Celebrating Psychiatric Nursing History

November 2014
Issue 7
On-Line Publication
ISSN 1929-1647
Celebrating
Psychiatric
Nursing
Histor y
CANADIAN JOURNAL
PSYCHIATRIC NURSING RESEARCH
A Peer- Reviewed Publication
Contents Issue 7 - November 2014
National and International News
4
EDITORIAL 10 Dr. Beverley Hicks
An Analysis of Canadian Psychiatric Mental Health Nursing 13 Mary Smith and Dr. Nazilla Khanlou,
through the Junctures of History, Gender, Nursing Education, and Quality of Work Life in Ontario, Manitoba, Alberta,
and Saskatchewan..
Parting at the Crossroads: 24 Dr. Veryl Tipliski, RPN
The Emergence of Education for Psychiatric Nurses
in Three Canadian Provinces, 1909 - 1955.
Advance Education for RPNs: 39 Kimberley Ryan-Nicholls, RPN
A Hard Fought Battle.
An outline of the history of the examinations for mental 52 Margaret Hawthorn Williams
nurses organised by the (Royal) Medico-Psychological
Association UK
History of Specialist Mental Health Services 56 Simon Lawton-Smith and Dr. Andrew
McCullock
The Vision for Mental Health Nurses in Eire (Ireland) 61 AN BORD ALTRANAIS - Ireland’s
Regulatory Nursing Authority
Myth of Mental Health Nursing and the Challenge of 63 Dr. Phil Barker, PhD, RMN
Recovery
Please direct any comments, questions or suggestions to the Executive Editor at [email protected]
with subject line: Comments
-2-
The Importance of Psychiatric Nursing
History
History is consistently acknowledged as crucial to the identity of
a profession. In the case of psychiatric nursing this is perhaps
more so, as published accounts of the history of nursing rarely
pays attention to the specialty of mental health. The aim of this
month’s journal is to provide a overview of the history of mental
health nursing in Western Canada.
The Editorial by Dr.Hicks as well as the articles by Smith and
Khanlou, Tipliski and Ryan-Nicholls demonstrate not only the
difficult path that psychiatric nursing has trodden but also the
factors that influenced its unique development as a separate
independent health care profession. The Manitoba / Ontario
border has become the demarcation between two different models of psychiatric nursing practised within one country.
The above authors highlight that an understanding of history is
essential in interpreting contemporary mental health service
delivery and seeking to overcome the professional distance
between mental health and other branches of nursing. The
impact of mental illness on disease and disability burden is
receiving more recognition than has previously been the case. It
is now commonly understood that approximately 20% of the
population will experience a mental illness at some stage during
their lives. Unfortunately this recognition is not reflected in the
funding of mental health services, or in strategies to identify and
rectify shortfalls in the nursing workforce. There is still an embargo of the trans-provincial migration of the Registered Psychiatric
Nurse into Eastern Canada.
History provides an exploration of two areas. Firstly an overview
of the current funding devoted to mental health and secondly an
examination of workforce data with a view to recognising likely
future trends for psychiatric nursing. The data demonstrates the
existence of a double dilemma, firstly that the need for psychiatric
nurses is likely to increase, and secondly that the looming workforce crisis in North America may be more severe than has been
anticipated.
Professional organizations and associations in nursing are critical for generating the energy, flow of ideas, and proactive work
needed to maintain a healthy profession that advocates for the
needs of its clients and nurses, and the trust of society. History
has demonstrated that all psychiatric nurses to engage in their
professional organizations and associations, noting how these
organizations contribute to the accountability and voice of the
psychiatric nursing to society.
Journal pages maybe downloaded
and printed as a PDF
The Board of Editors
Marian Anderson - Alberta
Dr. Dean Care - Manitoba
Karen Clements - Manitoba
Dr. Beverley Hicks - Manitoba
Melodie Hull - British Columbia
Dr. Larry Mackie - Executive Editor
Sue Myers - Saskatchewan
Dr. Kathyrn Puskar - USA
Dr. Phil Woods - Saskatchewan
Dr. Michel Tarko - British Columbia
Dr. James Welch - UK
November 2014 - Issue 7
ISSN 1929-1647
An Online publication.
Dr. Larry Mackie
Executive Editor
All editorial matter in this Journal are the opinions of
the authors and not necessarily those of the Journal
Editors. The CJPNR assumes no responsibility or
liability for damages arising from any error or omission
or from the use of any information or advice contained
in this Journal including editorials, studies, reports,
letters and any advertisements.
National and International NEWS
Not be prohibited from holding the position under existing laws.
Details of new 'fit and proper person' test for NHS
leaders unveiled. April 2014
A director could be deemed to be unfit if:
A register of poor performing Chief
Nursing Officers and Directors
of Nursing as well as other
healthcare leaders is to be set
up by the Care Quality Commission to prevent unfit managers working and moving
between organisations. Under plans to bring in a new fit
and proper person test, the Commission for Quality
Care will record concerns about individual directors.
This includes where directors deemed to be unfit resign
before the regulator has imposed any conditions on their
trust. Those individuals deemed unfit under the new
check would then be removed from their posts or barred
from joining a new organisation, preventing failed senior
managers from moving between different providers, the
government said. “This test will allow us to make sure
that those leading organisations are up to the job”.
The details have emerged in draft regulations for the
new test published by the Department of in March
2014. It will cover persons at board level or equivalent
in all organisations registered with the CQC, whether in
the private, public or voluntary sectors.
They have been convicted of a criminal offence or
sentenced to three months in prison within the last five
years;
They are an un discharged bankrupt;
They are subject of a bankruptcy order,
They have un discharged arrangements with creditors;
They are included on any barring list preventing
them working with children and vulnerable adults.
The Department of Health claims the test will close a
“regulatory gap” with directors being the only group not
subject to existing fit and proper tests. It will apply to
board directors and their equivalents including executive directors, non-executive directors, chairs and trustees. It will not apply to foundation trust governors.
The test will be used when an organisation registers
with the CQC for the first time and when a new director
More Evidence Links Traumatic Brain
is appointed to an organisation that it already inspects.
Injury to Dementia - 2014
Creating a fit and proper person test for healthcare
leadership is a key recommendation following the public
inquiry into failures at the Mid Staffordshire Foundation
Trust. Ministers hope the new test could be put into
A new study adds weight to the evidence
place as early as October 2014. The government exsuggesting a link between traumatic brain
pects around seven directors would be found to be unfit
injury (TBI) and later dementia.
each year.
The study shows that older veterans who had a past TBI
severe enough to seek medical attention had a 60%
The regulations describe that to qualify as a fit and
increase in the risk of developing dementia compared
proper person a director of an organisation must:
with those without a history of such a head injury.
Be of good character;
"There seems to be growing evidence that traumatic
Have the qualifications, skills and experience brain injury may be a trigger for earlier onset of dementia
later in life, and our results add to this evidence," lead
necessary for the role;
author, Deborah E. Barnes, PhD, University of California, San Francisco, commented. "If an older patient is
Be capable of undertaking the position;
known to have had a traumatic brain injury earlier in life,
Not have been responsible for misconduct or then doctors need to look more closely for cognitive
mismanagement in the course of any employer symptoms. This is something to be aware of as a consewith a CQC registered provider;
quence of traumatic brain injury."
-4-
NEWS
The authors can't directly extrapolate their results to
younger people, "but combined with other studies it does
appear that head injuries have long-term consequences."
The researchers conclude that their findings also "raise
concern about the consequences of blast-related injuries
in today's veterans, as well as the growing rate of TBIs
in the civilian population."
The observation of the additive association of medical
and psychiatric diseases "with TBI in the future risk of
dementias suggests that the relationship between HT
and dementia is complex," Dr. Savica adds. "In contrast
to the sensational accounts in the mass media, neuroscientists must take a careful and comprehensive approach
and avoid oversimplified claims of causality."
"This would have required looking in more detail into all
the records. For this study we just looked at the top-line
information," she noted. "This told us whether there had
been a traumatic brain injury at some point that was
severe enough for the patient to seek some medical
attention."
Most occurred late in life, but some were early in life, she
added. "We know when the medical visits happened but
we don't know the exact date of the injury. We also don't
know if the head injury occurred as a result of being
engaged in active military service or under more regular
conditions applicable to civilians. All that information
would require drilling down to different layer of medical
records."
She added, however, that this might be the next step in
the research — to look in more detail at those 1200
For the study, Dr. Barnes and colleagues analysed patients with brain injuries to see what those injuries
"top-line" information from the electronic medical records were and exactly when they occurred.
of 188,764 US veterans aged 55 years or older (mean
age, 68 years) extracted from the Veterans Affairs Na- Dr. Barnes explained that other studies looking for an
tional Patient Care Database. These veterans had at association between TBI and dementia have shown
least 1 inpatient or outpatient visit during both the base- conflicting results. "Some have found an association;
line (2000 - 2003) and follow-up (2003 - 2012) periods some have not. There is a lack of consistency. In generand did not have a dementia diagnosis at baseline. al, the more severe the injury the stronger the relationTraumatic brain injury and dementia diagnoses were ship with subsequent dementia."
determined by using International Classification of DisOther dementia risk factors, including depression and
eases, Ninth Revision, codes.
post-traumatic stress disorder, compounded the risk in
this study. "Each risk independently increased the risk of
A total of 1229 veterans had a current TBI diagnosis dementia and together they were additive," she noted.
during the baseline assessment period. The most common types of injury were intra-cranial injury without skull
fracture (43%), skull fracture (21%), late effects of TBI More Reason to Prevent Head Injury
(14%), and post concussion syndrome (4%), while 27%
Their findings underline the importance of preventing
of the injuries were unspecified.
Results showed that during the 9-year follow-up period, further injuries in those who've already had one, as well
16% of those with a TBI developed dementia compared as first injuries.
with 10% of those without a past brain injury. After
adjustment for demographic characteristics, medical co- "While we can't change the past — ie, the fact that there
morbid conditions, and psychiatric disorders, this gave a has been a head injury, these results make it even more
hazard ratio of 1.57 (95% confidence interval, 1.35 - important to try and prevent head injury by wearing
helmets and seat belts, et cetera," she said. "And if there
1.83).
The magnitude of the increased risk was generally simi- has been a head injury, then we should be focusing even
more on doing everything possible to reduce other risk
lar for all types of TBI diagnoses and severity levels.
factors for dementia. This may include making sure the
In addition, those with a previous TBI developed demen- individual engages in physical and mental activities and
tia on average 2 years before those without such an is socially active; this helps build brain resilience. We
injury (78.5 vs 80.7 years). Those who did not develop also need to be efficient at treating cardiovascular risk
dementia died 2.3 years earlier if they had a TBI com- factors and dealing with mental health issues. "
pared with those without such an injury (77.0 vs 79.3
years).
Veterans Database
Dr. Barnes noted that the strengths of the study included
the large number of participants and the fact that the
information on both brain injury and dementia was extracted directly from health records, "so we were not
relying on self reporting." The use of medical records
also meant they could control for many confounders.
But she pointed out that they did not always have the
exact date or details of the TBI.
-5-
NEWS
Scientists link 80 new genes to
schizophrenia
July 2014
A UK Mental health trust trials world’s first
anti-psychotic patch August 2014
The Research and Development Team at Surrey
and Borders Partnership
NHS Foundation Trust UK
is trailing the world’s first
delivery of asenapine, an
anti-psychotic medication,
through patch application
as a new method of treatment for people with
schizophrenia or schizoaffective disorder.
The Trust is working in collaboration with clinical research company Richmond Pharmacology to investigate the use of a patch which releases asenapine
through the skin into the blood steam.
Asenapine is currently licensed to manage the symptoms of schizophrenia and bipolar disorder in the US
and licenced in the UK for treatment of bipolar disorder,
but this is the first time it has been administered using
a patch on the skin. The medication is absorbed into the
blood stream through the skin over a 24-hour period,
which can be a more comfortable method of treatment
for those who dislike injections or have difficulties remembering to take tablets. Evidence suggests that the
gradual absorption of the medication over a longer
period of time can reduce side effects associated with
the drug.
The trial is in an early phase of clinical research which
should be completed by December. So far the Trust
has had 9 participants and is seeking to recruit 15
more. This will then lead to later phase trials which will
be conducted globally over a longer period of time at
multiple centres with more participants involved.
The success of the trial is measured through regular
physical and mental observations of the participants.
Feedback from participants has so far been promising;
individuals have reported that they feel happier about
their treatment and show a greater understanding of
their condition.
One participant said: “The trial has been excellent. I
think the patch is better because I have a problem with
remembering to take my tablets. I have also experienced fewer side effects. With tablets when you take
them you get those side effects straightaway.”
Scientists have uncovered 80 previously unknown genes which may
put people at risk of developing
schizophrenia.
The team from Cardiff University
believe the findings of their largestever global genetic study of the disease shows it can have biological
causes and put it on a par with other medical conditions.
Study lead Professor Michael O'Donovan said: "For
many years it has been difficult to develop new lines of
treatment for schizophrenia, hampered by a poor understanding of the biology of disease.
"Finding a whole new bunch of genetic associations
opens a window for well-informed experiments to unlock the biology of this condition and we hope ultimately
new treatments."
Biological processes going awry
For the study, the group examined the genetic make-up
of more than 37,000 people with the condition, comparing them with some 110,000 people without the disease.
From this, they found more than 100 genes that make
people more susceptible to schizophrenia and are involved in the relay of chemical messages around the
brain or in the immune system. 83 of these genes have
never been pinpointed before.
Professor David Curtis, a co-author of the study from
University College London, said: "This study puts psychiatry into the same category as other parts of medicine.
"In the past we have struggled with the view that psychiatric conditions are not 'real' illnesses but early genetic
studies had limited successes. Now we show with
confidence that there are biological processes going
awry."
-6-
NEWS
the past year did not report any other type of substance
use. "With kids who say no to the first three, you don't
really need to ask further questions," Dr. Levy said.
Quick Screen can Identify, Classify
Adolescents’ Risky Substance Use:
Dr. Sharon Levy, MD, MPH, of
Boston Children's Hospital and
her colleagues had initially developed a more complex tool containing
several
additional
questions. But they found that
asking young people about their
use of alcohol, tobacco, marijuana
and other substances over the
past year was enough to classify them into four categories of risk.
The sensitivity and specificity of the screening testswhich were the same for both the Screening to Brief
Intervention and the longer version-were 100% and
84% for identifying non-tobacco substance use; 90%
and 94% for substance use disorders; and 75% and
98% for nicotine dependence.
Patients were randomised to self- or interview-administered screening, and each approach was equally effective.
"The way kids respond tells us exactly where they are in
terms of substance use," Dr. Levy said. "There's still a
majority of primary care clinicians who triage the risk
level based on their clinical impression," she added.
"We know that's insufficient because it's really hard to
The American Academy of Paediatrics (AAP) recom- know just by looking at a kid or casual conversation to
mends that primary care doctors screen adolescents for get a sense of whether or not they've started having
problems."
SUD,
"It turned out that not only did the test work as well, in
some cases it even worked better than including the
extended information," Dr. Levy told Reuters Health in a
telephone interview.
The AAP also recommends that adolescents who are
not using substances be given positive reinforcement;
those who use substances infrequently without associated problems receive brief medical advice to quit; and
that young people with SUD receive brief interventions
or treatment.
Dr. Levy and her colleagues received a grant from the
National Institute on Drug Abuse to develop a brief
screening tool for paediatricians and other primary care
doctors to use in assessing adolescent substance use.
The tool included multiple choice questions about frequency of use of eight different substances (none, once
or twice, monthly, weekly, almost daily, or daily), along
with additional questions.
The investigators tested the tool in 213 adolescents,
including some who were visiting their primary care
doctor for routine medical care and others who were
visiting a substance abuse program. The goal was to
categorize
them into four groups: no past year alcohol or drug use;
past-year alcohol or drug use but no substance use
disorder; mild or moderate substance use disorder; and
severe substance use disorder.
Stimulation with a low-strength electromagnetic field
device immediately improves mood in patients with
major depressive disorder (MDD) and bipolar disorder
(BPD), new research shows.
Results from a randomised, double-blind, sham-controlled study are exciting, especially because the effects
were so rapid, lead author Michael L. Rohan, PhD, a
physicist at McLean Hospital and Harvard Medical
School, Belmont, Massachusetts. We have something
that is working on the depressed state in either major
depressive disorder or bipolar disorder," said Dr. Rohan.
"Whether it's more effective in either one of them, we
don't know, but it seems to have an immediate effect on
the depressed state."
The device holds "great potential" as a clinical tool for
psychiatrists, Dr. Rohan added. The study was published in the August 1 issue of Biological Psychiatry.
Serendipity
The ability of the rapidly oscillating electromagnetic
field, called low-field magnetic stimulation (LFMS), to
improve mood was discovered "serendipitously" about
a decade ago. Researchers who were carrying out
Just under 60% reported no non-tobacco substance experimental MRI scans to assess brain chemistry nouse; 23% reported use but did not meet criteria for SUD; ticed changes in depressed bipolar patients.
10.3% had mild or moderate SUD; and 8.9% had severe
SUD.
The investigators found that just asking a study participant the initial question about substance use frequency
which the researchers refer to as the Screening to Brief
Intervention - was enough to put them into one of the
four risk categories. They also found that young people
who reported not using tobacco, marijuana or alcohol in
-7-
NEWS
Dr. Rohan believes that the differences between active
and sham treatments were not significant in the individual diagnostic groups because these groups did not
have enough participants. He pointed out that the differences did reach significance when the data were comThe US Food and Drug Administration (FDA) has deter- bined across groups.
mined that the device carries a nonsignificant risk. Dr.
Rohan described the LFMS device as being similar in Mood was also assessed with the self-rated Positive
size and shape to "an old-fashioned mailbox." Patients and Negative Affect Schedule (PANAS). There was
lie on a bed with a padded headrest. The top of their greater improvement in scores among both BPD and
head fits into the device, leaving the rest of their head, MDD patients receiving the active treatment. In this
case, the difference was statistically significant not only
including their eyes, exposed.
for the combined sample but also for BPD patients
Compared with transcranial magnetic stimulation alone, although not for MDD patients alone. No adverse
(TMS), which uses electromagnetic pulses to stimulate effects linked to the device were reported.
nerve cells, and electroconvulsive therapy (ECT), which
induces "small self-repairing seizures," LFMS uses Potential Mechanisms
fields that are "at least 100 times weaker," said Dr.
There is evidence that rapidly fluctuating magnetic fields
Rohan.
that are below the threshold for depolarization can still
Although ECT is "the most successful treatment for influence neuronal activity. This, noted the authors,
depression," it carries a cost, he said. "Patients come in suggests potential cellular mechanisms of action. Alregularly and they get sedated; the treatments are inva- though this is still speculative, Dr. Rohan suggests the
device may interact with the nerves in the area of the
sive."
dendrites where synapses are located.
High Hopes
"The synapses have an electrical function as well as a
The new study included 63 patients aged 18 to 65 years chemical function, and I suspect that we are interacting
with BPD or MDD who were stably medicated but still with the electrical function in the dendrites." Because
symptomatically depressed and who scored 17 or more the device seems to provide immediate relief, it might
on the observer-rated 17-item Hamilton Depression prove useful as a treatment "bridge" in the emergency
Rating Scale (HDRS-17). Most patients took multiple department, where psychiatric patients may end up in
crisis, although the psychiatric community will eventualmedications throughout the study.
ly determine the best application, said Dr. Rohan. He
Patients were randomly assigned to receive 20 minutes pointed out that antidepressant medications take severof active (n = 34) or sham (n = 29) treatment. The al weeks to exert a clinically meaningful improvement in
inactive device resembled the real one in every way, mood and that even ECT requires 2 to 3 treatments per
down to the faint beeping noise it emitted. Neither the week during a period of up to 4 weeks.
patients nor the operators could tell the difference.
Researchers are now studying the properties of LFMS
"Because the placebo effect is so high in antidepressant to determine the optimal frequency, spatial distribution,
and timing of the electromagnetic field needed to prostudies, we had to be very careful about that sham,"
stressed Dr. Rohan. "When you have an exciting new duce an antidepressant effect. Dr. Rohan is doing further investigation of the potential mechanisms of the
device like this, people have high expectations."
device. He is also participating in a study of 72 patients
Directly before and after the treatment, the mood of the that is looking at the effect and duration of multiple
patients was determined with the HDRS-17 and the self- treatments, the results of which he estimated would be
rated visual analogue scale (VAS), which is designed to available by the end of 2015. Elsewhere, a multisite
be responsive to an immediate change in mood. The study funded by the National Institutes of Health is
study showed that the mean improvements in VAS comparing the device with antidepressant interventions,
score were greater for active compared to sham treat- said Dr. Rohan.
ment by 0.8 points for BPD (95% confidence interval
[CI], -.6 to 2.1; P = .60), 1.6 points for MDD (95% CI, -.4
to 3.6; P = .17), and 1.1 points for the combined sample
(95% CI, .2 to 1.9; P = .01).
Mean improvements in HDRS-17 score were greater for
LFMS than for sham by 2.5 points for BPD (95% CI, -1.2
to 6.2; P = .34), 3.2 points for MDD (95% CI, -3.3 to 9.6;
P = .74), and 3.1 points for the combined sample (95%
CI, .5 to 5.8; P = .02).
After further research, Dr. Rohan designed and built the
portable tabletop device that is now being studied. It
consists of a magnetic coil, an amplifier, a waveform
generator, and a computer.
-8-
NEWS
Overseas nurses and midwives 'face shorter
assessments' in the UK
Similar checks have already been adopted by other
healthcare regulators, according to the NMC.
Nurses and midwives who complete their training in
hospitals outside Europe will now face shorter tests to
check they are fit to work in the UK.
The regulator says: "This will ensure the hundreds of
nurses and midwives who trained overseas and wish to
practise in the UK are assessed in a a proportionate
and robust way, in order to protect the public."
The Nursing and Midwifery Council (NMC) says its
plans include a computer-based exam and tests in
simulated clinical scenarios. And the regulator says
these will replace the minimum three months of supervised practice currently required. But nurse leaders
warn they need more details to confirm checks are
adequate.
Jackie Smith, the NMC chief executive, said: "The new
system will not replace the need for employers to ensure that the staff they recruit display the behaviours,
skills and knowledge necessary for the specific role to
which they are recruited, and provide further support
and development as required."
At the moment nurses and midwives who have trained
overseas make up about 10% of the workforce registered to work in the UK. Around 1,000 nurses a year
come to work in the UK from outside the European
Economic Area - the majority from Australia, India or
the Philippines.
The NMC says one of the reasons behind the change
to assessments is that the current supervised placements - which can last between three months and one
year - are not fast enough to meet demand.
The regulator says the system is "not agile enough for
employers who need to recruit quickly".
And the experts report applicants have had difficulties
obtaining places on the programme, as they are in short
supply.
The new tests, planned to start in the autumn, consist
of two parts:
·
A computer-based multiple choice exam, discussing various situations
·
Observing applicants during simulated healthcare scenarios
Dedicated workers
Janet Davies, executive director of nursing at the Royal
College of Nursing said: "Health care in the UK relies
on the hard work and dedication of many nurses who
trained overseas. "These proposals may well form part
of a more robust and consistent mechanism for ensuring that nurses who work in the UK are equipped to
practise in the UK.
"However, we need to know more about how nurses will
be evaluated as part of this system before we can judge
whether or not the system is adequate.
"Whether nurses come from the EU or the rest of the
world, it is vital that employers are recruiting them for
the right reasons and supporting them when they get
there.
"Too often, nurses are recruited from overseas to fill
short term gaps and given inadequate support to care
for patients well."
Official figures suggest some 67,000 nurses and midwives who completed training outside Europe currently
hold NMC registration.
This adds to the present workforce of more than
670,000 nursing and midwifery staff who have trained
within Europe and gained registration with the UK regulator.
