International Council of Nurses - ''The Current Status of Mental Health/Psychiatric Nursing and Some Future Challenges''

International Council of Nurses The International Council of Nurses (ICN) is an independent, nongovernmental federation of national nurses' associations (NNAs) in over 100 countries, representing over 1.2 million nurses worldwide. Founded in 1899, ICN is the oldest and largest international professional organization in the health care field. Since its inception it has been working for the improvement of health services and the recognition of nursing's vital role in health care. As a representative body, ICN works closely with international organizations on matters affecting health in all parts of the world. As a federation of nurses' associations, ICN encourages its members to develop nursing standards, work on health policy development, and advance the nurse's economic position. With its broad-based and flexible services and programmes, ICN is a valuable resource for associations seeking guidance in many areas, including greater involvement in health-related government policymaking and planning. Nurses, as educated professionals responsible for the wellbeing of their patients, must modify their customary image by becoming the patient's advocate in all areas of their professional competence and in all health care situations. ICN helps nurses to: - take a stand on issues affecting health care and promotion - get involved in the development of health care policy and health care planning, and - safeguard human rights in areas that are the responsibility of nurses.

1. Introduction

Up to the mid-20th century, nursing's role in mental health/psychiatric care was predominantly linked to conditions and attitudes prevailing in psychiatric/mental institutions. For the most part, nurses worked in settings where they had received their training and consequently had an institutionalised perspective of patient care. Patients' human needs - those of self-respect, quest for independence, and self-esteem - were often ignored.

Although significant changes in models of care have occurred during the intervening years, two major relatively new developments have dramatically altered the mental health/psychiatric field this past decade, including the roles and functions of mental health/psychiatric personnel. These concern the major advances in all fields of basic and clinical neuroscience and thus approaches used to diagnose and treat mentally ill persons, and the influence of social, economic and political factors on patient care, e.g. deinstitutionalisation of persons with mental disorders.

2. Mental Health and Human Rights

The Preamble of the Declaration of Luxor on Human Rights For The Mentally Ill adopted by the World Federation for Mental Health on 27 January 1989, upholds the inalienable rights of persons "publically labelled or professionally diagnosed, treated or confined as mentally ill, or suffering from emotional distress". It states that "difficulty in adapting to moral, social, political or other values in itself should not be considered a mental illness" and regrets that persons inappropriately labelled continue to be confined as mentally ill. The Declaration stresses that "the fundamental rights of mentally ill persons shall be the same as those of all other citizens and that these include, among others, the right to dignified, humane and qualified treatment..." (1).

The slow public and professional response to instigate changes in the treatment and care of patients with mental disorders can be attributed to many cultural, social and physical factors. In some countries, this neglect is a leftover from the days when social deviance was thought to be a natural outgrowth of innate depravity, deserving punishment and discipline (2, 3). Around the turn of the century in the United Kingdom, the medical practitioner's assumption about mental illness was that it was worse than disease and "that people who were seen to be disordered were dangerous" (4). Laws, even up to 1955, were mainly designed for the protection of society in that they reflected the belief that mental patients were dangerous (5).

It was not until the late 1940s when the United Nations Universal Declaration of Human Rights was passed that a wider public debate began on the rights of persons with mental disorders and their institutional care. Although attitudes of both the public and health professionals have begun to change, there still remains an underlying entrenched prejudice against mental illness. Even the Alma Ata Declaration on primary health care does not explicitly include mental health care as one of its essential elements although it can perhaps be inferred (6).

The international nursing community adopted its first Code of Ethics in 1953 at the time when the Grand Council of the International Council of Nurses met in Brazil (7). This Code, which was revised in 1973 and reaffirmed by the Council of National Representatives in 1989, has been translated into many languages and speaks of the four fundamental responsibilities of the nurse: to promote health, to prevent illness, to restore health and to alleviate suffering. Furthermore it states that the need for nursing is universal, and that inherent in that is respect for life, dignity and rights of man, unrestricted by consideration of nationality, race, creed, colour, age, sex, politics or social status. Although The Code for Nurses holds no judiciary power, it does provide nurses with a guide for action based on the fundamental values and needs of society.

