Free Nursing Essays- Explore how the role of the mental health nurse could be enhanced by the understanding of the sociological, political and economic factors that influence mental health care.
Introduction
The role of the mental health nurse is one that has evolved within living memory from that of a comparatively unspecialised health worker, with little autonomy, in the Asylums of the UK, to a highly trained and specialised semi-autonomous worker who is capable of providing effective healthcare in a variety of settings. The law has been reformed dramatically over the last fifty years and significantly further in the last decade (Department of Health 1998-2000) . As a direct consequence of this process of evolution, the training of the mental health nurse has had to encompass many more factors from outside of the “normal” curriculum that it did even a decade ago. It is fair to say that the mental health nurse is a more rounded professional as a result of this training.
The Government has declared mental health as being one of its top three priorities in the Health Service partly, it could be argued, because of the general sense of lack of progress that is felt by the healthcare professionals throughout the service (Department of Health (1999b) . It can be argued that our hypothetical mental health nurse would have to be aware of all these issues if they were to perform their role to maximum advantage
The effectiveness of any healthcare professional is a direct consequence of their training and experience. It therefore follows that the wider education of the mental health nurse in the influences of sociology, politics and economics – insofar as they are relevant to the speciality – will enhance their role in their particular facet of the job.
In order to justify this statement we need to examine the literature on the subject.
Literature Review
A good place to start this examination of the question is the excellently analytical paper by Chan (2002) This paper poses the provocative question “In whose best interests?” and refers to the various reforms of the Mental Health Act (most notably the 1998 reform). Chan points out that the treatment of the mentally ill has evolved dramatically over the recent past. One only has to think of the Victorian Sunday afternoon pastime of being entertained “at the Asylum” that was only just over 100 yrs. ago. He makes the point that the legislation by which society has sought to control and provide for the mentally ill, has been a reflection of society’s own views. The White Paper “Reforming the Mental Health“ encapsulates this very point. It revolves around the whole concept of the Paternalistic State in deciding just what a patient’s “best interests” are, and these are also influenced by considerations of risk assessment and possible legal liability.
In the context of this piece, Chan also examines the whole concept of power over the free will of the patient. This is of huge relevance to our hypothetical nurse’s understanding of the ethical and practical issues that are inevitably faced in day to day practice. The thrust of the Act is to place even greater responsibilities on the health care professional, by demanding greater attention to the ethical dimension of decision making, particularly in the currently “grey areas” of potentially dangerous patients and those with untreatable personality disorders. The current guidelines state that the patient cannot be restrained against their will unless “they pose a danger to themselves or to others”. This, on the face of it seems both reasonable and easy to interpret, but yet it lies at the heart of the ethical difficulties of dealing with the mentally unwell. Doctors and Administrators will make their decisions, but it is the mental health nurse who, in some respects, can be considered the last stage of advocacy for the patient whilst nevertheless having to ensure that all appropriate safeguards for the General Public are still being maintained. In this respect this Act recognises – some would argue, for the first time – that the mental health nurse has a social responsibility as well as the hitherto medical one. The role of the mental health nurse has expanded in this area within the last decade or so. Towards the closing years of the last century it was a common practice for the medical staff to do a ward round in a hospital and discuss management of the patient amongst themselves – occasionally even in the absence of the patient. More modern practice has tended to favour a far more open style of patient management. Open multi-discipline discussions are now “the norm” and consensus decisions are generally arrived at. The role of the mental health nurse is vital to this process. Firstly because they are more intimately involved with the patient and, of all the healthcare professionals, are likely to be the ones who know all aspects of the patient’s life the best and secondly, the training that the mental health nurse receives today is far broader and in greater depth than it was even a few years ago. The mental health nurse is therefore arguably in the best position to give feedback to the decision-making group that is both relevant, practical, ethical and professional. The issue that Chan raises regarding “whose best interest” exemplifies this point. It was not unknown, in the past, that patient management decisions were made with public (and, to a lesser extent) professional interests put before those of the patient. Sections were signed on the grounds that the patient “might” cause harm or “it was for his own good”. Modern practice is far more biased towards Human Rights and patient empowerment and education. Orders of imposition or compulsion are less frequently used and the mental health nurse’s voice is crucial to helping maintain the rights of the patient.
Taking this argument on a stage further Symonds (1998) evaluates the philosophical and sociological aspects of the mental health legislation. We have touched upon the ethics of assessment “dangerousness” in a patient and the degree to which that allows society to restrain them. Symonds takes this argument and explores it fully with the analysis that it is the prediction of dangerousness that is the factor on which decisions are made. He broadens the debate with the pronouncement that one of the factors that influences prediction is colour and ethnicity. He is clearly right to be concerned at those patients who enter a mental health system who’s priority is control at the expense of care.