-9-
In
Canada,
there are two
kinds of psychiatric nurses, those who
are uniquely
educated to be
psychiatric nurses and who have separate regulatory
bodies, and those who call themselves psychiatric nurses by virtue of their place of work or their inclination,
these are general Registered Nurses who may or may
not have additional education in psychiatric nursing.
In the four western Canadian provinces, where most of
the uniquely educated registered psychiatric nurses live
and work, their presence has become accepted, while
nursing bodies in Eastern Canada still do not always
fully understand the significance of this large workforce
in the West. For many years the distinct group called
psychiatric nurses or registered psychiatric nurses
(RPN) was of little interest to other nursing groups in
Canada as their primary places of work were the large
mental hospitals where very few general nurses wished
to work.
But in 1954 the mental hospital psychiatric nurses came
to national attention when, at its bi-annual convention,
the Canadian Nurses Association expressed the wish to
discontinue the separate group of psychiatric nurses.
But their efforts were thwarted by the Western medical
superintendents of the large mental hospitals who were
familiar with the work of the dedicated and stable work
force. The superintendents gained the support f the
chief psychiatrist of Canada and the movement to abolish psychiatric nurses was defeated (Tipliski, 2004
)Twenty two years later the Manitoba Association of
Registered Nurses proposed a similar idea, that psychiatric nurses were unnecessary as were licensed practical nurses. The suggestion met with the displeasure,
not only of the superintendents of the provincial mental
hospitals but also the provincial government which was
concerned with the workforce requirements of the mental hospitals. The government refused to eliminate the
psychiatric nurses and licensed practical nurses and
instead called for a review of all nursing education in
Manitoba with the psychiatric nurses and licensed practical nurses having equal representation on the review
panel. With the elimination of psychiatric nurses and
practical nurses being off the table the future of psychiatric nurses was secured. From time to time there continues to be calls for the elimination of the psychiatric
nurses by those who do not understand either the workforce implications or the philosophical impact, neverthe-
less the group has survived and thrived and now
constitute a 5000 strong mental health work force in
Western Canada and with a Masters Degree in Psychiatric Nursing offered by Brandon University the future
seems secure.
However political security comes with philosophical
responsibilities. Historical interest in the phenomena of
psychiatric nursing and its endurance in Western Canada has increased over the past twenty years, and has
resulted in a number of scholarly works which have
either sought to explain, what is considered an anomaly
of Western Canada, or to celebrate it as a unique
profession which is distinctly different from general
nursing. The use of the title nurse has often confused
the fundamental differences between the two groups
and its use may have had more to do with expediency
than accuracy. The term nurse had an acknowledged
and privileged place in the health professions and in
trying to gain respectability for the mentally ill and those
who cared for them the term nurse served the purpose.
The review article in this issue by Smith and Khanlou
provides a useful overview of these differing perspectives.
The defenders of the distinct profession of psychiatric
nursing have focused on the fact that its genesis was
very different from general nursing. The psychiatric
nurses emerged from an asylum environment where the
skilful management of daily life and unpredictable behaviour became the hallmarks of the profession rather
then the sterile techniques and ritualised practices of
general nurses. The nurse-patient relationship, often
called the heart of psychiatric nursing has been referred
to as the analogue of technique of the general nurses
(Dooley, 1998).
Beside the observable behaviours of the patients, mental illness itself defies accurate description and lacks
confirmatory evidence such as x-rays and laboratory
findings typical of physical illness. Nevertheless many
attempts have been made to fit mental illness into the
medical paradigm of diagnose, confirm, and treat, not
always with success. There are many with vested interests who join the discussion on how to categorize and
treat people with mental illness. The discussion occurs
not only in medical, sociological and philosophical circles, often the public believes it too has a right to
suggest or even demand that people with mental illness
be treated in a particular way, usually by permanent
incarceration.
- 10 -
EDITORIAL
Beverley Claire Hicks, PhD, MEd, BScN,
President of the Canadian Association
for the History of Nursing
This conflict between seeing mental illness in the same
paradigm as physical illness while also admitting it is
different is a dilemma familiar to psychiatric nurses.
Today there is a move to call many mental illnesses
neurological-behavioural diseases and to locate mental
disorders in the brain, while this has had some success,
the majority of patients with mental illness continue to
exhibit behavioural and emotional experiences for
which physiological substrates may or may not be detectable. However, with more sophisticated techniques
for exploring the brain the search for physiological explanations for emotional and social behaviour continues. Will such human experiences as love, grief, rage,
compassion or anguish be found at a synapse? The
danger of this kind of reductionism is that emotional
experiences disordered or not, may be reduced to a
chemical reaction. What if the troubled mind is found in
the disordered grey matter and emotional suffering is
reduced to bad chemistry? If a disordered brain is the
cause of the disordered mind what are the implications
for psychiatric nurses?
What is the psychiatric nurse to do if mental illness is
caused by neurotransmitter depletion or excess? Most
psychiatric nurses certainly subscribe to the value of
medication that works at the synapses, they have seen
the dramatic results, but psychiatric nurses have also
seen emotional suffering that cannot be fixed by administering a pill. The human experience of emotional suffering often defies any attempts at amelioration by
pharmaceuticals.
nurse seek relief or meaning of psychological pain or
psychiatric symptoms. We have come a long way from
the kitchen table, where the first psychiatric nurses in
Manitoba hammered out a modest constitution in 1960,
to the halls of academia. We need to continue to grow
and to contribute to a body of knowledge from our
privileged place. It is time to liberate our philosophical
imagination and craft a philosophical perspective that
captures emotional pain regardless of psychiatric diagnosis? While we may be politically secure we now must
become philosophically sophisticated.
References:
Tipliski, Veryl. “Parting at the crossroads: the emergence of psychiatric nursing in three Canadian Provinces: 1905 - 1955. Can Bull Med Hist. 2004;21(2):253-79.
Dooley, Christopher. “When Love and Skill Get Together: Work, Skill and the Occupational Culture of Mental
Nurses at the Brandon Hospital for Mental Diseases,
1919-1946.” Master's thesis, University of Manitoba,
1998.
At one time the word psyche had the same meaning as
the soul and the origin of the word “psychiatry” is derived from the Greek iatros tes psuches which means
“healer of the soul”. Comparisons have been made
between psychiatry and religion as both attempt to
ameliorate or transform ambiguous life situations into
meaningful experiences and many of these spiritual or
psychological experiences share the same cognitive or
emotional distressed states. Attention to the human
experience and the spiritual distress of psychological
suffering may well be the particular space that is unique
to psychiatric nursing.
What does this mean for psychiatric nurses and their
unique place in the mental health system?
Psychiatric nurses have gained a legitimate and respected place in Western Canada which has historically
been denied to them in other parts of Canada, however
with this place comes responsibility. There is no uniquely articulated philosophy of psychiatric nursing constructed by RPNs. In the evolution of a profession,
gaining legal status usually precedes attention to the
deep philosophical meaning of the work of the profession. What is the unique space attended to by psychiatric nurses? It may be at the intersection of the spirit and
the psyche where deep questions about the nature of
the being human and the nature of anxiety, despair, joy
and suffering are posed. For individuals with a mental
illness these questions are particularly poignant and this
may be the place where both patient and psychiatric
- 11 -
Dr Hicks, retired from the position as Assistant
Professor from the Faculty of Health Studies at
Brandon University, Manitoba.
In 2012, Beverley appointed the President of the
Canadian Association for the History of Nursing.
Presently, Beverley is a Board Director and CoChair for the Registered Psychiatric Nurses Foundation Inc. That awards scholarships to undergraduate and graduate psychiatric nursing
students.
RPNF
NEW JOURNAL FEATURE
Commencing in JANUARY 2015, the Journal will feature a
Continuing Education section in the form of Psychiatric Nursing
Rounds. Each round will present either a case study or a disease
pathology.
Nurses who wish to receive a certificate of continuing education
(CE) to keep within their ongoing competency profile of continuing education may click on the “Submit” button at the end of each
feature to complete a request for this CE certificate. It will be
emailed to you within 2 working days.
A personal Honour Code is in place, so when requesting a certificate for acknowledgement, each nurse declares they have actually
read the feature and, if required, answered the quiz that follows.
The honour code in this circumstance is defined as: “ unsupervised arrangement in which readers avail themselves to continuing education articles and are relied upon to to act without
direct supervision”.
We hope you will enjoy this new feature and partake of this
learning opportunity.
Dr. Larry Mackie
The Executive Editor
- 12 -
Psychiatric Nursing Rounds
PSYCHIATRIC NURSING
ROUNDS
An Analysis of Canadian Psychiatric Mental
Health Nursing through the Junctures of
History, Gender, Nursing Education, and
Quality of Work Life in Ontario, Manitoba,
Alberta, and Saskatchewan.
Dr. Nazilla Khanlou
1. Introduction
The account of the way
Canadian psychiatric
mental health nursing (PMHN) has emerged into its
current state can provide an insightful perspective that
fosters a better under- standing of its present challenges and opportunities. This review paper examines the
development of Canadian PMHN in Ontario and the
western provinces since the beginning of the 20th
century. Canada consists of 3 territories and 10 provinces. With a population of approximately 34,880,500,
Canada had the highest growth rate of the G8 countries
in the 2011/2012 period [1].
In Canada, registered nurses (RNs), registered psychiatric nurses (RPNs), licensed practical nurses (LPNs),
and nurse practitioners are employed in the area of
psychiatric or mental health care. RPNs are a regulated
separate profession in the provinces of Manitoba,
Saskatchewan, Alberta, and British Columbia (For the
purposes of this paper RPN refers to registered psychiatric nurses that are only legislated in the four western
provinces. In Ontario, registered practical nurses, also
abbreviated to RPN, provide care in all settings and are
not solely specific to or trained in the area of psychiatric
mental health. When RPN is used in this paper, the
reference is to registered psychiatric nurses.)
Statistics on the various types of nursing professions
employed in psychiatric or mental health care can
reflect pertinent conditions in relation to the Canadian
mental health system. For instance, in 2010, 5.1% of
all RNs in Canada were working in the mental health
care sector, a slight decrease from 2007 where 5.2 were
employed in this same area [2]. In Ontario alone, between 1993 and 2003, there has been a 29.4% drop in
the number of nurses working in the psychiatric sector
[3]. The number of RPNs increased by 3.8% since 2007
but the RPN workforce remained at 1.5%. The proportion of full time RPNs in psychiatric nursing decreased
from 67.8% in 2007 to 62.2% in 2011. The RPN profession
also has the highest percentage of males, 22%, of all the
Canadian nursing professions [2]. According to the
Canadian Nurses Association, nurse practitioners (NPs)
account for 0.9% of the entire number of RNs [4]. Of the
2,486 NPs employed in Canada, 1,482 or 60% work in
Ontario. The percentage of NPs working in psychiatric
mental health in 2010 was 1.4% [4].
and
Mary Smith
in Canada suffer from mental
health problems. The Canadian
Community Health Survey by
Statistics Canada was completed in 2003 and is scheduled again in 2013. This will enable further comparisons
of how Canada fairs in terms of prevalence of mental
health disorders and the mental health services
available [5]. In 2003, it revealed that two-thirds of those
who experience mental health problems do not receive
mental health services [6]. Furthermore, persons living
with mental illness may have difficulty competing for
limited health care due to high rates of poverty and
disability [7]. In 2012, the Institute for Clinical Evaluative
Sciences and Public Health Ontario released the report
“Opening eyes, opening minds: the Ontario burden of
mental illness and addictions report” [8]. This report
measures the extent of mental illnesses in Ontario in
comparison with the prevalence of other medical conditions. Addictions and mental illnesses represent an enlarging burden. The need for improved accessibility of
mental health services is emphasized [8]. The size of the
PMHN workforce and the accessibility of services may
impact mental health care for Canadians.
Historically, the deinstitutionalization trend that began in
the 1960s resulted in many persons with mental illness
being released into the community where a serious lack
of mental health services prevailed [9]. This led to a
significant portion of individuals with mental illness to
become imprisoned in jails or detention centers with
limited access to mental health care. Additionally, a
revolving door phenomenon occurred where previously
institutionalized individuals were readmitted into acute
psychiatric care settings [9].
To further understand the Canadian context for PMHN,
it is useful to be familiar with developments concerning mental health care in Canada. There are recent
major initiatives underway in Canada with regards to
mental health reform. In 2005, a national review of the
Canadian mental health system took place as outlined
in the Kirby report [10]. In 2006, the Standing Senate
Committee on Social Affairs, Science and Technology
completed the final report entitled “Out of the shadows
at last—transforming mental health, mental illness and
addiction services in Canada” [11]. As the mental health
care system was considered to be fragmented, the final
report made recommendations for the reformation of
mental health care. The assembly of a Mental Health
Commission to enable a national strategy for mental
The statistics concerning the employment of nurses in the health care was emphasized by Michael Kirby, the
mental health care sector are meaningful when consid- chairman of the Standing Senate Committee on Social
ered in light of the statistics concerning how many people
- 13 -
Affairs. Funding for the commission came in 2007, and
in 2009, the Mental Health Commission of Canada released the framework “Towards recovery and wellbeing: a framework for a mental health strategy for
Canada” [12]. Seven goals are set in this framework
that represent how a transformed system will appear.
The goals depict that everyone should have the
opportunity for optimum mental health and well- being
[12]. The Mental Health Commission has recognized
that there is a lack of opportunities for Canadians with
mental health disorders to achieve optimum mental
health. This calls for key stakeholders, that is, groups
interested in responding to people with mental health
concerns, to address ways to further the provision of
mental health care. Nurses are the largest group of
healthcare providers, and nurses who provide mental
health care are important stakeholders in meeting the
mental health care needs of Canadians.
In 2012, the Mental Health Commission of Canada
released the blueprint “Changing directions, changing
lives: the mental health strategy for Canada” [13]. Six
strategic directions are given in this report including
the provision of mental health services and treatments
accessible to the people who need them. Reference
to the vital role nurses have in conjunction with the
team of health care providers to fully achieve the
strategic directions is not explicit in the 2012 report.
Community health nurses are instrumental in providing
mental health care in the community. In addition, NPs
are becoming increasingly more common in providing
primary health care within Canada. Their role in the
assessment, diagnosis, and treatment of mental health
disorders may be extremely useful to further the
strategic direction concerning enhanced accessibility
to treatment. Collectively, nurses and nurse practitioners
have a critical role in the strategic direction as identified
by the Mental Health Commission of Canada. A national
strategy is needed, and mental health care providers will
need to be included in this strategy according to the
Kirby report [10]. Nurses who form the largest group of
health care workers in Canada may need to be strong
stakeholders in the strategic direction for mental health
care in Canada. The commission has yet to clearly voice
how health care and nurses will be reorganized to
support accessible services and treatments.
Kirby [14] indicates the pivotal position that mental
health care providers have and also addresses concerns regarding the stress levels and mental health of
health care professionals themselves. Indeed this leads
to concerns regarding the quality of nursing work life for
PMHN and how this specialty is responding to the
demands of the mental health care system. The
analysis of the history of Canadian PMHN can enable
a better understanding of why PMHN is the way it is
today. With this understanding, opportunities for further
PMHN development, education, and future research
may surface.
explore how nursing will move to foster improved
mental health care. At this time, there is a shortage
of research studies that look at how the current
nursing workforce specifically addresses improved accessibility to mental health care. Career pathways to
become NPs that specifically work in mental health are
lacking, where NPs may diagnosis and treat mental
health conditions. As an NP working in mental health
care, the options for pursing advanced mental health
nursing education in Canada are limited. PMHN
education varies across Canada and unlike the United
States there is no legislated psychiatric mental health
nurse practitioner (PMHNP) role. Also RPNs may wish
to become advanced practice nurses or PMHNPs that
are able to diagnose or prescribe psychotropic medications. A regulated PMHMP’s role may further the
accessibility of mental health care in Canada. There
are opportunities for nurses to achieve a master’s degree in mental health in Manitoba; however, there are
no programs in Canada that specifically yield PMHNPs that may diagnose or prescribe medications particular to mental health care. The educational programs for
nurses also vary in each province in terms of content and
the prerequisites. With the variety of diff rent educational approaches to PMHN in Canada, the career path to
advance nursing practice in PMHN is complicated. An
RPN in the western provinces has had different preparation than an RN working in mental health care in Ontario. How these diverse PMHN educational approaches
have come to be and their implications for Canadian
PMHN can provide useful insights to inform future directions to PMHN in Canada.
2. Materials and Methods
2.1.
Review Aims and Research Question. The
purpose of this inquiry is to understand the current
state of mental health nursing in Canada through the
intersections of history, gender, nursing education, and
quality of work life as evidenced by the existing research
and literature. The research question that guided it was
as follows: what does the research reveal about contemporary Canadian PMHN in terms of the junctures of
history, gender, education, and quality of PMHN work life?
An integrative methodology was determined to be most
suitable for this review due to the scarcity of data on
the organization and efficacy of Canadian PMHN.
Rigor was maintained through evaluating primary sources for method- ological quality. The integrative review
includes the stages of problem identification, literature
search, data evaluation, data analysis, and presentation.
2.2. Integrative Review.
Whittemore and Knafl [15] explain that the integrative
review is particularly suited to inquiries with limited
Given the need for increased accessibility to mental existing empirical research. Historical events in PMHN
health care and treatment, it is helpful to further are relevant to how this field has come to be. Yet few
- 14 -
research studies exist on Canadian PMHN, and the
studies are in the form of social historical analyses that
reflect on the events of the past. Moreover, there is a
paucity of data pertaining to Canadian NPs specific to
mental health care and NP mental health education.
Sociological, critical, and social historical analyses,
reports, and surveys on Canadian nursing and Canadian mental health care offered insight into the field of
Canadian PMHN that furthered this inquiry (see
Tables 1, 2, and 3). In the integrative review, according
to Whittemore and Knafl [15], diverse methodologies
may be incorporated to further a comprehensive grasp
of issues suited to the complexities of health care. Both
quantitative and qualitative research may contribute to
the perspective concerning a phenomenon. The culmination, analysis, and evaluation of diverse data and
research regarding PMHN enabled a perspective that
may begin to further understand- ing mental health care
in Canada in light of the lacking research solely
pertaining to Canadian PMHN or PMHNPs.
2.3. Theoretical Perspective.
A sociological perspective allows for a critical assessment of common assumptions and fosters recognition of
opportunities and constraints that shape our circumstances, the interplay between societal forces and
personal lives, and of human diversity [16]. In addition,
the concept of gender stratification is comprehensively
analysed within sociology and is applicable to the topic
of this paper. Gender stratification concerns the imbalanced division of privilege and power between females
and males [17]. A sociological perspective is appropriate for this inquiry as nurses are employed within
gendered hierarchal structures that interact and are
influenced by the larger political con-text.
Feminist theories, emerging from a sociological perspective, address patriarchy, power structures, and
gender inequality. They are concerned with the societal
organization and interactions that maintain male
authority and female subordination [18]. A feminist perspective enables the depiction of the social structures
leading to the devaluation of women. Social order then
becomes the problem rather than women themselves
[18]. The intent in this work is not to devalue women
or nurses but, rather, to illuminate the social structures
that have persevered throughout history and have influenced PMHN education and quality of work life. The
sociological perspective applied here encompasses
feminist concepts.
The primary literature search involved databases, the
internet, and published online journals. The databases
included CINAHL, PsycINFO, Evidence-Based Mental
Health, Cochrane, PubMed, and ProQuest. Published
online journals were accessed through Blackwell
Synergy and Sage. Primary search results were then
analyzed to search their references for secondary sources of interest. The databases were accessed through the
York University Library, Toronto, Ontario and Queens
University Library, Kingston, Ontario. Texts were borrowed through the assistance of the librarian at
Waypoint Centre for Mental Health Care, Penetanguishene, Ontario.
Through combinations of keywords, topics searched for
included psychiatric nurses in Canada, Canadian psychiatric nursing history, Canadian psychiatric nursing
education, Canadian mental health nursing, Canadian
psychiatric men- tal health nursing, Canadian nurses and
gender, quality of life for Canadian psychiatric mental
health nurses, stress experienced by psychiatric nurses
in Canada, registered psychiatric nurses in Canada,
work stress of nurses working in mental health, literature review on psychiatric mental health nursing in Canada, sociological perspective of psychiatric nursing,
psychiatric mental health nurse practitioner, mental
health nurse practitioner education, and sociology of
nursing stress. The searches included English language
reports, studies, reviews, editorials, and narratives and
was limited to Canadian sources and Canadian PMHN.
The intent was to better understand the Canadian
context of PMHN. International comparisons were
beyond the scope of this undertaking. With regards to
the unique Canadian historical influences shaping
PMHN, 14 studies were selected as relevant. There
was a lack of studies that focused solely on the
Canadian PMHN experience as many reports
included RPNs and RNs. RNs in the provinces east of
Manitoba do not have a separate psychiatric regulation,
as do the western provinces. No studies were found on
the education in Canada for NPs in mental health. As a
result data often combines all nurses. This made it
difficult to discern the unique state of Canadian PMHN
from that of all Canadian nurses.
3. Results
The results from the literature review are divided into
three sections. The first section reviews the literature
from 2 sources that include a critical sociological perspective. The next section considers the interrelation of
history, gender, and the development of education for
Canadian PMHN through the review of 6 social, historical, and analytical studies. The final section focuses on
A sociological perspective also bridges history and how the quality of Canadian mental health psychiatric
things are today. Wright [19] calls this way of thinking nurses work life from 6 survey reports.
the sociological imagination that grasps the connection
between history and the way we are and the way we are 3.1. Studies with a Sociological Perspective Relevant
becoming. The history of PMHN seen through a sociolog- to PMHN.
ical perspective can promote an understanding of its
Wall [20] utilized a sociological outlook, as described
current state.
in Section, to critique nursing practice settings and
nurs- ing research. The experiences of nurses can be
further understood through a lens that encompasses
2.4. Search Strategies.
professionalization and organizational influences. In
- 15 -
addition, gender is ingrained in all of nursing where a
patriarchal culture manifests. According to Wall [20],
the control of medicine over nursing is evident in nursing’s utilization of quantitative approaches in research
that is consistent with the history of medicine. Health
care, being a largely institutionalized entity, has its own
way of socializing nursing and continues to place medicine at the apex of health care despite health care
reformation. Conversely, Wall [20] does not comment on
the socialization or culture of medicine with regards to
gender, as medicine being once an overwhelmingly male
profession increased the number of female practitioners.
Furthermore, the discussion by Wall [20] discusses
nursing in general and does not specify particular
sectors of nursing such as NPs. Nevertheless, a critical
sociological paradigm may help to further understand
issues in nursing and PMHN related to knowledge,
gender, professionalization, and organizations [20].
McGibbon et al. [21] utilized Smith’s [22] sociological
frame of institutional ethnography to reconsider the stress
in nursing through interviews, focus groups, and observation of paediatric intensive care nurses [21, 22].
Results suggest that stress is framed within the social
structure of organizations that may have hierarchical
and power-based relations. Articulating patient matters
may be challenging in organizations with hierarchical
systems. This may contribute to the level of stress
nurses experience. Studies concerning nursing stress or
vicarious trauma often neglect how gender influences
the life of nurses. Theories that are utilized in nursing
research may avoid gender analysis. Without a
gendered analysis, occupational stress may not be
illuminated or solutions may not be identified. Nursing
may further benefit by utilizing a gender perspective in
research to potentially unveil social patterns that may
influence teamwork and collaboration. Gender, race,
and class are aspects of nurses’ identities but may not
be within the range of the theory utilized for the
research. This may lead to research that may neglect
identification of concerns for nurses [21]. The critical
gendered and sociological perspectives as depicted by
Wall [20] and McGibbon et al. [21] provided the lens
in how PMHN is perceived in relation to the following
results.
3.2. Intersections of History, Gender, and Education
for Canadian PMHN.