3. Extent of the Problem

Mental illness takes an enormous toll. According to a World Health Organization (WHO) report on 48 of the world's most prevalent diseases, mental disorders affect approximately 200 million people (8). It is unlikely that the extent of the problem is accurately reflected in this figure, as, for example, mental illness caused by episodic or insidious wife or child abuse often go unreported. Armed conflict, violence, and displacement are other situations which have lasting detrimental effects on their victims, especially children. A study of children living in Northern Ireland found that psychological disorders and mental illness increased considerably among children and adults during the 1968 riots and violence in Belfast (9). Considering that there are world-wide approximately 25-30 million refugees and internally displaced persons, exclusive of those affected by armed conflict, the magnitude of the actual number of people who might be suffering from some form of mental disorder becomes staggering.

4. Impact of Social and Scientific Developments

First launched in the 1950s, deinstitutionalisation has brought chronically mentally ill patients out of hospitals and into communities. Many factors have contributed to this revolution in the care of the mentally ill, among which was the human rights concern to release institutionalised patients from their often enforced confinement.

In communities where deinstitutionalisation has been carefully planned, benefits have been substantial and individuals previously committed to long-term in-patient care have been successfully integrated back into society. But this has not been done without costs. In New South Wales, for example, it was recognised early that increased levels of training and retraining were needed for all staff involved in the development of community based mental health services. Implementation of the programme included the upgrading of existing community mental health services and provision of a variety of different living arrangements, e.g. hostels and group homes. Rehabilitation (living skills centres, activity centres) and community support teams were also provided to assist both the clients and their families (14). Other groups that have alleviated the burden of care for families are self-help organizations and concerned citizens groups.

However, deinstitutionalisation can lead to great human suffering if ill conceived and poorly supported. In some industrialised countries, large numbers of persons with chronic mental disorders have been thrust into unprepared communities. Financial constraints, lack of political commitment and professional inertia have led to: inadequate numbers of appropriate alternative care facilities; mosaic staffing patterns and inconsistent qualifications of staff; sporadic linkages and referrals for care and treatment; and poor continuity of care. Consequently, readmissions are high and the number of homeless chronically mentally ill persons has increased. Among these are young people addicted to alcohol or other drugs who cannot or are hard to engage with traditional health care and community services.

McBride notes that there is a shift away from the behavioural sciences to the neurosciences in the organizing frameworks of psychiatry. "Imaging techniques now permit looking into the living human brain to identify structural defects in specific regions... New drugs are being developed to correct biochemical imbalances. The study of genetics is moving away from a focus of rare disorders to common ones with growing attention to enzyme deficiencies" (16). These new developments have revolutionised the management of patients with mental disorders, especially in countries with easy accessibility to psychotropic drugs.

In many developing countries improvement in the care and treatment of patients with mental disorders have been negligible, because of traditional concepts surrounding mental illness. In some societies such patients are thought to be cursed, while in others they are worshipped since they are believed to represent spirits or are messengers of God. Many of these societies reject modern concepts of psychiatric and mental health, as they do not relate culturally relevant alternative approaches to traditional beliefs (17). It is especially in this domain that more research and resources are needed.

5. Psychiatric Versus Mental Health Nursing

The distinction between psychiatric disorders and mental health problems is vague. This confusion is reflected in the various names used to describe the field, e.g. psychiatric and mental health nursing, psychiatric nursing, mental health nursing, or psychosocial nursing and a reason for the use of 'mental health/psychiatric' in this paper. According to McBride, the "name problem was itself connected with existing conceptualizations both of whether mental illness and mental health exist on the same continuum and whether psychiatric nurses have a distinct role to play in treatment of brain disorders". Current emphasis on mental health rather that on psychiatric care, she notes, "may have been prompted by the wish of practitioners to identify with nursing's health-oriented perspective rather than with the medical model..." (18).

