Rita McEwan

A compilation of various documents, texts and citations. 

 

Paths – Patterns In Psychiatric Nursing

1900-1940’s

Attendants (male) nurses employed and assigned to patient care – not only in wards but almost all other hospital services – gardens, laundry, and delivery.
Lectures for male/female staff on weekly basis from medical officers and matrons.
Text books, department rule book ‘Red Book’ published by British Psychological Association published ?1888
No educational requirements for employment or training programs
Examinations – written paper
Oral interviewed by Director Mental Health Department who visited all hospitals and conducted interview and questions. Successful candidates awarded Psychiatric Nurses Medal from Department of Health – usually sent by mail in small box. No ceremony to celebrate the candidate’s passing.

1942 Nurses/Midwives Board established a register for psychiatric nurses
Conditions were required to be met:
The first professional examination required of general nurses was opened to psychiatric nurses. Lectures were to be taken at the nearest general hospital training school
Successful students transferred to general hospital for further 1½ years training and if successful in final examination were admitted to the General Nurses Register.
General nurses were required to undertake a 2-year psychiatric nurses training and were admitted to the psychiatric register.

Major changes, which influenced nurse training, registration and interchanging between general and psychiatric practice:
a) opening of Psychiatric Schools of Nursing
b) closure of general and psychiatric programmes
c) introduction of 4-year comprehensive education programme allowed lectures/experience in psychiatric nursing – early experience variable, not always well planned, poorly supervised but improved as polytechnic graduates mixed with hospital trainees and problems discussed in a reasonable way and the results were pleasing to both sides.

There were some differences and problems on both sides – particularly regarding membership of the PSA – psychiatric nurses had always been members of this association and believed all nurses working in psychiatric hospitals should become members. General nurses on the other hand regarded their membership and allegiance lay with the Registered Nurses Association but eventually both sides concentrated on the objectives of each to the benefit of all.

Eventually the following changes brought about significant changes from ‘Training’ to ‘Education’ as the objective of the nursing programmes:

• the disestablishment of psychiatric and psychopaedic hospitals and training schools took place over a period of time although some services and facilities were required to meet the need for special care. More psychiatric and mental health programmes and staff were retained.
• psychiatric units of various sizes and purposes were established in general hospitals on inpatient and outpatient basis. Clinics were opened which provided easier access to specialist and general psychiatric and mental health services.
• finally Departments of Nursing Education spread to universities where specialised degree programs in mental health and psychiatric nursing became increasingly available.

Why and how did I become a psychiatric nurse and why did I never really want to do anything else?

I think, like a lot of us, did so because we needed a job. I’d gone to Nelson to pick fruit but it wasn’t ready for me so a friend said why don’t you go to the mental hospital – they are advertising for staff – lots of male staff are enlisting for war and there are vacancies.

It seemed a good idea. The hospital provided me with a single room, a uniform and I earned enough to buy a posh Raleigh bicycle – very new, very expensive and the latest thing on the market.

I once cycled from Nelson to Greymouth, train to Christchurch, bike to Waitaki and Oamaru, then back to Nelson.

My first job at the hospital was to clear the Medical Superintendent’s house. I was very put out but the pay and new bicycle kept me at it.

I finished the three-year program when changes began.

Psychiatric nurses were offered a two-year general course and registration in order to be properly trained and professionally registered. By the time I had finished all this at Gisborne Hospital the world of psychiatry was really opening up. Mental health was a universal objective – nationally and internationally – books, papers, conferences national and international were organised in many countries – distinguished lecturers traveled widely – literature, papers, reports were available.

As a participant in this new world of mental health education one had access to the literature, travel, conferences and one could arrive ready with increasing prestige and confidence for a level of practice formerly undreamed of. One in which assistance, support and encouragement together with increasing confidence that with appropriate care patients could be restored to a level of mental health. One began by looking at this person designated a ‘mental patient’ from the moment they were admitted and what a load to carry and restriction this placed on nursing practice and on the patient.

The broadening of ones mind through education in its various forms encouraged me to stay and eventually experience education as a tutor, management as matron in various hospitals and educator through departmental services and travel.

All this kept me in the mental health psychiatric field all my working life – both at home in New Zealand and abroad in the pacific, Europe and Middle East.

The profession kept changing
I kept changing
There was never time to think of doing anything else.

 

Rita McEwan

‘From kindly guardians to true professionals’

Rita McEwan’s story exemplifies the development of Mental Health Nursing in Aotearoa/New Zealand. It resonates with many of us, in that she has been involved as a Nurse during times of great change as have many of us. Beyond this, she has been involved as a leader, promoting Nursing as a discipline and a profession with a clarity of purpose and vision.

Rita became a Trainee Psychiatric Nurse (what a loaded title that is!) at Ngawhatu Hospital, Nelson as a means of making money after a spell of fruit picking. She graduated Registered Psychiatric Nurse in 1943.

In his 'Report on mental hospitals of the Dominions, 1944', The Director General stated:- 'It is essential for the proper training of nursing staff that our Matrons should hold the double general and psychiatric nursing qualification …. many of our nurses are on special leave for general training”. One of ‘our nurses’ was Rita, who graduated Registered General Nurse from Cook Hospital, Gisborne in 1945.

Returning to Ngawhatu, Rita was appointed Tutor (Sister Tutor I suppose), cleaned out the barn for use as a classroom and started teaching. Here she formulated her philosophy; that Nursing should move from “Red Book and the Rule Book” to a reliance on literature, research, reflection and consciousness. This included the substitution of “The Training Record” with an organised curriculum. In short, Rita found her place as the foremost proponent of Mental Health Nursing as a profession in this country.

It is this focus that Rita has brought to all her subsequent positions: in education at Ngawhatu, Oakley and the School of Advanced Nursing Studies. This is the underlying motivation of her work as Assistant Matron (Tokanui), Matron (Kimberley) as Nurse Inspector at the Department of Health and finally (“to return to where I began and where my heart is”) as Principal Nurse at Porirua.

