Education And Debate

Has nursing lost its way? Dual perspective

BMJ 1995; 311 doi: (Published 29 July 1995) Cite this as: BMJ 1995;311:303
  1. Jacqueline A Short, senior registrara
  1. aBarrow Hospital, Barrow Gurney, Bristol BS19 3SG

    National Institute for Nursing, Radcliffe Infirmary, Oxford OX2 6HE, Ann Bradshaw, Macmillan lecturer in palliative nursing. Faculty of Health Studies, University of Wales, Bangor LL57 2EF, Mike Nolan, senior lecturer in nursing research. Merton, Sutton and Wandsworth Health Commission, London SW15 2SW, Heidi Lempp, primary health care facilitator for HIV/AIDS and sexual health.

    It was with a mixture of pride and trepidation that I rounded the final bend and drove up to the same psychiatric hospital that had seen my arrival as a student nurse 17 years previously. I was back again, but this time as a senior registrar in psychiatry. Would anyone recognise me? Would my nursing colleagues welcome me or treat me with suspicion for defecting to the other side? The moment of truth was looming.

    Nursing roots

    At the age of 18 I surprised myself and disappointed my school by deciding to train as a nurse. What a waste of a grammar school education! In a misguided attempt to combine my chosen career with travelling the world, I joined the Queen Alexandra's Royal Naval Nursing Service. The defence cuts had started. By the time I had become a state registered nurse three years later, I had seen Portsmouth, Plymouth, and Southampton. It was while on secondment with the army at the Royal Victoria Hospital, Netley, however, that my initiation into psychiatry started. That initiation became a baptism of fire when I began further training to become a registered mental nurse, but this time, as a civilian in an NHS psychiatric hospital.

    As I drove slowly through the grounds again, memories came flooding back. I cringed at my own ignorance. The ward sister's words still ring in my ears at my attempts to safely contain and distract my first manic patient by joining in with the infectious laughing and dancing. But for my crisp uniform and white cap, sister would have thought there were two manic patients on her ward.

    Red “suicide caution cards” were received and signed by the “specialling” nurse with as much enthusiasm as if she was receiving the black spot. There was no diffuse team responsibility here. For however long the sister or charge nurse decreed, a nurse would be responsible for ensuring the whereabouts and safety of the patient deemed at risk of suicide. It was mentally and physically exhausting. We looked wistfully at the doctors who swept into the ward for their comparatively brief encounters and then left for their academic meetings.

    It was not until I became a ward sister that I felt that consultants could be addressed with any form of clinical equality. They could often be encouraged or cajoled to include nurses when teaching junior doctors on ward rounds. Such teaching fostered my own academic interest in a subject that was so intrinsically fascinating but of which my knowledge only extended to the skills demanded by my own profession. I threw myself vigorously into nurse education, reading around my subject and wanting to know more and share more with each group of nursing students assigned. It was as a registered nurse tutor that I finally decided to take the plunge, and as a mature student who felt like Methuselah I entered medical school. I emerged several years later with a large overdraft and a resolve to become a psychiatrist.

    I resisted the lure of returning to my old, familiar hospital to undertake my postgraduate training; it seemed almost incestuous. Instead, I spent four years training and working in a completely different mental health service, which broadened my experience and offered alternative models of care. Now, as a senior registrar, I feel that there has been a decent enough period of absence for me to return to continue my higher professional training.

    Evolution or revolution?

    Six months have passed since I arrived at my old psychiatric hospital. What has changed? Was I right to be worried? The first few weeks were whirlwinds of hugs and recognition. Most of us had gained some grey hairs and wrinkles. Tales were exchanged and then we each surveyed the other in our new roles. My nursing colleagues have evolved into managers and skilled therapists, and the talk is of “clients” and “empowering.”

    I feel like a dinosaur as I slowly realise that psychiatric nursing is not the profession I recall. Caring junior nursing colleagues have adopted the role of “client's advocate,” and the teaching is centred on psychosocial concepts of mental health. Mental illness seems to be a perjorative term and its very existence questioned. Of course, there is an important psychosocial component in the presentation of mental illness, but it is clearly not the whole story. Mental illness undeniably affects a patient's physical and mental state, and too rigid an adherence to the principle of patient autonomy can have serious, and sometimes life threatening, consequences. For example, it is a fine dividing line between encouraging disturbed “clients” to accept drugs that they do not feel they require or to adopt a more healthy sleep routine, and being patronisingly coercive. Recognition of that line, however, has always been one of the skills unique to the psychiatric nurse. Working alongside patients and helping them with their activities of daily living seems to have become the province of the health care assistant.

    Some would argue that these changes are for the better, and that focusing on basic tasks devalues psychiatric nursing. I am not so sure, and neither are some of my senior nursing colleagues. It seems that in striving to become a respected profession, psychiatric nursing is losing that unique body of knowledge and skills that defines it as a profession. Instead, the main emphasis seems to be on academic sociological and psychological principles, with little teaching of the practical skills of psychiatric nursing, which not only preserve a patient's dignity but also keep the patient alive. For example, to gain the trust and confidence of a severely depressed or demented patient so that he or she may be helped to wash, dress, and eat requires more than just a pair of hands. Assistance with these private tasks helps to build the therapeutic relationship on which assessments of mental state are accurately based.

    Nurses may lose their role of helping patients with activities of daily living


    Clinical teaching placements can no longer offer these practical skills, as the senior nursing colleagues from whom nurses previously learnt so much have been caught up in the tide of health service reforms and in many cases no longer have any contact with patients with acute conditions. With the move to community care, others are now working as primary therapists in the community. The role models of the specialist skills needed for acute, inpatient care have gone. The nursing profession in general has never properly recognised, or rewarded, those clinical nurses who chose to stay at “ward level.” They are regarded either as lacking in direction and initiative or as being too rigid and unable to adapt to the new progressive thinking. Perhaps that explains my defection.

    At least as a doctor I am able to maintain my contact with patients, and perhaps also take up the role of advocate, by encouraging junior nursing colleagues to see patients in a more holistic light and not to dismiss the medical model. We must address this imbalance. The right of our patients to have the best multidisciplinary care depends on it.

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