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Exploring the Culture of Community Psychiatric Nurses

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Exploring the Culture of Community Psychiatric Nurses Durham E-Theses Out of the institution?: exploring the culture of community psychiatric nurses. Bilbe, Marshal Edward Stuart How to cite: Bilbe, Marshal Edward Stuart (2004) Out of the institution?: exploring the culture of community psychiatric nurses., Durham theses, Durham University. Available at Durham E-Theses Online: http://etheses.dur.ac.uk/3114/ Use policy The full-text may be used and/or reproduced, and given to third parties in any format or medium, without prior permission or charge, for personal research or study, educational, or not-for-prot purposes provided that: • a full bibliographic reference is made to the original source • a link is made to the metadata record in Durham E-Theses • the full-text is not changed in any way The full-text must not be sold in any format or medium without the formal permission of the copyright holders. Please consult the full Durham E-Theses policy for further details. Academic Support Oce, Durham University, University Oce, Old Elvet, Durham DH1 3HP e-mail: [email protected] Tel: +44 0191 334 6107 http://etheses.dur.ac.uk 2 Out of the Institution? Exploring the Culture of Community Psychiatric Nurses. Marshal Edward Stuart Bilbe Abstract. The literature shows that there is a lack of knowledge about the practice of the relatively new profession of community psychiatric nurse who initially train in hospitals and then move to the community. The research undertaken for this thesis is designed to address this lack of knowledge by exploring the views of community psychiatric nurses practicing in South Durham. Using a Weberian perspective, it was proposed that the collective cultural beliefs of the CPNs would reflect perceived differences between hospital and community psychiatric nursing. The culture was explored through 30 semi-structured interviews with the CPNs working for South Durham Mental Health Trust in 1996/7. A series of cultural beliefs (categorised as "themes") were found which described views about the differences between psychiatric nursing in hospital and the community, in the disorders found in each patient group, relationships with consultants psychiatrists and general practitioners, relationships with other health and social care professionals and what constituted a "good" community psychiatric nurse. There was also a theme which related to all the others, which concerned threats to their professional identity, as seen by the CPNs, in terms of their status as a distinct group of health care workers. The findings show that the CPNs provide care for a wider range of disorders than found in hospital patients. There is no mandatory training which leads to a variety of strategies by which they learn to treat unfamiliar disorders. Relationships with medical staff, and other professionals, have to be re-negotiated when moving from hospital to community. It also appeared that the CPNs perceived a threat to their professional identity as a consequence of the changes in mental health care which were occurring at the time of field work, involving both the NHS and social care agencies. Out of the Institution? Exploring the Culture of Community Psychiatric Nurses. Marshal Edward Stuart Bilbe Thesis submitted for the degree ofMaster of Philosophy University ofDurham Department of Sociology and Social Policy 2004 A copyright of this thesis rests with the author. No quotation from it should be published without his prior written consent and information derived from it should be acknowledged. The copyright of this thesis rests with the author. No quotation from it should be published without their prior written consent and information derived from it should be acknowledged. Table of Contents. Preface 4 List of Abbreviations Used in the Text. 5 Introduction 6 Chapter 1. Mental Health Care in the Community. 12 The concept of "community". The asylum as an "institution". The issues in "community care". Chapter 2: The development of community psychiatric nursing. 36 The "parallel strands" in the story of the development of modem mental health care. Mental health nursing- transition from "attendants" to "caring profession" Gender Issues The Mental Health Act 1983 Problems of definition and scope in psychiatry The influence of clinical psychology Issues in Community Psychiatric Nursing. Chapter 3. The research setting. 63 South West Durham and South Durham. The structure of mental health services and development of CPN services. Summary of CPN Activity in South Durham at the time of fieldwork - 1995/1996. Chapter 4. Theoretical approach and design of the research 72 Weber: the concept of bureaucracy and the NHS as a bureaucracy. Weber and Culture. 1 Ontological and epistemological continuity in Weber's theory. How the concepts of bureaucracy and culture helped to frame the research. Method Qualitative research- strengths, weaknesses, validity and reliability "V erstehen" as method Themes for the interviews The sample of CPNs for interview. Entry to the field. Data collection Data transcription Data analysis. Chapter 5. Results of the analysis of the collected material. 