Tipliski [23] contributes to the understanding of Canadian PMHN history in the study entitled “Parting at the
crossroads: the emergence of education for psychiatric
nursing in three Canadian provinces,” 1909–1955. Gendered roles may have permitted psychiatry to maintain
control of psychiatric nursing education in the western
provinces. Unlike Ontario, where nurses were able to
assume control over PMHN, thereby allowing PMHN
incorporation into general nursing education, the provinces of Manitoba and Saskatchewan permitted psychiatry to prevent the merging of PMHN with general
nursing. From here, as Tipliski explains, two different
models for Canadian PMHN education developed lead-
ing to the class of the RPN that only exists in the
western provinces [23]. This may have fostered a partition in the PMHN nursing force in Canada, as the RPN
designation presents a separate regulation of nurses
that is nonexistent east of Manitoba.
Tipliski [23] describes how the nursing leaders of
Saskatchewan and Manitoba failed to assert control
over nursing education. In 1955, the Canadian Nurses
Association (CNA) recognized how the separate training
that was occurring in the western provinces was not conducive to the efforts to professionalized nursing for all of
Canada. Unfortunately, a progressive movement by the
nursing leaders of that time to bring psychiatric nursing
under the umbrella of general nursing in the 1950s dissolved. This left the western provinces with a split nursing
educational approach where psychiatric nurse training
remained separate from general nursing education and
in the hands of psychiatrists [23]. Although psychiatric
nursing is no longer controlled by the psychiatrists in
the western provinces, separate training for RPNs remains. From this perspective, it can be appreciated how
female nursing leaders in Ontario influenced historical
developments to integrate psychiatric nursing education,
which was consistent with earlier efforts made by CNA
to converge the psychiatric nursing education with
general nursing in the western provinces. Ontario nurse
leaders were able to gain control over their own
nursing education and practice and were aided by the
government. Tipliski [23] explains how the Ontario
male medical superintendents attempted to keep
mental nursing separate from general nursing thus hindering the professionalization of nursing. The contributions from Nettie Fidler in 1933, a nurse graduate from
the Toronto General Hospital, together with a report by
Professor George Weir that recommended the merging
of general with mental nursing, stimulated the progression by the Registered Nurses Association of Ontario
(RNAO) to advocate for closure of the separate schools
providing only mental health training [23]. It is possible
that this account may overlook some of the other possibilities accounting for how PMHN developed in diverse
ways, yet Tipliski [23] provides a description of the
history of PMHN that may help to explain how gender
dynamics influenced the development of PMHN in Canada. Despite the variation between educational approaches that resulted in the RPN designation for the provinces
West of Ontario, there is a lack of evidence revealing
how PMHN care varies given the differing education
preparations.
Of interest is Tipliski’s [23] reference to how gender may
have been a factor in the development of the RPN designation of the western provinces. This relates to the feminist concepts of patriarchy. Brown [18] defines patriarchy
as a social system that holds several assumptions. One
assumption portrays women as being assigned a
social function. In nursing, as Tipliski [23] depicts
nurses were assumed to be fitting to provide care due
to their female gender with their inherent ability to
nurture. The view of female nurses as nurturers may
have been a patriarchal belief held by the male medical
superintendents. Another patriarchal assumption is that
- 16 -
women are thought of as weaker and less strong. Tipliski
[23] also considers the patriarchal context of PMHN,
where the nurse leaders of the western provinces may
have struggled against the authority of the medical
profession. On the other hand, Tipliski [23] does not
speak of the power issues between general nursing and
medicine or the professionalization the regulated
psychiatric nurses of the western provinces experienced.
Dooley [24] argues that the separate class of psychiatric
nurses in Manitoba developed their own unique craft
that is specialized for the mentally ill population. In this
study, the account from Manitoba mental health nurses of
the 1930s supports the view that the development of
their nursing profession was the outcome of their cooperation with physicians. Female mental health nurses in
Manitoba considered themselves skilled and at a higher
level than the male attendants. The female nurses were
often in supervisory positions directing the personal care
given by the male attendants. This contrasts with
Tipliski’s [23] view on the separate division of psychiatric
nursing being related to paternalistic structures and in
which female mental nurses could not overcome male
physicians and psychiatrist’s domination that sought
control and power. Yet the Manitoba mental health
nurses that would become RPNs asserted their distinct
class, and this has enabled the continuation of the
separate training for mental health nursing that continues to manifest inside the western provinces. Evidence
to suggest that the separate divisions of psychiatric
nursing education in Canada that have any effect on
the quality of mental health care has not been substantiated in research.
One must also acknowledge the circumstances that
influenced Canadian women as nursing leaders in the
past. For instance, Dooley [24] describes the social
context of the inter-war years where women were
looking for ways to support themselves, and mental
health nursing provided a way to live that would provide
regular meals and housing for mental health nurses.
From this description, it is possible that PMHN also developed in diverse ways in Canada as a result of social
and economic circumstances in addition to gender influences, that have yet to be fully explored.
Hicks [25] provides further details concerning Manitoba’s
adoption of the RPN model. Through a genealogical analysis, the study considers historical circumstances that
led to the RPN model. Gender stands out as a main
influence in this movement where the male leaders of
the psychiatric nursing associations of the adjacent
western provinces were influential in drawing Manitoba to
call for the distinct nursing class. The male nurses of the
RPN psychiatric nursing associations in the western
provinces developed a collegial relationship with the
male attendants of Manitoba who sought RPN status.
This presents an interesting insight with regards to
gender, in that the men were able to increase their
strength and power through the joining with the male
psychiatric nurses of Manitoba. This also diverges form
Tipliski’s view where the psychiatric nurses were
submissive to medical authority in relation to the
female gender. In addition, the separate psychiatric
RPN distinction was favoured by the male medical superintendents as there was a lack of interest by the
general nurses to work in psychiatry [25], which may
have also furthered the movement towards the RPN
class. Hicks [25] considers the large number of male
attendants and the significance of gender in the
creation of the RPN designation. Male attendants
provided custodial care and sought to provide nursing
care that would elevate the status of the male attendants. Unlike Dooley [24] and Tipliski [23] who focus on
the female gender of nursing, Hicks [25] depicts the
collegiality and support of male RPN leaders of the
western provinces. The Canadian Council of Psychiatric
Nursing provided support to the Manitoba attendants
who sought RPN status [25]. The RPN emergence may
be seen as a way for the male gender to enter into
nursing in a time where nursing was culturally enshrined
as a female role and the attendants of psychiatric
institution sought status and class through the RPN
profession. In this way, Hick’s study demonstrates how
male gender has influenced the history of Canadian
PMHN [25].
Boschma et al. [9] examined nurses’ stories that further
the understanding of the development of PMHN in Alberta. RN status was recognized as being desirable for
PMHN and could be achieved by mental health nurses
by taking an extra 18 months of training in a general
hospital after completing 2 years in a psychiatric
hospital. Women were sought as nurses by the
governing psychiatrists for their caring and compassionate nature. The male attendants were excluded
from nursing because of their gender and became
increasingly resentful. The male attendants sought recognition and professional status. Like Saskatchewan,
the separate status from RNs was lobbied for by the
male attendants and in 1963 registration was given to
psychiatric nurses [9]. In this sense, the development of
the separate RPN status stems from the gender division
that favoured RN status to females leaving male mental
health attendants to seek professional status by becoming RPNs. Similar to Hicks [25], Boschma et al. [9] also
indicate the influence of male attendants. This differs from
the view held by Tipliski [23] that mainly denotes the
oppression of largely female nurses by the medical
superintendents. Likewise, the account by Hicks [25]
and Boschma et al. [9] also varies from the perspective
by Dooley [24]. Dooley [24] explains that the female
psychiatric nurses saw the RPN category as separate
and offering more to the mental health care of patients
than the general nurse education could offer. Despite
the development of the RPN class, mental health care
in Alberta continued to suffer and the need for further
education continued pressure to achieve RN status [9].
Professionalization through the regulation of RPNs is
described further by the interweaving of data from Boschma’s case study of community mental health in Alberta
[26] and Hick’s historical review of psychiatric nursing
in Manitoba [27]. Boschma [26] explains that Alberta
graduates from the mental hospitals that started in the
- 17 -
1930s met with resistance from the general nursing
organizations leading to the forma- tion of the separate
professional organization for RPNs. Hicks [27], consistent
with Tipliski [23], indicates that the Alberta Association
of Registered Nurses (AARN) had opposed the plan by
superintendent Charles Baragar to establish a program to train psychiatric nurses. The AARN recommended that general nurses may complete a postgraduate psychiatric course or combine with general nursing
students during a third year of training. They also
suggested the hiring of general nurses who were
unemployed. Baragar, however, was able to succeed
in his intentions through his appeal to the minister of
health, and the program was implemented. This program included a total of 4 years of instruction at the
mental hospital with 2 of these years occurring at the
general hospital. Male attendants were restricted from
attending and had to complete a three-year psychiatric
program. The male attendants went on to successfully
lobby for the Alberta psychiatric professional nursing
association [27]. Hicks [27] explains that the association’s activities during that period may have been more
union type activities rather than professional. In the
1950s, the movement to form the psychiatric nursing
association was developing in Manitoba. The Canadian
Nurses Association recommended combining the RN
and psychiatric training programs in disapproval of the
two models emerging for psychiatric nursing in
Canada. Despite efforts to organize this endeavour, Canadian Nurses Association’s (CNA) plans were never
realized [27]. Boschma [26] and Hicks [27] further
explicate that beyond the development of the RPN
profession to meet the poor staffing of the mental
health facilities, the profession of psychiatric nursing in
the western provinces grew to deliver a much needed
service that provides specialized mental health nursing
differing from what general nursing could supply. The
RPN profession may advance mental health nursing
knowledge and care through the experiences gained from
this profession’s unique historical development.
3.3. Quality of Canadian Mental Health Psychiatric
Nurses Work Life.
In 2001, the Canadian Nursing Advisory Committee
(CNAC) formed as a result of the recommendations by
the Advisory Committee on Health Human Resources
(ACHHR). The ACHHR’s first recommendation of the
Nurs- ing Strategy for Canada [28] was to create the
CNAC. The CNAC included nursing representatives
from the three nursing professions of RNs, RPNs, and
LPNs. The CNAC’s main goal concerned the quality of
nursing work life and the identification of provincial and
territorial strategies to enhance nursing work life. With
the shrinking workforce this was deemed a high priority.
The CNAC’s recommendations concern all nursing
workplaces including settings that pro- vide PMHN.
The CNAC commissioned 6 projects which looked at
strategies to improve workplaces, costs related to absenteeism and overtime, workload issues, satisfaction of
nurses in the workplace, workplace respect, and autonomy and health care organizational structures [29]. As a
result, 51 recommendations were made to the ACHHR.
The recommendations can be summarized into three
categories. The first category concerns management
issues and resources. There is a need to reduce nursing’s pace and intensity, increase full time work, decrease
sick time and overtime, and enable full scope of
practice. The second recommendation speaks to professional work settings that foster a thriving and dedicated
workforce. Respect for nurses is key to this recommendation, as well as education at the master and doctoral
levels. Education for nurses should be accessible in
remote and rural areas. Violence and abuse in the
workplace must be addressed. In the third recommendation, monitoring of the health of nurses and workplaces and disseminating information to keep nurse
abreast of initiatives and education are considered. Accreditation, awards to promote quality of nursing work
life, continued research on the nursing workforce,
implementation of regional nursing committee recommendations, national nursing retention, and recruitment campaigns with a heightened emphasis for diverse and
aboriginal groups are a few activities mentioned within
this recommendation [29]. The recommendations strive
to rectify the main issues that concern the shortage of
nurses, the lack of educational opportunities, the limited
scope of nursing practice, and the unfavourable working
conditions, which are also applicable to the RPNs and
RNs who provide PMHN. However, the CNAC recommendations lack consideration of gender and its intersection with professionalization and workplace culture that
culminate in the core of issues, including patriarchal
culture- and power-based hierarchical organizations that
impact nursing work lives [20, 21]. Lacking also from
the CNAC recommendations is reference to PMHN
being a stakeholder in mental health. As a stakeholder,
PMHN needs to organize as a united front, so that its
voice is heard. This may be challenging as more
powerful stakeholders, like medicine, have traditionally
dominated health care [20, 21].
Maslove and Fooks [30] conducted a study to determine
the degree of implementation of the 51 CNAC recommendations made in 2002 as requested by the Office of
Nursing Policy at Health Canada. Policies of the stakeholder organizations were assessed to determine their
impact on facilitating the implementation of the recommendations. Their methodology included scanning of
websites, sending letters to 94 stakeholders to determine their progress, and interviewing 14 informants to
identify barriers and supports. The 94 stakeholders
included employer organizations, the federal government, provincial/territorial governments, unions, professional associations/regulators, educators, research
community, and national organizations. There was a
50% response rate from stakeholders. Findings were
then shared with nursing stakeholders at a roundtable
to enable feedback [30].
The recommendation to increase the number of education seats occurred in a uniform manner. However,
other recommendations occurred in some areas but
not all, and there was difficulty in determining what had
occurred nationwide. Implementation of the recommendations including workload measurement systems, in-
- 18 -
creased full time positions, analysing sick time,
increasing nurse mentors, and flexible scheduling were
not consistently taking place throughout Canada. Key
informants favoured regulation at the provincial versus
the national level. The lack of stable funding was
depicted as a barrier to implementation of the recommendation to develop secure jobs. The varying professional associations and regulatory colleges that exist in
each province may complicate assigning recommendations [30]. Respondents addressed lack of interest
from government regarding nursing issues. Accountability is seen as critical to implementation of the recommendations made by the CNAC. Determining what
organizations should be responsible for is a priority
concern, and employers need support to enable improvements that will impact nursing quality of work life
[30]. Organizations may require government funding in
order to implement the recommendations that will enhance nursing work environments.
Together, the CNAC’s recommendations [29] and the
study by Maslove and Fooks [30] include data from
RPNs and general nurses who also provide psychiatric
care in the provinces east of Manitoba. Issues pertaining to violence and abuse were seen as priority issues
[30]. Poor working conditions may negatively impact
quality care, and the lack of action and accountability by
organizational and provincial territorial leaders and their
support to employers [30] may adversely impact the
mental health of both nurses and the Canadian population, which they serve.
Findings from the 2005 National Survey of the Work and
Health of Nurses (NSWHN) [31] examined the health
of Canadian regulated nurses as related to their work
environment. The data as presented here was collected
between 2005 and 2006. Nineteen thousand nurses
inclusive of RNs, RPNs, and LPNs were surveyed with
a response rate of 80%. More than one-quarter reported
being physically assaulted. Of note is that 44% of males
reported assault compared to 28% of female nurses.
The reasons for this finding are not elaborated upon in
the 2005 NSWHN. It is not known if this points to male
nurses being more likely to be assaulted or more likely
to report assault. Forty-four percent of nurses reported
emotional abuse. High physical demands were reported
by 75% of LPNs, 60% of RNs, and 45% of RPNs.
Gender difference was not specified for physical demands, that is, if male or female nurses reported higher
physical demands. The mental health of nurses was
adversely associated with evening shifts and employment in long-term care facilities. Lack of respect and low
support from coworkers and superiors were linked with
poorer mental health. In addition, the mental health of
nurses was also affected by elevated job strain, low
autonomy and control, and poor physician relations. One
in ten nurses reported having depression and needing
to take time off in relation to their mental health. The
finding of depression in nurses is compared with the
overall employed population that utilized data from the
Workplace and Employee Survey, Labour Force Survey,
and the Community Health Survey [31]; however, comparisons with specific groups or professions are not
explicit. Of all nurses, including both male and female,
9% experienced depression. The experience of depression by sex was not included for nurses but for all;
employed the 4% of men and 7% of women experienced depression. Also at the time of this study in
2005, one-fifth reported their mental health difficulties
interfering with their jobs. Quality of care was negatively
affected by inadequate staffing. Thirty- eight percent of
nurses felt that staffing was inadequate. Improvements
in quality care were related to improved management
and more staffing [31]. The findings of this survey may
further illuminate the working conditions for nurses and
the implications for their mental and physical health.
The Health Policy Research Bulletin (HPRB) is published
usually twice yearly by Health Canada with the purpose
of reinforcing the evidence that supports decision
making in health policy. In 2007, the HPRB’s issue, titled
“The working conditions of nurses: confronting the
challenge” [32], focused on the Canadian nurses’ working conditions and implications for the country’s health
care system. Between 1997 and 2005 overtime by
RPNs, LPNs, and RNS increased in all areas where
nurses work by 58%. In light of the high overtime
rates, it is questionable if the current level of full-time
nursing positions in mental health care in Canada is
sufficient to adequately care for those with mental
illness. All areas in nursing face similar pressures concerning increased overtime and a need for more full time
work; however, mental health settings entail frequent
interactions with challenging and difficult behaviours.
This may intensify the stress on nurses working in
mental health care where there is shortage of full- time
nurses.
Robinson et al. [33] conducted a study with a
cross-sectional design. A survey of 1015 RPNs in
Manitoba was conducted to determine the predictors,
prevalence, correlates, and distribution of vicarious
trauma and burnout. The survey included the Maslach
Burnout Inventory, the Traumatic Stress Institute Belief
Scale, and a section on post-traumatic stress disorder
(PTSD) symptoms. Seventy-nine percent of the respondents were female, and 20.2% were male. Emotional exhaustion was the highest in RPNs working in
community services and acute care hospitals. Constant
interruptions, burdensome responsibility, increased trauma work, depersonalization, and elevated vicarious trauma scores were linked with higher emotional exhaustion
levels. With regards to vicarious trauma, 21% had persistent thoughts in relation to client trauma, and 30%
experienced a heightened level of arousal. Client
trauma is the exposure to a stressful experience that
overwhelms a person’s coping mechanism. Fifty-five
percent of those involved in client trauma met one
criteria of PTSD, and 48% responded that symptoms
were troublesome to some degree. Lack of peer support
and skills to deal with trauma could be rectified by increased education and team building. The RPNs in this
study also reported a high level of personal accomplishment, which is associated with low burnout [33].
Personal accomplishment includes the perception that
clients are improving and the RPNs have the skills
- 19 -
According to Ryan-Nicholls [34], the shortage of RPNs
is a concern of the existing RPNs. Previously, it was
believed that de-institutionalisation would perhaps leave
RPNs without jobs. Now, there are not enough RPNs to
fill the vacant positions. In addition, participants in the
focus groups discussed concern about the 2-year
diploma program changing into the 4-year baccalaureate degree for RPNs, graduating only 15 students per
year as compared to 60 students per year from the
diploma program [34]. Therefore, the issues for RPNs
parallel to the issues of the broader nursing workforce,
where the shift to higher education has impacted the
Ryan-Nicholls [34] studied the repercussions of health size of the nursing workforce, but at the same time the
reform in RPNs. Seven focus groups with RPNs from a nursing graduates of today have increased knowledge
diversity of health care settings took place in Manitoba to meet the current challenges of health care.
over a nine-month period. The themes that emerged
consisted of changes from institutional care to the com- 4. Discussion
munity, variations in professional position, primary and
secondary care and prevention, lack of provincial com- The diversity between the organization of PMHN and
munication, and consistency amongst policies. De-insti- edu- cation between the western provinces and the rest
tutionalisation was considered to have largely of Canada has connections with events of the past and
impacted the practice setting of RPNs. This change intersects with gender, professionalization, and the preled to an extension of their roles in many different set- dominating organizational culture. The historical analytings including emergency departments, treatment cen- ses of nursing may foster additional inquiries that may
tres, and acute psychiatry. RPN professional status has benefit nursing knowledge through learning from past
required a move to more autonomous roles within the approaches and gaining new perspectives.
primary care setting where professional competence is
emphasized. Emphasis on health promotion and preven- Overall PMHN in Canada is challenged to further itself
tion is in contrast to the traditional approaches that fo- to meet the lack of accessible mental health services.
cused on treating illnesses in institutionalised settings. There is evidence that nurses are stressed, and there
Study participants described lack of consistency with is a need to enhance a coordinated national approach
mental health standards, protocols, and policies in the for advanced degrees in PMHN. The lack of a uniform
region. This was not conducive to the provision of mental approach to PMHN education in Canada has consequences for the further development of PMHN and may
health services [34].
generate barriers to further PMHN to meet the growing
In the same study, the RPNs became more familiar mental health care challenges. The implementation of
with the growing emphasis client-centered care and the standards by the Canadian Federation of Mental Health
need for mental health consumers to be involved in Nursing is brought to the discussion here in order to
the decision making process. The transition from the explain how standards are an important way to address
traditional institutionalised care where decisions were the diverse forms of PMHN education. The standards
made for the clients had left some RPNs feeling unpre- foster an overarching educational approach for PMHN
pared and concerned that the client may not choose that enables quality PMHN practice. In 2006, the third
what is best for them. The importance of engaging the edition of the Canadian standards for psychiatric-mental
family has become more apparent and this contrasts to health nursing was released in an effort to prompt
the way care was provided in the past where family nurses to adopt the standards into daily practice and
involvement was limited in the institutional setting [34]. further nursing reflection on their work [35]. The latest
The education of RPNs and RNs is essential to meet the standards were developed after consultation with Canachanging approaches to caring for those with mental dian consumers of mental health across Canada. Beal
illness and the growing recognition of the impact of et al. [36] acknowledge that systemic issues, that is,
social determinants of health on the health and well-being labelling, stigma, caregiver, and treatment role, affect
of diverse populations. There is scant research that PMHN but emphasize the need for nurses to know their
clearly indicates how the diverse educational prepara- clientele to foster therapeutic relationships. Systemic
tion of nurses working in psychiatric care impacts the factors including workforce size, workload, violence in
quality of care for persons with mental health disor- the work- place, nursing scope of practice, and accessiders. Given the burden of mental illness in Canada bility to PMHN may have important implications for
there is need for more research that analyses the psychi- PMHN and their daily practice. PMHN education strives
atric educational preparation of nurses in relation to to produce nurses whose practice meets or exceeds the
accessibility to mental health care and therapeutic and standards [36]. However, systemic factors must be adtreatment outcomes. Client-centered care requires advo- dressed to foster PMHN’s delivery of high quality care
cacy and involvement with family and community that are consistent with the standards for psychiatricbeyond the confines of institutional care and this may mental health nursing. Furthermore, as an influential and
require increased education specific to the changing strong stakeholder that can affect change in mental
dynamics of mental health care within the community health care, PMHN may benefit from a uniform
setting.
educational process throughout Canada.
necessary to help individuals with mental health disorders. The study is significant in that it mirrors the results
of the studies in the preceding discussion concerning
nursing quality of work life. Stress is evident in nurses
working in mental health care and impacts the mental
health of the caregivers. On the other hand, personal
accomplishment was high amongst the RPNs, and this
may decrease burnout. How this impacts client care
requires further study.
- 20 -
Also of concern is the mental health of nurses who
experience high stress. As nurses are mostly women
and nurses form the largest group of health care
providers, the ramifications for the health and productivity of the Canadian society are especially disconcerting
if the majority of nurses are experiencing reduced
quality of work life. As Wall [20] and McGibbon et al. [21]
point out, a sociological paradigm enables the discussion of sensitive issues including the gendered impact
over nursing and the need for research from a perspective that views critically the influence of gender on quality
of nursing work life. The labour divisions in organizations
where nurses practice are entrenched in hierarchal
power struggles that undermine nursing knowledge and
autonomy and contribute to poor quality of work life and
stress.
4.1. Limitations of Review.
There were limitations encountered in this review.
Although several studies were found in relation to the
history of PMHN for the western provinces and Ontario,
no studies were located that convey the full PMHN
history of eastern Canada. While there were government documents concerning the quality of work life for
all nurses, it was difficult to abstract information
specific to PMHN from these documents. For instance,
although the NSWHN found a high incidence of depression amongst nurses, the percentage of nurses in
PMHN experiencing depression was not given. It is
acknowledged that the whole puzzle of what PMHN is
like in Canada is not complete. Furthermore, as NPs
are becoming more established within the Canadian
health care system there is a need for increased research that reveals NP mental health care initiatives
and activities. At present, there is a lack of research
pertaining to Canadian NPs employed in mental health
and their quality of work life. Despite this, the findings
reported here depict important points regarding the
issues that concern all of PMHN and how they impact
the provision of mental health care for Canadians.