The Government’s White paper “Reforming the Mental Health Act “ is generally speaking, regarded as being a very liberal document which is seen as a natural evolution of the other major reforms of the latter part of the last century (1959 onwards). Grounds (2001) produced a very illuminating overview of the recent mental health reforms which is beyond the scope of our consideration here but underlines the need for our hypothetical mental health nurse to be fully appraised of the climate of change in the area
The natural progression of this exploration of the issues that confront the modern mental health nurse is to explore how the modern mental health services are organised. Johnson et al (2001) provide an incisive insight into the current structure and functioning of an Inner London Authority and then compares them with the provision across the country as a whole. This article examines the sociological, political and the economic factors that are relevant to the issues. It spends a lot of time describing the evolution of the mental health service from the Institution-based provision of the 60’s and 70’s to the comprehensive community-based services that are the mainstay of our current mechanism for caring for the mentally unwell. This particular paper is very well written as it contrasts and balances the positive issues that we have just outlined with the negative aspects of modern-day health service provision. Aspects such as a high staff turnover, difficulties in relating to line-management principles, social exclusion because of the stigma still associated with mental illness are all considered together with the current government provision of resolution mechanisms such as crisis teams and the assertive outreach initiative. Such measures are clearly essential not only for the enhancement of our hypothetical mental health nurse but an understanding of such issues is actually important even for the basic functioning in the modern NHS.
The whole topic of social exclusion is take further by Repper and Perkins (2003) . Their very erudite book examines the availability of mental health care in the socially excluded segments of our society. Any mental health nurse could not consider themselves competent and fully educated without a grasp of these issues
One aspect of the current structure of the mental health services that is often overlooked, but nevertheless has a vital role to play in the modern integrated NHS, is the Liaison Mental Health Services (LMHS). It was designed to deal with the needs of patients who had mental health needs but were caught up in the “mainstream” services provided by the NHS. Callaghan et al. (2003) reviewed the role of this “Cinderella service” and its contribution to the welfare of many mainstream patients. They point to its economic value in the current provision in the A&E departments of out DGH’s. The sociological impact of these services is assessed, emphasising the value of the LMHS in helping clients to access mental health provision and the benefit to the community in both economic and social terms
One of the major expenses in the provision of mental health care (and indeed any type of health care) is the economics of medication provision. In a service which runs on a finite, cash-limited budget, the provision of the most economically sound form of treatment is one of the major factors in management decision making for a given patient. The modern mental health nurse has a major role to play here and the advent of the nurse practitioner is therefore all the more significant. Clearly the more that the mental health nurse understands of the economics of prescribing, the more efficient role they can play in the whole spectrum of patient management. Usher and his colleagues (all mental health nurses) have constructed an excellent paper on the issue (2001) their particular exploration centred on the economics (and the ethics) of PRN prescribing which they found to be frequently ineffective, sub-optimal and wasteful. Given the fact that, in the field of mental health, drug prescribing is frequently a mental health nurse’s fairly autonomous role, the link between better understanding and enhanced performance could not be clearer.
In consideration of the economic facet of this argument, one should not overlook possibly the biggest single economic aspect of the whole mental health service provision and that is it’s Human Resources. The mental health nurse is a very valuable commodity – a fact that is often overlooked. Edwards et al. (2000) looked at the wastage of this resource through stress and burn-out. One could argue that this point encapsulates elements of all three of our germinal issues for our nurse. The economics of the situation are clearly implicated, the sociological impact both for the community and, on a personal level, for the nurse concerned, together with the political decisions that may well have contributed to the situation are all discussed. Most people working within the NHS would agree that the evolving politics of the service has been responsible, in the main, for one of the main causes of stress in the workplace and that is pressure of work together with the lack of enough personal time to deal with the stress that it creates
In the context of our discussion of the value of sociology to the modern-day mental health nurse there is a fascinating paper by Pinikahana (2003) who looked at the arguments on both sides of the debate. Pinikahana provocatively quotes Sharpe who argues that there is no need for the modern nurse to understand sociology as they have to operate within tight sociological confines that are already defined by modern practice. A moment’s reflection can clearly reveal that the argument is seriously flawed as both Cooke and Porter are quoted in the article as arguing that (as we have discussed earlier) the mental health nurse is a bastion of protection for the disadvantaged patient and, in some cases, his advocate as well. To do this without an understanding of the sociological principles involved would clearly be a futile exercise
Sociology is perhaps the fledgling science in respect of any study of the mental health services. Rogers and Pilgrim (1993, 2001) have produced an excellent series of books looking at this issue (and many others) . Any modern appreciation of the complete role of the mental health nurse would be unfinished without the understanding of the concepts of social responsibility. The title of this piece asks us to consider the enhancement of the role of the mental health nurse. We feel that it would be reasonable to argue that sociology is actually both central and essential to the profession.