111 Recap of assumptions. Themes from the interview data: Theme 1: Moving from being an RMN in hospital to a CPN in the community - and changing styles of work. Theme 2: CPNs' views on mental disorders and the nursing needs for people with mental health disorders - the dichotomy between "mental health problems" and "mental illness". Theme 3: CPN practice is holistic. Theme 4: Relationships with medical staff - the change from working with/for consultants on a hospital ward to working in the community with GPs. Theme 5: Relationships with other professions and disciplines in mental health care. Theme 6: CPNs' apparent autonomy. The linking theme. :CPNs and their professional identity. Chapter 6. Discussion. 184 Review of the theoretical ideas used in the research. The first question: Is there a CPN culture? 2 The second question: What are the constituent values of this culture? The third question: How are hospital acquired views accommodated in the community framework and what effect, if any, do they have on practice in the community? The linking theme. Links between the research literature and the fmdings. Wider issues contributing to the debate over the future of community psychiatric nursing services, arising from the research. Wider issues contributing to the debate over the future of community psychiatric nursing services, arising from the research. Implications for the future developments of the CPN service. Critique of the work. Reflections on the research Acknowledgements. 218 Appendix 1: 219 Mental Health Legislation during the 20th Century in the UK. Appendix 2: 245 Specimen CPN team operational policy. Appendix 3: 250 Blank Interview Schedule. Bibliography and References 252 3 Preface. "There are nine and sixty ways, of constructing tribal lays, and all ofthem are right" (Rudyard Kipling) 4 li!N'Il' Behavioural nurse therapist CIH!C Community Health Council CMIH!'Il' Community mental health team CJP>N Community psychiatric nurse ][J)!E'Il'll! Department of the Environment, Training and the Regions ][J)oJHI Department of Health IEC'Il' Electro convulsive therapy IENJI! English Nursing Board GNC General Nursing Council GP General practitioner GPJFIH! General practitioner fund holder LA Local Authority MlHI Mental health MDHlA Mental Health Act 1983 MHJP> Mental health problems Mll Mental illness NHS National Health Service JP' AM Profession(s) allied to medicine PCG Primary care group PC'Il' Primary care trust ll!GN Registered General Nurse lRMN Registered Mental Nurse ll!MO Responsible medical officer §Wlll> South West Durham Health District UKCC United Kingdom Central Council for Nursing, Midwifery and Health Visiting 5 In the past the convention for beginning a story was "once upon a time ... " and that phrase is still a fitting start for the present account. In 1987 my first employment with the National Health Service (NHS) was a research project which included a survey of the work of a mental health unit in what was then South West Durham District Health Authority- roughly the Local Authority areas of Sedgefield and Wear Valley Districts in County Durham. The unit was based at, and dominated by, Winterton Hospital, near Sedgefield, which was a large mental hospital founded in 1858 and housing, in 1987, nearly eleven hundred patients who originally came from all over the Northeast of England, with a few from farther afield. As part of the Government's policy of finding alternatives to long-term institutional care a community psychiatric nursing (CPN) service was created in 1976. This engaged a small team of eleven people, with a manager, based in Spennymoor in 1987 with outreach sessions at doctors' surgeries throughout the South Durham area At that time there was little information routinely collected in the NHS beyond an annual count of the number of referrals received by the team and the number of contacts they had made with their patients, now to be called "clients". This data collection itself was a recent innovation, introduced following the deliberations of the Komer Committee on the need for management information in the NHS (Komer Report, 1982). However, the "Komer" data, as it came to be known, did not provide any information about the nature of the work the CPNs were undertaking, the setting in the community or the problems for which the clients were being referred. The CPNs worked with a degree of isolation from the hospital and unit managers. This led the General Manager of the time, who was a qualified psychiatric nurse and also Director of Nursing, to seek further information about the activities of the CPNs. His instructions were "go out there and find out what the hell they are doing, will you". At that time the NHS favoured quantitative research therefore much of the 1987 survey was concerned with demographic and epidemiological analyses of the 6 CPN caseload. To supplement these data a short qualitative questionnaire was also used which enabled the CPNs to identify issues of importance to them.
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