A Narrative History of Psychiatric / Mental Health Nursing in the Asylum / Mental Hospital System in Ireland from 1940 to 1970. ‘Always remember they are some mother’s child’ By Eithne Cusack RPN, RGN, MSc Psychotherapy, MSc Healthcare, PG Dip Professional Supervision Research Supervisors: Prof Joe O’Hara & Dr Elaine McDonald Thesis submitted for the award of EdD Institute of Education Dublin City University January 2021 Declaration I hereby certify that this material, which I now submit for assessment on the programme of study leading to the award of EdD is entirely my own work, and that I have exercised reasonable care to ensure that the work is original, and does not to the best of my knowledge breach any law of copyright, and has not been taken from the work of others save and to the extent that such work has been cited and acknowledged within the text of my work. Signed: ID No: 16211649 Date: 6th January, 2021 Dedication I dedicate this work to the patients who were admitted and resided in Irish mental hospitals / asylums and who educated us regarding social and human vulnerability. & To my psychiatric nursing colleagues who worked within these institutions and responded with courage, compassionate and dedication. They crafted the cornerstone of the profession of psychiatric nursing in Ireland. i Acknowledgements I would like to express my gratitude to a number of people without whose support, this thesis would not be possible: I would like to express my deep gratitude for the generosity of the psychiatric nurses who gave me their time and narrated their experiences to inform this study. It was an absolute privilege for me to meet with them, they were truly inspiring. My sincere gratitude to my supervisors Professor Joe O’Hara and Dr Elaine McDonald for their support and encouragement throughout this process. I appreciated all the guidance they generously gave to me. To my children Caitríona, Ciarán, Fergal and Brian for all their help, support, love and friendship, they are a constant source of sustenance for me and I am so proud to be their mother. My deepest thanks go to my husband Ned for helping me to fulfil so many of my life’s goals. His unwavering encouragement and support and deep understanding of psychiatric nursing is inspiring. ii Table of Contents Declaration i Acknowledgements ii Contents iii List of Tables vii List of Figures vii List of Abbreviations ix Abstract x Chapter One 1. Introduction 1 2. Context of emergence of the area of research 2 3. Rationale for this study 3 4. Purpose of the Study 4 5. The scope of this study 5 6. Contribution of this study 8 7. Language 8 8. Structure of Thesis 9 Chapter Two Literature Review 2. Introduction 11 2.1. Literature review methodology 12 2.2. Background and Context 12 2.3. The Asylum System in Ireland 13 2.3.1 The Social/Physical Environment of Asylums 15 2.3.2 Asylum Administrative Structures 18 2.3.3 Legislation & Policy 20 2.4. Social theory of asylums 24 2.5 Historical social context 27 2.5.1 Containment 28 2.5.2 Economic context 29 2.5.3 Education 32 2.5.4 The Catholic church 33 2.6. Historical Treatment Approaches in Asylums 38 2.7 The History of Nursing 38 2.8. Policy Reports Pertaining to Psychiatric Nursing 43 2.9 Psychiatric Nursing 45 2.9.1. The Profession of Psychiatric Nursing 45 2.9.2. Defining the role of the Psychiatric Nurse 47 2.9.3 The role of the Psychiatric Nurse 52 iii 2.9.4 Others perceptions of psychiatric nurses 53 2.9.5. The language of Psychiatric Nurse V Mental Health Nurse 56 2.10 Recovery’s Core principles 58 2.11. Origin,Education and Professional Training for Psychiatric Nurses 59 2.11.1. In the 1800s 60 2.11.2. In the 1900s 61 2.11.3. In the 2000s 63 2.12. Regulation of the Profession 64 2.12.1 The Profession of Psychiatric Nursing 65 2.13 Conclusion 68 Chapter Three Methodology / Research Design 3 Introduction and background 69 3.1 Overview of Paradigms 69 3.1.1 Social Constructionism 70 3.1.2 Hermeneutics 71 3.2 Theory of Nursing 75 3.2.1 Peplau’s theory of Nursing 75 3.2.2 Henderson’s theory of Nursing 75 3.2.3 Johnston’s theory of Nursing 75 3.2.4 Orem’s theory of Nursing 77 3.2.5 Roy’s theory of Nursing 77 3.2.6 Neuman’s Systems theory 77 3.2.7 Benner’s theory of Nursing 78 3.3 Conceptual Framework 79 3.3.1 Caring 79 3.3.2 Mayeroff’s theory of caring 80 3.3.3 Campbell’s theory of caring 81 3.3.4 Watson’s theory of caring 81 3.4 Research Design 82 3.4.1 Rationale for Qualitative research design 83 3.4.2 Narrative Research 84 3.4.3 Narrative Inquiry 85 3.4.4 Oral History 88 3.4.5 The Voice of Memory 90 3.4.6 The Role of Reacher 92 3.5 Data Collection Methods 93 3.5.1 