"Psychiatric nursing is dead. Long live mental health nursing!", a quote recently reported in a nursing journal from the UK (19), supports this assumption. The change in emphasis reflects the way in which the philosophy of nursing itself has changed, according to the article. The Royal College of Nursing's Society of Psychiatric Nursing will change its name to the Society of Mental Health Nursing.

The core of the issue concerns nursing's quest to establish its own identity relative to patient or client care. In the past, psychiatric nursing's identity, particularly in mental health/psychiatric institutions, has been strongly influenced by whatever model of patient care was practised in the setting. The four main models were: the medical, psycho-therapeutic, behavioural and socio-therapeutic models. Each model, which formed the basis for professional practice, attempted to explain psychiatric disorders based on its own conceptual framework (20).

Although no universal model of mental health/psychiatric nursing has yet emerged, the core of what constitutes nursing can be found in the following, which is ICN's definition of nursing.

"Nursing,... encompasses the promotion of health, prevention of illness, and care of physically ill, mentally ill, and disabled people of all ages, in all health care and other community settings.... the phenomenon of particular concern to nurses is individual, family and group responses to actual or potential health problems. The unique function of nurses in caring for individuals, sick or well, is to assess their responses to their health status and to assist them in the performance of those activities contributing to health, recovery, or to dignified death, that they would perform unaided if they had the necessary strength, will, or knowledge and to do this in such a way as to help them gain full or partial independence as rapidly as possible..." (21).

6. Mental Health/Psychiatric Nursing Education

6.1 Historical Perspectives

Early mental health/psychiatric training schools prepared direct entrance nursing personnel, i.e. students did not receive a basic education in general nursing. Such schools were placed within psychiatric hospital settings to ensure a steady supply of nursing personnel conforming with institutional needs. Their numbers, however, are steadily declining.

The inclusion of mental health/psychiatric nursing subjects as part of a general nursing syllabus is a relatively new phenomenon. In 1933, for example, when the ICN Board of Directors and the Grand Council met in Paris and Brussels for the Quadrennial Congress, a resolution was passed by delegates from 30 countries to endorse the principle that mental nursing and hygiene be included in the general curriculum of all schools of nursing (22).

In the US, it was not until 1937 that the body responsible for accrediting schools of nursing considered psychiatric nursing to be an essential component of general basic nursing education, and even in the 50s it was still not generally recognised that psychiatric nursing content was helpful for the entire spectrum of nursing practice (23).

The development of mental health/psychiatric nursing as a post-basic nursing speciality started in the late 40s in the United States. The development of specialties, according to Hoeffer and Murphy, can be attributed to three social forces: new knowledge pertinent to the field, technological advances, and the response to public need or demand. It was in response to the public's need for an increase in the supply of mental health professionals that gave the US National Institute of Mental Health the impetus in 1948 to provide funds to establish the first advanced programme in mental health nursing in the U.S. (24).

6.2 Basic specialisation versus post-basic specialty preparation

The governing body of the ICN, the Council of National Representatives (CNR) accepted as a policy in 1985 The Report on the Regulation of Nursing'. The policy the CNR approved is that programmes of nursing education should generally parallel those for other professions as to setting, level, academic credentials, control, and general standards and that one of those standards should be "liberal and professional education preparing for the general practice of nursing in all settings, primary secondary, and tertiary." (25) According to the Report, the scope of preparation and practice of a nurse is: the capacity and authority to practise primary, secondary, and tertiary health care competently as a generalist in all settings and branches of nursing, and the capability and legal responsibility to supervise and direct auxiliaries. The scope of preparation and practice of a nurse specialist is defined as: advanced education and expertise in a branch of nursing, built upon the nurse base of competence and authority for generalist practice in all settings and branches of nursing.

The fundamental question of what it means to be a 'nurse' and the related issue - the merits of basic specialisation versus general nursing education - are still, however, being debated by nurse leaders. As pointed out by Butterworth, there "is a common level which all nurses should and could attain if they all have 'caring' at the centre of their interpersonal dealing with patients" (26).