This argument is taken still further by the consideration of the levels of use of mental health services. These levels are still largely determined by socio-economic factors. Drukker et a. quantified the issue in their recent paper (2004) . They discovered that the consumption of the mental health services was highest in neighbourhoods that had the highest levels of informal social control and lowest in areas of socio-economic deprivation. Given the fact that higher levels of social control tend to be associated with higher degrees of contact, this is further evidence for the need of our hypothetical mental health nurse to be aware of sociological issues.
Some would argue that the nursing profession, as a whole, has long been regarded as a political pawn to be tossed back and forth in the arena of public opinion. To some extent this may well be true and the profession has both benefited and suffered as a result. The internal politics of nursing is equally a minefield. Some would criticise it for being focused on fragmentation and separation rather than striving for alliance formation. Davis (2002) considers the question in great detail going as far as to describe the politics of the nursing profession in general as immature in its views but equally commends it for helping to bring the profession out of the era of political neglect that it had been through in the past. We do not presume to pass comment on the issue as there are clearly two sides to the argument but our hypothetical mental health nurse would be well advised to be politically aware in the current climate within the profession.
Discussion
It is, of course, possible that out hypothetical mental health nurse could have come through their training completely oblivious to the sociological, political and economic factors that are generally considered to be an integral part of the mental health service (and indeed the whole NHS). It is even arguable that they could even function to a degree in complete ignorance of these issues. These areas, however, have become a vital, and ever expanding part of the day-to-day function of virtually every health professional. Ignorance of these areas to any significant degree would mean that their function would, by any analysis, be gravely impaired.
One of the characteristics of a professional worker is the ability to function in an autonomous setting. Our mental health nurse would not be able to function in any meaningful way if they were ignorant of the issues outlined above. Given the fact that hopefully all mental health nurses aspire to behave in a fully professional manner, the issue for debate is not so much how much these elements enhance their role as health professionals, but the degree to which they are essential for it.
References
P. CALLAGHAN, S. EALES, T. COATES & L. BOWERS (2003)
A review of research on the structure, process and outcome of liaison mental health services
Journal of Psychiatric and Mental Health Nursing
Volume 10, Issue 2, Page 155-165, April 2003
P. Chan (2002)
In whose best interests? An examination of the ethics of the UK government's White Paper 'Reforming the Mental Health Act'
Journal of Psychiatric and Mental Health Nursing
Volume 9, Issue 4, Page 399-404, August 2002
Celia Davies (2004)
Political leadership and the politics of nursing
Journal of Nursing Management
Volume 12, Issue 4, Page 235-241, July 2004
Department of Health (2000):
Reforming the Mental Health Act (Cmnd 5016-I-II).
London: HMSO. 2000
Department of Health (1998)
Modernising Mental Health Services: Safe, Sound and Supportive. London: Department of Health: HMSO : 1998
Department of Health (1999a)
Report of the Expert Committee: Review of the Mental Health Act 1983. London:
Department of Health: HMSO: 1999
Department of Health (1999b)
Reform of the Mental Health Act 1983: Proposals for Consultation (Cmnd 4480). London: HMSO: 1999
Department of Health (1999c)
The National Service Framework for Mental Health.
London: Department of Health:1999
Drukker, G. Driessen, L. Krabbendam, J. van Os (2004)
The wider social environment and mental health service use
Acta Psychiatrica Scandinavica
Volume 110, Issue 2, Page 119-129, August 2004
D. EdwardsP. Burnard D. Coyle A. Fothergill B. Hannigan (2000)
Stress and burnout in community mental health nursing: a review of the literature
Journal of Psychiatric and Mental Health Nursing
Volume 7, Issue 1, Page 7-14, February 2000
ADRIAN GROUNDS, (2001)
Reforming the Mental Health Act
The British Journal of Psychiatry (2001) 179: 387-389
S. Johnson, M. Zinkler & S. Priebe (2001)
Mental health service provision in England
Acta Psychiatrica Scandinavica
Volume 104, Issue s410, Page 47-55, December 2001
D Pilgrim, A Rogers (1993)
A Sociology of Mental Health and Illness
Buckingham: Open, 1993
J Pinikahana (2003)
Role of sociology within the nursing enterprise: Some reflections on the unfinished debate
Nursing and Health Sciences
Volume 5, Issue 2, Page 175-180, June 2003
Jennifer Rankin (2004)
Developments and Trends in Mental Health Policy
Working paper one. ippr 2004
J Repper, R Perkins (2003)
Social Inclusion and Recovery a Model for Mental Health Practice
Bailliere Tindall, London, 2003
A Rogers, D Pilgrim - (2001)
Mental Health Policy in Britain
Palgrave, Basingstoke, 2001
Bob Symonds(1998)
The philosophical and sociological context of mental health care legislation
Journal of Advanced Nursing
Volume 27, Issue 5, Page 946-954, May 1998
K. Usher D. Lindsay J. Sellen (2001)
Mental health nurses' PRN psychotropic medication administration practices
Journal of Psychiatric and Mental Health Nursing
Volume 8, Issue 5, Page 383-390, October 2001