Interview 94 3.5.2 Narrative Interview 95 3.5.3 Interview Process 96 3.5.4 Research Questions 97 3.5.5 Participants Selection Process 99 iv 3.5.6 Profile of Participants 101 3.6 Ethical Approval 103 3.6.1 Ethical Review 103 3.6.2 Confidentiality 104 3.6.3 Data Collection Procedures 105 3.6.4 Trustworthiness & Credibility of data 105 3.6.5 Field Notes 106 3.6.6 Critical Friend 107 3.7 Data Analysis 107 3.8 Description of the approach to analysis used in this study 107 3.9 Analysis of Data 108 3.9.1 Framework for analysis 108 3.9.2 Narrative Data Analysis 109 3.9.3 Data Analysis Using Qualitative Data Software 110 3.9.3.1 Verification of data 114 3.9.4 Reporting the findings 115 3.9.5 Limitations of the study 116 3.10 Conclusions 118 3.11 Summary 118 Chapter Four Findings 4 Findings 119 4 Introduction 119 4.1 Theme One: The Asylum System 120 4.1.1 The Physical Environment 122 4.1.2 Working Conditions 125 4.1.3 Institutionalisation 127 4.1.4 Asylum practices 128 4.1.5 A patriarchal system 130 4.1.6 Patient Presentations 134 4.1.7 The psychiatrisation of normal stressful life experiences 141 4.1.8 Patient Activities in the Asylum 142 4.1.9 Medical Treatments 144 4.2 Theme Two: Influences on psychiatric nursing 147 4.2.1 Reasons for going into Psychiatric Nursing 148 4.2.2 Influence of Psychiatrists 149 4.2.3 Influence of Catholic Church 151 4.2.4 Legislation and Health Policy 152 4.2.5 Influence of Trade Unions 155 4.2.6 Influence of introduction of Anti-Psychotic drugs 156 4.2.7 The influence of Nurse Training 159 4.2.8 External Influences 163 v 4.2.9 A Social Community 164 4.3 Theme Three: Professional Challenges 166 4.3.1 Stigma 166 4.3.2 Societal stigma 169 4.3.3 Professional stigma 170 4.3.4 Shame 172 4.3.5 Professional Voice 173 4.4 Theme Four How nurses conceptualised their roles 174 4.4.1 Nursing in the asylum 175 4.4.2 Resocialisation 176 4.4.3 Deinstitutionalisation 179 4.4.4 Introducing the Community 180 4.4.5 Caring 182 4.4.5.1Caring “for” 182 4.4.5.2Caring “About” 184 4.4.6 Family Caring 185 4.4.7 The Human Connection and Relationship based care 187 4.4.8 Emotional Literacy & Resilience 189 4.4.9 Conclusion 190 Chapter Five Discussion 5 Introduction 191 5.1 Medical Dominance 192 5.2 Struggle for Voice 193 5.3 The Social Construction of the Profession of Psychiatric Nursing 195 5.4 Stigma 196 5.5 A Disenfranchised Profession 197 5.5.1 Impact of Stigma 198 5.5.2 Abuse 198 5.6 Gender 201 5.7 Nursing Practice 202 5.8 A Nursing Model of Care 205 5.9 A Nurses Role 208 5.10 Professional Agency 209 5.11 Caring 211 5.12 Contribution of this study 214 5.13 Conclusion 218 5.14 Limitations of the study 219 5.15 Implications for further research 220 5.16 Recommendations 221 5.17 The personal learning of the researcher throughout this study 221 References 222 vi Appendices 263 Appendix 1: Ethical Application Appendix 2: Ethical Approval Codebook\\ Appendix 3: Participants Profiles Appendix 4: Phase I-Generating Initial Codes (Open Coding Appendix 5: Phase 2-Developing a Thematic Framework Appendix 6: Example of Flow from codes to categories to themes Appendix 7: Example of the role Analytical Memo Appendix 8: Example of role of Integrated Annotations List of Tables Table 3.1 Elements of Inquiry Table 4.1 Thematic Representation of Research Findings List of Figures Figure 2.1 Asylum Construction Programme in Ireland Figure 2.2 Recovery’s Core Principles Figure 3.2 Overview of Research Design Figure 3.3 Data Collection Methods Figure 3.5 The Number of Years of Experience the Respondents have Figure 3.6 Respondents Nursing Qualifications Figure 3.7 Respondents Place of Employment Figure 3.8 Overview of Analysis Process from Raw Data to Findings Figure 3.9 Phase One of Thematic Analysis Figure 3.10 Phase 2-Developing a Thematic Framework vii List of Abbreviations ABA An Bord Altranais ACMHN Australian College of Mental Health Nursing ANA American Nurses Association CAQDAS Computer-assisted qualitative data analysis software CPN Community Psychiatric Nurse EEC European Economic Community ECT Electro Convulsive Therapy FPRN Female Registered Psychiatric Nurse GNC General Nursing Council IIMHN Irish Institute of Mental Health Nursing ITGWU Irish Transport and General Workers Union MRPN Male Registered Psychiatric Nurse NMBI Nursing & Midwifery Board of Ireland NUI National University of Ireland RD Research Diary RGN Registered General Nurse RMS Resident Medical Superintendent RPN Registered Psychiatric Nurse UK United Kingdom WHO World Health Organisation viii A Narrative History of Psychiatric / Mental Health Nursing in the Asylum / Mental Hospital System in Ireland from 1940 to 1970.