely to be a psychiatric nurse. But if it was,
it might be Phil Barker.
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