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Today is to be celebrated for many different reasons, especially when looking at the history of nursing. It is 21 years since the very first intake of nursing students to the University of Stirling, 50 years since the University itself was created, and soon will be 70 years since the creation of the NHS. Not just that, but it’s recognised as Mental Health Awareness day. With all this to celebrate, I thought it provided an exciting opportunity to look back on the history of mental health nursing, and views on mental health to see how it has changed and developed. But just how much progress has been made from the conception of the role of the mental health nurse?
For almost two centuries, mental health nurses have struggled to win recognition for their unique contribution to the health and wellbeing of those in their care. Nolan (1993) has well documented the historical timeline of mental health nurses, as well as how they have been viewed by society. From very early on nurses rarely had access to resources which would have enabled them to fully care and treat those suffering. It was the doctors who employed the nurses that taught, trained, examined, and decided what their role should be.
Because of this and the constant development of theory and practice, nursing experienced frequent therapeutic shifts over the decades causing even nurses themselves to feel confusion about their own role and name. During the 18th-19th centuries, they went by the term ‘keeper’, and had a small role of domestic duties, caring for ‘patients’ and keeping them manageable for the doctors. It wasn’t until after 1845 with the emergence of the asylum systems and implementation of the medical model, which attributed all mental illness to biological errors, that they then shifted to ‘attendants’ to seem more humanitarian and gained more responsibility.
From the mid-19th century, the term ‘nurse’, widely recognised today, began to be used. This helped to push for ‘mental nurse’ to become an official title in 1923. The model of practice then shifted to the new field of psychology, bringing forward interventions that are still used, such as psychoanalysis and behaviourism. The medical model remerged later in the century when famous treatments like electro-convulsive therapy became popular. It wasn’t until the late 20th century that models pushed for treatment to be done out in the community thanks to the NHS Care and Community act (1990). At this point nurses were encouraged to be autonomous in their profession and develop their skills to lead and solely deliver care and treatment, with the aim to re-skill and empower those with mental illness.
Despite all this growth, development, and therapeutic shift, this is not how mental health nurses were seen by the general public or even some health professionals. Nolan (1993) commented that the historical view of mental health nurses is that they are lazy, lacking in motivation, compassion, and intelligence. The stigma that clouds mental illness has fogged public perceptions of those who suffer from it, and those that try to ameliorate those suffering.
An early example of this is obsessions with witchcraft, which developed during the medieval times. Countless numbers of people (mostly women) were executed as they were believed to be witches. In 1682, Temperance Lloyd was the last person accused and executed in England, but recent research suggests that she suffered from dementia (Wright, J. 2010). The stigma fed into the fear and paranoia of the supernatural, leading to the deaths of too many. Just think, if these ‘witches’ had been alive today, how would they be treated? Would they still be ‘witches’, or people needing help for a mental illness?
Today, mental health nurses aim to work alongside those experiencing mental ill health while promoting independence, advocacy, and person-centred care. Mental Health Nurses are a caring constant for those in need during the lonely and enduring experience of mental illness; supporting their recovery, providing the essential aspects of treatment not many realise are vital: support, comfort, and presence.
Today’s nurses work long, hard, hours to help a person feel themselves again. But yet both are faced with the same dark cloud fogging perceptions. The stigma looming over mental health is still very much present, and can be an obstacle to accessing care. The historical view on mental health nurses remains to be held by many, including health professionals. The amount of comments like “they’re not real nurses” for example I have heard is disheartening for a 3rd student nurse like myself.
However, it is not just the staff that this view effects. Wright (2010) found that when the NHS Care and Community act (1990) came into place the public protested against those with mental illness living and being treated in the community, in fear for public safety. Yet, it is 6 times more likely that those with mental illnesses are to be murdered than commit murder. Such views like this create a vicious cycle leading to discrimination, low treatment effect, or high relapse rates which reinforce stigma (Sartorius, N. 2007). This could be detrimental to those experiencing mental health, and could possibly be linked to the rise of suicides in Scotland in 2016 (728) from the previous year (672) (ChooseLife. 2017). To me, this highlights the importance of further work being done to raise awareness of mental health with the aim to eradicate stigma, but is this enough?
Improvement is always possible; Wright (2010) suggested bringing in mental health nurses to schools as a potential opportunity to increase awareness and knowledge, and for possible early intervention work. Evidence on the impact of mental health nursing is at its strongest in decades, with a drive for more nurses to be recognised for being a key resource in effective delivery of services (Barker. 2009). More is being planned to tackle these issues too, but this is something anyone can help with. Charities supporting mental health are out there offering fund raising events and education, so anyone can help, even if it’s just through being open minded.