4.2. Implications for Nursing Practice.
While NPs have made significant progress in achieving
prescriptive authority in the area of primary care,
minimal movement has occurred regarding the feasibility of NPs specializing in mental health. In Canada, there
are no educational programs or legislated provisions for
NPs who wish to specialize as a psychiatric NP or who
already have extensive experience providing mental
health care [37]. The existing situation for NPs practicing within mental health care settings is hampered by
the absence of recognition for the psychiatric mental
health nurse practitioner (PMHNP) in Canada. Prescriptive authority can only be obtained in Ontario through
registration in the extended class in the designated
specialties, NP paediatrics, NP-Primary Health Care and
NP-Adult. The educational programs that prepare NPs
for these specialties focus on the medical and physiological aspects of the specialties with limited content
on mental health [37]. In 2011, open prescribing
became possible for Ontario NPs. The Nursing Act,
1991, no longer stipulates the prescribing of only listed
medications by NPs [38]. With the exception of medications under the Controlled Drugs and Substances Act,
NPs are now able to prescribe medications commonly
used in mental health care. This allows NPs to further
their care for clients needing mental health care;
however, it may also point to the need for comprehensive mental health training for NPs. It beckons
further exploration if the existing mental health nursing
programs offered throughout Canada could enable the
development of PMHNP programs that would enable
RNs or RPNs and NPs to obtain the competencies of the
PMHNP. Communities with insufficient mental health
care resources may be better served by nurses with an
expanded scope of practice with specialized mental
health education. In addition, although there have been
changes to legislation, specifically regulation 965 of the
Public Hospitals Act, that gives admitting and discharging privileges to NPs; changes to the mental health
act have not been made and regulated forms enabling
admission to a hospital for psychiatric assessment
cannot be completed by Canadian NPs [37]. When the
NP is the person’s main care provider, it would seem
prudent that the NP should be involved in decisions
concerning psychiatric admission and discharge.
The variability of PMHN in Canada presents both challenges and opportunities to the advancement of PMHN
education. Given the challenge for increased accessibility to mental health care services and treatments, the
development of already existing nursing programs in
Canada could bond by striving to achieve the same
psychiatric educational nursing standards. To further
mental health care it may be possible for all nursing
programs to uphold the same standards for
psychiatric nursing education. The CNA motioned a
resolution in 2005 to include RPNs as it was recognized
that a separate national level for RPNs would hinder
professional nursing practice and the power for Canadian nurses to advocate for change [39]. Amending the
division between RPN and RNs and to enable
certification and eligibility of CNA membership for both
groups may strengthen the Canadian PMHN workforce.
Gallop [40] considers how the education system in
Canada lacks prospects for nurses working in mental
health to obtain advanced degrees in PMHN, although, as previously mentioned, there is new potential for RPNs and nurses to obtain master degrees
specializing in mental health nursing west of Ontario.
As mental health care is no longer confined to
institutional settings and mental health training is
pertinent to all areas of health care, the necessity for
advanced mental health education is relevant to all
health care settings where nurses practice. Nursing
needs to facilitate advanced education in mental health
so that people within the primary care setting also
benefit from the knowledge and expertise of nurses who
have additional mental health education. Bridging programs or additional educational opportunities for psychiatric nurses wishing to broaden their knowledge
specifically to prescribe psychiatric treatments or medications may be helpful. Partnerships between provincial
nursing bodies to foster national standards for PMHN
- 21 -
education and bridging programs to a PMHNP
program if developed may represent new opportunities
for all Canadian nurses. The report entitled “Canadian
nursing education in Canada statistics,” 2009-2010 [41],
conducted by the Canadian Nurses Association (CNA)
and the Canadian Association of Schools of Nursing
(CASN), reveals an increase of 64.3% from 2009 to
2010 for graduates for doctoral programs [4]. In 2010,
47.6% of NPs had a master’s, and 0.8% of NP had a
doctorate degree [4]. More nurses and NPs are acquiring advanced degrees. With this trend for advanced
education, it is likely that mental health education for all
nurses and nursing research pertaining to mental
health and PMHN will flourish. Advanced PMHN
education offers possibilities to further mental health care
for Canadians.
[4] Canadian Nurses Association, “2010 Workforce Profile of Nurse Practitioners in Canada,” 2012,
http://www2.cna-aiic.ca/CNA/
documents/pdf/publications.
[5] Statistics Canada, “Canadian Community Health
Survey— Mental Health (CCHS),” 2012, hmdb/p2S
db=imdb&adm=8&dis=2.
[6] Statistics Canada, “Canadian Community Health Survey: Mental Health and Well Being,” 2003,
http://www.statcan.gc.ca/daily-quotidien/0.
[7] Health Canada, “Sharing the Learning. The Health
Transition Fund. Ottawa: Health Canada,” 2002.
[8] S. Ratnsingham, J. Cairney, J. Rehm, H. Manson,
and P. A. Kurdyak, “Opening eyes, opening minds: the
Ontario burden of mental illness and addictions report,”
An ICES/PHO Report, Institute for Clinical Evaluative
5. Conclusion
Sciences and Public Health Ontario, Toronto, Canada,
PMHN in Canada must take action to meet the goals as 2012,
set out by the Mental Health Commission of Canada.
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all Canadian nursing education programs may positive- and professional identity in psychiatric nursing practice
ly impact mental health care. Advanced education for in Alberta, Canada, 1930–75,” Nursing Inquiry, vol. 12,
PMHN including the development of a Canadian PMH- no. 4, pp. 243–255, 2005.
NP program may further the accessibility of psychiatric
[10] M. J. Kirby, “Mental health reform for Canada in
treatments. Psychiatric mental health education for all
the 21st century: getting there from here,” Canadian
nurses will complement primary health care and the
Public Policy: Analyse de Politique, vol. 31, s1, pp. 5–12,
provision of mental health care in general hospitals and
2005.
community settings. Efforts to unite and form partnerships with the varying groups providing PMHN at a [11] The Standing Senate Committee on Social Affairs,
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a red flag for all leaders in the Canadian health care
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and barriers to advanced education in mental health health strategy for Canada,” 2009,
nursing. Although the full picture of what Canadian
mental health nursing looks like today cannot be fully [13] Mental Health Commission of Canada, “Changing
realized by this synthesis, important issues facing directions, changing lives: the mental health strategy for
PMHN have been identified through the analysis of Canada,” 2012,
history and application of a critical and gendered sociological lens. Another chapter on the evolution of Cana- [14] M. Kirby, “Mental health in Canada: out of the shaddian PMHN has yet to be written; hopefully, it will entail ows forever,” Canadian Medical Association Journal, vol.
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to provide the best care possible.
[15] R. Whittemore and K. Knafl, “The integrative review:
updated methodology,” Journal of Advanced Nursing,
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Mary Smith, MScN, BScN, Primary Care NP, RN, is a
Faculty member at Queens University, Kingston, Ontario and currently undertaking her doctoral studies.
Nazilla Kanlou, PhD, Associate Professor, School of
Nursing, Faculty of Health, York University, Ontario.
Dr Kanlow is a member of the Thesis Committee and
doctoral supervisor.
- 23 -
Parting at the Crossroads:
The Emergence of Education for
Psychiatric Nurses
in Three Canadian Provinces, 1909 - 1955.
Dr. Veryl M Tipliski, RPN
Abstract.
The Study
Early in the 20th century, nursing emerged as an
essential part of psychiatry' s attempt to provide scientific care for insanity. Throughout Canada psychiatric nursing is a specialty of general or registered
nursing. In Western Canada, however, it is also a
separate and distinct profession known as registered
psychiatric nursing (RPN). To further the study of
nursing history, this paper examines the emergence
and early development of mental hospital nursing in
Canada, tracing the changing patterns of nurse
training from 1909,when Ontario's asylum training
school movement was established, to 1955, when
education for psychiatric nursing split along the Manitoba-Ontario border into two models. Through case
studies in three provinces (Ontario, Manitoba and
Saskatchewan), this study examines the question of
how Canadian psychiatric nursing developed into
two entirely different models.
During the 20th century,an interplay of social, political
and economic factors emerged which shaped the
development of psychiatric nursing and influenced
the evolution of the two models. In addition,there
were forces within nursing itself, including the
effects of specific strategic decisions taken by
nursing's leaders and the continuing role of nurses'
resistance to the authority expressed by those within
the medical profession. The development of psychiatric nursing is best understood by focusing on the
point where psychiatry's authority intersected with
the gendered limitations of nursing's leaders. This
struggle represented a contest for control over
education for mental hospital nursing. This paper
argues that the turning point in the battle for control
of Canadian education for psychiatric nursing occurred when nurse leaders refused to allow the
specialty of psychiatric nursing to be taken over by an
expanding psychiatric monopoly. The distinct psychiatrist-controlled Western Canadian-style apprenticeship training was halted at the Manitoba-Ontario
border. That nursing leaders persevered in the struggle to gain authority for psychiatric nursing education
was a significant contribution to the development
of Canadian nursing education and the psychiatric
nursing specialty. Remnants of the themes found in
the study endure to the present as organized nursing continues to struggle with issues around autonomy and authority over education and practice.
Early in 20th century North
America, nursing emerged as an
essential part of psychiatry' s
attempt to provide scientific
care for the insane. 1 For
the first time, uniformed pupil nurses contributed to the
new image of the Canadian asylum as a hospital for
the medical treatment of insanity. 2 And although
the importance of historical research in nursing is
now well-recognized, we know little about the history
of psychiatric nursing.3 Canadian historian Kathryn
McPherson, for instance, noted that she purposefully
excluded psychiatric nursing from her work. 4 This is
not to imply that there has been no historical research on Canadian psychiatric car. There has but
it has focused on asylum care, psychiatry,attendants
and recently,patients. 5 The move from untrained asylum attendant to trained mental nurse was a critical
turning point in the care of insane patients,6 but psychiatric nursing has had almost no acknowledgment
in this history. 7 It seems to have fallen into a historiographical gap between Canadian scholarship on the
histories of psychiatric care and general nursing. On
the other hand, groundbreaking contributions have
been made to the historiography by Olga Church,
Peter Nolan, and Geertje Boschma, nurse historians who have studied psychiatric nursing's development in the United States, Britain and the
Netherlands,respectively 8. Clearly, it is time to assess the development of psychiatric nursing in Canada.
In the mid-1950s in Canada, psychiatric nursing split
regionally at the Ontario-Manitoba provincial border
into two models, one as a specialty within general or
registered nursing, the other as a distinct occupation
known as registered psychiatric nursing (RPN). 9 This
study began with a perplexing question: How did
Canadian psychiatric nursing develop into two
entirely different models? 10 In most other western
countries,psychiatric nursing developed into either a
nursing specialty or a distinct profession, without a
geographical break. 11 In this paper, I have attempted to answer the question by describing the emergence and early development of training for mental
- 24 -
gent upon mandatory general hospital affiliations.
North American nurse leaders believed in a generalist nurse preparation ; however, the GNAO was in
the early phase of its registration movement, and
including mental nurse graduates was done to
encourage better patient care. It was also done out
of concern for their "sisters"' professional status
and because American nurse registration bills
were including such graduates. 22 And as one
editorial noted: "If young men specialized in a
THE EMERGENCE OF MENTAL NURSE TRAIN- branch of medicine prior to seeking recognition as
a medical doctor, that they would be considered
ING IN ONTARIO, 1909-39
insane, yet young women repeatedly do this very
In the early years of 20th-century Ontario, asylum thing. Something must be done to help these
care for the insane was essentially custodial. women."23 That "something" became the mandatoHowever, late in the first decade there was a ry general affiliation, whereby mental hospital
concerted provincial government effort to begin pro- student nurses were required to spend a lengthy
viding new methods of care in a more hospital-like period of time at a nurse-run general hospital trainsetting. In keeping with a new focus on somatic ing school. While affiliations took students away from
treatments, the province changed the name of its psychiatrist controlled mental hospital work, it made
institutions from asylums to "hospitals for the them eligible for general nurse registration, thereby
insane."14 But even as "psychiatric care was enhancing their professional status.
being launched," the presence of a general
hospital trained nurse was uncomrnon. 15 Asylum The GNAO leaders' efforts to exert at least some auannual reports referred to "the trained nurse" or thority over mental nurse training through mandatory
"the infirmary nurse," meaning that a graduate general affiliations was perceived as a threat to the
nurse was on staff, but cared only for insane pa- medical superintendents' monopoly on mental nurse
tients experiencing physical health problems. 16 training, to the medical hierarchy and to the
The bulk of care was provided by untrained male government's training school movement. 24 The
and female attendants, and although some medical superintendents wished to maintain an apasylum medical superintendents attempted to prenticeship approach and were not concerned with
obtain more general trained nurses for their insti- "helping" mental nurse students achieve general hospitutions, mental nursing was not appealing to tal affiliations. 25 They lobbied the government for
nurses who had received no instruction on the mental nurse graduates to be considered as equal
topic. 17
to general nurse graduates in the GNAO's Registration Act, and along with medical colleagues from small
Dr. C. K. Clarke, Medical Superintendent of the To- rural hospitals, fought against the GNAO obtaining
ronto Hospital for the Insane, had already em- authority over nurse training and registration. The
braced "the craze for hospital nurses and medical superintendents' power and status were
established nurse training for his female attendants centered within their institutions. When they were
at both the Toronto and Rockwood (Kingston)institu- threatened by the actions of the GNAO, they
tions, and the provincial government mandated that responded by seeing that when the GNAO finally
in order to project the general hospital image of achieved its Registration Act in 1922, "the association
nurse training, other medical superintendents join was guarded by the government and level-headed
Oarke in offering a three year standardized mental medical men were placed on the Board."27 Ontario
nurse training curriculum, commencing in nurses had been hindered by their gender and marOctober,1909.19 Training schools were to be a key ginal political position. 28
piece in the province's effort to provide new somatic
treatments, for example hydrotherapy, in a more However, while the legislation recognized insane
hospital-like setting. And as their American col- hospital training schools, it stipulated that general
leagues had done, medical superintendents them- affiliations would be required for nurse registration. 29
selves developed and delivered the provin cial While it took a few years and even more resistance from
curriculum and examinations for mental nurse train- the medical superintendents, Ontario nurse leaders
ing in hospitals for the insane at Kingston, Toronto, were victorious. In 1925, a six-month terminal
Hamilton, London, and Brockville. 20 Pupils and general affiliation for mental nurse students was
graduate mental nurses gradually replaced instituted, 30 and while the medical superintendents
untrained female attendants on the female "side” retained control of their schools, the affiliation was key
or half of the institution, but there were few in effecting the professional transition from mental to
general trained nurses present at the medically registered nurse in Ontario's institutions. It enabled
nurse leaders to begin drawing mental nurse training,
controlled insane hospitals. 22 Nevertheless, the
its students and graduates,under general nursing's
leadership of the Graduate Nurses' Association of
umbrella and away from the medical superintendents'
Ontario (GNAO) decided from the association's intight grasp. And while the leadership expressed disception that such schools would be recognized dain for the government's administration of their
and their graduates eligible for registration, contin- Act,31 the government's heavy involvement with
hospital nursing in the neighbouring provinces of
Ontario, Manitoba and Saskatchewan over the 50
years leading to the split. 12 This is a story about
a tug-of-war between the leaders of Canadian nursing and psychiatrists for the control of education for
psychiatric nursing. 13 I argue that the key players'
success or failure in this quest for control resulted in
the development of two very different models of Canadian psychiatric nursing.
- 25 -
both the nursing profession's registration movement
and the insane hospitals' training school movement
was clearly advantageous to the leaders' victory. In
1930, again at the insistence of the RNAO leadership,
general affiliations were increased to nine months and
placed within the training program. 32And while some
medical superintendents complained of "too much
professionalism by the RNAO," most were in agreement with the general affiliation for their students. 33
THE PSYCHIATRIC AFFILIATION AND ONTARIO
NURSES
Prior to 1930, in most Canadian general hospital training schools, there was little reference made to nursing
care of the mentally ill. 34 The bulk of care was still custodial and not considered especially relevant to general
nurse training. One exception was the school at the
Winnipeg General Hospital, where student nurses had
been receiving a psychiatric affiliation at the nearby
Winnipeg Psychopathic Hospital since 1920. 35
In the early 1930s,Ontario nurse leaders,like their
American colleagues,began grappling with the idea
that psychiatric nursing education could no longer
be set apart from general nursing education. 36 Some
of this new thinking was in response to the postwar
mental hygiene movement in both countries. In an
attempt to close the gap between medicine and
psychiatry, psychiatrists emphasized the mental
health needs of the whole population, initiating a
new awareness of psychiatry' s scope beyond the
asylum. Even the term "psychiatric nursing was
new. 37 Nurse leaders such as Nettie Fidler came to
believe that psychiatric affiliations for general hospital
students could help to improve the care of all patients,
general and mental. 38
She wrote:
“The whole question of psychiatric nursing education has only recently been considered. General
nursing should not exclude any one type of disease
and the insight is indispensable in handling every type
of patient, whether his disability is mental or physical. Psychiatry is part of general medicine and
psychiatric nursing cannot be regarded as separate
and distinct from general nursing. As one authority I
would like to quote from the report of the Survey of
Nursing Education in Canada, which stresses the need
for the psychiatric nursing experience for every student nurse.” 39
Fidler's use of Professor George Weir's report, Survey of
Nursing Education in Canada, as her rationale was
telling, for it clearly affected the development of
education for psychiatric nursing in Ontario,and elsewhere .40 Weir too, had been influenced by the
mental hygiene movement, and called for organized
nursing to close the gap between general and mental
hospital nursing. Like nurse leaders, he disagreed with
specialized entry-level training. 41 Instead, he viewed
psychiatric nursing as an important new specialty of
nursing, thereby confirming its significance for nursing
leadership. 42 He recommended psychiatric affiliations
for all general hospital students. This recommendation
was incorporated into the Canadian Nurses' Association'
s (CNA) Proposed Curriculum for Schools of Nursing in
Canada.43
Weir's report encouraged a more assertive RNAO
leadership concerning nursing education and practice issues,44 and in the mid-1930s, that took shape
in yet more struggles between the leaders and the
government and its medical superintendents over
the future direction of training for mental hospital
nursing. Overly optimistic, the RNAO requested that
the province close all nine of its specialized training
schools, and instead, use those institutions and
schools for psychiatric affiliations for general hospital
students. 45 However, the needs of the pragmatic
medical superintendents differed from those of
idealistic nurse leaders. With 12,000 patients requiring care, and 436 mental student nurses (of 690
female staff} providing specialized apprenticeship
work, the medical superintendents were not about to
give up control of their schools to nurse leaders
off ering the still tentative three-month educational
experiences. 46 However, despite the superintendents' monopoly, the nurse leaders achieved
some success. A government mediated compromise was reached with the closure of the three
smallest training schools and the appointment of two
registered nurses, Esther Rothery and Edith Dick, to
direct education and practice, including the desired
psychiatric affiliations.47 For the first time,nurse leaders achieved a visible presence within the provincial
mental hospital system, further helping to pull
education for mental hospital nursing under
general nursing's umbrella. 48 While mental hospital students and nurses delivered care under the
medical superintendents, nurse leaders advocated
nursing authority for their education and determinedly worked toward that goal. 49 Hand-in-hand
with strong nursing leadership, the government's
authority over all things pertaining to nurse training, general and mental, assisted in the early development of both mental hospital nursing, and
psychiatric nursing in Ontario.
THE EMERGENCE OF MENTAL NURSE TRAINING IN MANITOBA, 1921-39
In response to the desperate need for nurses to
care for mentally ill World War I veterans, and more
than a decade after standardized mental nurse
training was established in Ontario, the first mental
hospital training school west of the Great Lakes was
begun at the Brandon Hospital for Mental Diseases
in 1921.50 In contrast to the Ontario government's
officially mandated and tightly regulated mental hospital training school system, the two schools established in Manitoba were institution-specific and
developed according to the whims of their medical
Superintendents. 51 Brandon's Medical Superin-
- 26 -
tendent, Dr.Arthur Baragar, with the support of his
wife who was a graduate nurse, transformed all female civil servant attendant positions into pupil nurse
positions. He hired as many RNs as he could entice
to the rural institution to serve as head nurses, and
modelled his school on the ideals of general hospital training. 52 Consistent with the Ontario situation,
male attendants were excluded from nurse training.
53
In contrast to Ontario, where the mental hospital
training school movement and the GNAO's registration movement developed in tandem, albeit not
smoothly from their inceptions, Manitoba's two mental hospital schools were unregulated latecomers to
the nurse training field. Further, the Manitoba government's role with mental hospital nurse training
was minimal and it had no authority over the
Manitoba Association of Graduate Nurses' (MAGN)
Registration Act. 54 Thus, when Baragar attempted
to improve the quality of training and care at his
hospital by including an 18-month general hospital
affiliation, Mani toba's nursing leadership reacted
swif tly. In stark contrast to their Ontario colleagues,
instead of seeking some MAGN authority over mental
hospital nurse training through prescribed general
hospital affiliations, the leadership secured legislative amendments which made it more, rather than
less difficult for mental nurse graduates to become
registered nurses. 56 Baragar was eager to share
control of mental hospital nurse training with organized nursing, but the MAGN leadership clearly had
little regard for medical superintendents and their
hospitals,57 and in 1927, chose not to become involved
with mental hospital nurse training.
Located in North Battleford and Weyburn, Saskatchewan's geographically and socially isolated mental
hospitals off ered no training until 1930.61 At that
time, the medical superintendents began lectures to
their male and female attendants, and by 1937 training had evolved into an optional three-year, 100-hour
lecture course. 62 As in Manitoba, the Saskatchewan government had no direct involvement in the
training. But Dr.James MacNeill, North Battleford' s tyrannical Medical Superintendent and Saskatchewan' s
powerful Commissioner of Mental Hospital Services,
did not embrace the traditional general hospital nurse
training model for his province's mental hospitals; a
significant difference from both his Manitoba and Ontario colleagues. Female and male attendants were of
equal status and there was no idealistic goal for females
to affiliate in order to become registered nurses. 63
Further, MacNeill was stubbornly closed to the idea of
registered nurses working in his institutions; even his
own matron was not a registered nurse. 64 During the
depression, several registered nurses were interested
in working at the two hospitals and his colleague in
Weyburn was desperate for RNs to direct care for
patients undergoing the risky, new insulin coma treat
ments. 65 However,MacNeill would not hire RNs unless
they first took his lectures and spent one year apprenticing as a nurse-attendant. 66 Since few RNs did so,
MacNeill expanded the attendant training to include
nursing skills. 67
Needless to say,MacNeill was perturbed that Professor Weir did not consider that mental hospital attendants and registered nurses were one and the
same,as far as their training was concerned.