One of the central principles upon which the position taken by the CNR is based relates to the development of the nursing profession and its potential social contribution. It sets forth that increases in the complexities of health care and its social milieu call for the heightened capabilities of nurses, as citizens and practitioners to meet new challenges. To encourage the development of nursing's potential, educational requirements should include liberal, social, scientific, and technical education; and nursing service standards should reflect the changing health care needs and enhanced professional capacities (27). Such a foundation, ICN believes, is laid during the generalist preparation for practice. The debate is how to develop post-basic specialist programmes which arise from a model of generalist nursing practice, and yet expand the nurses role into the specialty domain in a way that builds and develops nursing skills, provides quality care controls, assures credibility to the consumer, as well as meeting the particular needs of that specialty.

All nursing students in basic general nursing programmes apparently now study mental health/psychiatric subjects, although the length of the study, its placement within the curriculum and the intensity of clinical experiences vary considerably from country to country and even from province to province or city to city within a country. Mental health/psychiatric subjects are either taught as individual courses or integrated with other themes throughout the curriculum. For example, under a course heading 'Health Promotion', the psycho-social needs of persons in different age groups may be identified and, using the nursing process, students learn about such problems as addiction, depression, child abuse or stress.

The skills, knowledge and attitude that nursing students are expected to demonstrate at the end of such a programme allow them to assess an individual's psychological state and, within a general nursing framework, to plan and implement nursing interventions. Without further preparation or supervision, however, the roles of graduates of basic comprehensive or traditional nursing programmes in relation to caring for mentally ill persons are necessarily limited. Such roles may include:

- assessing the individual and his/her immediate environment and planning therapeutic nursing interventions;

- providing direct care, including distribution of medications and monitoring for their effects;

- teaching individuals and families skills, e.g. of daily living, and educating them on preventive mental health measures;

- interacting and liaising on the individual's and family's behalf with other care providers or services;

- consulting with other team members, both inside and outside institutions on continuity and coordination of care and its overall management;

- acting as the patient's and family advocate to influence decisions;

- evaluating and revising treatment plans and schedules.

Specialty education at the post-basic and graduate levels builds upon basic nursing competencies and stresses the interdependent roles of other mental health/psychiatric team members. Such programmes prepare nurses to apply a broad array of intellectual and interpersonal skills to change in some beneficial way the lives of people in both institutional and community settings (31), for example, in caring for children and adolescents and elderly who are mentally ill.

6.3 The Constraints

Major economic, social and political constraints hinder the development of nursing education in general and mental health/psychiatric nursing education in particular.

The 1989 Report of the Director-General to the WHO Executive Board noted, for example, that "All developing countries report that only very meagre financial resources are allotted to nursing education" and that "many nurse teachers.... have no teaching qualifications". Furthermore, according to the Report, "even when community experience is indicated in the syllabus, often in practice it is not provided, or the hours are drastically reduced..." (32).

Economic constraints and lack of political will have kept educational opportunities and salaries for nurses at a minimum. Few countries have continuing education programmes available for nurses.

Low salaries also affect mental health/psychiatric nursing education. One country reported that all well qualified nurses had left the country for better paying jobs elsewhere and that this had created a critical situation, as most colleges of nursing had no qualified psychiatric instructors left to teach the students. Such personnel shortages also cause a great void of leaders in the clinical area, limiting improvement of nursing services for mentally ill persons.

A further complicating element in the educational sphere is the preparation of many different levels and categories of nursing personnel, whose functions upon graduation are more closely linked with the absence or presence of other mental health professionals, such as psychiatrists or psychologists than with their educational preparation (33). In the absence of other mental health professionals, nurses may be thrust into positions of making clinical decisions concerning individual patients for which they have not been adequately prepared.