It is this clear focus that persuaded the World Health Organisation to send Rita to establish, advise and monitor Mental Health Nursing education in Singapore, Iran and Egypt. Rita, incidentally, remembers that Iran and Egypt had university based Nursing education in the 1960’s.

Rita also visited Philippines, Fiji, Thailand, Nepal and Indonesia reporting on the adequacy of Mental Health Nursing Education in an international audit.

Furthermore, Rita’s clear sightedness and perception led to her appointment to a variety of Boards and Committees, most notably the Oakley Committee of Inquiry (the Gallen Committee) in 1983.

Finally, Rita’s contribution has been recognised by the award of the MBE in 1981 and as the first recipient of the NZNA Gold Medal of Honour in 1983.

In honouring Rita, we also remember and acknowledge the movement of Mental Health Nurses and Nursing away from the “Procedure Manual” towards an entirely different mode of practice, one which emphasises human independence and dignity and which holds to professional standards and awareness.

Rita’s own comment on her career is that she “was there when the clouds burst and was able to see the possibilities”. She has led us with her clarity of vision and her ability to enthuse those around her. She can tell us about the patient who made her supper before her Senior Mental Health Nursing exam, she can remind us about the advent of psychotropic medications and recall the first time ECT was used in this country.

But most importantly, her work and the honour she accepts from us reminds us that Nursing – Mental Health Nursing – is in our hands and we can develop it and ourselves in a conscious, aware and responsible manner. The future is ours.

Rita has helped us move from “kindly guardians” towards professionalism. Today we thank her.

E te whaea
Tena Koe
Tena Koe
Tena Koe

 

NZ Nurses Association Award of Honour - First Recipient

Citation – Rita McEwan

The first recipient of the New Zealand Nurses’ Association Award of Honour has always striven for excellence in her own nursing practice, and has been unstinting in her efforts and dedication to improve standards of both nursing service and nursing education, particularly in the area of mental health.

After gaining her psychiatric qualification with distinction in 1943, she qualified as a registered general nurse then as a registered maternity nurse. She also holds the Diploma of Nursing from the Post-Graduate School for Nurses (renamed the NZ School of Advanced Nursing Studies in 1970).

Her work experience spans clinical, educational, administrative and advisory positions both in New Zealand and with the World Health Organisation. These include tutorial positions at Ngawhatu and Avondale Mental Hospitals, Auckland (the latter now known as Carrington and Oakley Hospitals); Nurse Instructor, the Principal of the School of Advanced Nursing Studies; service as a World Health Organisation psychiatric nurse educator in Singapore, Iran, Egypt and then as a short term consultant in South East Asia and the Pacific.

She has held administrative positions as Matron of Levin Psychopaedic Hospital and Training School and Tokanui Hospital; Nurse Inspector, Department of Health with special responsibility for psychiatric hospitals; and Principal Nurse of Porirua Hospital until her retirement in 1978.

She was made a Member of the Civil Division of the Most Excellent Order of the British Empire (MBE) in 1981.

In recent years she has been a nurse consultant and member of the Treatment Committee of the Alcoholic Liquor Advisory Council; a selector for Volunteer Services Abroad, and is a trustee of the Bailey Nursing Education Trust. In addition she was appointed a member of the Committee of Inquiry into Procedures at Oakley Hospital in 1982.

Over the years she has contributed much expertise through her membership of many diverse committees of the New Zealand Nurses’ Association and was the Association’s nominee as a psychiatric nurse on the Nurses and Midwives Board.

Her untiring service and significant contribution to the nursing profession, the Association and to health care both at a national and international level make her a most worthy and suitable recipient of the first New Zealand Nurses’ Association Award of Honour.

 

Rita McEwan – keynote speaker

A Personal Perspective

Harae Mai, Naumai

Colleagues and Friends, the last time I spoke in public, or almost the last time I spoke in public, the gentleman chairperson introduced me and said, here’s Rita McEwan to talk to you, now I don’t really need to introduce Rita McEwan because everyone knows who she is. There were two nurses sitting behind me and I heard one say “I don’t know who she is, who is she?” I decided at that point it was high time I retired from Public Service and declined any invitations. It was a perfectly justified comment. However, this invitation was much too tempting and one you couldn’t really expect me to turn down. The opportunity to be with you is very exciting and I thank you very much for asking me to be here. I also, in view of that remark I made to you, am very pleased to see some old friends and familiar faces here amongst the audience. Nurses I have worked with for many years, nurses who have contributed greatly to the Psychiatric Nursing Service. I see Pat Ballie over in the corner and Muriel Dandy and Cath Richardson. And if I’ve missed anyone I should have seen, please forgive me. It is a pleasure to see old friends and familiar faces and I hope too, to meet some of our friends from Tokanui, some of our friends from Porirua, I hope to meet new ones during the next three days.

So, thank you for asking me here.

I’m really impressed with the programme and I don’t wish to share any profound thoughts with you, you’ve got so many interesting speakers that you’re anxious to hear. I thought I might share with you some of the things that happened to me as a nurse, some of the things that shaped my personal philosophy and views.

My introduction to Psychiatric Nursing was a very brief introduction with the medical superintendent on a Friday who said “You can have a job, we’d like you to start on Monday.” Well at that point it was a job I was after, so I took it. On Monday I arrived and the Matron got hold of me and said “Here are some patients you go down to the medical superintendent’s house, he’s gone on holiday. You clear the house and wash the blankets.” As I rapidly had come out of domestic service, I wasn’t too enchanted. My second job was on a ward and the ward sister said “Today you wash the kitchen ceiling.” I ventured to suggest she was mistaken and that she really meant the kitchen walls and she told me “in my ward you wash the walls and the ceiling.” It was a very black day. In the kitchen there was a coal stove. As soon as I took the first wipe of the ceiling, all the soot fell down on me. Again, I think I wondered why I was where I was, but I couldn’t work it out.