Further,he did not believe that Weir's recommendation
for psychiatric affiliations for general hospital students
would be of any use whatsoever to his hospitals. 68
THE PSYCHIATRIC AFFILIATION AND MANITOBA
He declared: "Weare dealing with disorders of emotion,
NURSES
not physical disease . I am of the belief that the care
In the mid-1930s, led by Kathleen Ellis and encour- of mental patients has got to be worked out from the
aged by the mental hygiene movement and Dr. inside. Psychiatry has got to save its own soul." 69
Weir's recommendations ,the MAGN made a credible MacNeill's strong beliefs about apprenticeship-style
attempt to organize mandatory psychiatric affiliations mental hospital training and his adherence to the
for the province' s general hospital students. 58 psychiatric monopoly clearly set the future direction
However, while
exempt
from
government for Saskatchewan. In the late 1930s,a surprised Onauthority,organized nursing in Manitoba was at the tario colleague pointed out to MacNeill that his provmercy of politically influential general hospitals' boards ince was 25years behind Ontario in the area of mental
of trustees that resisted losing their students' service to hospital nurse training. 70
psychiatric affiliations. 59 And in 1935, a powerful
coalition of hospital trustees blocked the MAGN's at- THE PSYCHIATRIC AFFILIATION AND SAStempt to initiate this educational experience. Conse- KATCHEWAN NURSES
quently, the only psychiatric affiliation in place in
Manitoba was the one established two decades As she had done in Manitoba, when Kathleen
earlier between the Winnipeg General Hospital School Ellis arrived in Saskatchewan to begin her position
of Nursing and the Winnipeg Psychopathic Hospital. as registrar/student advisor with the Saskatchewan
Compared to the Ontario situation, organized nursing Registered Nurses Association (SRNA) in 1937,
in Manitoba had almost no presence in either mental she attempted to initiate three-month psychiatric affilihospital or psychiatric nursing at the end of the decade. ations for the province's general hospital students. 71
Predictably, she struggled with MacNeill, who would
agree to affiliations to his hospitals only if they were
THE EMERGENCE OF MENTAL HOSPITAL TRAINa minimum of nine months, and preferably, a year
ING IN SASKATCHEWAN, 1930-39
in length. 72 MacNeill focused on his belief in student
service, whereas Ellis desired an educational experi- 27 -
ence. 73 MacNeill refused to negotiate and their struggle was cut short by the outbreak of World War Il. 74 At
that time,the only affiliation offered in Saskatchewan
was between the Regina General Hospital School of
Nursing and the hospital's own psychopathic ward.
75 Although imposed by MacNeill, the lack of a
nursing presence made RNs insignificant to Saskatchewan's mental hospitals.
THE POST-WAR SHORTAGE OF MENTAL HOSPITAL NURSES DRIVES EDUCATION
At the end of World War II, provincial governments in
Ontario, Manitoba and Saskatchewan and their financially starved mental hospitals, found themselves in
the midst of a crisis involving too many patients and
a severe shortage of students and nurses to provide
care. Across the country, almost one-half of all hospital beds were occupied by the mentally ill. 76 Fifty
thousand patients were "jammed onto wards that
were built for thirty-five thousand, and Manitoba and
Saskatchewan shared the distinction of having the
most overcrowded institutions. 77 The postwar national nursing shortage was most acute at the
country's 36 mental institutions. Of 33,338 practising
RNs, only 500 were employed at such hospitals, a
reflection of the shortage and amplified by difficult
mental hospital working conditions. 78
The war created new public, government, and professional interest in psychiatric and mental health care,79
but above all else,it was the mental hospital nursing
shortage that influenced the approaches taken by
Ontario, Manitoba, and Saskatchewan in the postwar
development of education for mental hospital nursing.
Although these geographic neighbours were dealing
with an identical dearth of trained nurses, the
approaches taken by organized nursing, governments, and medical superintendents within each
province varied dramatically.
ONTARIO NURSES LEAD THE MOVEMENT TO
PSYCHIATRIC AFFILIATIONS
With 16,000 patients under care in 15 Ontario mental
hospitals,the government could ill afford to lose its
students or graduate nurses. 80 However, the war
had opened up new employment opportunities for
young women, and there were more and better
paying positions within the expanding general
hospital system. Students and nurses alike were
refusing to train and work under unreasonable conditions. 81 There was a postwar exodus of 25% of the
RN staff and a 50% drop in enrolment at the six training
schools.82 In 1947, there were only 74 students attending these schools and some schools did not have
enough students to offer a first-year class..
The medical superintendents assumed that eventually
there would be an influx of students, but the RNAO
leadership assessed that interest in all specialty training schools was waning.84 Concerned about patient
care and the mental hospital nursing shortage, the
association chose 'the place of mental nursing in the
reconstruction period" as the theme of its 1945 annual
meeting. As Members heard that "we should hide our
faces in shame" and "care of psychiatric hospital patients is our responsibility; should we not accept it as a
challenge?" 86 The RNAO' s public resolve to meet
this challenge through mandatory 12-week psychiatric affiliations and an expanded theoretical course was
groundbreaking, for it set the future direction of
education for mental hospital nursing in the province.
87 Hand-in-hand with the commitment to affiliations,
was a government-solicited recommendation from
the leadership to implement a standardized nurses'
aide course at the provincial hospitals, something
which Ontario's medical superintendents had long resisted, fearing aides would simply replace registered
nurses. 88 It was notable that while the medical
superintendents supported the move to psychiatric
affiliations, they were not yet ready to relinquish control of their small schools, perhaps for what they symbolized. 89 Nevertheless,shrinking enrolments saw
three more schools close in the early 1950s. 90 By then,
education for psychiatric nursing had been embraced
by mainstream nursing education, with all but three
general hospital schools sending some or all students
for the psychiatric affiliations. Only the perennial lack
of student accommodations at the provincial hospitals
prevented the RNAO from making it mandatory. 91
MANITOBA NURSES RETREAT FROM PSYCHIATRIC NURSING
In an attempt to stem the wartime loss of mental
nurse graduates from the Brandon Hospital for
Mental Diseases, a handful of nurse leaders organized a combined mental plus general nursing program. 92 Considering MARN's earlier disinterest in
the mental hospital training program, it seemed a
bold step. However, this program evolved because it
was mutually advantageous to the affiliate general
hospitals that were also short of student nurses. 93
Nonetheless , it proved popular, and by 1950 the
school's enrolment had increased significantly. With
the incorporation of general nurse education, mental nurse training at Brandon was tilting toward the
long established Ontario model and the method favoured by its own medical superintendents. 94 It
was notable, therefore, that under new leadership in
the early 1950s, the MARN unexpectedly called for
the termination of the popular combined program
along with the province' s two other mental nurse
training programs. Rather than nurse training
schools, it advocated a consistent approach to
mental hospital staffing through the employment of
licensed practical nurses and nurses' aides, but not
registered nurses.95
On a similar note, it was telling that in contrast to the
RNAO's commitment to psychiatric nursing education, there was no action taken by MARN leaders
concerning psychiatric affiliations. A request for assistance had come from the government and its medical superintendents, who desired mandatory
- 28 -
psychiatric affiliations, both for student service and to
encourage RN employment at the provincial hospitals. However, the leadership believed that such
affiliations were "premature"and that if it forced the
issue upon the still-reluctant general hospitals'
boards of trustees, the passage of MARN's then
open Act would be jeopardized. 97 In sacrificing the
psychiatric affiliation for timely legislation, Manitoba
nurse leaders once again lost a perfect opportunity
to gain a role and presence in mental hospital nursing. Mental hospital nurses were not organized or
legally recognized, and the door was wide open for
registered nurses. Further,there is no doubt that the
MARN's refusal to take over control of education
for mental hospital nursing influenced the government's decision to instead initiate its first provincewide, standardized, apprenticeship style mental
nurse training program exactly what the leaders did
not want. 97
general students affiliating and the British model of
training mental nurses. RNs were not available for
administration and teaching and the SRNA was not
going to lower its standards. Instead of depending
on RNs, why not raise the status of our own
hospital workers to semi-professional. It was decided to reorganize the staff training program to make
psychiatry rather than nursing the focus. The curriculum was developed by our medical superintendents.
104
Both Douglas and McKerracher had first consulted
with Kathleen Ellis and the SRNA about the possibility of a combined program with general hospital
affiliations for female mental hospital students. 105
While Ellis was concerned about the quality of the
mental hospital program, before the SRNA and McKerracher could negotiate a plan, McKerracher determined that it would be 'too complicated to send
Mental nurse training then tilted toward the new West- hospital staff away on affiliations." 106
ern Canadian model, making registered nurses irrelevant to mental hospital nursing in Manitoba. That the While the SRNA leadership had privately contemManitoba government and its medical superintend- plated the idea of RNs taking full responsibility for
ents launched a new mental hospital nurse training mental hospital nursing with a commitment to psychiprogram in 1953, just as Ontario nurse leaders were tak- atric affiliations, it concluded that the historical lack of
ing over responsibility for education for mental hospital a RN presence at the hospitals made that commitment
nursing from medical superintendents, was indicative non-feasible. 107 Nevertheless, Ellis still viewed such
of longstanding differences,both in leadership regard- affiliations as a vital educational experience,and reing psychiatric nursing, and in relationships among the quested an arrangement with McKerracher. 108
However,McK erracher's priority was the provision
key players in each province.
of hospital service, and like his predecessor he
refused
to
participate.
109
Without
The SASKATCHEWAN GOVERNMENT
affiliations,Saskatchewan
RNs
lost
education
for psyCREATES A NEW NURSING PROFESSION
chiatric nursing and the specialty.
When Premier Tommy Douglas and his Co-operative
Commonwealth Federation (CCF) Government came
to power in Saskatchewan in 1944, the province' s two
mental hospitals were in crisis. Under MacNeill's
rein, Saskatchewan had the highest rate of psychiatric
institutionalisation across Canada, with 500 marginalized, under trained attendants and ten RNs providing
care to 4,500 patients. 98 Journalist Le Bourdais
wrote:''”It is the lack of trained staff ....Saskatchewan
has not had adequate mental hospital training
schools and must now pay the penalty of that
neglect." 99
The interventionist Douglas Government set out to reform the health care system,and chose the personable
authoritarian, Ontario psychiatrist Dr.Donald (Griff)
McKerracher, to lead mental hospital reform. 100 Reform
was dependent upon a trained staff and McKerracher' s dilemma was "how best can mental hospital
nurses be trained?" 101 He decided to "reverse the
Ontario approach to mental nurse training," 102 calling it Saskatchewan's "unorthodox program" and justifying it on the grounds that "it was best for
Saskatchewan at that time." 103 His speech to the
American Psychiatric Association (APA) offers insight into
McKerracher' s pragmatic decision-making:
The graduates of McKerracher's three-year, 500-hour,
salaried apprenticeship program were known as
graduate attendants or nurse attendants and while
McKerracher' s goal had been only to improve the
quality of their training, a few male attendants
desired the professional designation "psychiatric
nurse." 110 The training program was the "jewel in
the crown" of Douglas' mental hospital reform, and
in an effort to appease hospital workers with close
political ties to the CCF party, 111 the government
took the training program one step further. In
March, 1948, it passed the Psychiatric Nurses Act,
creating a distinct profession for its attendants. 112
While the SRNA tolerated the new psychiatrist controlled training program, Ellis argued against the
creation of a separate nursing occupation, citing
these points:
To obtain staff I considered three programs: the
combined mental and general leading to the RN,
- 29 -
1. The term "psychiatric nurse" is a misnomer.
In Canada and the United States it means an
RN who has had a course and experience in
psychiatric nursing.
2. The SRNA has tried for 10 years to establish
reciprocal affiliations with Saskatchewan's mental hospitals,to no avail.
3. Bill 69 was prepared hurriedly and requires
more time for study by all parties.
4. The Bill will affect mental hospital developments Notably, both studies recommended the utilization of
in this province. 113
trained mental hospital nurses' aides as an interim
measure to the RN shortage, similar to what general
Ellis' leadership was limited by her gender and hospitals had instituted. The parallel need for mandashe was unable to withstand the political manoeu- tory affiliations to prepare more RNs for psychiatric
vring, a powerful collusion of male attendants and hospital work was likewise stressed. 118 The dual
legislators
committed
to
social democratic recommendations to institute a national 1 2 month
principles,and the paternalism of the day. The leap training course for mental hospital nurses' aides
from trained attendant to psychiatric nurse was a perturbed Saskatchewan's Dr.McKerracher and Britstunning victory; the concept of psychiatric nursing, ish Columbia's Dr. Gee. Theirs were the only provinces
as described by the SRNA,was forever changed in where psychiatric nursing was a legislated occupation.
Saskatchewan. This legislation signalled a watershed 119 Their mental nurse training programs were
moment in the development of psychiatric nursing in based upon lengthy apprenticeship-style service unCanada.
der medical superintendents at western mental hospitals, and thus neither psychiatrist wanted an
THE FINAL BATTLE FOR CONTROL OF PSYCHI- educationally oriented program under nursing’s auATRIC NURSING
thority. 120
As the 1950s began,education for mental hospital nursing was not developing as a seamless model across
the geographic boundaries of these three neighbouring provinces. For the first time provincial variations
and struggles, including the nursing shortage,
moved onto the agendas of both the Canadian
Nurses' Association (CNA) and the federal government. British Columbia nurse leader Edith Pullan
asked the CNA to intervene in the strained relations
between RNs and "non-registered mental hospital
nurses" in her province, and to study the inconsistent
training of the latter group. 114
For similar
reasons,Alberta's psychiatric director urged the federal government's Health and Welfare's Mental
Health Division Advisory Committee to study the "nonregistered mental hospital nursing" situation and develop a uniform national training program for that
group.
The Advisory Committee on Mental Health consisted
of provincial psychiatric directors whose role was to
advise the Mental Health Division. 115 The data
gathered from its studies confirmed that a gap had
indeed developed between Ontario and Western
Canada, with nurses' associations west of Manitoba
reporting that "non-registered psychiatric nurses" had
simply replaced attendants at mental hospitals. 116
The Mental Health Division's survey illustrated the
difference between Ontario and British Columbia
mental hospital staffing patterns, and assessed that
Western Canadian training programs were not a desirable option for mental hospital nursing:
It is a confusing and varied group of ten schools
developed to meet hospitals' needs. In many hospitals service to the hospital comes before learning.
Students are obliged to carry out nursing procedures on patients before being taught. Graduates
are called "psychiatric nurses" whether legal or not.
Training varies between the provinces, between
schools within a province and between genders in
some schools. Their courses are not educationally
sound. 117
However,the Ontario government and its medical
superintendents, at the recommendation of Ontario
nurse leaders, had already decided to begin training
nurses' aides to supplement its RN staff. Further,
some Ontario psychiatrists viewed the new Western
Canadian psychiatric nurses as "glorified ward
aides,not authentic nurses."121Gee and McKerracher
had little choice but to undertake a high-stakes
mission to extend their monopoly on Western
Canadian-style psychiatric nurse training eastward.
They hijacked the Mental Health Advisory Commit
tee's agenda, and transformed the original recommendation for a standardized nurses' aide course
into one which recommended their own distinct
psychiatric nursing programs.122
How did the transformation occur? The task to develop a standardized nurses' aide course for the Advisory Committee on Mental Health fell to its small
Subcommittee on Training, and included Gee, McKerracher, and a Quebec psychiatrist. It became the
"train" to carry out the western psychiatrists' mission.
The two western psychiatrists first lobbied Dr. Charles
Roberts, new Chief of the Mental Health Division and
chairman of both committees, to take their psychiatric nurse training programs to the national level. 123
Once convinced, Roberts acted as the "engine." Along
with Gee and McKerracher, Roberts rewrote reports,
changed minutes, manipulated information, and held
back documents from Dr. Donald Cameron who was
Deputy Minister of Health and Welfare, as well as from
the Advisory Committee. 124 The goal of the three
psychiatrists was to first gain the CNA s approval of
Western Canadian psychiatric nurse training programs, and with the CNA validation in hand, recommend that the Advisory Committee institute the
western programs across the country.125 Without any
input from organized nursing, Dr. Cameron endorsed
the programs at Roberts' urging and requested that
the CNA accept the Western Canadian definition of
psychiatric nursing as a distinct profession, just as the
Saskatchewan government had legislated a newly
- 30 -
defined profession of psychiatric nurses in 1948. 126
Their actions revealed a process driven by ambitious
and powerful personalities, political manoeuvring
and in some instances, indiscretions. Medical superintendents had always controlled nurse training at
their institutions,and that tradition continued among
some of Canada's psychiatric elite at the national level.
The struggle between nurse leaders and these psychiatrists for control of education for mental hospital
nursing escalated into a battle at the 1954 CNA
biennial meeting in Banff, Alberta. Notably, but consistent with Gee's, McKerracher's, and his goal, Dr.
Roberts brought his government's paternalistic message to Canada's nurses, without the knowledge of
the Advisory Committee on Mental Health:
It is felt that a three-month psychiatric affiliation will
fall short in providing mental hospital nurses . t has
been suggested that the use of RNs supplemented by nursing aides will meet the mental hospitals' needs. This is impossible. It seems to many of
us that a clear case exists for the training of the new
profession of psychiatric nursing. This new nurse
would have equal status to the RN . A new approach to mental hospital training is required and
it is already being done in Western Canada. I hope
that the Canadian nursing profession will support this
new approach. 127
Roberts exaggerated regarding how "many" psychiatrists he spoke for and he did not offer those in attendance an explanation as to why a mix of RNs and
nurses' aides would not help with the nursing
shortage. Understandably, as nurse leader Elizabeth
Bregg saw it, Canadian nurses were close to losing
this specialty to psychiatry, just as they had in
Saskatchewan. She warned delegates:
“Psychiatric nursing has emerged as a specialty of nursing requiring professional preparation . Shall we attend to this [nursing shortage]
before some other group does it for us? The
complication of the newly created "psychiatric
nurse" split from the profession is obvious. It is
a stop-gap, but in terms of what this change
has done to the future of the psychiatric nursing
specialty is nothing short of disastrous. Psychiatric nursing skills are therapeutic, not custodial.” 128
The pivotal point came in January 1955 when a CNA
committee chaired by Bregg, together with Canada's
Chief Nursing Consultant, Dorothy Percy, determined
that the solutions arrived at by psychiatrists for the
separate training of psychiatric nurses in Canada's
three westernmost provinces, were not appropriate for
the whole country. Their assessment was that the curricula were educationally weak, especially in nursing content, and that they were psychiatry-controlled
apprenticeship programs. 129 Such programs were
inconsistent with the leadership's move to profes-
sionalize nursing education. With the specialty of
psychiatric nursing under attack and in danger of being
replaced, the stakes were high,and in opposition to the
government’s request, the leaders refused to endorse
Western Canada’s new training programs . 130 This
decision created anxiety and confusion for Roberts and
his two colleagues; nurse leaders had foiled their mission. Moreover,in what might be described as an act of
subversive activism not unlike what Ontario nurse
leaders had done throughout the centurythe leadership attempted to pull Western Canadian psychiatric
nurses under general nursing's umbrella,with a
simultaneous offer to help the government develop an
innovative combined program. 131 With all players except Saskatchewan at the table,132 this federally sponsored project made steady progress until the late
1950s when key members resigned and it collapsed.
133
Its demise had startling, unintended outcomes. What
had threatened to become a national issue for
Canadian nursing a separate nursing occupation
under psychiatry' s control remained as such only for
the country's three westernmost nurses' associations.
134 The project's failure, together with the imposed halt
in the psychiatrists' eastward movement of Western
Canadian style apprenticeship training at the
Manitoba Ontario border,signified a "parting at the
crossroads" in Canadian education for psychiatric
nursing. At that time, Percy advocated pragmatically
that, "for the time being in the west, both education
models might develop along parallel lines." 135 Almost
50 years later, save for the ironic, recent melding of the
two models of education in Saskatchewan, the situation remains unchanged. 136
CONCLUSION
This paper has described how an interplay of social,
political, economic, and especially nursing professionalization factors shaped psychiatric nursing' s emergence and influenced its regional split into two different
models. Some of the findings mirror themes found in
the development of general nursing. The ambiguous
and subordinate status of nurses and their lack of
control over education, which continuously surfaced in
this study, is a perennial nursing issue. That said, the
unrelenting inter-professional tension between the
nursing leadership and psychiatrists was exceptional,
and was based on more than longstanding p a t e r n a l i s t i c convictions about the medical hierarchy.
It was about power.
Until World War II, psychiatrists held little status within
the health care community, and to compensate, they
amplified their authority within their own mental
hospitals and in their professional relationships. 137
They had a monopoly over mental hospital nurse
training because they initiated apprenticeship style
schools on their turf. General nurses were late comers.
The pattern evidenced was that of an amplified
psychiatric authority intersecting with the gendered
limitations of nurse leaders as the leadership attempted
- 31 -
to raise the standards of mental hospital nursing, based nursing, might well be applicable in continuing
on the ideals of general nursing education. The gen- the development of nursing education.
dered limitations clearly differed between the three
provinces' nursing leadership,indicative of longstanding
differences in relationships among key players in each
province.
Considering the power wielded by psychiatry and the
leadership limitations, it might have been easier for
nurse leaders to give up the struggle. However, the
national nursing leadership understood the implications of an expanding psychiatric monopoly, and,
determined about how they wanted students to be
educated for psychiatric nursing, refused to be victims.
That they persevered in the tug-of-war to gain authority over education for psychiatric nursing was a significant contribution, to both the development of Canadian
nursing education and the psychiatric nursing specialty.
ACKNOWLEDGMENTS
The research on which this article is based was
generously supported by the Hannah Institute for
the History of Medicine Scholarship, the University of Manitoba Duff Roblin Fellowship, and the
Canadian Association for the History of Nursing
Graduate Scholarship. The dissertation from
which this article is derived was awarded the 2003
George Geis Dissertation Award for the Canadian
On a more subdued note, there were instances of empty Society for the Study of Higher Education.
rhetoric and a lack of leadership concerning care of the
mentally ill.Even as they struggled with psychiatrists and
less than ideal mental hospital conditions, Ontario nurse
leaders gradually took responsibility for psychiatric
nursing care by embracing and pulling that education
into mainstream nursing education. In stark contrast,
Manitoba leaders allowed their professionalization struggle with psychiatrists to get in the way, and even as
education for psychiatric nursing was offered to them,
retreated. Thus,as Bregg warned Canadian nurses not
to do, 138 the Manitoba leadership gave responsibility
for care of the mentally ill to another group. While
Saskatchewan leaders did not retreat neither did they
embrace psychiatric nursing. They were interested in
the educational aspects, but because of practical
issues, their interest in responsibility for care of the
mentally ill was tentative. Saskatchewan's nursing
leadership lost psychiatric nursing, but clearly,the circumstances were beyond its control. There are implica- NOTES
tions for nursing and nursing education found in this
study. Remnants of the themes outlined in this paper 1 Edward Cowles, "Training Schools for Nurses
survive to the present, as organized nursing continues and the First School in McLean Hospital," in Henry
to struggle with issues concerning authority over Hurd, ed., The Institutional Care of the Insane in the
education and practice. The attempt by some psychi- United States and Canada (New York: Arno Press,
atrists and the federal government to introduce the West- 1916), p. 289-300.
ern Canadian model of training to ameliorate the 2 Patrick Connor, "Neither Courage nor Persevercountry's mental hospital nursing shortage in the 1950s, ance Enough: Attendants at the Asylum for the
parallels recent struggles between organized nursing Insane, Kingston, 1877-1905," Ontario History 88,4
and provincial governments in Manitoba, Saskatch- (1996): 251-72.
ewan and British Columbia, over the model of education 3 Christopher Maggs, ' A History of General Nurswhich could best address the current nursing shortage. ing: 1800-1900," in W Bynum and R. Porter,
eds.,Companion Encyclopedia of the History of MediIn all three western provinces, at issue was how cine (London: Routledge, 1993), p. 1309-28.
nursing students were to be educated, diploma or de- 4 Kathryn McPherson, Bedside M atters: The Transgree, with governments viewing the shorter diploma formation of Canadian Nursing, 1900- 1990 (Toronto:
model as a practical solution. 139 Western Canadian Oxford University Press, 1996), p. 21. McPherson
pragmatism aside, nursing was and is primarily a wom- suggests that there is a need for a separate study
en' s profession; and issues of gender and the value on psychiatric nursing.
placed on nursing as an academic discipline relative to 5 Connor, "Attendants at the Asylum," p. 251-72;Ian
more traditional disciplines, cannot be dismissed. 140 Dowbiggin, Keeping America Sane: Psychiatry and
Eugenics in the United States and Canada, 1880-1940
While distressing losses have been experienced, les- (New York: Cornell University Press,1997);Jaines Mosons learned from the nursing leadership as it strug- ran, "Keepers of the Insane: The Role of Attendants
gled to gain control of education for psychiatric at the Toronto Provincial Asylum, 1875-1905,"
Social History, (May 1995): 51-75; Geoffrey
- 32 -
Reaume, "999 Queen Street West: Patient Life at the
Toronto Hospital for the Insane, 1870-1940,"PhD dissertation, University of Toronto, 1997;Edward Shorter, TPH:
History and Memories of the Toronto Psychiatric
Hospital,1925-1966 (Toronto: Wall & Emerson,1996); SEO
Shortt,Victorian Lunacy: Richard M .Bucke and the Practice of
Late Nineteenth Century Psychiatry (Cambridge: University Press, 1986); and Cheryl Krasnick Warsh, M
oments of Unreason: The Practice of Canadian Psychiatry
and the Homewood Retreat, 1883-1923 (Montreal:
McGill-Queen' s University Press,1989).