Devon Buchanan, Student Nurse, University of Stirling
10 October 2017
- Barker, P. (2009) Psychiatric and mental health nursing : the craft of caring. 2nd ed. London: CRC Press.
- Chooselife.net. (2017). Chooselife -Statistics suicide in Scotland. [online] Available at: http://www.chooselife.net/evidence/statisticssuicideinscotland.aspx [Accessed 6 Oct. 2017].
- Nolan, P. (1993) A history of mental health nursing. 1st ed. London: Chapman & Hall.
- Sartorius, N. (2007) Stigma and mental health. [online] Available at: http://search.proquest.com/docview/199002822?pq-origsite=gscholar [Accessed 4 Oct. 2017]
- Wright, J. (2010). A history of mental health and wellbeing, part 2. British Journal of School Nursing, 5(8), pp.458-459.
“As a mental health professional, how do you deal with a struggling family member? Mental health student nurse Leanne describes her experience.
“Today, the Scottish Association for Mental Health (SAMH) launched the Going To Be campaign that raises awareness about the number of children affected by mental health problems and how lack of support impacts their goals, dreams and ambitions for the future. ”
For the full post, published 11 May 2017 please visit Leanne’s Nursing Times blog online.
15 May 2017
The recent approval of revalidation by the Nursing and Midwifery Council is a topic in which has initiated many debates and discussions over the past few months. The process, designed to strengthen the three-yearly registration renewal process, aims to increase professionalism amongst nurses.
Initially, many argued against revalidation, as they feared the introduction would be a burden which could spark a surge in the number of fitness to practice referrals. However, after pilot procedures and test studies were carried out with over 2,700 participants, early data analysis discovered the process to be straightforward and beneficial.
In order for nurses and midwives to revalidate every three years, they are required to undergo 450 practice hours, 35 hours of continuing professional development, five pieces of practice related feedback, five written reflective accounts, a reflective discussion, a health and character declaration, a professional indemnity arrangement, alongside confirming they have met the revalidation requirements.
The introduction will be influential to all nurses as it promotes a culture of professionalism by taking responsibility for their own professional development where they can reflect and focus on their own behaviours in the workplace, rather than those of others. This will empower them to make positive changes within their practice, through small improvements, whilst promoting and maintaining higher standards and quality of care within the NHS.
It will also help to extinguish the blame culture, by focusing on what we could do differently to avoid errors in the future.
Finally, it will also enhance public protection and patient safety, along with increasing the public’s credibility for nurses, as nurses will consciously be focusing on the quality of care given to their patients.
As a current student, revalidation will affect me from the moment I graduate. For example; students who are due to graduate in August 2016 will be due to revalidate in August 2019. For current students it may be easier to adapt and adjust to as it is already a requirement as opposed to trying to get used to the introduction of it.
We are also in a fortunate position as we already spend a considerate amount of time working on modules and reflections, in order to enhance our learning and to allow for self-improvement. Personal learning and development is a life-long experience within the nursing profession, and it allows us to maintain high standards of care, enhance our care skills and further develop our knowledge base. The introduction of revalidation will raise the standards of nursing, and promote professionalism, making nursing an attractive profession for prospective students.
Ceire Casey, Mental Health Student Nurse
21 December 2015
The state of maternity care in Scotland has been examined by University of Stirling researchers working with the Scottish Government.
The national report Having a baby in Scotland 2015: Listening to Mothers documents the story of more than 2000 new mothers.
Produced in partnership by the Scottish Government and Stirling’s Nursing, Midwifery and Allied Health Professions Research Unit (NMAHP RU) – it shows women are accessing care earlier in pregnancy with significantly more contacting a midwife first when they are pregnant.
Communication between women and maternity care staff appears to be good with most women reporting that they were listened to, spoken to in ways that they could understand and involved as much as they wanted in decisions about their care. The high level of trust women had in staff was evident, in particular during labour and birth.
Areas where care could be improved – particularly in relation to mental health – were highlighted, based on women’s responses to the survey.
Around one third of women felt that they were not given all the advice they needed about emotional changes they might experience and around one quarter were not given information about who to contact for advice about emotional changes if they needed it.
Additionally 44 percent of women said they did not get enough information to help them decide where to have their baby and 24 percent said they were not offered a choice about where to have their baby.