Now learning to be a Psychiatric Nurse over these 3 years in which I believe I was in a state of confusion, or not really being able to work out learning to be a psychiatric nurse at that time.

Well, those of you who were with me will remember we had the rule book. And everything you needed to know about Psychiatric Nursing was there. If it wasn’t there you didn’t really need to know it. So you learnt it. In preparation for a final examination you wrote a paper and you had a letter undertaken by the then Director General and they conducted the exams so he came round all the hospitals and conducted the exam. Well I went on to the ward that morning all nice and shining, clean shoes, nice uniform, starched veil to meet the great man and impress him and the ward sister came up and she said “Would you like to wash the walls in the corridor.” And I thought, ‘Oh no not again.’ This time I was brave enough to say, ‘No sister, I wouldn’t’ and then something which I’ve never forgotten happened. A patient who ran the kitchen in that ward and who herself was a registered nurse, who really felt in the three years that I was in that hospital I was a devil, and I remember on night duty she used to throw open the window of the dormitory and call out “God come down and strike McEwan”. That lady that morning bought me out a tea tray with freshly starched cloth, a pot of tea, a jug of hot water and a cup and saucer and hot scones. And I guess she was reliving some of her days, when she was a nurse taking examinations. And that was the difference.

About this time an organisation called the Nurses and Midwives Board decided that a lot of things were happening, that it was seen opportune to make Psychiatric Nurses respectable. And we were offered the opportunity of being admitted to the register undertaking the state preliminary examination and being granted a 15 month concession in a general nurse programme. Now it was Muriel Dandy who fronted up to the medical superintendent and did a deal with him on behalf of herself and myself that we would like to do this. And he said “Well what do you want to do that for?” Perhaps, if you can get 6 nurses. And 6 of us started to do this state preliminary examination. I can remember cycling 7 miles into the Hospital to take a lecture. But only 2 of us ever finished and that was Muriel Dandy and myself.

Then we went off to Gisborne Hospital to learn to be ‘Proper’ nurses. I think we were the first two psychiatric nurses to be seen on the premises and we got some very old fashioned looks for the first 3 months, but gradually we were accepted into the Nursing Profession.

Then it was back to psychiatric nursing, wait for it, back to my cleaning jobs. The medical superintendent said “Rita, you can be the tutor.” That’s the way appointments were made in those days. I said “I’ve just come back as a proper nurse and all I want to do is nurse.” He said “You can be that, now there’s an old house on the hill full of hay bales, if you’d like to clean it out …” So we had school out under the trees and cleaned it all out, and then it all started.

It was about this time that a great deal more literature began to appear. A few books, some journals, some papers and gradually this trickle became a stream and this stream became a flood almost. Out of a whole range of new ideas, new theories, some of it written by nurses, some of it by other professionals, but there was this wonderfully exciting stream of literature. The views were held of how to nurse a state called mental health and that we ought to be aspiring towards this and helping patients to aspire toward the level of mental health which they thought possible. It was seen that nursing could help people in this process of aspiring to be in a better state of health.

Psychiatric nursing itself was defined as a human experience, a process. For me at this point a light went on. I felt inside “I think I’m beginning to know what this is about.” And all that follows flowed from that moment. I think when you have that moment, it never really leaves you. It never really goes away and it remains the source and the strength that illuminates our practice. When I left education and I moved to administration, here I learnt that if I stood still and really listened to the people that I really cared about and cared for there was a great deal more that I needed to learn and could learn from them. Now for me this happened in psychopaedic nursing strangely enough I arrived at Kimberley as a very reluctant matron on a cold bleak horrible day and Kimberley looked most unattractive. This lady met me and said, “Oh are you McEwan, there’s not much of you is there?” I said, “There’s been enough up till now.” Well she supervised me for a week and left me with much misgivings and her last words to me were ‘McEwan, take that look off your face the children know what you’re thinking, now pick them up and touch them.’ There was no way at that point, that I could do it.

One day a ward sister came to me and she said “Will you come to Johnny’s birthday party?” And this was a little grossly deformed child, couldn’t walk, could make himself understood, but couldn’t really talk, very handicapped. He was always around tugging at my uniform, so I went to his birthday party. All his friends were gathered at the table with jellies and cakes and candles and at his place at the top of there was a pile of parcels. He went straight to that pile of parcels and didn’t open one of them. He just took them and gave one to each child. Well, this still breaks me up, it nearly broke me up and my learning curve went up just like that. It was a pretty shattering experience for clever me. Another time I was in a situation where a group of women were taken on a holiday, first time out of the hospital for years. Taken to a holiday house, from a back ward, women who had been in hospital most of their lives for many many years and someone had the inspiration to take some of these women on holiday. Amongst them was a lady who was known to be mute withdrawn, uncommunicative chronically psychotic …, all labels. And one of the nurses said to her one day “How have you managed all these years?” And she looked at the nurse and said “Don’t worry dear, I have a very rich inner life.” Well we nearly all fell apart at that one because about this we knew nothing. We were busy caring for people and knew nothing.

My 10 years experience in Singapore, Iran and Egypt in a variety of roles, mostly as nurse educator really just confirmed the truths and consolidated my own personal perspective of philosophy of psychiatric nursing. Here I was in a strange, strange land, particularly in the Middle East, with thousands of years of history and the new religion where the past echoes today, but tomorrow was in God’s hands. And you couldn’t really shake tomorrow because of Allah. God’s will – he would do it, if not, it wouldn’t happen. The new language, new customs, all very strange. Set up a school of nursing and here was a hospital that really was, well, I can’t begin to describe it. Three thousand patients, no nurses, or few nurses, until we began some training programme, no resources, no facilities, little water, poor food, dirt, different attitudes, where do you start? Well, we started by going to a bazaar and we bought cotton and cloth and soap and shampoo and those Eastern ladies just adore to make themselves up and we bought make-up, mirrors, combs, lipsticks, rouge. And we went back and we sat on the ground where the women were huddled in corners and gradually hands reached out for cotton and cloth to embroider and we made a curtain. For the first time in years they saw themselves, enjoyed themselves and laughed.