6 Connor,''Attendants at the Asylum," p.264-68.
7 Historians who have acknowledged the trained
mental hospital nurse include Connor, ' Attendants at
the Asylum," p. 264-68; Margaret Gorrie, "Nursing"
in Edward Shorter, ed., TPH: History and Memories of
the Toronto Psychiatric Hospital 1925-1966 (Toronto:
Wall & Emerson, 1996), p. 193-217; Krasnick Warsh,
Moments of Unreason, p. 101-20.
8 Geertje Boschma, The Rise of Mental Health Nursing:
A History of Psychiatric Care in Dutch Asylums, 18901920 (Amsterdam: Amsterdam University Press,
2003) and "Creating Nursing Care for the Mentally
Ill: Mental Health Nursing in Dutch Asylums, 18901920," PhD dissertation, University of Pennsylvania,
1997; Olga Church, "That Noble Reform: The Emergence of Psychiatric Nursing in the United States,
1882-1963," PhD dissertation, University of Illinois,
1982; and Peter Nolan, A History of Mental Health
Nursing (London: Chapman & Hall, 1993) and "Psychiatric Nursing, Past and Present: The Nurses Viewpoint," PhD dissertation, University of Bath, UK, 1989.
9 Archives for the History of Canadian Psychiatry
and Mental Health (AHCPMH), Canadian Mental
Health Association, National Office Records:
Committee on Psychiatric Mental Health Services,
Subcommittee of the Scientific Planning Council (Tyhurst Committee), Dorothy Percy, "Working Paper
on Nurses, Aides and Attendants," 1957, p. 3.
10 Throughout my nursing career I attempted to
find the answer to this question, without luck. For
the full study,see Veryl Tipliski, "Parting at the
Crossroads:The Development of Education for
Psychiatric Nursing in Three Canadian Provinces,
1909-1955," PhD dissertation, University of Manitoba, 2002
.
11 In the United States, psychiatric nursing became
a specialty of nursing. In Britain, it developed into a
separate occupation.
12 The histories of nurse training and practice are
intertwined and Nolan suggests that the development of psychiatric nursing can be traced through
the changing patterns of training. Nolan, A History of
Mental Health Nursing, p. 19.
13 Leaders included nurses who were hospital superintendents, teachers,directors of provincial and
national nurses' associations, and nurses who
filled key positions within such associations.
14 Archives of Ontario (AO), RG18-501,Box 1,"Report
of Commission on the Methods Employed in Caring
for and Treating the Insane" (Toronto: King's Printer,
1908); and Government Documents,''lmnual Report
of Inspector of Insane Asylums," 1905, p. x-xi.
15 AHCPMH,Journal Collection, Edward Ryan, "Seven
Years' Advance in the Ontario Hospitals for Mental
Diseases," The Bulletin of the Ontario Hospitals for the Insane 6,1 (1912): 3-11.
16 AO, Government Documents, 'Annual Report
of Inspector of Insane Asylums, Toronto Asylum", 1906,p. 3.
17 Ryan, "Seven Years' Advance," p. 5.
18 AO, Government Documents, 1906,p. 4; and
Connor,''Attendants at the Asylum," p.
264
68.Also see Krasnick Warsh, Moments of Unreason,
for a description of the training school developed at
the private Homewood Retreat in 1906.
19 AO, Government Documents, PS Microfiche, Provincial Secretary for the Province of Ontario, "Training Schools for Nurses, Ontario Hospitals for Mental
Diseases," Bulletin of the Ontario Hospitals for the Insane, 4, 1(1910): 4-6. See note 54 for the male attendant
situation.
20 Ibid. No reason was given as to why the remaining five provincial hospitals did not begin schools at
this time.
21 AO, Government Documents, 'Annual Report of
Inspector of Hospitals for the Insane, Hamilton
Hospital," 1912, p. 24. At this hospital, there was
no super intendent of nurses and only one nurse
lecturer. Female nurses did not work on the male
side.
22 Canadian Nurses Association Archives (CNA),
Journal Collection, Graduate Nurses' Association of
Ontario, "Second Meeting of the Graduate Nurses'
Association of Ontario," The Canadian Nurse, 1, 2
(1905): 11-20; AO, RG8-9, Container 12, 1916, Nurses Registration, See letters written to Armstrong
around Justice Hodgins' commission, especially
Supportive Statement "H."
23 Winnipeg General Hospital Nurses Alumnae Archives (WGHA), Journal Collection, Editor, "The
Right 'fraining School," The Canadian Nurse, 8,12 (December 1912): 674.
24 AO, RGB-9, File 2.18,Box 2, Letter from Dr. C. K.
Clarke, Toronto Asylum, to Hon. J. P. Whitney,MP,
Assistant Provincial Secretary,21April1906; and RGS9,Container 12,1916,Letter from Superintendent J.
Mitchell,Brockville Hospital for the Insane to Mr. 5.
Armstrong, 29 January 1916.
25 AO, RG8-9, File 2.18, Box 2; RGS-9,Container 12.
26 AO, RGB-9, File 2.18, Box 2; RGB-9, Container
12; Dr. Hobbs, Superintendent at Homewood,
wrote Dr. Ryan, Kingston, telling Ryan that he sent
Judge Hodgins, Commissioner, a letter,28 January
1916.
27 AO,RGB-9, File 2.18, Box 2.The superintendents'
early opposition was maintained until 1922. Some of
their tight control can be explained by the status
differential between themselves and their medical
colleagues. To compensate, they exerted control inside their institutions.See Gerald Grob,Mental Illness
and American Society, 1875-1940 (Princeton: Princeton
University Press, 1983), p. 244-47.
- 33 -
28 CNA, Journal Collection, Editor, "Editorial," The Canadian Nurse, 18,7 Ouly 1922): 401.
29 Registered Nurses Association of Ontario Archives (RNAO), 96A-1-20, GNAO Historical, "Summary of History of the GNAO, 1904-1925," 1926, p. 17.
30 College of Nurses of Ontario Archives (CNO),
Council of Nurse Education, Waiver File, 1923,Letter
from E. MacPherson Dickson to superintendents of
nurses,Ontario Hospitals, 1August 1923.Her letter
clarified that "future" students needed a true affiliation, not just a post-graduate course.
(MARN), 47-24-058, Board Meeting Minutes, 14 January 1935.
41 Weir, p. 295.
42 Weir, p. 301.
43 Weir, p. 368-69;WGHA, Curricula, ' A Proposed
Curriculum for Schools of Nursing in Canada," Canadian Nurses Association, 1936, p. 91-95. It was used
until post World War II.
44 Natalie Riegler, Jean I.Gunn, Nursing Leader (Toronto: Fitzhenry & Whiteside, 1997), p. 129, 159-74.
45 AO, RGl0-107-0-165 Container 22, File: Nurses,
31 CNA, Journal Collection, 1922.
General, 18-7-3, Letter from Dr. McGhie, Deputy
32 CNO,Council of Nurse Education, Book Minister of Health to Dr.MacNeill, Commissioner of
1,Minutes,1924-1937, Special Meeting with Dr. McGhie, Mental Services,Province of Saskatchewan, 25 July
14 November 1930 to discuss training at provincial 1938.McGhie described the situation, 274
mental hospitals.
33 AO, RGl0-20-A- 1, File 1.1, Minutes of Superintend- 46 AO, Government Documents, ' annual Report
ents' Conferences, December 1930-0ctober 1949, 8 of Training Schools for Nurses, Ontario Hospitals,"
December 1930 meeting with McGhie and physi- 1932,p.88. Some superintendents believed nurses
cians. The superintendents knew that their schools had to have their initial training at a mental hospital to
would not be recognized and that they would not be of value. Others did not believe the leadership was
attract students. As well, they did not want to go back actually prepared to organize affiliations. See
WGHA, Journal Collection, Dr. George Stevenson,
to the days of the female attendant.
34 George M. Weir, Survey of Nursing Education in Can- "Ward Personnel in Mental Hospitals", The Canadiada (Toronto: MacMillan, 1932), p. 66. It is often referred an Nurse, 31,1Ganuary 1935): 5-10.
47 CNO, Council of Nurse Education, Book 1,
to as the Weir Report or the Weir Survey.
35 WGHA, Annual Reports, Box 6, Superintendent of Minutes 1924-1937, 27 March 1934; Book 1,Activities
Nurses Report, 1919-1920. Some students in each of the Council, 1924-1937,1935.Schools were closed at
class received the affiliation. Notably, this training the Ontario Hospitals, Toronto, Whitby and Cobourg.
preceded the opening of Manitoba's two provincial The superintendents refused to hand over the mental nursing component of the curriculum.
mental hospital schools.
48 Rothery was responsible for increasing the general
36 RNAO, Box 33,96B-1-09,Nursing Education Sec- affiliation to one year and she and Dick organized
tion, Minutes,1928-1931. Gertrude Garvin led a Com- several psychiatric affiliations for general schools.
mittee on Psychiatric Training. It planned affiliations AO, Government Documents,"Annual Report of Onfor some Toronto area schools with the Toronto Psy- tario Hospitals Schools of Nursing," 1938, p. 23.
49 For details about student life at the Ontario
chiatric Hospital.
37 WGHA, Journal Collection, Dr. C. Farrar, "Chang- Hospital,Hamilton, see Tipliski, uParting at the Crossing Views Relative to Mental Disorders," The Cana- roads," p. 218-26. Little was found about the relationdian Nurse, 26, 1 (January 1930): 3-9. The mental ship between the nurse leaders and mental hospital
hygiene movement helped to professionalize the psy- students, other than their advocacy role.
chiatric discipline. Psychiatric nursing was an Ameri- 50 AHCPMH, Canadian Mental Health Association,
can term which gradually took the place of "mental Alvin Mathers,"Mental Hygiene in Manitoba," The Bulnursing,0
but
the
terms,including
"mental letin (1929): 3-4.Veterans were returning to Manitoba
hygiene,"were used interchangeably by Canadian with shell shock (war neurosis) and there were no
trained mental nurses. Also see note 36.
nurse leaders.
38 Fidler was a Toronto General Hospital graduate
and the Toronto Psychiatric Hospital's first nursing 51 Provincial Archives of Manitoba (PAM), Gov. Doc,
director. She did a post-graduate course in psychi- Man, SPR, 1928, Box 7, File 5, Commission to Inquire
atric nursing at Johns Hopkins and was an advocate into Conditions at Brandon Hospital for Mental
for incorporating the course into general nursing cur- Diseases,8 Aug 1928. It was revealed that the schools
ricula. She later became director of the School of Nurs- had no official ties to government, perhaps because of
ing at the University of Toronto. See Gorrie, "Nursing," a change in government and erroneous assumptions.
The Chief Provincial Psychiatrist, Dr.Alvin Mathers,
p. 193-217.
was responsible for the hospitals. The second school
39 WGHA, Journal Collection, Nettie Fidler,"Psychiatric
was created at the Selkirk Hospital for Mental DiseasNursing," The Canadian Nurse, 29, 11 (November 1933):
es within a few years.
571-78.
52 PAM, RG18B2, Box 4, File: Brandon Hospital,
40 Manitoba's nursing leadership also perceived 1926,Nurses Duties, p. 7,31October 1926. Pupil nurse
Weir as the "authority"-his report was the stimulus for duties were included in the females' job description,
their attempt to establish psychiatric affiliations. See and as long as they attended classes, they received
Manitoba Association of Registered Nurses Archives an annual raise.
- 34 -
53 Brandon University, McKee Archives, Brandon
Mental Health Centre (BU McBMHC), SB3,File
1,Progress Report, 1922-1926,p. 1.The men received
optional lectures from the superintendent, but these
were held irregularly and few did so. The goal for
both Ontario and Brandon was that, in time, female
nurses would replace untrained male attendants on
the male "side." Women were perceived as better
able to provide emotional care and understanding, related to their traditional domestic maternal roles. See
Boschma, The Rise of Mental Health Nursing, p. 81-111
and p. 175-96 for an examination of the gendered nature of mental nursing. Also see McPherson, Bedside
Matters, p. 38-41 for a discussion on women's monopoly on nursing and the hospital as "family."
54 Ethel Johns and Beatrice Fines, The Winnipeg General Hospital and Health Science Centre School of
Nursing, 1887-1987 (Winnipeg: WGH School of Nursing, 1987),
p. 46-47. Nurses in Manitoba were the first to
obtain registration in 1913; the government had no
authority over MAGN activities.
55 PAM, "Brandon Hospital for Mental Diseases, Annual Report," 1924-25, p. 6. The St. Boniface Hospital
accepted some of Baragar's students. Also see
MARN, 47-24- 058, Board Meeting Minutes,25 May
1926.
56 MARN, 47-24-058,General Meeting Minutes,
27January1927. "Recognized" hospital was defined as
a general hospital and specialty hospital students
were required to obtain a minimum of 18 months general affiliation. Also see PAM, RG 18B2,Box 3, Deputy
Minister,File: Brandon Hospital, 1921-27, Letter from
Baragar to Mathers and McClean with amendment
attached, 15 February 1927. Baragar noted that the
mental hospitals were at the mercy of powerful general hospitals for the affiliation because it was voluntary,
not prescribed.
57 WGHA, Journal Collection, Alvin Mathers, "Mental
Hygiene and Nursing," The Canadian Nurse, 24, 8 (August 1928): 425-31.Mathers told a CNA annual meeting
that some" in organized nursing still shunned
involvement with mental hospitals. Perhaps this was
related to the medical superintendents' lack of status
within medicine and because nurses identified with
general medicine. For a description of the status
differential between superintendents and their medical colleagues, see Edward Shorter, A History of Psychiatry: From the Era of theAsylum to the Age of Prozac (Toronto:
John Wiley & Sons,1997), p. 65-68.
58 MARN, 47-24-058, Board Meeting Minutes, 14
January 1935. Kathleen Ellis was Superintendent of
Nurses at the Winnipeg General Hospital, and as
a Johns Hopkins graduate, valued the psychiatric affiliation. See University of Saskatchewan Archives
(UofS), College of Nursing, Ellis Files.Also see note 38.
59 MARN,47-24-058,Board Meeting Minutes,25 April
1935; PAM, GR157,Health and Welfare Minister's Office Files, 1941-59, Open letter from Gertrude Hall,
MARN secretary,4 January 1943.
60 MARN, 47-24-058, Board Meeting Minutes, 13 June
1935 and 5 September 1935.
61 Saskatchewan Archives Board (SAB), PH3, File
4B, Middleton, 1933-4, Letter to Deputy Minister of
Public Health, Dr.E Middleton, from Dr.A.
Campbell,Weyburn, 16 February 1933.
62 Donald McKerracher,''A New Program in the
Training and Employment of Ward Personnel," American Journal of Psychiatry, 106, 10 (October 1949):
259-64. Some lectures were mandatory,but the full
lecture program remained optional.
63 SAB,PS, File A17,Public Service,Mental Hospital
Prerequisites, Letter to P. Shelton, Chairman, Public
Service Commission, from J. MacNeill,22 Dec 1930.
For insight into MacNeill' s power see SAB,R-999,22
(172D3), "Report of Commission of Inquiry into the
Administration of the Provincial Mental Hospital, North
Battleford," 8 April 1946.
64 SAB,SRNA, R-993,43F (4.2-9), Registrar,Report to
the President and Council of visit to North Battleford, 15
May 1938. Ellis reported that the matron was a school
teacher.
65 SAB, PH3,File A9, Letter to Dr. MacNeill from Dr. A.
Campbell, 6 December 1937. Besides the difficult
economy, RNs became more interested in mental
hospital nursing work with the arrival of more somatic
treatments.
66 SAB, PH3,File A9,Letter to Dr.A. Campbell from J.
MacNeill, 30 December 1937. The apprenticeship
involved the same salary and work as attendant training.
67 McI<erracher,''A New Program," p. 262.
68 SAB, PH3, A9, 1932-35, Letter from Dr. MacNeill to A
Campbell, 2 April 1932; Weir, Survey of Nursing Education, p. 524. For details about why he was defensive,see
note 28.
69 SAB, PH3,A9,1932-35.
70 AO, RGl0-107-0-165, Container 22, File: Nurses,
General, 18-7-3, Letter to Dr.MacNeill from Dr.
McGhie, 8August1938.McGhie noted that in Ontario,
mental hospital student nurses entered from high
school, set on becoming RNs. They were not salaried
civil servants but received a small allowance.
71 University of Saskatchewan, College of Nursing, Ellis Files,Report to the Committee on Policies Affecting
Schools for Nurses,SRNA, K. Ellis, 3 March 1938.She
noted a lack of RNs in mental hospital nursing and
that the affiliation was essential. Ellis came to the
province from Teacher's College, Columbia
University.She became the first director of the University of Saskatchewan nursing program. See Ellis
Files, Clippings.
72 SAB, SRNA, R-993, 43F (4.2-9), Letter to K. Ellis
from Miss Jacques, 5 December 1938. Jacques, the
matron, wrote for MacNeill.
73 SAB,SRNA, R-993,43F (4.2-9), Letter to H.Jacques
from K. Ellis,29December 1938. She
is clear that the experience was so that students could
apply it to all areas of nursing.
74 SAB, SRNA, R-993, 43F (4.2-9), Letter to Premier
T. C. Douglas from K. Ellis, 25 September 1944.
75 University of Saskatchewan College of Nursing,
Ellis Files, 1938, p. 6.
- 35 -
76 National Archives of Canada (NAC), RG29, Vol.
905, File 438-5-1, Mental Health Division, Survey of
the Nursing and Attendant Situation of the Mental
Hospitals of Canada, p. 3-5,1947.All provincial mental hospitals had suffered financially through the depression and war.
77 Donald Le Bourdais, "Canada's Shame: Our
Mental Hospitals, Part 2," Liberty (8
February 1947): 8-9, 38-41.
78 NAC, RG29,Vol. 905, File 438-5-1, p. 6.
79 PAM, H-16-19-1, Temporary Box 18, Box 3, Health
and
Welfare
Minister's
Office
Files,
Psychiatry,1944-49,Letter to Ivan Schultz (and allprovincial health ministers) from Dr. C. Hincks,15
January 1946.
80 AO, RGl0-107-0-174, Container 24, Nurses, 18-73, 1947, Minutes of meeting with Dr. Montgomery
and nurses,10 July 1947.
81 AO,RGl0-107-0-423,HS15-2,Container 65, Fitzsimmons Survey,1943-44,Survey of Nursing in the
Ontario Hospitals, 1943.
82 AO, RGl0-107-0-174, Container 24, 18-7-3.
83 CNO,Council of Nurse Education, Report to
RNAO, 1947.
84 AO, RGl0-107-0-172, Container 24, Nurses, 187-3, 1945, Memo from J. Phair to R. Montgomery,22
May 1945; and RNAO,Green Books, Minutes, 194445,Board of Directors meeting, 30 September 1944.
85 RNAO,Green Books, Minutes, 1944-45,Annual
Meeting, 12-14 April 1945.
86 WGHA, Journal Collection, Laura Fitzsimmons,
"Mental Hygiene and Mental Hospital Nursing," The
Canadian Nurse, 41, 7 Only 1945): 523-26; and Hilda
Bennett, "Preparation for Psychiatric Nursing," The
Canadian Nurse, 41,7 Ouly 1945): 539-41.
87 CNO,Council of Nurse Education, Book 3, Minutes, 17 June 1948; and RNAO,Box 33,Curriculum
for Schools of Nursing in Ontario, 1949. All schools
were to have the affiliation in place by 1951.
88 AO,RGl0-20-A-1, File 1.2,Superintendents' Conferences, Minutes,1945-49,Report from Special
Committee on Psychiatric Nursing, 30 September
1947. The committee had been appointed to advise
government on the crisis and recommended aides
as RN assistants.
89 AO, RGl0-107-0-175, Container 24, Nurses 18-7-3,
1948, Letter to G. Fairley from Edith Dick, Director
of Nurse Registration, 20 February 1948.
90 The schools at the Ontario Hospitals London,
New Toronto and Hamilton were closed.
94 BUMcBMHC,SB6,File 1,Julia Ryfa, "Message to
Students," The Ego (1952-1953): 50; SB17, Graduations, Letter to R. Hoey, Minister of Education from
Dr. Pincock, 18 May 1931.
95
NAC,
RG29,
Vol.
317,File
435-6
4,Pt.2,Subcommittee on Training, "Some Comments
and Opinions Regarding Psychiatric Training Expressed by Provincial Nurses' Associations," Gertrude Hall,CNA, March 1952, p. 3-4.
96 MARN, 47-24-058, Board Meeting Minutes, 14
January 1953. Only six of 16 schools offered the
affiliation to some or all students.
97 PAM,H-16-19-1,Box 3,Temp. Box 18,Health and
Welfare Minister's Office Files,1950- 57,Meetings, 28
October 1953. This decision came within a few
months. Unlike other western provinces, the government did not legislate the program and its graduates.
98 SAB, R-999, 22 (172 D3), «Report of Commission," p. 4; McKerracher, "A New Program," p. 259.
99 Le Bourdais,"Canada's Shame," p. 9.
100 SAB, R-11-14-19, 1944-1952, Editor, "Saskatchewan Shows the Way," Toronto Star Weekly, (26
June 1952): 3-6. McKerracher was a University of
Toronto medical graduate (1935) and a staff psychiatrist at the Toronto Psychiatric Hospital.
101 McKerracher, "A New Program," p. 260.
102 McKerracher, "A New Program," p. 262.
103 SAB, SRNA, R-993,43F (4.2-9), Letter to K Ellis from
D:t: McKerrache 3 December 1948.
104 McKerracher, "A New Program," p. 264.
105 SAB, R-11, 14-31, Letter to K. Ellis from I C.
Douglas 12 October 1944; and SAB, SRNA, R993,43F (4.2-9), Letter to K. Ellis from Dr.McKerracher,
23 December 1946.
106 SAB, R-11, 14-31, Letter to K. Ellis from Dr.
McKerracher, 4 February 1947. The concern was
that the staff was on salary and not purely students.
Also see letter to Dr. McKerracher from K. Ellis, 23
January 1947. There were just 10 days between
their letters.
107 SAB, SRNA, R-993, 39A (3.2-2-2), Letter to Ethel
James, President, from K. Ellis, 8 March 1948.
108 SAB,SRNA, R-993,43F (4.2-9), Letter to
Dr.McKerracher from K. Ellis,23January1947.
109 SAB,SRNA, R-993,43F (4.2-9), Letter to K. Ellis
from Dr.McKerracher,18 June 1947.
110 SAB, R-33.5,109 (13-5-2), Letter to Dr. Shumiatcher from L. Gardiner,2 April 1947. For Mckerracher' sopposition to the graduates being called
"psychiatric nurses," see SAB, SRNA, R-993,39A (3.291 NAC, RG29,Vol. 317,File 435-6-4, Pt. 2-2), Letter to E. James from K. Ellis, 3 March 1948. For
3,Subcommittee on Training, Memo to Dr. C. Rob- several years after,he referred to them as aides.
erts from Dorothy Percy, 3 March 1954.Almost 2000
students had the experience in 1953.
111 SAB, R-335,109 (13-5-2), Letter to L. Gardiner
92 MARN, 47-24-058,Board Meeting Minutes, from I C. Douglas,22 January 1948. The CCF was
11May 1942 and 16 February 1949.
rooted in the labour movement and attendants
93 PAM, MGlOBll, Box 17, Winnipeg General Hospi- belonged to the Canadian Congress of Labour.
tal Board Of Directors, Minutes, 3 November 1942; 112 SAB, R594, Box 22, Session 1948, 5th Session of
GR157,H-14-21-1,Temp. Box 14,Health and Welfare 10th Legislature.
