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inpatient care, the anxiety in this case being provoked by the psychic pain and fragmentation of the acutely
mentally ill person.
This concern and awareness converged with new developments in the organisation of nursing care in the US:
nursing models, the nursing process and primary nursing. The order in which these arrived in the UK, and their
penetration of psychiatric nursing practice, has varied over time and across the country. However it would be
fair to say that the nursing process was the first and most influential of these developments. It was a method of
nursing work that sought to systematise and improve practice through the implementation of a cyclical process
of assessment of patients’ needs, planning care, implementing that care, and evaluating it. Early nursing
research in the UK did demonstrate that when the nursing process was implemented, the quality and continuity
of care improved. It was eventually universally used in nursing, forming part of the move towards individualised
care (McFarlane & Castledine 1982). The nursing process continues in use today, shaping the documentation
and practice of in-patient psychiatric nursing, although the degree to which it has been successful, or as
successful as it could be, remains open to question. Amongst community psychiatric nurses, the nursing process
has been subsumed within the care programme approach, which is a multidisciplinary commitment to a shared
care plan.
Nursing models (Meleis 1985) flowed out of a pre-occupation with trying to define what nursing was, and what
made it distinct from the activities of other healthcare occupations. Such theorising was associated with the
move of nursing education into the University sector and the initiation of degree and higher level degree courses
in nursing, coupled with aspirations towards a higher professional status. A multitude of such nursing models
were produced, nearly all of which were based upon general nursing practice, with the intention that such
models could shape nursing curricula as well as the practice of nursing – particularly the assessments and care
plans being formulated through the use of the nursing process. Some of these models, particularly that of Peplau
previous mentioned, were imported and applied to psychiatric nursing in the UK, again emphasising the
interpersonal nature of psychiatric nursing and individualised care. Models reached the height of their influence
in the 1980s, but are now mostly absent from both education and the practice of mental health nurses in the UK,
with the exception of the Tidal Model which will be discussed further below. It has been argued elsewhere that
any such models have to start from what psychiatric nurses actually do and contribute to acute inpatient care if
they are to remain influential, rather than seek to arbitrarily redefine nursing work as something else (Bowers
2005).
Primary Nursing was the last of the great US nursing innovations to jump the Atlantic. Associated with the
name of Marie Manthey (Manthey 1980), primary nursing was a way of organising the nursing team across
shifts so that one qualified nurse was always in charge of the care of a fixed number of patients, whether the
nurse was present or not. That nurse carri ed out the nursing assessment, drew up the nursing care plan, reviewed
and evaluated that care, and was responsible for interdisciplinary liaison and communication with the patient’s
family. When the primary nurse was not on duty, other nurses (who were primary nurses for other patients)
acted as associate nurses and delivered the care as prescribed by the primary nurse. This organisation gave the
primary nurses considerable autonomy and responsibility, and again enhanced individualised care and
strengthened the nurse-patient relationship. Only a small number of wards in psychiatry made a thorough
implementation of primary nursing (Bowers 1987;Bowers 1989;Ritter 1985), but reports were generally
positive. Before any more widespread implementation could occur, the UK government mandated that every
patient should have a ‘named nurse’ (Department of Health 1991). Such allocations were carried out and remain
so today, however the specific responsibilities of the ‘named nurse’ were not defined by policy, thus the role
became titular and the opportunities presented by primary nursing proper were lost.
Sadly, none of these three innovations was specifically elaborated for how individualised care was to be
delivered to acutely psychotic patients, or how a nurse-patient relationship was to be built up across the divide
of cognitive deterioration, suspicion, delusional beliefs and sometime coercive treatment. So although they
thrust nurses into such relationships, they were left to devise on an ad hoc, learn by experience basis, how to
actually do it.
Outside the mainstream: Laing, Berke, Mosher and Barker
Arising out of the phenomenological and existential philosophies of the 1950s and 60s, coupled with general
systems theory, Laing argued that psychoses were the product of dysfunctional family communication and
upbringing and represented and sane response to an insane society. Leaving mainstream psychiatry, Laing set up
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