Psychiatric nursing as an entity has really only evolved since the Second World War. Psychiatric nurses (now often referred to as mental health nurses in the United Kingdom and Australasia) can now be found in most countries of the developed world, although in the developing world, psychiatric nursing is still not defined as a specific discipline. In many countries, psychiatric hospitals are still staffed by untrained ‘Attendants’ who may have some supervision from general trained nurses. Nevertheless, a number of initiatives, notably those of the Geneva Initiative in Psychiatry⁽¹⁾ in Eastern Europe and the former Soviet Union and the World Health Organization in African countries, have provided specific training in psychiatric nursing techniques.

The development of psychiatric nursing across the world needs to be seen in the context of changing and evolving patterns of mental health care. De-institutionalization, with the attendant setting up of community mental health teams, has prompted a range of innovations in psychiatric nursing and the psychiatric nurse of today, who in the United States and Europe is likely to be a university graduate, is a very different person to that of the nurse working in the post-Second World War asylums of 40 years ago.

In this chapter, we examine the development of psychiatric nursing in some detail and particularly emphasize the role of psychiatric nurses working in the community. Community psychiatric nursing first developed in the United Kingdom nearly 50 years ago and this model has been followed in countries such as Australia and New Zealand. However, this community role has not developed to any great extent in the United States, where the main presence of psychiatric nursing remains in hospital-based care. Furthermore, in the United Kingdom and Australasia, the development of community initiatives has seen the role of the psychiatric nurse blurring with that of other mental health professionals. Chapters such as this cannot really do justice to the whole range of techniques used by psychiatric nurses; neither can it examine in any detail the differences between psychiatric nursing practices across the world. However, a description of psychiatric nursing in six important areas will provide the reader with an appreciation of the range and diversity of psychiatric nursing skills:

In the past three decades the population in psychiatric hospitals across the developed world has fallen dramatically in England from 160 000 to 30 000 beds over a period of 25 years and the duration of inpatient care in the United Kingdom in 2007 is approximately 36 days. However, today’s inpatients are a population with much greater levels of illness than was previously the case; they tend to be more treatment-resistant, have complex problems, and display high levels of substance abuse and violence.⁽²⁾ As a corollary of this, a greater proportion of patients are now detained under mental health legislation. Inpatient facilities consist of acute psychiatric units, local secure units, and high secure psychiatric hospitals for those patients who pose high levels of danger to themselves and others. In the United Kingdom, four high secure hospitals contain approximately 1600 patients. It should also be noted that, due to the large numbers of people with psychiatric problems in prisons, there are now several hundred psychiatric nurses employed in prison settings to carry out a range of assessment and treatment procedures. In addition, the NHS also has a number of ‘in reach’ schemes, which include sending NHS staff into prisons on a sessional basis.

Given that community care in the western World is now the norm, inpatient care is now seen as a short-term measure with the dual purposes of stabilizing the patient’s condition and keeping the patient safe. Psychiatric nurses have a role to play in the overall assessment of the patient and, given that the nurse is—literally— with the patient 24 h a day, the observation of the patient’s mental state and behaviour is of considerable importance. Unfortunately, this is an area where, outside the United States, a number of problems exist and suicide rates by inpatients are unacceptably high.⁽³⁾ In the United States, inpatient wards tend to be much more secure than wards in countries such as the United Kingdom and Australia and, therefore, the incidence of inpatient suicide is much lower. The UK National Confidential Inquiry into suicides and homicides⁽³⁾ demonstrates that nearly 200 suicides by inpatients occur every year, with hanging on the ward itself being still prevalent at unacceptably high levels. Recently the National Institute for Health and Clinical Excellence (NICE)⁽⁴⁾ has published guidelines, which include the observation of patients at risk. This guidance sets out very careful protocols for the observation of patients at risk and includes recommendations regarding the prevention of absconding. In the United Kingdom and Australia, open-door policies still operate in acute psychiatric units and it is being increasingly recognized that balancing the rights of the patients against safety is a difficult issue. Nurses also have a major role to play in providing patients and their families with information about condition and treatment. We also know that there are interventions that can be applied by nurses, which would lead to improved outcomes. For example, Drury et al.⁽⁵⁾ showed that a cognitive behavioural therapy package improved longer-term outcomes. Similarly, Kemp et al.⁽⁶⁾ showed that motivational interviewing and psychoeducation methods produced clear, clinical, and economic benefits in patients who have compliance problems with medication.

With regard to the containment of violent behaviour, which is now so common in inpatient settings, nurses in the United Kingdom have been assisted by very comprehensive evidence-based guidance from the National Institute for Health and Clinical Excellence (NICE),⁽⁴⁾ which sets out clear guidance on the use of de-escalation techniques and control and restraint, as well as providing a comprehensive algorithm for the use of rapid tranquillization. In respect of rapid tranquillization, nurses are now provided with the necessary skills to observe and monitor patients following rapid tranquillization, including the use of pulse oximetry and blood pressure. Whilst nurses in Australasia use the same methods of managing violent behaviour as nurses in the United Kingdom, psychiatric nurses in most European countries and in the United States use various forms of mechanical restraint and a very wide range of devices, including belts, straps, nets, and jackets. Whilst it needs to be recognized that there are a range of social and cultural influences that determine how violence in mentally ill people is managed, it is important to note that the evidence base for all forms of violence management, including rapid tranquillization, is very poor and a Cochrane review found that there is no evidence base for the use of seclusion and restraint.⁽⁷⁾

In order to appreciate the current practice of psychiatric nurses working in the community, it is important to say something about the historical context. Until the early 1980s, community psychiatric nurses (CPNs) in the United Kingdom were generally based in large, Victorian psychiatric hospitals and worked mostly within a consultant psychiatrist team responsible for the follow-up of patients after discharge from hospital. Their main responsibilities were the administration of medication and the provision of general, supportive care, mostly to people with schizophrenia, the elderly with functional and organic illnesses, and to people with other serious and enduring mental illnesses. Initial research on the effectiveness of community psychiatric nurses produced very positive results. In a randomized trial conducted by Paykel et al.⁽⁸⁾ CPNs were compared with psychiatric registrars in the provision of aftercare for patients who had suffered an acute episode requiring hospitalization. In general terms, this study showed that there was an equivalent outcome on clinical, social, and economic measures. Some 20 years ago, CPNs in the United Kingdom began to diversify their practice and separated themselves from consultant psychiatrists, attaching themselves to primary care settings and taking referrals directly from GPs. By 1990, a national survey showed that 40 per cent of CPNs worked in primary care.⁽⁹⁾ The vast majority of this work involved treating people with depression, anxiety, and adjustment disorder, using counselling-based approaches. Whilst this work by CPNs became very popular with GPs and mental health professionals in general, research into the effectiveness of their work demonstrated that they were largely ineffective. Gournay and Brooking⁽¹⁰⁾ carried out a randomized controlled trial involving 11 CPNs, working in six primary care settings in North London. In this study, 177 patients were randomized to either routine continuing care from their GP or to CPN intervention. The majority of patients had adjustment disorders and various states of general depression and anxiety. Patients, in both the CPN and
continuing GP care groups, showed significant improvement on a range of measures, clinical status, and social functioning but, at post-treatment and follow-up, there was no difference in outcomes demonstrated. Patients allocated to CPNs showed high levels of dropout (50 per cent) and patient satisfaction rating did not correlate with outcome measures. An economic analysis⁽¹¹⁾ showed that, per unit of health gain, CPN intervention was very expensive compared with interventions for people with schizophrenia. The Paykel and Gournay and Brooking studies still represent the only research evidence regarding the efficacy of CPNs working with common mental disorders.