In countries where symptoms of mental illness are still closely linked with cultural taboos, beliefs and superstitions, a mental health/psychiatric curriculum based on Western ideas is at times used for lack of alternative. Often, such curricula are disease-oriented, hospital- based, overspecialised and out of line with the mental health needs of the people (34). Unfortunately, not enough research has been carried out in the socio-anthropological sphere to determine which traditional approaches to care and treatment of mentally ill people are effective. It is not surprising, therefore, that many people in those countries prefer the services of traditional healers over those of 'modern' medical care which, at times, constitutes prison-like conditions with only minimally trained personnel to provide custodial care.

Many countries are reporting a drop in enrolment of students at the basic level and an even greater reduction in the number of students indicating a preference for psychiatric nursing either immediately upon graduating from a basic programme or choosing to study it at higher level following basic nursing education (35, 36). Specific reasons for this decline were not given. Nevertheless, from available information certain assumptions can be made:

- changes in mental health services and treatment and the placement of patients in community settings has led to role diffusion, creating uncertainty about what the future for mental health/psychiatric nurses will hold;

- unpleasant student experiences in clinical settings, remaining prejudice and fear, and lack of mental health/psychiatric nurse role models are discouraging students from choosing the field;

- health personnel shortages are resulting in understaffed units in institutions and large client load in community settings, standards of nursing care are difficult, if not impossible to maintain, leading to professional frustration and 'burn-out';

- students are aware that a career structure and other incentives in the field are inadequate or lacking;

- continuing education opportunities are limited.

Redressing some of these problems requires strong nursing leadership, political commitment and an infusion of funds. The future of mental health/psychiatric services will continue to depend to a large extent on the functions and roles carried out by nursing personnel. In turn, the quality of those services will be greatly influenced by the educational preparation of its practitioners and their living and working conditions. Culturally appropriate basic and continuing education, based on national needs and resources, and adequate remuneration and opportunities for career advancement are necessary for nursing personnel to perform at the standards of mental health nursing practice that the profession has set for itself.

7. Mental Health/Psychiatric Nursing Practice

7.7 In Transition

In developed countries, the care of persons with mental illness was, up to the mid-20th century, largely provided in public psychiatric institutions staffed predominantly by aides (37). Much of the care in these institutions was custodial and trained nursing personnel performed traditional roles - e.g. bathing, feeding, toileting and dressing, and preventing patients from harming themselves and others. In subsequent years, other functions were added, such as assisting with hydrotherapy, electroshock or insulin coma, while counselling patients only recently emerged as a role.

Today, in many countries, psychiatric/mental health nurses are the only mental health professionals to have the twenty-four-hour responsibility for patients in the in-patient or institutional settings, and therefore, are the prime care givers and monitors of patient progress.

With refinement of clinical skills through ongoing supervision of practice, a generalist nurse should be able to assume, among other roles, the following (adapted from American Nurses' Association Standards of Child and Adolescent Psychiatric and Mental Health Nursing Practice (38)):

- therapist who shares the responsibility for providing an atmosphere in which all activities and behaviours are focused on the therapeutic care of the individual;

- counsellor or teacher;

- collaborator with other mental health and psychiatric professionals in assessing the needs and planning for the care of the individual and family;

- advocate and change agent who provides for the physical, mental health and other needs of the individual;

- promoter of mental health with individuals, families, groups and communities;

- participant in the research process and implementor of research findings.

In addition to the roles of a generalist nurse, graduates of specialty programmes who have had supervised clinical experiences may be expected to assume the following roles, among others (adapted from American Nurses' Association Standards of Child and Adolescent Psychiatric and Mental Health Nursing Practice (38)):

- therapist, e.g. psycho, play, drama for individuals, groups and families;

- clinical supervisor of patient care staff and graduate nursing students;

- administrator of mental health and psychiatric nursing services;

- educator of nurses and other care personnel in a variety of institutional and community settings;

- consultant to professional and nonprofessional persons or groups concerned with the general welfare, education and care of individuals;

- researcher who contributes to the theory and practice of mental health and psychiatric nursing through research in this field or a related field.