Minister's Office Files, Letter to I.Schultz from Dr. G. 113 SAB. SRNA, R-993,39A (3.2-2-2), Letter to PreFiddes, 30 August 1946.
mier Douglas from K. Ellis, 8 March 1948. Psychiatric
- 36 -
nurse was a newer and more prestigious term than
mental nurse.
114 CNA, Minutes of Executive Committee, 8-10
Feb 1951. Pullan's request came through the RNABC.
115 NAC, RG29, Vol. 1689, File 437-11-3, Pt.1, Mental
Health Div., Mental Health Advisory Committee Meeting Minutes, 5 June 1952, p.18. Alberta's psychiatric
nurses did not have legislation, just an association.
Money was available through the National Health
Grants Program for such an undertaking. For
information about the Advisory Committee, see
Harvey Simmons, Unbalanced: Mental Health Policy
in Ontario, 1930-1989 (Toronto: Wall and Thompson,
1990), p. 87-88.
116 NAC, RG29, Vol. 335, File 436-5-5, Mental Health
Div., Nursing, "Information on Psychiatric Training
for Nurses," CNA, October 1951,p. 9.
117 NAC, RG29, Vol. 317, File 435-6-4, Subcommittee
on 'fraining, Memorandum from Edith Kemp, 22
February 1953, p. 6-7.
118 NAC, RG29, Vol. 317,File 435-6-4, p. 11-12 and
NAC, RG29,Vol. 1418,Subcommittee on 'fraining,
Submission on Psychiatric Nursing to Mental Health
Division, CNA, September 1953, p. 5. Nurse registration was a provincial responsibility, and affiliations could not be forced onto associations. Ittook
until 1970 and the country wide adoption of the CNA
registration exam, before all provinces mandated
this affiliation. Letter from Judith Oulton, Executive
Director, CNA, to writer, 14 March 1994.
119 NAC, RG29, Vol. 1689, File 437-11-3, Pt. 1, Minutes, 24 September 1953, p. 14-16. McKerracher
was proud of his training program and promoted it
to colleagues within the APA. BC followed Saskatchewan in enacting legislation for psychiatric nurses.
120
NAC, RG29, Vol. 1689, File 437-11-3, Pt.
1,Minutes, 24 September 1953,p. 15.
121 AO, RGl0-107-0-178, Container 25, Nurses,
18-7-3, Memo from Dr. J. Weber to Dr.R. Montgomery 16 December 1953. The western doctors
were likely unaware of what their Ontario colleagues thought about the new western nurses.
122 NAC,RG29,Vol. 317,File 435-6-4, Pt. 3,Memo to C.
Roberts from Dorothy Percy,29 December 1953.
123 NAC, RG29, Vol. 1690, File 437-11-5, Pt. 1, Minutes, 7 December 1953, p. 8. The Quebec
doctor,George Reed, had little input after he advised
that Quebec's RNs would not recognize the western
program. Roberts was a willing accomplice, however
in his biography, he recalled that he was of "tender age
and experience" when he became Chief. See Charles
Roberts,From Fishing Cove to Faculty Council ...and Beyond (Calgary: Pondhead, 1995), p. 72.
124 NAC, RG29, Vol. 305, File 435-3-7, Subcommittee on Training, Letter from McKerracher to Roberts,
29 September 1953; Letter to McKerracher from Roberts, 6 October 1953;Vol. 317,File 435-6-4,Pt. 3,Letter to
Roberts from Gee, 23 October 1953; Memo to Dr. G.
Cameron from Dr. Roberts, 8 January 1954; and
Letter to Dr. Gee from Roberts, 14 September 1954.
Being on both committees allowed Roberts, the
Chief, to do such manoeuvring. Also see Simmons, Unbalanced, p. 89- 90 for a description of a generally
ineffective
federal/provincial
mental
health
bureaucracy,at least compared to the American situation.
125
NAC,
RG29,Vol.
317,File
435-6-4,Pt.
3,Subcommittee on 'fraining, Letter to Roberts from
Gee, 17 August 1954.
126 NAC, RG29, Vol. 317, File 435-6-4, Pt. 3, Letter to
P.Stiver from Dr.G. D. Cameron,
26 April 1954.
127 CNA, Annual Meeting Folios,1912-54, Box 2,File
5,Charles Roberts,' ddress to the Meeting of the CNA,"
Banff, 10 June 1954,p. 2.
128 WGHA, Journal Collection, Elizabeth Bregg,
"Providing Nursing Service for the Mentally Ill," The
Canadian Nurse, 50, 11 (November 1954): 883-87.
Bregg was Supervisor of Nursing at the Toronto
Psychiatric Hospital.
129 NAC, RG29,Vol. 318,File 435-6-4, Pt. 4, Letter to
Dr.Gee from Dr. Roberts, 10January 1955. Percy was
employed by the Department of Health and Welfare,
and was Roberts' colleague. She was first in the department to examine the curricula. Besides Bregg, committee members were from Ontario, Quebec and British
Columbia.
130 NAC, RG29,Vol. 318, File 435-6-4,Pt. 4,Letter to Dr.
Roberts from Dr.Gee, 4 January 1955.
131 NAC, RG29,Vol. 318, File 435-6-4, Pt. 4, and NAC,
RG29,Vol. 1418, Minutes, 8 July 1955, p. 4. Roberts and
Gee were agitated and suspicious, but accepted
that a different curriculum was their only hope for
western psychiatric nurses to become recognized
across Canada.
132 NAC, RG29,Vol. 318, File 435-6-4, Pt. 4, and NAC,
RG29,Vol. 1418, Minutes, 8 July 1955,p. 5. McKerracher
and his psychiatric nurses pulled out when the decision
was made that western psychiatric nurses would
affiliate for general nursing. McKerracher was not
interested in an educationally based program under
nursing, and his nurses did not wish to dilute their
distinct profession. Manitoba was not invited to participate.
133 NAC, RG29,Vol. 1690, File 437-11-5, Pt.1,' Summary
of Psychiatric Nursing," 1960, p. 8. The demise was
in 1957-58. The Advisory Committee never received
a standardized nurses' aide course.
134 The province of Manitoba sat on the east-west
divide because its mental hospital nurses were not
legally recognized until 1960.
135 AHCPMH, CMHA, Percy, "Working Paper," 1957, p.
4.
136 Susan Taylor Wood, "Changing Times: A Historical
Review of Psychiatric Nursing Education in the Province of Saskatchewan,"Master's thesis, University of
Regina, 1998, p. 91-95. The province's separate
psychiatric nursing education program joined the
mainstream general nursing education program.
137 See notes 28 and 58.
138 Bregg, "Providing Nursing Service," p. 885.
- 37 -
139 D. Nairne and A. Paul, "Province Brings Back Diploma
Nursing Plan,"Winnipeg Free Press, 29 January 2000, p.
A12. Also see e-mail to deans and faculty, Canadian
Association of University Schools of Nursing, from
Doris Callaghan, British Columbia Coalition, 2 January
2002. In late 2002 the BC government decided to
phase in baccalaureate education. For the Saskatchewan situation, see e-mail to Karen Wall,Chair,Nursing,
Red River College, from Dean Yvonne Brown, College
of Nursing, University of Saskatchewan, 26 January
2000.
140 Canadian Nursing Advisory Committee, Our Health,
Our Future: Creating Quality Workplacesfor Canadian
Nurses (Ottawa: Government of Canada, 2002), p. 11.
Veryl Margaret Tipliski, PhD, CPMHN(c), RPN,
RN, is a nurse educator at at Langara College,
Vancouver, British Columbia, Canada teaching
mental health nursing in
Higher Education.
Veryl was also a nurse educator at Red River
College, Winnipeg, Manitoba.
- 38 -
Advanced Education for RPNs:
Kimberley Ryan-Nicholls, MEd (DE), BScN, RN, RPN
Associate Professor - Brandon University Faculty of Health Studies
RPNs collaborating with RNs and LPNs in the delivery
of mental health services (Ryan-Nicholls, 2004).
LPNs are located in every Canadian province and territory. They receive theoretical and clinical education in
one to two year post-secondary (community college)
programs, have their own defined scope of practice, and
are
regulated
through
legislation
in
each
province/territory.
Introduction
Registered Psychiatric Nurses (RPNs), within Canada,
are educated and regulated as a distinct profession in
Manitoba, Saskatchewan, Alberta and British Columbia
(Canadian Institute of Health Information, 2003). Although RPNs have provided professional mental health
services for over 80 years (Canadian Institute of Health
information, 2003), little has been written about their struggles for recognition and understanding. Besides
experiencing relentless objection
to their very existence, RPNs also
encountered persistent resistance to the attainment of advanced educational preparation.
By writing this paper, the author
attempts to shed some light
upon the challenges encountered by RPNs, first for their very
existence then later for attainment of advanced educational
opportunities. An overview of the
three regulated nursing professions within Canada sets the
stage for an investigation of the
tensions that arose in the mid
1970s, among the Canadian nursing workforce, reached a boiling point in the mid 1980s
and continued to percolate, over the next three decades, while RPNs pursued advanced educational opportunities, specifically designed for Registered
Psychiatric Nursing as practiced in the four western
Canadian provinces.
The Canadian Nursing Workforce:
An overview
The Canadian nursing workforce is comprised of three
regulated professions including: Licensed Practical
Nurses (LPNs), Registered Nurses (RNs), and Registered Psychiatric Nurses (RPNs) (Canadian Institute for
Health Information, 2003d). Members of these distinct
nursing professions work in a variety of roles and settings across the continuum of health services, with
Every province and territory within Canada has RNs.
The educational requirement for entry to practice of this
particular nursing group can be either a diploma or
degree. Mental health knowledge and competencies are
initially covered in the diploma and baccalaureate nursing education programs. Baccalaureate prepared RNs who have
attained advanced education
preparation can specialize in
psychiatric/mental health nursing. This type of specialty is a
certification offered through the
Canadian Nurses Association
(CNA), in collaboration with the
Canadian Federation of Mental
Health Nurses.
RPNs are educated within the
Canadian provinces of Alberta,
British Columbia, and Manitoba, and recognized as a nursing
discipline in Western Canada
as well as in other countries (i.e.
the United Kingdom, Australia,
New Zealand and Bermuda). In
some of these countries, RPN
practice is distinctly regulated by separate legislation,
complete with their own standards for practice, and
provincial licensing bodies (Austin, Gallop, Harris, &
Spencer, 1996).
RPNs have provided mental health services for over 80
years in western Canada and for many years were
primarily employed in mental health centres and psychiatric wards of general hospitals (Canadian Institute of
Health Information, 2003). In response to a shift in
patient population during the mid-1960s, RPNs began
practicing in smaller, community settings with a progression to current employment settings that include: “community, social services, and/or welfare, correctional
institutes, regional hospitals, family service agencies,
and nursing homes” (Canadian Institute of Health Information, 2003 p. 29).
- 39 -
“While RPNs possess a wealth of both general and
psychiatric nursing knowledge and skills, their primary
area of expertise is in providing services to individuals
whose primary care needs relate to mental and developmental health ” (Canadian Institute of Health Information, 2003 p. 29). RPNs “also focus on psychosocial
forces that influence health, and are dedicated to helping the community attain and maintain their health at
optimal levels” (Canadian Institute of Health Information, 2003 p. 29). Until recently, most RPNs graduated
from a diploma program prior to entering the workforce.
While post-basic education has been available for
RPNs close to three decades in Manitoba, entry-level
baccalaureate education for RPNs has only been offered since 1995.
Due to the geographical variation, comparison of RPN,
RN and LPN national numbers is problematic. However, comparisons can be made across particular regions. In 2012, 4,720 RPNs (99% of RPNs) practiced
in direct psychiatric/mental health care, in Western
Canada. Please see Table 1: Registered Psychiatric
Nursing Workforce, by Area of Responsibility (Direct
Care Only) and Jurisdiction, Western Provinces, 2018
and 2012 (Canadian Institute of Health Information,
2014a, September 14).
During this same year, of the 13,500 RNs providing
direct psychiatric/mental health care nationally, 3,056
(less than 23.0 %) were practicing in this particular
area of responsibility, within the four western provinces. Please see Table 2: Registered Nursing Workforce,
by Area of Responsibility (Direct Care Only) and Jurisdiction, Canada, 2008 and 2012 (Canadian Institute of
Health Information, 2014b, September 14).
Additionally, of the 4,031 LPNs engaged nationally in
direct psychiatric/mental health care, 294 (less than
2%) practised in this area of responsibility, within the
western Canada. Please see Table 3: Licensed Practical Nursing Workforce, by Area of Responsibility (Direct Care Only) and Jurisdiction, Canada, 2008 and
2012 (Canadian Institute of Health Information, 2014c,
September 14).
When the number of RPNs employed in
psychiatric/mental health is compared with RNs and
LPNs employed in same area of responsibility, within
western Canada, the numbers are revealing. In 2012,
there were less combined numbers of LPN and RNs
(N=3350) practising in direct psychiatric/mental health
care than the total number of RPNs (N=4720) practising in all areas of direct psychiatric/mental health care
excluding Medical/Surgical (Canadian Institute of
Health Information, 2014, September 14). Clearly, the
number of RPNs practising within the four western
provinces is meaningful. RPNs “represent the largest
single group of mental health professionals in western
Canada” (Canadian Institute of Health Information,
2003 p. 29).
On the surface, the conflicts of past and present,
among the Canadian nursing workforce, appear to be
no more than mere tensions amongst nursing groups.
However, when layers are peeled back and examination extends beyond the superficial, clear and present
dangers including discrimination and stigma by association; territoriality and threats of abolition, for RPNs
become obvious.
Historically Registered Psychiatric Nursing, as practiced in the four western Canadian provinces, has been
marginalized and misunderstood. More than a century
has passed since Bedford Fenwick (1896) asserted
“everyone will agree that no person can be considered
trained who has only worked in hospitals and asylums
for the insane” (p. 429). Eight decades later, the Manitoba Association of Registered Nurses (MARN) (1976)
(renamed the College of Registered Nurses of Manitoba, (CRNM) wrote RPNs “were legislated into existence as instant panaceas for crisis situations:
registered psychiatric nursing evolved to cope with
custodial care in mental hospitals at a time when those
hospitals were known in the vernacular as “Insane
Asylums”, and which are aberrations of the past” (p.
86).
“Philosophically, RNs during the 1970s and 1980s did
not believe in the existence of the profession of Registered Psychiatric Nurses” (Osted, 2010 p. 1). This
belief was perhaps never so marked as during the time
MARN (1976) published Nursing education: Challenge
and Change, also known as “the blue book”. While
referring to the diploma program for RPNs, The MARN
(1976) asserted first; “this program seems a needless
extravagance when the technical nurse (diploma registered nurse) can be prepared in the same length of
time to give nursing care to the whole person, whether
the individual’s health problem is primarily emotional or
physical in origin” (p. 111) and second; “such a change
in strategy might promote more than lip-service to the
concept of quality in health care. Otherwise, those
agencies of government which have the ultimate decision-making powers about costs and expenditures
may be pursuing a penny-wise and pound-foolish
course with the tax payers’ money” (MARN, 1976 p.
162).
The MARN believed that there should be only one
profession of “Nursing” and that that profession would
include Registered Nurses only. According to the
MARN (1976) “a more logical means of organization
would be to consolidate the funding of all nursing
education under the Department of Colleges and Universities Affairs with the control of nursing education
remaining with the MARN” (p. 123). Blatant territoriality
was demonstrated by the MARN (1976) while recommending:
● That in order to bring order and substance into
nursing education, all programmes for the edu-
Conflict: Past and Present
- 40 -
cation of nurses be conducted in the general
education setting (p. 162).
as well as for those patients who, having managed well in the community may encounter particular stressors that require brief periods of
hospitalization in psychiatric in-patient units”
(Purkis, M.E., 2004 p. 2).
● That the MARN determine the number and types
of nursing education programmes that may exist
in the province and that all proposed programmes must meet the MARN’s requirements Countering these assertions, Cutcliffe (2005b) argued “I
wish to challenge the rather parochial views espoused
for initial and ongoing approval (p. 162).
in the response from UBC… Providing the academic
● That the MARN be empowered by the Govern- standards are equivalent to a generic Masters of Nursment of Manitoba to establish a Task Force to ing (and there is no documented reason to suggest that
develop and ensure a sound orderly plan to they would not be), the only thing preventing these
accomplish the transition of nursing education emancipatory options would be the lack of imagination
into the general education setting and the phas- on the part of the academy (or the ‘political’ interests of
ing of levels, one into the other, to accomplish those currently holding the position of the dominant
discourse.) (p. 17). Cutcliffe (2005b) went on to contest
two levels of nursing only (p. 163).
“The response from the Director of Nursing at UBC is
● That the profession prepares, in line with the more measured and more thoughtful, but it still contains
Canadian Nurses’ Association recommendation, a number of ‘interesting’ positions, assumptions, assertwo types of practitioners only: i.e. the profes- tions and inaccuracies. It is inaccurate, considering the
sional nurse prepared in the university and the international evidence, to suggest, quote “RPNs augtechnical nurse prepared in the Community Col- ment the RN workforce in mental health service delivery
and have never been the sole provider (or indeed the
lege (p. 163).
majority provider) of that form of nursing service” (p. 16).
Despite the passage of four decades since the MARN
published “the blue book” discrimination against RPNs According to Osted (2010) “Over and above everything
has continued to thrive. In 2004, several highly respect- else, we work with people who have learned to hide their
ed Canadian RN leaders made some uninformed and illness or condition rather than suffer the stigma and
damaging claims against the profession of registered discrimination that they receive from the majority of the
psychiatric nursing. Although not published like those of public. We continue to share that stigma and, to a
the MARN, these claims were made in a public forum certain extent the discrimination that goes with it” (p. 2).
and remained posted on the web for 30 days. Disparag- Just a few years ago, Smith (2011) claimed that RPNs
ing comments made by University of British Columbia cannot apply a holistic perspective nor client centered
(UBC) and University of Victoria (UVic) Faculty of Nurs- care due to a lack of the full range of knowledge affording representatives during an invitational review of ed by a comprehensive general nursing education proKwantlen University College’s proposal to offer a Bacca- gram. Moreover, Smith (2011) criticized that “a social
injustice is taking place because mental health consumlaureate Degree in Psychiatric Nursing included:
ers receive sub-standard care within the western Cana● “In our view, bolstering a small anomalous seg- dian provinces due to the differing models of psychiatric
ment of the nursing workforce in a manner that nursing education that exist” (p. 15).
effectively bypasses the conventional RN designation is a misguided efficiency and one whose
implications may haunt policy makers as this
new breed of practitioner finds roadblocks to Attempts to Abolish the Profession
Attempts to abolish RPNs appear to originate as a result
career advancement” (Thorne, 2004 p. 5)
of both direct and indirect means. Direct means is evi● “If the RPN is to advance to a role beyond that of dent both in verbal statements and overt actions made
RN assistant, then these individuals deserve the by Registered Nurses, the dominant nursing group,
full skillset and privilege of being RNs, with bac- within Canada, both past and present to abolish the
calaureate degrees…” (Thorne, 2004 p. 5). “The profession.
limiting of a nursing diploma program to one
aspect of human functioning (mental illness) has Abolition: direct means
long been a critique of programs such as the one In publishing the Blue Book” the MARN recommended
proposed here. In all other areas of our country, the elimination of both Registered Psychiatric Nurses
the accepted standard for entry-level nursing and Licensed Practical Nurses. RPNs were certainly
preparation for employment in mental health and aware of some animosity but it was not until this publicapsychiatry is the BSN” (Purkis, M.E., 2004 p. 2). tion that the threat became blatantly clear. Nursing
Education: Challenge and Change, was overt evidence
● “Nurses with a generalist education are much of the magnitude of peril that RNs posed for RPNs.
better prepared to offer the full scope of knowledge and practical skill development to support According to the MARN (1976) “the program leading to
patients with long-standing psychiatric disorders a diploma in psychiatric nursing may have had releand enter hospital for an acute physical ailment vance when it was initiated, but in light of developments
in the disciplines related to mental health and illness and
- 41 -
the delivery of mental health services, it is obsolete” (p.
115). Moreover, the MARN (1976) affirmed that “narrow
specialization, with a few skills even at a high level of
expertise, only perpetuate and/or increase fragmentation of services, with subsequent depersonalization and
alienation of consumers” (p. 79) and subsequently
recommended that “in light of the proposed changes in
health care services, the demands for these groups
should be reduced, and increasing efforts made to
reach realistic proportions of diploma and university
prepared registered nurses” (MARN, 1976 p. 78).
In response to this threat, the RPNAM (now known as
the CRPNM) mobilized its volunteer resources and
prepared a submission to the O’Sullivan Task Force on
Nursing Education. That Task Force recommended
maintaining psychiatric nursing as a separate group.
Not many years ago, Cutcliffe (2005a) confronted attempts to eliminate RPNs, “right now, the RPN community within BC is facing one of the most significant
threats to the very continued existence of the specialism and concomitantly, the eradication of specialist
RPN preparation. These challenges are bound up within the context of the proposals emanating from
Kwantlen and Douglas colleges to offer a Bachelors of
Psychiatric Nursing and more specifically in the ‘peer
responses’ produced by the University of British Columbia and the University of Victoria” (p. 18).
Abolition: indirect
Between 1999 and 2001, the Nursing Education Program of Saskatchewan (NEPS) program admitted students into a combined program of both Bachelor of
Nursing and Bachelor of Psychiatric Nursing. Upon
graduation from the program the student declared
which program they were graduating from. It was this
type of program that RN leaders proposed would solve
the “RPN problem” (Thorne, 2004) by providing the
advantage of upgrading (or laddering) mechanism over
the separate psychiatric nursing baccalaureate degree
allowing individuals to expand skills required for nursing
practice in mental health contexts while preserving the
rights and privileges of baccalaureate prepared RNs,
including access to graduate education in the discipline
and the qualifications for the full set of professional,
educational, and clinical leadership roles (Thorne, 2004
p. 2).
However, maintaining a culture capable of socializing
students effectively to psychiatric nursing as a profession was a particular challenge in NEPS, since psychiatric nursing was a minority profession within the faculty
and a route chosen by a minority of students, the
challenge became how to ensure that within the dominant culture of the program, room was also made for
the psychiatric nursing professional culture (Registered
Psychiatric Nurses Association of Saskatchewan,
2001). Registrations by Saskatchewan psychiatric
graduates plunged significantly from 40 in 1997 to four
two years later followed by three registrations and then
only two in 2000 and 2001 respectively (Registered
Psychiatric Nurses Association of Saskatchewan,
2001).
Convinced that a lack of marketing of the psychiatric
nursing education program within NEPS almost exclusively contributed to the decline in Registered Psychiatric Nursing Association of Saskatchewan (RPNAS)
registrations, the Registered Psychiatric Nurses Association of Saskatchewan (2001) challenged “it is unlikely that, precisely at the time NEPS was started, health
care system restructuring and labour market trends,
alone, would have eliminated, almost entirely, a labour
market of this size (p. 6). Following several years of
recommendations made by the RPNAS to NEPS with
little or no effort in evidence made to address these
concerns the NEPS program was denied approval. The
NEPS program failed to meet six out of the nine program evaluation criteria (Registered Psychiatric Nurses
Association of Saskatchewan, 2001).