No curses, no discharges, just human beings reaching out to other human beings in a way which eased a lot of pain. Back in New Zealand I had a strong feeling when I was appointed to the School of Advanced Nursing Studies, which I loved, I was going to retire in three or four years and I really wanted to close the circle of my experience by coming back to Psychiatric Nursing. Everyone thought I was mad, I thought I was mad. How was I going to go back? A vacancy appeared at Porirua Hospital for the first appointment of Principal Nurse. A voice in the back of my head said “Rita, this is you, go for it.” It wasn’t the easiest job I ever had, but “I’m glad I had the nerve to do it. It was there that I found a lot of things that had been going on in New Zealand while I was away, and it gave me great joy to work with so many nurses who I see here today and so many other professionals who are better prepared, more skilled, more innovative, more daring, brighter, more ready and willing, more willing to extend themselves in all sorts of directions, to extend their education, develop new services, to try them out until they get some where they wanted to be, and to branch out into many areas of specialisation which many of you have done, and I’m dying to hear about it. I was impressed with what was being done in practice, in the main, and in the curriculum development and I was envious I had missed out on a lot of this. The contribution you all made with all your talents, with all your strengths and abilities is going to ensure that you’re going to leave psychiatric nursing in a much better state than you found it, and I have a personal belief that’s the most one can do for one’s profession to ensure its growth, to make sure the students and people you work with are going to know a lot more than you know and going to be a lot better than you are because of the influence that you bring. Make sure that through your strength, vigilance, advocacy that the sad and shattering events from Oakley and Carrington never happen again in this country. If you truly represent what you say psychiatric nursing stands for, then stand up, stand tall and speak out on behalf of those who are under siege and crying out for care. Do that will you.

 

 

WORLD HEALTH ORGANISATION ORGANISATION MONDALE DE LA SANTE
REGIONAL OFFICE BUREAU REGIONAL
FOR THE EASTERN MEDITERRANEAN POUR LA MEDITERRANEAN ORIENTALE

GROUP MEETING ON MENTAL HEALTH EM/GR.MT.MH./10

Alexandria, 4 – 7 September 1972 (English Only)

The Training of Mental Health Nurses

By

Dr S Salama¹ and Miss R McEwan²

The title of this paper implies nurse participation in services of a preventative and community nature as well as in hospital function. This is in conformity with current mental health and psychiatric care concepts.

It is expected that a person admitted to hospital will sooner or later leave its protection and adapt himself to his particular society. Traditional, specialized or general hospitalization seems to separate the individual from the community for too long a period of time with subsequent serious diminution of his social and work skills. One of the basic tenets of present day psychiatric practice is that preparation of the patient for eventual confrontation with the demands of his society begins at the time of admission. The preservation of the patients’ skills and abilities is part of the responsibility of all members of the psychiatric team but the nurse, because she is the most constant member of the team in contact with the patient, can make a special contribution if she has appropriate education and support.

Prolonged stay in hospital is expensive from the point of view of the national economy and the best utilization of hospital beds and a major trend in psychiatry is towards the promotion of mental health and prevention or early detection of mental illness by providing community services such as clinics, out-patients departments, mental health centres and the attachment of psychiatric units to general health services and departments. The psychiatric hospital continues to fulfil its major role as a curative and rehabilitation centre albeit providing sheltered residence and care for long stay patients, for those who come under special clauses within the framework of Mental Health Acts or legislation and those who because of the nature of their disorder or handicap are unable to participate in or contribute to, ordinary community life. Many psychiatric hospitals have been successful in raising the standard of care from custodial and punitive to therapeutic and rehabilitative and this change is of considerable importance and significance to the whole mental health movement. These developments however have been dependent upon the supply of re-oriented professional, administrative and auxiliary staff who are committed to a dynamic approach to psychiatry. It has been stimulating to doctors and nurses to participate in a service of a comprehensive nature and to move freely from one area of service to another.

Today in the Arab Republic of Egypt there is a planned movement in the Ministry of Public Health towards the construction of additional psychiatric residential and non-residential facilities including the allocation of beds for psychiatric use in general hospitals. One of the major problems is how to provide appropriately trained nursing staff.

In considering the nursing needs of the area under discussion it is uneconomical and impractical to introduce a completely new class of nurse. The demand already exceeds the supply; training is expensive; books, equipment, and buildings have to be provided. For nurses working in psychiatry the value of specialized training is obvious but from the point of view of preventive work there is every advantage in introducing basic principles of mental health and psychiatric nursing in the curriculum of the generally prepared nurse. It is the belief of the writers that by doing so nurses already engaged in public health, maternal and child health as well as those in non-psychiatric and psychiatric department of general hospitals can add a new dimension to their work and function affectively in the area of mental health. Much of the reluctance to serve in psychiatric field stems from its isolation from the main stream of professional education and practice both in medicine and nursing. It is hoped that psychiatric nursing will then be seen to be a part of nursing – not something apart.

Nursing education programmes should be designed to make the best possible use of existing nursing staff while at the same time providing opportunities for special preparation for those who will hold key positions in psychiatric nursing service and education. Versatility is important if the most economical use is to be made of nursing manpower resources in a developing and comprehensive health service designed to provide the highest possible standards of care to the nation. With these objectives in mind it is believed that the country and the people can best be served if the training of mental health and psychiatric nurses is undertaken in the following way.