Mental health/psychiatric nurses have been in the vanguard as positive agents for change in many countries. For example, in Uganda, psychiatric clinical officers - nurses who have received advanced training at Makerere University - are highly respected mental health practitioners who are fully responsible for mental health/psychiatric services, particularly in rural areas. Similar advanced educational programmes for nurses have been developed in Botswana, Lesotho and Zambia (40).

In the UK, nurses launched a rehabilitation centre to help mentally disturbed patients learn many of the skills needed to move towards less restricted life-styles in the community or in institutions. Based on research findings, the rehabilitation programmes help people to lead a better quality of life, for example, through learning 'living skills' (41).

In many countries, nurses are conducting research and demonstrating patient outcomes related to nursing care, such as studies on sleep deprivation, effects of homelessness, aspects of the addictive cycle and high risk pregnancy.

Innovative mental health/psychiatric programmes initiated by nurses can probably be found in every country; however, major constraints impede their widespread development.

7.2 Constraints

It appears that some mental health/psychiatric nurses have not easily adapted to the deinstitutionalisation of the mentally ill, possibly because psychiatric nursing has not identified its unique professional perspective (42). Nurses, according to Nolan, have adopted a 'lay' or 'common sense approach' which prevents them from realising their full therapeutic potential. He claims that training has not helped since it has failed to provide nurses with the skills needed to engage patients in therapeutic relationships.

Pollock, using a small sample for a study on the work of community psychiatric nursing, found that nurses with limited resources and lack of direction were establishing their own modus operandi and defining their own work practices while trying to produce the best match of needs to resources (43). Barnum calls this the "nursing's angel complex": the notion that no matter what pittance of support nurses get, they can fly (44).

Simpson, having examined selected research reports on community psychiatric nursing (CPNs), noted that "on the one hand ... CPNs are enthusiastically embracing a new role with a client group not appropriate for psychiatric (medical) intervention, and on the other.... they are not equipped to do so" (45). He claims that there "appears to be no research at all indicating whether community psychiatric nursing interventions are, in fact, systematic and rooted in sound theoretical and research-based practice". Barratt notes that CPNs are a relatively new group of carers and are still experimenting with their role within society while, as Brooker reports, they are in a rapidly developing area of mental health nursing (46,47).

In many developing nations, where there is usually one psychiatric hospital for the entire country, problems of mental health and psychiatric nursing are closely linked to other problems of general health and socioeconomic origin, but above all, according to Wankiiri, to inappropriate organization, inappropriate curricula and manpower shortages (48). The author states:

"The few existing psychiatric hospitals are for the most part old custodial institutions-overcrowded, understaffed and rarely able to provide more than just chemical therapy and electroconvulsive therapy. Their forbidding appearance also greatly contributes to the negative image of psychiatric nursing among the public...."

The isolation of the mentally sick in uncongenial surroundings has led to a situation in which most African health workers in the rural areas are unwilling or unable to follow up such patients. They do not regard the promotion of community mental health, the prevention of mental illness, and the identification and management of mentally sick patients as their responsibility.

According to Peplau, what is most "needed now are psychiatric nurses within the profession to track research findings, coming from all sciences, and to serve as interpreters of those findings for the nursing profession" (49).

Mental health/psychiatric nursing practice cannot be viewed in its entirety without looking at the issues that influence its practitioners. In most countries, there are widely reported shortages of nursing personnel. Many studies have shown reasons for this: poor working conditions, low salaries and limited career opportunities, increased demand for highly trained nurses but a decreased pool from which to recruit young people, lack of professional autonomy and a low image of the field.

Improving the educational preparation of mental health/psychiatric nurses, and developing a research data bank and a solid theoretical foundation on which to base their practices, must go hand in hand with better working conditions (e.g. salary and remuneration), greater autonomy within an interdisciplinary setting, opportunities for further educational advances and career development, and participation in policy-making. In addition, needs and resources studies must be conducted to provide valid data on nursing personnel, to be used with some consistency in staffing services.