Report author Helen Cheyne, midwife and Professor of Midwifery Research in the NMAHP Research Unit at the University of Stirling said: “One of the most striking findings was around women’s mental health in the six weeks following birth. A recent report shows that almost a quarter of women who died between six weeks and one year following birth did so from mental health related causes. It is essential that all women and their families know the signs and symptoms of mental health problems following birth and who to contact if these occur.
“The report recommends that NHS Boards should examine whether local maternity and perinatal mental health services meet current best practice recommendations to support maternal mental health. All midwives, health visitors and medical staff caring for pregnant and postnatal women should undertake recognised training to ensure there is support for mothers who experience mental health problems.”
The report from the NMAHP Research Unit concludes with six recommendations including the appointment of post-natal care champions in every maternity hospital, ensuring one to one care of women by skilled midwives throughout labour and birth remains a priority and that all women should have choices about where their antenatal and postnatal care and place of birth happens.
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15 December 2015
Prof Margaret Maxwell has blogged for the National Institute for Health Research this weekend:
“A quarter of the UK population will experience some kind of mental health problem during their lives, most commonly depression and anxiety. The likelihood of someone with physical health problems also experiencing mental health problems is now well recognised, although the nature of the relationship between depression and physical disease or illness remains ambiguous.”
One in one hundred people will experience schizophrenia in their lifetime. Schizophrenia can be managed well with a person-centred combination of therapy and medication and an emphasis on recovery. Many of us are likely to know people who are affected by the symptoms of schizophrenia but are still managing to lead fairly ordinary lives.
However, for others living with more severe symptoms, schizophrenia can be a distressing and highly debilitating experience. Symptoms experienced such as hearing voices or seeing things (hallucinations) often fail to respond to medication. Even when antipsychotic medication is effective, the side effects of weight gain, apathy, shaking or lack of drive are also debilitating. More effective drugs are urgently needed, however despite promising leads there has not been ground-breaking progress in drug development for schizophrenia for many decades.
One emerging non-drug therapy proposed for the treatment of schizophrenia and the symptom of hearing voices is transcranial magnetic stimulation (TMS). TMS is a device which involves the skilful application of a strong magnetic field close to the scalp surface. TMS is a relatively painless and non-invasive technique which stimulates parts of the brain. Researchers over the last decade have set about assessing whether this promising new therapy TMS could be an alternative treatment for people who do not respond, or do not cope well with medication.
Researchers have typically used ‘randomised controlled studies’ to assess the effectiveness of TMS. This has usually meant randomising people with schizophrenia – with their full consent – into an experiment of either having TMS or having ‘sham’ TMS (i.e. identical process without the magnet switched on). Therefore, randomised controlled studies are a way of comparing two groups of people with schizophrenia who are as identical as possible in every way except for the active ingredient of the TMS itself.
Although many of these study results have now been reported by researchers across the world, the results differed widely and there was no consensus on whether TMS should be routinely used in practice. Therefore we set out to achieve this consensus by reviewing all the reported TMS studies of schizophrenia using Cochrane methodology (the internationally recognised highest standard of review). The purpose of our Cochrane review was to assess the quality of all reported studies, and then combine the results into one analysis (a ‘meta-analysis’) to give summary estimates of whether TMS is effective, or not.
We found that from 41 reported studies (1473 people) there was some evidence to suggest TMS may improve certain symptoms such as hearing voices when compared with ‘sham’ TMS. However, because we also graded many of the studies as ‘low’ or ‘very low’ quality evidence, this meant we were uncertain that TMS was effective, and could not make firm conclusions about using TMS as routine treatment for schizophrenia.
To be clear, this is not the same as researchers doing low quality studies, but rather that frequently the way the study was conducted was not reported to a sufficient standard to rule out risks of bias. This is frustrating, and authors who are reporting on study results are urged to adopt clear reporting practices to remove ambiguity by using standards such as the CONSORT criteria. Journal editors should consider routinely recommending the use of CONSORT criteria and lift restrictions on word limits which inhibit full reporting.
In future, high quality research studies AND high quality reporting of these studies is very likely to have an important impact on whether we can confirm TMS alleviates some symptoms of schizophrenia, but for now we remain quite uncertain. It is important that the research community pursues this aim so that we can improve the quality of treatment provided to people who are living with the debilitating symptoms of schizophrenia.
1 October 2015
Dougall N, Maayan N, Soares-Weiser K, McDermott LM, McIntosh A. Transcranial magnetic stimulation (TMS) for schizophrenia. Cochrane Database of Systematic Reviews 2015, Issue 8. Art. No.:CD006081.