Phase One: The establishment of a Department of Psychiatric Nursing Education
In order to assist the Ministry of Public Health in the achievement of its objectives and taking into account national resources and economic factors of time, money and personnel the writers propose the establishment of a department of psychiatric nursing education within a state psychiatric hospital setting where a wide range of clinical experience could be offered. The department would be staffed by psychiatric nurse educators and clinical instructors. It would be independent of demands for nursing service. It would be responsible for:

- teaching psychiatric nursing to basic students from three year diploma
programmes who come to the hospital for clinical experience in psychiatric
nursing;
- all nursing educational activities connected with the hospital e.g. in-service
and continuing education programmes for existing staff and those in key
positions in non - psychiatric areas.

The requirements would be:
- the agreement of the Minister of Public Health and the Hospital Administration;
- the allocation of a budget sufficient to meet educational needs and employment of staff;
- the agreement of Ministry and hospital authorities to provide and maintain at
approved clinical standards, units or sections within the hospital for educational
purposes e.g. outpatients department, admission, short and long stay sections.

Phase 2: Preparation of Nurse Educators and Instructors
The selection of graduates from University and Diploma Schools of Nursing for preparation as teachers and clinical instructors is the next step to be considered. Nurses selected to teach should have completed :

(a) a programme of basic nursing education (at University level);
(b) specialization in psychiatric nursing;
(c) preparation for teaching.

Graduates from the University School who have both theoretical and clinical psychiatric nursing in their undergraduate programme should be selected and sent for additional clinical experience in psychiatric nursing and preparation as teachers. Courses which would meet these needs are available in the United Kingdom. On return these nurses would:

- provide staff for the department of psychiatric nursing education
- advise and approve appropriate clinical areas for psychiatric nursing experience and practice.
- teach mental health and psychiatric nursing in basic programmes.
- develop and teach in post basic and in-service education programmes conducted by the department.

Graduates from post diploma psychiatric nursing course offered at Kasr el Eini Hospital should be offered the opportunity for extended clinical experience and preparation in psychiatric nursing at Asfuriyeh Hospital, Lebanon. On return these nurses would be attached to the department of psychiatric nursing education and employed as clinical instructors. They would be responsible for:

- clinical teaching of basic three-year diploma students during their clinical psychiatric experience;
- clinical teaching of students undertaking in-service education experience.

It is essential to point out that clinical requirements for experience in psychiatric nursing in existing curricula is minimal or has been neglected because of the lack of properly prepared clinical instructors. Any programme designed to prepare mental health nurses must ensure that students have opportunities to work with patients under supervision.

Phase Three: Development of In-Service Education Programmes
In-service education is the process of growing or learning while “in-service” or on the job, it is the responsibility of the employing agency to provide opportunities for such growth and development, to keep their staff aware of current trends in nursing education and nursing service and to furnish opportunities for leadership training³.

Mary Sewell, “An Overview of In-service Education, The Canadian Nurse LVIII, May 1962, p.413

Mary Sewell, “An Overview of In-service Education, The Canadian Nurse LVIII, May 1962, p.413

( ³ Mary Sewell, “An Overview of In-service Education, The Canadian Nurse LVIII, May 1962, p.413)

The fundamental need for continuing education is readily recognized in a dynamic society. In professional work where knowledge is accumulating rapidly it is a vital necessity if clients are to be offered the best standard of service and care of which the profession is capable.

³Mary Sewell, “An Overview of In-service Education, The Canadian Nurse LVIII, May 1962, p.413

The purpose of the proposed in-service education programme would be to:

- improve the nursing care offered to persons who are emotionally ill;
- extend such care to the community through a variety of service in which nurses are employed;
- provide nursing staff who can assist in the early detection of mental ill health and in curative and rehabilitation services.

The programmes would be the responsibility of the staff of the psychiatric nursing education department attached to the psychiatric hospital as outlined above.

Nurses who are presently employed in psychiatric nursing service appear to be mainly occupied in the management and administrative aspects of nursing. Therapeutic contact with individuals or groups of patients is minimal. Diploma students and graduates are not required to undertake patient assignment nor do they have clinical practice under supervision. They lack an appreciation of basic principles of psychiatric nursing and the application of these principles in a nursing situation. At the present time with the exception of undergraduate students psychiatric nursing is taught by already overburdened medical staff. If nurses in psychiatric services could be taught by a qualified nurse educator to work with patients and to help them in building constructive personal relationships one of the major objectives of treatment would be ensured. Nurses working in clinical settings other than psychiatry should also be offered in-service courses in mental health and psychiatric nursing. A guide to in-service education is attached as Appendix I.

Phase Four: Development of Basic Nursing Curricula
The psychiatric content of the three year Diploma and one year post diploma course in psychiatric nursing was examined by the writers. It is suggested that nurse educators at Ministry and University level together with psychiatric nursing educators form a group for the express purpose of developing the mental health and psychiatric nursing content of basic two and three year nursing programmes and to ensure that clinical, experience in psychiatric nursing is part of the requirement.

Studies of particular value to all nurses lie in the areas of:

- communications and interpersonal relationships;
- group dynamics and function;
- human growth and personality development;
- patterns of behaviour in health and illness;
- basic principles of psychiatric nursing;
- therapies which require nursing participation, social, psychological, physical, chemotherapeutic.

These proposals are submitted for discussion and consideration in the belief that they offer a reasonable, logical, practical, economic and effective way to prepare mental health and psychiatric nurses to work in the services envisaged by the Ministry of Public Health and to develop in nurses a new awareness of their responsibility to offer comprehensive nursing service to people with health problems.

Work in psychiatric medicine and nursing has been largely unpopular for reasons which are well documented and known. It is noted however, that it is possible to attract and retain nurses of the right calibre in this field if they are offered the opportunity to prepare themselves, reasonable working conditions, incentives and rewards.