8. Nursing Legislation

According to the ICN Regulation of Nursing Study, in a large majority of countries the regulations governing nursing practice are inadequate for dealing with the complexity and expansion of the nursing role to meet today's health care needs (50). Based on the findings of the study and recognising the worldwide nature of the problem, the International Council of Nurses launched a global project to involve national nurses' associations and senior nurses in the ministry of health in the critical examination of national nursing legislation and regulations with the aim to bring about necessary changes. As a result, many NNAs are now more acutely aware of the actions that need to be taken to redress the problem and have begun the initiatives.

9. National Nurses' Associations (NNAs)

Several mental health/psychiatric specialty branches within national nurses' associations have developed standards for practice and for education that spell out desired levels of performance, situations or conditions, and criteria - which can be used for comparison. Furthermore, NNAs and their specialty groups have made submissions to government authorities on such issues as:

- the delivery of services to mental clients as a priority in 1990;

- the legal status of mentally ill people;

- proposals for new mental health legislation;

- statement of nursing needs to increase appropriations for mental health/psychiatric care;

- sale of liquor bill;

- standards for informed consent;

- safe staffing levels;

- changes in levels of education;

- upgrading of physical facilities;

- proposals concerning community care for adult mentally ill and mentally disabled people and the health of those in prison;

- substance abuse.

10. Future Developments

Looking into the future, mental health/psychiatric nursing education at the general basic level will focus largely on prevention and concepts of healthy living, and will include theory and clinical experience in public policy, biological-psychological basis of behaviour, social psychology, sociology, normal physiology, and will be based on 'humanistic-holistic caring' as the central core of all nursing practice. The generalist nurse will be mainly concerned with preventive and promotive aspects of mental health in all settings - e.g. homes, schools, clinics, hospitals, factories.

The nursing care of mentally ill persons both in institutions and in the community will be provided by nurses prepared at the post-basic or graduate level, working individually and within interdisciplinary mental health teams. Using an integrated theoretical perspective, their approach to care will provide for "a range of services including supportive care, rehabilitative care and crisis intervention as well as more traditional forms of psychotherapeutic interventions" (52). In addition, mental health/psychiatric nurse specialists will carry out many functions related to the promotion of mental health and the prevention of mental illness in a broad variety of settings, across the age span, infant to geriatric.

Post-basic and other graduate programmes will be able to attract an adequate number of well-qualified applicants because mental health/psychiatric nursing is respected for its special skills and knowledge autonomy, opportunity for innovation, and availability of supportive supervision, as well as the opportunity it provides to influence policy decision which both directly and indirectly affect mental health/psychiatric services. These services will be culturally relevant and integrated within the primary health care system of the nation. In addition, mental health/psychiatric nurses' expertise will be publically recognised and financially rewarded.

11. Summary of Nursing Issues

(Note that the following issues vary worldwide, some being more prevalent than others)

General issues

- There remains prejudice against any behaviour perceived to be bizarre, deviant, strange or nonconformant, and society, including health professionals has sometimes cruel ways of dealing with people exhibiting such behaviours.

- The development of mental/psychiatric health as a complex psycho-socio-health discipline has been relatively slow compared to other fields such as surgery. Consequently, humanistic, holistic and scientific methods to deal with the problems are not yet well formulated.

Policy-making and Political Will

- Continuing low priority is given to all aspects of mental health/psychiatric, including: funding for education, services, research, facilities, supplies, health personnel development; changing laws, acts and recognition of human rights violations; prevention of unemployment, substance abuse, person abuse, eg child, spouse, the elderly; promotion of recreation, leisure and relaxation.

- A clear framework for national decision-making in mental health is lacking.

- Mental health has yet to become an integral component of primary health care.

- Nurses, for the most part, have been excluded from participating in policy decision-making at all administrative levels.

Nursing Practice

- There appears to be no clear 'nursing framework' on which mental health/psychiatric nursing services can be modelled.

- There is a general shortage of effective mental health/psychiatric nurses' role models.

- While some nurses view the changes that are taking place in the mental health/psychiatric field as a positive development for nursing, others fear role diffusion.

