Community psychiatric nursing explained: an analysis of the views of parents, carers and nurses

This study examines the work of two community psychiatric nursing services and evaluates performance in terms of how this was perceived by carers. Despite differences in the organisation of their services, similarities in the work emerged. A structured interview format - Repertory Grid Technique and the Laddering procedure - is used to explore the nurses' view of the work. A type of questionnaire, the Personal Questionnaire Rapid Scaling Technique is used to elicit the carers' and patients' view of the community psychiatric nurses, and to explore the carers' perception of the helpfulness of this intervention. The study shows that the emphasis of the nurses' work is on "making the system work' - with little guidance and direction, either from service organisers or from planners. Paradoxically, despite appearing to operate using varied modus operandi, the nurses provide a remarkably uniform service. The service appears to be uniform because of the constraints of finite resources (which limit the number of ways in which the nurses can work), and because the nurses are socialised into the work by their peers. The reality of community psychiatric nursing is that the nurses are not providing individualised care, but instead continually having to juggle resources and to justify post hoc the care that they give. This has never been previously documented, and must now be recognised by educationalists, managers and planners. Another major finding is the emphasis the nurses placed on 'developing relationships'. This is vital to the community nurses, to allow them to make the system work (manage crisis, provide early treatment and prevent hospital admissions). Although the nurses take an eclectic approach to model use, the importance of 'developing relationships' reflects the nurses' use of the 'social model', and contradicts previous findings which emphasised medical model use, by (hospital-based) psychiatric nurses. Satisfaction with the relationship is an, important feature of nurse/patient contact. The nurse is not perceived to be helpful to all carers, either for problem relief, or for the experience of caring; carers though, were unanimous that contact with the nurse was generally helpful. The importance of 'developing relationships' reflects the Ideology of 'individualised care' used by the nurses; this approach succeeds in making carers and patients feel cared for and helped. The nurses' work is patient focused and preoccupied with making the 'system' function, rather than providing comprehensive relief to carer's difficulties. Care offered to carers is secondary to that offered to patients, and limited by available resources. Carers were 'used' by the nurses to 'make the system work', although they did not feel 'used'. Certain aspects of caring are shared with the community psychiatric nurse, others are neglected. The more extreme feelings and experiences of carers are not relieved by contact with the nurse. (This is in contrast to 'problems', where, for some carers, extreme problems, appear to have been helped). The factors associated with the 'helped' carers are unknown. This study shows that individual nurses clearly express the goals in their work, whereas the community psychiatric nursing services, in contrast, seem to be unclear about their's. Future managers must be more explicit about their aims and goals, and introduce a research component to evaluate and monitor the performance of local services