 

Appendix 1

A Guide To The Development Of In-Service Education In
Psychiatric Nursing

I Objectives

- to develop an effective orientation programme for personnel of the nursing department;
- to provide an environment conducive to learning, to increase skills and improve work satisfaction;
- to motivate staff members towards self development;
- to promote effective relationships with all groups within the hospital;
- to understand, participate in and support all research and studies in nursing and allied fields;
- to assist each member of the nursing staff to:

(a) improve his ability to establish constructive relationships with patients and their families and with co-workers;
(b) increase his knowledge and understanding of scientific principles basic to intelligent nursing care and to gain increased skills in the use of techniques in care and treatment of the patients;
(c) utilize for his own growth the knowledge and resources available from educational programmes and professional groups in the hospital and community.

II Principles

- the environment should help participants to develop self discipline, intelligent curiosity and the ability to think clearly and to acquire the knowledge necessary for practice of nursing;
- the programme should be flexible enough to add or omit material according to the needs of the participants;
- instructors should value the experience which the participants bring to the programme and consider this in their teaching;
- participants should share in planning the programme and feel part of it;
- the objectives should take into account the needs of the agencies in which the nurses are employed;
- the programme should be educationally sound and based on principles of learning;
- the participants should be treated as adult learners;
- the nurse instructors must have the proper preparation, attitudes, skills and enthusiasm to motivate and stimulate participants to learn;
- the emphasis should be directed to the care of the individual as a total being: both his physical and psychological well-being must be considered;
- practical experience should be emphasized and provided concurrently with theory;
- seminars and open discussions should be encouraged and a free exchange of ideas, opinions and experience stimulated;
- self evaluation should be encouraged and personal examination of individuals’ needs ensured;
- evaluation should be continuous and communicated to the participants;
- doctors and others contributing to the programme or in the health agencies where the nurses are employed should be made familiar with the new role of the nurse after she has received her in-service preparation in mental health and psychiatric nursing.

III Content

- social anthropology of the Egyptian community, and its implication for nursing service;
- inter-personal relationships with emphasis on the recognition of personal needs and the needs of others;
- psychiatric nursing theory and practice with emphasis on:
(a) the psychological needs of healthy individuals;
(b) the psychological needs of healthy individuals during crisis situations;
(c) the psychological needs of psychiatric patients:
- physical and psychological origins of physical and mental disorders and the relationship between the two.

References

Hamn, Betty H., Hartsfield, Sandra L., - Motivation Influencing Students in Psychiatric Nursing – Nursing Research, 19:1, January – February 1970.
Ministry of Public Health, Arab Republic of Egypt – Curriculum of three year diploma students.
Parker, Annie R., - In-service Education – Busy Work or Basic Need?
American Journal of Nursing, 68:11, November, 1968, p. 2404 – 7.
Topalsi, Mary, - Selecting Appropriate Health and Psychiatric Nursing Content for Associate Degree Nursing Programmes – The Journal of Nursing Education, 9:3, August, 1970,
p. 19 – 25.
University of Cairo, Kasr el Eini Hospital – Curriculum of One Year post Diploma Psychiatric Nursing Course.
Walsh, Joan E., - Teaching Psychiatric Nursing in Diploma and Associate – Degree Programmes – Nursing Outlook, 15:6, June, 1967, p. 30 – 35.
World Health Organization, Technical Report Series No.105 – Expert Committee on Psychiatric Nursing, First Report, Geneva, 1956.
World Health Organization, Technical Report Series No.347 – Expert Committee on Nursing, Fifth Report, Geneva, 1966.
Unpublished Material
Salama, Samira I., - A Study of a Day Treatment Programme – Unpublished Master Thesis, Boston University, 1965.
Salama Samira I., - A Guide for and In Service Programme for Community Nursing in Egypt – Unpublished Doctoral Thesis, Boston University, 1968.

 

 

Mental Health – The Pivot Of Human
Relationships

by

Nassereh A Roboobi SRN, SCM, BSc
Consultant in Mental Health and Psychiatric
Nursing, Chief Registration and Legislation,
Nursing Division, Ministry of Health,
Teheran, Iran.

and

Rita McEwan RN, RPN, RMN, Dip of
Nursing (NZ), WHO Psychiatric Nurse Educator,
Teheran, Iran.

---------------------------------

In this paper we propose to look at the forces and factors which enable man to live and work in harmony with himself and his fellows and to consider their relevance to the nursing situation.

The responsibility of those of us whose concern is good administration, good education and good practice in nursing is to create a climate which will permit a person to develop his talents and potentialities and make a satisfying and useful contribution to the society in which he lives and works. Consideration has to be given to the provision of proper materials and equipment but more important is the climate in which a person works and learns. The problem of creating such a climate is largely one of understanding human needs and accepting the importance of mental health to human well-being, efficiency and happiness.

What then are the forces and factors and the basic principles of mental health which we believe to be effective in human relationships? Are they tangible or intangible? Can they be identified and analysed? Are they innate or acquired? If our work is to be successful, our patients well cared for and we are to help others assume positions of responsibility then we have an obligation to be clear thinking and well informed about such matters and to demonstrate in our behaviour and relationships our belief in their validity.

We are not alone in our search for the key to such problems. In all walks of life, in families, organizations, institutions, places of work and in the high councils of nations man is continually seeking better understanding of his fellows and ways which will lead to peaceful and cooperative living. Human behaviour, its mysteries and complexities, have occupied the greatest minds of the ages and been expressed in the drama, painting, poetry and prose throughout the centuries.

One of the great debts we owe to Freud is that he was not merely content to describe human behaviour but went a long way towards explaining it. He forced us to an acceptance of the reality of the unconscious and an awareness that human behaviour is largely unconsciously motivated towards the satisfaction of needs and is thus, in all its infinite variety, purposeful and goal seeking. Human personality and behaviour is now subject to scientific study and research and there is an enormous body of knowledge on which we can draw for help and guidance. Success in human relationships is not a matter of luck or chance and there is ample evidence to support the view that the person who is successful demonstrates in his behaviour the positive attributes of mental health.