- More clinical research is needed to determine the specific effects of nursing interventions on patient outcomes.

- Regulations and laws governing mental health/psychiatric nursing practice are outdated or absent.

- Inadequate salaries, lack of a career structure, poor working conditions, increased demand for highly trained professional staff and few incentives are contributing to the mental health/psychiatric nursing personnel shortage.

- Mental health/psychiatric nursing personnel functions appear to be more closely linked with the absence or presence of other mental health professionals than with their educational preparation.

Nursing Education

- Mental health/psychiatric nursing education is changing from a medical to a nursing orientation.

- Lack of both financial and human resources, coupled with political inertia have seriously affected the necessary development of training programmes for mental health/psychiatric nursing personnel at the in-service, post-basic and graduate levels.

- The number of programmes preparing direct entrance mental health/psychiatric nurses is decreasing.

- More programmes for preparing post-basic and graduate level mental health/psychiatric nurses are being offered but still remain inadequate.

- There is a critical shortage in some countries of qualified mental health/psychiatric nurse educators to teach at the basic, post-basic and graduate levels.

- The mental health/psychiatric nursing curriculum in some countries is culturally inappropriate.

- Inappropriate or unpleasant clinical experiences and ineffective instructional techniques for students can have long lasting negative effects, such as fear of mentally ill people or unwillingness to work in the field.

12. Recommendations to national nurses associations and governments

Nursing Practice

- Support the development of a mental health/psychiatric framework on which national policy decisions can be based.

- Support and/or undertake clinical research studies to determine what specific effects various nursing interventions have on patient outcomes.

- Carry out mental health/psychiatric nursing personnel needs and resources studies at country level that fit into national health plans.

Nursing Education

- Develop plans at country level to meet educational needs of all levels of mental health/psychiatric nursing personnel, including continuing education needs.

- Support the development of culturally relevant curriculum models.

- Develop guidelines for clinical practice for nursing students.

- Develop guidelines for curriculum development.

Nursing Education and Nursing Practice

- Involve mental health/psychiatric nursing personnel at all levels of policy decision-making.

- Support the development of leaders and role models, especially in clinical settings.

- Support the development of managers and educators.

- Support the development of career structures including in clinical settings and the determination of educational preparation for different grades/steps.

- Propose incentives or other ideas to increase the attractiveness of mental health/psychiatric nursing, e.g. greater autonomy.

13. References

1. The World Federation for Mental Health. The Declaration of Luxor -Human Rights For The Mentally Ill, adopted 17 January 1989 by the Nile Congress at Luxor.

2. News Focus. The hell called Leros, Nursing Times, 85(39), 1989, p. 18.

3. Mc Causland M. Deinstitutionalization of the mentally ill: Oversimplification of complex issues. Advances in Nursing Science, 9(3), 1987, pp 24 - 33.

4. Lemmer B & Smits M. Facilitating change in mental health. Chapman and Hall, London, 1989, p. 1.

5. Curran W J & Harding T W. The law and mental health: Harmonizing objectives. World Health Organization, Geneva, 1978, p. 10.

6. WHO & UNICEF. Primary health care. A Joint Report. Geneva, 1978.

7. Bridges DC. A history of the International Council of Nurses 1899-1964 Philadelphia, J B Lippincott Co. 1967, p. 168.

8. WHO Features. No 140, April 1990.

9. Fraser M. Children in conflict. London, Penguin, 1974, p. 208. (As reported in: Children in situations of armed conflict. UNICEF, No. E/ICEF/1986 (CRP 2, 10 March, 1986, p. 8.)).

10. Slavinsky A. Psychiatric nursing in the year 2000: From a non-system of care to a caring system. Image-Journal of Nursing Scholarship 16(1) 1984, pp 17-20.

11. McClausland M. Deinstitutionalization of the mentally ill: Oversimplification of complex issues. Advances in nursing science, 9(3), 1987, pp 24-33.

12. Peplau H. Tomorrow's world. Nursing Times, 7 January, 1987, PP 29-32.

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