What are these attributes and what is mental health? Definitions of these terms are as numerous as there are writers on the subjects. The words mean only what the writer intends them to mean. ⁴Jahoda expresses this view “A definition in itself solves no problems and does not add to knowledge. All that can be expected of it is that it may be useful. Definitions often contain implicit personal or general philosophies. They often specify how human beings ought to be and carry moral or Utopian overtones.” Certain aspects of thought, feeling and behaviour can however, be identified as characteristic of mental health. A person who best helps another to a feeling of security and worth is one who is aware of his own needs and recognises these in others, he has the capacity to be himself and to reveal himself to others without fear, pretense or duplicity; he can recognise and tolerate his weaknesses and is aware of and has respect for his strengths and abilities; he can deal with the anxieties and tensions of everyday life without resort to psychotic or neurotic behaviour and finds his commitment to and involvement with people an enriching and maturing experience. Other personal attributes – status, skills, knowledge, intelligence or education may evoke admiration and respect but they alone do not make for harmonious relationships. The pivot is the person’s capacity to function and use his attributes in a mentally healthy, creative and satisfying way.

Fundamental to good relationships is the recognition and understanding of basic human needs. Human relationships fail and misunderstanding, tension and conflicts arise if basic human needs are not met, whether these be physical, psychological or social, with the result that behaviour is characterised by a lessening of personal and social confidence, inconsistency in reactions and less sense of purpose and direction in life. ⁵Jourard points to one of the major barriers in human relationships. This is the confusion in our minds between role relationships and interpersonal relationships. There tends to be a preoccupation with professional roles which to many spell security, safety and act as a shield of righteousness.

There are many social pressures on nurses which reinforce the playing roles. Expectations, the public image of the nurse – for which we ourselves are largely to blame – sentiment and sentimentality, idealized and romantic ideas about nurses and nursing. In the fact of all pressures it is difficult to be oneself and to infuse into ones work those personal qualities without which we cannot truly be nurses but only play at nursing.

In administration the responsibility is twofold. One is the efficiency of the work and the other the well-being of the people at work. There are few problems in relation to the efficiency of the work. The majority of people with whom we have to deal are trained, experienced and professionally competent – in other words they know their work. The matter of concern is that too much time and attention is devoted to the technical and organisational aspects of the work and too little to the people. Many of us are preoccupied with the order of things, with routine, order and discipline and the working out of schemes on paper, organisation charts and curricula. It is not suggested that routine, order and discipline are out of place in nursing or indeed out of place in our lives. What is suggested is that these factors are not at all incompatible with the satisfaction of a person’s needs and with creative nursing. It may be that our knowledge of how to get work done well is too vague or that we do not consciously make the best of what we know. Or we know and are conscious but our learning has been such that we are unable or afraid to apply what we know in our relationships with people. We have accepted the theory but are unwilling to put it to the test. As a result we are often puzzled and disturbed as to why, when so much time and thought and energy is devoted to organisation and planning, the outcome should fall so far short of our hopes and expectations. If one realistically thinks about the problems with which we are daily confronted in nursing far and away the large percentage are human problems and not problems with work.
Believing that mental health is the pivot of human relationships how can the principles, if applied and used in a positive way, contribute to the achievement of our goals? First comes the consideration of basic human needs. People need to know that they are regarded and respected as individuals; that they are accepted into the group; that they are loved and approved and that the environment in which they work is essentially under democratic leadership. In addition to the above they will have particular and special needs related to their professional situation. The needs of peers and colleagues will differ from the needs of students and other allied workers, but all will look to the leader for satisfaction of these needs. There is no magic or set prescription for resolving these problems. Human beings vary in many aspects of their behaviour and their reactions often appear illogical, inconsistent, unpredictable and unreasonable. The leader is not expected to be a paragon of all the virtues but she is expected to be human and understanding, to be aware of her commitments and to be able, at least in part, to meet these needs. Under what type of leadership do groups function best? Authoritarian? Democratic? Laissez-faire? Primarily it will depend on the type, aims and function of the group but generally speaking groups function best under democratic leaderships. Such groups expect and accept the authoritarian role which the leader must assume at certain points but in such groups they feel free to express their feelings and opinions.

In education for nursing similar consideration needs to be given to the basic principles of mental health and human relationships. If education is a process which frees the mind and one by which we help a person to learn then the communication and relationship between those who teach and those who are taught is of special significance and importance, for not only must we teach the skills required in nursing but try to develop attitudes, ideas and philosophy which will fit the student for a nursing way of life. Are these principles really incorporated into our teaching practice or are we satisfied with teaching a certain number of hours as specified in the curriculum? We are dealing with students with a range of capacities and abilities. The majority of them come to nursing with a strong desire to help people. Too often their introduction is not the people whom they have come to help but to a skeleton, an empty bed or inanimate doll. After a certain amount of practice on these “things” the student is considered ready to take her place at the bedside where she finds that patients are not so conforming or cooperative as the objects on which she has been practicing and that they show reactions which are not always favourable to her and with which she is not usually able to cope. The inclusion of the social sciences in the curriculum was an attempt to increase the nurses knowledge of people, of human growth and development, of personality and behaviour and so to help her to develop skills in human relationships and the ability to be of real help to those who are distressed. Current nursing and research literature indicates all to clearly that we have not nearly achieved this state.

In many areas the teaching in mental health, psychology, sociology and psychiatry leaves a lot to be desired. Some have taught them as subjects and failed to see the relationship between the physical and social sciences. Others have confused mental health and psychology with ethics and etiquette in a “be kind to patients” philosophy. Many consider the subjects to be relevant only to psychiatric illness and disorders while others regard them as a burdensome addition to an already heavy teaching load. Frequently they are included only after other requirements of the curriculum have been met and too often come towards the end of the training period when the student is assuming more responsibility for organisation and management and less for direct patient care. In some cases they are dealt with at a very elementary level and considered fit for serious study only when the nurse takes up post graduate work.

If we seriously believe that interpersonal relationships are an important part of nursing then surely these studies should form the students introduction to nursing and be woven into the whole fabric of her education and related, integrated and applied to all areas of theory and practice. We have taken upon ourselves the responsibility for total patient care. We express concern for the patient’s physical, psychological and social well being. This is an awesome responsibility and we should seriously consider whether we are in fact adequately equipped to undertake it. Goethe’s phrase “there is nothing more frightful than ignorance in action” might well give us cause for thought. Are we competent to read, interpret and understand behaviour with the same skills and efficiency that we read, interpret and understand changes in biological functions? Are we able to transfer our skills from the physical to the psychological field with ease and confidence? If not, in what ways can we redesign service, education and field practice in nursing to bring about the desired changes?

A frank and critical appraisal of curriculum content and methods of teaching is undoubtedly overdue and necessary and a reassessment and evaluation of field practice as part of the education of the nurse. The acceptance of mental health as the pivot of human relationships and a conscious effort to cultivate and maintain good relationships with all members of the health team is vital if our concern for the patient is to be manifest to him. The patterns of interaction between doctors, nurses and patients are not different from those between other people except in one respect. With sick people deeper emotions are involved than is apparent in the ordinary contacts of everyday life. The interplay between the nurse and her patients can be very disturbing to both if the nurse does not understand these deeper forces and how to deal with the situation. She needs to be helped to know more than that the patient is anxious, worried and upset about his illness. She needs to bring to her care an appreciation of what illness means to a person in his ongoing process of living, not just an isolated, painful incident in his life. An educational experience and studies which are designed to increase the nurses perception and develop her sensitivity to peoples needs should give us nurses who can work successfully with people and for people.

If the practice field provides opportunities for learning and is considered part of nursing education the questions to be considered are – what can the student learn? how best can learning take place? what has to be unlearned? and what relevance should this experience have to her professional and personal development? Clinical practice in the psychiatric field is probably one of the most difficult to arrange satisfactorily. Students are often apprehensive, instructors uncertain, the change is too dramatic, the environment so different. Yet it is vital in the education of the nurse and often remains one of the most vivid of her memories. Here she can learn the uncommunicative, the withdrawn, the attention seeking, the over active, the regressed, the hostile and aggressive patterns of behaviour need to be understood in terms of the degree to which they are part of the emotional component of illness and an expression of human needs. She can observe in the mentally ill their inability to form warm relationships with others and so come to recognise the positive attributes of mental health. She may acquire that most difficult of human qualities – the ability to listen and refrain from giving advice. She should learn the benefits to patients of calm, quiet, acceptance and tolerance. She will learn the disruptive effect which mental illness has on family life, the community and the national economy and thus the importance of preventative work by nurses in the fields of public health, obstetric and paediatrics. She should learn to be dissatisfied with a nursing service which neglects to give care to those who occupy the majority of hospital beds in most countries of the world.

Learning in mental health and human relationships can best be made meaningful through the students’ affiliation to a psychiatric hospital. She will learn best if what has been taught is seen to have meaning and if the subjects have formed part of her orientation to nursing and made a continuous study and related and integrated to the total content of the curriculum. The skills required are difficult to describe verbally and it is recognised that factual information, that is telling a person, does not of itself markedly affect undesirable attitudes or prejudice. Exposure to studies and actual experience, if well planned and supervised may lead to some modification of stereotyped ideas so that the student is less likely to allow former beliefs to influence her so strongly and more likely to bring the forces of reason to bear in terms of acceptance, tolerance and understanding of people and their behaviour. Watching and working closely with experienced psychiatric personnel, having time to spend with patients as individuals or in groups, observing, recording and discussing are infinitely more satisfying ways of learning. During this experience a great deal of “unlearning” will undoubtedly take place.

Prejudice, bias and rigid concepts about psychiatric hospitals and patients will be modified. Pessimism regarding cases, treatments and prognosis of mental illness give way to optimism; curiosity about behaviour changed to concern for recovery. The student may have to abandon her idealized concept of herself in relation to a sick person for here in a psychiatric hospital, the patients are no longer conveniently trapped in neat white beds but are vocal, mobile and freely expressing their feelings. The bedside manner which has been her prop in former situations will no longer serve her and she will find self involvement essential.

What relevance has all this to the nurse’s professional and personal development? The basic principles of mental health once learnt, experienced and accepted as part of ones working philosophy are applicable in all situations whether of health or illness, in education, administration and practice. They are particularly so when one person is in a position to give help and guidance and others are dependent upon it. It has relevance since in all fields of human activity and endeavour we are striving for efficiency in work, the well-being of people at work and for personal satisfaction and happiness.

In nursing a fragmented approach to learning results in fragmented patient care. If we are committed to meeting the whole needs of the patient then it follows that both learning and practice must provide a whole and not a fragmented experience. Only and only in this way can the nurse learn to know and accept herself and therefore be a better nurse. Not until there is real integration of mental health principles will nurses really give patients the care to which they are entitled and provide for them the understanding, support and encouragement which will restore them to health with hope and confidence.

 

Bibliography

Jahoda, Marie Current Concepts of Positive Mental Health
New York Basic Books, 1958

Jahoda, Marie Race Relations and Mental Health
UNESCO

Jourard, Sydney M The Transparent Self
D Van Nostrand Company, Inc.,
Princeton, New Jersey, 1934

 

 ¹ Lecturer in Psychiatric Nursing, High Institute of Nursing, Cairo University

² WHO Psychiatric Nurse Educator, High Institute of Nursing, Cairo University

³Mary Sewell, “An Overview of In-service Education, The Canadian Nurse LVIII, May 1962, p.413

⁴Marie Jahoda – Current Concepts of Positive Mental Health – New York Basic Books 1958

⁵Sydney M Jourard – The Transparent Self – D Van Nostrand Company, Inc, Princeton, New Jersey.