With a ratio of one RPN to seven RN faculty “the Years
3 and 4 of NEPS, particularly in Saskatoon operate
without adequate RPN presence in the classroom, in
clinical teaching and supervision, in curriculum development and in governance” (Registered Psychiatric
Nurses Association of Saskatchewan, 2001 p. 6). Further, every student was not assured participation in
core clinical experiences in an acute psychiatric nursing
setting. Since the majority of students had limited contact with RPNs as faculty and in clinical learning experiences across the four years of the program, students
were denied opportunity to develop a professional identity congruent with the profession of psychiatric nursing
(Registered Psychiatric Nurses Association of Saskatchewan, 2001). Moreover, “many students commented that within the program, there was little
attention paid to psychiatric nursing as a distinct profession and very little information provided aside from
inviting representatives from RPNAS, early in the program (Registered Psychiatric Nurses Association of
Saskatchewan, 2001 p. 7).
In the time that followed, from 2001 to 2008, Saskatchewan did not have a basic education program for
RPNs. The decision to not approve the NEPS program
was not made lightly. The RPNAS understood membership concerns that if NEPS was denied approval, Saskatchewan would not have new RPNs entering the
profession. However, it was obvious a direct correlation
existed between the NEPS program and the absence
of new RPNs entering the profession. “Since the inception of NEPS, nine students had chosen to register with
RPNAS; a significant decline from the 40 who registered in 1997 (Registered Psychiatric Nurses Association of Saskatchewan, 2001 p. 7).
Forecasted warnings became reality when a program
taught primarily by RNs was established for RPNs.
Registered Psychiatric Nursing education within Saskatchewan became so watered down between the
years 1999 and 2001 that the demise of RPN education, relegated to the whim of RN educators was actualized albeit not directly, most certainly indirectly.
However, cessation of RPN education within Saskatchewan did not continue for too long. In 2008, the Sas-
- 42 -
katchewan Institute of Applied Science and Technology
(SIAST) began offering a diploma in psychiatric nursing
program with graduates eligible for registration with the
RPNAS in 2011. Having learned from the past, this
program maintains a strong presence of RPN faculty to
ensure graduates of the program have a clear sense of
the profession of psychiatric nursing upon graduation.
Advanced Educational Preparation:
Challenges & Successes
When RNs in Manitoba took steps to prevent establishment of advanced educational preparation by RPNs, it
was clear that territoriality lie at the core. The first
attempt by RPNs to gain access to university education
took place in 1968 through affiliation with the universities in Manitoba, who taught some courses in each of
the programs. Full proposals for undergraduate education in psychiatric nursing in Manitoba started being
developed in 1971 and continued until the mid-1980’s
“In mid-1986, the Government of Manitoba announced
the establishment of a post-diploma degree baccalaureate programs for RPNs and RNs at Brandon University
(BU)”. Although the establishment of the post-diploma
degree for RNs was free from conflict, serious resistance ensued against the establishment of the post-diploma degree for RPNs. Opposition was first apparent
when the MARN, Executive Director, wrote a letter to
the BU Dean of Science stating: “The MARN endorses
that RNs and RPNs not be given the same degree until
such time as there has been equalization of pre-entrance qualifications (Wiebe, 1986). BU was cautioned,
“It is anticipated there may be numerous problems
including jeopardy of the credibility of the programs”
Wiebe (1986).
In a letter from the Canadian Association of University
Schools of Nursing (CAUSN) president to the BU president CAUSN advised that instead of offering a postdiploma baccalaureate degree for RPNs, these nurses
should “be encouraged to study in their “own field”
acquiring general education as a Bachelor of Arts in
Psychology, without any pretense of having further
preparation in nursing. In essence, the students could
either be nurses or acquire a baccalaureate preparation
in a non-nursing program” (Thibaudeau, 1986). The
CAUSN president cautioned “a cause for alarm, however, is the fact that the degree reflects a somewhat
narrow specialization in only one of the fields of nursing.
Organized nursing at all levels endorses the principle of
generalized preparation to the baccalaureate degree.
Without it, graduates of the program leading to the
BScPN degree will not be eligible for admission to
graduate programs in nursing. Perhaps even more important, their employment opportunities and career options will remain confined to the field of psychiatric
nursing and they will experience continued ghettoization
within the health care field (Thibaudeau, 1986).
The tone of the letter was threatening and spoke volumes “we expect that the University will have considerable difficulty attracting academic staff to work in this
nursing program” (Thibaudeau, 1986). Specifically, BU
was warned if it did not address CAUSN’s concerns it
would be black listed and unable to secure faculty for
either programs. Registered Nurses hired as faculty for
the post-diploma programs disclosed openly that they
had been warned that if they agreed to teach in a degree
program that had the words “psychiatric nursing” in the
title, they would be ostracized by their peers; they would
lose access to any research funds; and their reputations
as Registered Nurses and as academics in that field
would suffer (Osted, 2011).
BU was further criticized by the University of Manitoba
(U of M) Faculty of Nursing for even contemplating to
offer a degree program for RPNs. The U of M Faculty of
Nursing (1986) warned that they were not prepared to
admit RPNs to a post-diploma program on an equivalent basis. Moreover, these same individuals expressed
concerns about a B.N. program with RPNs without
providing for the RPNs to become RNs.
Criticisms by CAUSN and the U of M Faculty of Nursing
had devastating effect on the profession of registered
psychiatric nursing. The MARN’s earlier (1976) recommendation “That the practice of any discipline using the
title “nurse” in its designation must come within the
definition of nursing adopted by the MARN and that
approval of the MARN must be mandatory for inclusion
of the title “nurse” in the designation of any category of
health care worker” (149) was reaffirmed when on February 10, 1987 the BU Senate passed a motion rescinding its previous motion that the post-diploma program
for RPNs be named the BScPN degree. Moreover, the
motion of February 10, 1987 prohibited post-diploma
RPN students to declare themselves for the BScPN
degree. The post-diploma program for RPNs was in
jeopardy. Just two months earlier, “BU received a letter
from the University Grants Committee (UGC) stating
they had approved the BScN program and deferred
consideration of the BScPN program until BU responded to concerns raised by the University of Manitoba”
(Nursing Advisory Committee on the Baccalaureate
Nursing Program, 1987).
Not long after and in direct response to pressures encountered from CAUSN and University of Manitoba
Faculty of Nursing, the decision was made to change
the originally approved name from BScPN to a Bachelor
of Science in Mental Health. Very few at the time,
realized just how close RPNs had come to losing their
post-diploma program. If the Government of the day had
not made the funding available contingent upon the
development and operation of both post-diploma programs Osted (2010) insists “I am certain that Brandon
University could not have withstood the opposition to the
post-diploma program for Registered Psychiatric Nurses and it therefore would never have existed” (p. 2).
Interestingly enough in 1995, none of this earlier opposition about program title occurred with the transfer of
the diploma program in psychiatric nursing to an undergraduate degree in psychiatric nursing at BU. “It was to
be a Bachelor of Science in Psychiatric Nursing” (Osted,
2009 p.14) (BScPN). However, opposition and lobbying
- 43 -
against the BScPN program did ensue and continued
until three weeks before the diploma students transferred to the baccalaureate program (Osted, 2009).
Despite the Deputy Minister’s recommendation that any
and all nursing education should be consolidated in the
U of M Faculty of Nursing instead of establishing a
psychiatric nursing program at BU, the RPNAM forged
on knowing fully that “if the program was transferred to
the U of M, psychiatric nursing education would disappear in Manitoba and the profession not far behind”
(Osted, 2009 p.14). Eventually, their efforts proved not
to be in vain. The RPNAM, in direct collaboration with
the BU president, succeeded in the establishment of
the first baccalaureate program in psychiatric nursing,
in Canada (Osted, 2009).
equivalent status to RPNs and its concerns about a BN
program with RPNs without providing transition plan for
the RPNs to become RNs, The University of Manitoba,
Faculty of Nursing did indeed recant on its original
position. In 2007, The University of Manitoba, Faculty
of Nursing began granting RPNs equivalent status to
RNs by accepting RPNs into its graduate program.
Finally, in January 2011. BU Faculty of Health Studies,
Department of Psychiatric Nursing began to offer the
Master of Psychiatric Nursing program, the first of its
kind in Canada.
British Columbia encountered opposition similar to that
of Manitoba while attempting to establish its undergraduate degree program for RPNs. All in all, instead of
preventing access by RPNs to advanced educational
preparation in BC, the opposition from two peer institutions; the University of British Columbia and the University of Victoria had the opposite effect. A persuasive
letter writing campaign by College of Registered Psychiatric Nursing of British Columbia (CRPNBC) representatives and provocative publications by RPN
leaders ensued. Within a year, Kwantlen University
College received all the necessary approvals and to this
day continues to offer a Baccalaureate Degree in Psychiatric Nursing.
Table 2: Registered Nursing Workforce by Area of
Responsibility
(Direct Care only) and Jurisdiction.
Western Provinces 2008 and 2012.
Table 1: Registered Psychiatric Nursing Workforce by
Area of Responsibility (Direct Care only) and Jurisdiction. Western Provinces 2008 and 2012.
Table 3: Licensed Practical Nursing Workforce by Area
of Responsibility (Direct Care only) and Jurisdiction.
Western Provinces 2008 and 2012.
More than a decade has passed since Crawford (2001)
argued for the urgent need to educate RPNs at the
graduate level with a clinical focus/specialization to
meet increasing mental health consumer/system
needs. A few years later, Health Canada (2003) cited
access to graduate education programs in nursing to be
extremely problematic for RPNs and openly acknowledged this lack of access as a problem of paramount
importance by issuing the statement that one of the
three key issues facing RPNs is “…access to graduate
education programs in psychiatric nursing” (p. 1). It was
recognized that graduate programs specifically designed for RPNs would facilitate educational preparation for advanced roles related to clinical practice,
leadership, research, administration, and education
(Ryan-Nicholls, 2004).
At present, few RPNs possess a master’s degree, even
fewer possess a doctorate degree, and no one has a
graduate degree with a specific focus in psychiatric
nursing, with the possible exception of persons who
possess a master’s degree in education and nursing.
Until recent, no Canadian University would accept an
RPN for admission into its Master of Nursing unless the
RPN first upgraded to an equivalent RN credential.
On a positive note, all of the unrelenting dedication by
such champions of registered psychiatric nursing as
John Crawford and Dr. Annette Osted during the battle
to secure advanced educational preparation for RPNs
was not in vain. Despite all of its criticisms against a
degree program for RPNs, its unwillingness to grant
- 44 -
2008 795
2012 807
Medical/Surgical
2008 †
2012 †
Pediatric
2008 †
2012 †
Geriatric/Long Term Care
2008 171
2012 170
Crisis/Emergency Services 2008 49
2012 60
Occupational Health 2008 †
2012 6
Oncology
2008 0
2012 0
Rehabilitation 2008 90
2012 77
Palliative Care
2008 0
2012 †
Children & Adolescent Services
2008 84
2012 86
Development Habilitation/Disabilities
2008 77
2012 47
Addiction Services 2008 27
2012 25
Acute Services
2008 202
2012 217
Forensic Services
2008 33
2012 36
Other Direct Care
2008 54
2012 77
(Count)
Total Direct Care
786
703
7
10
†
†
238
204
8
9
5
5
†
0
146
138
†
†
30
23
56
45
16
15
174
149
59
49
43
46
Man. Sask. Alta. B.C.
1,035
1,144
5
10
†
†
191
172
52
74
0
†
†
0
129
126
0
†
67
75
13
10
34
52
288
322
77
95
174
204
1,921
2,102
1†
1†
9
†
283
220
137
136
†
†
†
0
115
174
1†
10
95
108
54
47
82
131
500
705
230
211
382
341
4,537
4,756
32
36
15
8
883
766
246
279
12
15
6
0
480
515
12
21
276
292
200
149
159
223
1,164
1,393
399
391
653
668
Western Provinces
Table 1: Registered Psychiatric Nursing Workforce by Area of Responsibility
(Direct Care only) and
Jurisdiction. Western Provinces 2008 and 2012. Source: Nursing Data Base Canadian Institute for Health Information.
- 45 -
(Percentage Distribution)
2008 100.0%
100.0%
100.0%
100.0%
2012 100.0%
100.0%
100.0%
100.0%
Medical/Surgical
2008 †
0.9% 0.5%
2012 †
1.4% 0.9%
Pediatric
2008 †
†
†
2012 †
†
†
Geriatric/Long Term Care
2008 21.5% 30.3% 18.5%
2012 21.1% 29.0% 15.0%
Crisis/Emergency Services 2008 6.2% 1.0% 5.0%
2012 7.4% 1.3% 6.5%
Occupational Health 2008 †
0.6% 0.0%
2012 0.7% 0.7% †
Oncology
2008 0.0% †
†
2012 0.0% 0.0% 0.0%
Rehabilitation 2008 11.3% 18.6% 12.5%
2012 9.5% 19.6% 11.0%
Palliative Care
2008 0.0% †
0.0%
2012 †
†
†
Children & Adolescent Services
2008 10.6% 3.8% 6.5%
2012 10.7% 3.3% 6.6%
Development Habilitation/Disabilities
2008 9.7% 7.1% 1.3%
2012 5.8% 6.4% 0.9%
Addiction Services 2008 3.4% 2.0% 3.3%
2012 3.1% 2.1% 4.5%
Acute Services
2008 25.4% 22.1% 27.8%
2012 26.9% 21.2% 28.1%
Forensic Services
2008 4.2% 7.5% 7.4%
2012 4.5% 7.0% 8.3%
Other Direct Care
2008 6.8% 5.5% 16.8%
2012 9.5% 6.5% 17.8%
Total Direct Care
100.0%
100.0%
†
0.7%
†
0.8%
0.5% 0.3%
†
0.2%
14.7% 19.5%
10.5% 16.1%
7.1% 5.4%
6.5% 5.9%
†
0.3%
†
0.3%
†
0.1%
0.0% 0.0%
6.0% 10.6%
8.3% 10.8%
†
0.3%
0.5% 0.4%
4.9% 6.1%
5.1% 6.1%
2.8% 4.4%
2.2% 3.1%
4.3% 3.5%
6.2% 4.7%
26.0% 25.7%
33.5% 29.3%
12.0% 8.8%
10.0% 8.2%
19.9% 14.4%
16.2% 14.0%
Table 1 (Continued)
- 46 -
P.E.I.
N.S.
2008
5,154 1,314
2012
5,382 1,361
Medical/Surgical 2008
1,153 297
2012
1,199 278
Psychiatric/Mental Health 2008
298
100
2012
359
99
Pediatric 2008
174
38
2012
174
41
Maternal/Newborn
2008
249
92
2012
274
91
Geriatric/Long Term Care 2008
551
215
2012
486
205
Critical Care
2008
516
63
2012
585
61
Community Health
2008
496
98
2012
494
74
Ambulatory Care
2008
139
20
2012
222
35
Home Care
2008
41
72
2012
34
78
Occupational Health
2008
77
†
2012
94
†
Operating Room/Recovery Room 2008
274
55
2012
311
71
Emergency Care 2008
325
76
2012
359
97
Nursing in Several Clinical Areas 2008
260
63
2012
272
51
Oncology
2008
83
1†
2012
105
20
Rehabilitation
2008
43
15
2012
55
1†
Public Health
2008
69
31
2012
125
44
Telehealth
2008
41
0
2012
30
0
Other Direct Care 2008
365
61
2012
204
91
Total Direct Care
N.L.
Que.
Ont.
Man.
(Count)
7,471 6,954 54,541 82,690
8,210 7,383 58,093 85,595
1,447 1,462 11,298 14,208
1,269 1,489 11,493 10,676
484
427
3,446 5,270
515
472
3,599 5,361
310
155
922
3,156
271
142
941
1,886
487
421
3,061 5,392
511
442
3,178 5,574
991
883
6,533 8,951
1,126 963
6,218 9,214
601
509
3,122 8,276
601
535
3,773 6,231
345
647
3,711 2,874
389
659
5,560 0
275
261
0
3,649
282
327
0
0
321
0
2,896 0
298
0
2,915 0
90
72
601
1,256
79
68
528
990
558
365
2,629 4,054
489
394
2,917 4,178
558
477
4,854 5,700
619
551
5,217 6,018
187
135
5,216 0
127
118
4,635 0
175
153
1,560 0
169
184
1,878 0
120
191
964
1,613
99
193
1,033 1,620
176
216
360
4,064
174
215
322
3,631
0
46
672
0
0
37
690
357
346
534
2,696 14,227
1,192 594
3,196 29,859
N.B.
Alta.
B.C.
Y.T.
9,429 7,753 25,695 26,471
9,540 8,916 23,182 26,786
1,830 1,532 5,250 5,442
1,997 1,840 4,499 6,540
284
183
1,225 1,466
285
236
1,102 1,433
359
246
1,154 700
350
301
1,020 601
638
456
1,827 1,787
615
570
1,767 1,911
1,165 944
1,939 3,190
1,134 1,130 1,734 2,702
538
671
1,958 2,141
605
801
1,798 2,363
655
408
1,291 2,196
502
381
1,228 1,848
265
115
564
639
257
126
682
945
784
590
1,403 1,175
634
627
1,301 1,148
76
88
457
218
65
100
403
203
581
396
1,519 2,097
615
401
1,391 2,049
569
426
1,744 1,774
658
601
1,646 2,124
515
809
1,193 789
335
554
881
637
169
191
587
418
187
236
535
539
209
70
376
355
192
78
358
418
227
306
671
311
468
392
725
1,188
28
0
173
78
50
44
127
137
537
322
2,364 1,695
591
498
1,985 0
Sask.
285
321
47
52
7
11
6
†
16
20
21
26
10
14
73
84
5
†
16
18
†
†
13
16
35
36
10
7
†
†
0
0
17
24
0
0
5
†
1,083
985
102
100
30
28
14
1†
37
32
30
25
35
31
357
304
16
2†
53
37
9
13
42
32
102
104
121
127
†
†
0
†
40
50
36
0
58
5†
N.W.T/Nun.
228,840
235,754
44,068
41,432
13,220
13,500
7,234
5,747
14,463
14,985
25,413
24,963
18,440
17,398
13,151
11,523
5,948
2,906
7,351
7,090
2,952
2,551
12,583
12,864
16,640
18,030
9,298
7,744
3,351
3,857
3,956
4,065
6,488
7,358
1,074
1,472
23,210
38,269
Canada
Table 2: Registered Nursing Workforce by Area of Responsibility (Direct Care only) and Jurisdiction. Western
Provinces 2008 and 2012. Source: Nursing Data Base Canadian Institute for Health Information.
- 47 -
(Percentage Distribution)
2008
100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%
2012
100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%
Medical/Surgical 2008
22.4% 22.6% 19.4% 21.0% 20.7% 17.2% 19.4% 19.8% 20.4% 20.6% 16.5% 9.4%
19.3%
2012
22.3% 20.4% 15.5% 20.2% 19.8% 12.5% 20.9% 20.6% 19.4% 24.4% 16.2% 10.2% 17.6%
Psychiatric/Mental Health 2008
5.8%
7.6%
6.5%
6.1%
6.3%
6.4%
3.0%
2.4%
4.8%
5.5%
2.5%
2.8%
5.8%
2012
6.7%
7.3%
6.3%
6.4%
6.2%
6.3%
3.0%
2.6%
4.8%
5.3%
3.4%
2.8%
5.7%
Pediatric 2008
3.4%
2.9%
4.1%
2.2%
1.7%
3.8%
3.8%
3.2%
4.5%
2.6%
2.1%
1.3%
3.2%
2012
3.2%
3.0%
3.3%
1.9%
1.6%
2.2%
3.7%
3.4%
4.4%
2.2%
†
†
2.4%
Maternal/Newborn
2008
4.8%
7.0%
6.5%
6.1%
5.6%
6.5%
6.8%
5.9%
7.1%
6.8%
5.6%
3.4%
6.3%
2012
5.1%
6.7%
6.2%
6.0%
5.5%
6.5%
6.4%
6.4%
7.6%
7.1%
6.2%
3.2%
6.4%
Geriatric/Long Term Care 2008
10.7% 16.4% 13.3% 12.7% 12.0% 10.8% 12.4% 12.2% 7.5%
12.1% 7.4%
2.8%
11.1%
2012
9.0%
15.1% 13.7% 13.0% 10.7% 10.8% 11.9% 12.7% 7.5%
10.1% 8.1%
2.5%
10.6%
Critical Care
2008
10.0% 4.8%
8.0%
7.3%
5.7%
10.0% 5.7%
8.7%
7.6%
8.1%
3.5%
3.2%
8.1%
2012
10.9% 4.5%
7.3%
7.2%
6.5%
7.3%
6.3%
9.0%
7.8%
8.8%
4.4%
3.1%
7.4%
Community Health
2008
9.6%
7.5%
4.6%
9.3%
6.8%
3.5%
6.9%
5.3%
5.0%
8.3%
25.6% 33.0% 5.7%
2012
9.2%
5.4%
4.7%
8.9%
9.6%
0.0%
5.3%
4.3%
5.3%
6.9%
26.2% 30.9% 4.9%
Ambulatory Care
2008
2.7%
1.5%
3.7%
3.8%
0.0%
4.4%
2.8%
1.5%
2.2%
2.4%
1.8%
1.5%
2.6%
2012
4.1%
2.6%
3.4%
4.4%
0.0%
0.0%
2.7%
1.4%
2.9%
3.5%
†
†
1.2%
Home Care
2008
0.8%
5.5%
4.3%
0.0%
5.3%
0.0%
8.3%
7.6%
5.5%
4.4%
5.6%
4.9%
3.2%
2012
0.6%
5.7%
3.6%
0.0%
5.0%
0.0%
6.6%
7.0%
5.6%
4.3%
5.6%
3.8%
3.0%
Occupational Health
2008
1.5%
†
1.2%
1.0%
1.1%
1.5%
0.8%
1.1%
1.8%
0.8%
†
0.8%
1.3%
2012
1.7%
†
1.0%
0.9%
0.9%
1.2%
0.7%
1.1%
1.7%
0.8%
†
1.3%
1.1%
Operating Room/Recovery Room 2008
5.3%
4.2%
7.5%
5.2%
4.8%
4.9%
6.2%
5.1%
5.9%
7.9%
4.6%
3.9%
5.5%
2012
5.8%
5.2%
6.0%
5.3%
5.0%
4.9%
6.4%
4.5%
6.0%
7.6%
5.0%
3.2%
5.5%
Emergency Care 2008
6.3%
5.8%
7.5%
6.9%
8.9%
6.9%
6.0%
5.5%
6.8%
6.7%
12.3% 9.4%
7.3%
2012
6.7%
7.1%
7.5%
7.5%
9.0%
7.0%
6.9%
6.7%
7.1%
7.9%
11.2% 10.6% 7.6%
Nursing in Several Clinical Areas 2008
5.0%
4.8%
2.5%
1.9%
9.6%
0.0%
5.5%
10.4% 4.6%
3.0%
3.5%
11.2% 4.1%
2012
5.1%
3.7%
1.5%
1.6%
8.0%
0.0%
3.5%
6.2%
3.8%
2.4%
2.2%
12.9% 3.3%
Oncology
2008
1.6%
†
2.3%
2.2%
2.9%
0.0%
1.8%
2.5%
2.3%
1.6%
†
†
1.5%
2012
2.0%
1.5%
2.1%
2.5%
3.2%
0.0%
2.0%
2.6%
2.3%
2.0%
†
†
1.6%
Rehabilitation
2008
0.8%
1.1%
1.6%
2.7%
1.8%
2.0%
2.2%
0.9%
1.5%
1.3%
0.0%
0.0%
1.7%
2012
1.0%
†
1.2%
2.6%
1.8%
1.9%
2.0%
0.9%
1.5%
1.6%
0.0%
†
1.7%
Public Health
2008
1.3%
2.4%
2.4%
3.1%
0.7%
4.9%
2.4%
3.9%
2.6%
1.2%
6.0%
3.7%
2.8%
2012
2.3%
3.2%
2.1%
2.9%
0.6%
4.2%
4.9%
4.4%
3.1%
4.4%
7.5%
5.1%
3.1%
Telehealth
2008
0.8%
0.0%
0.0%
0.7%
1.2%
0.0%
0.3%
0.0%
0.7%
0.3%
0.0%
3.3%
0.5%
2012
0.6%
0.0%
0.0%
0.5%
1.2%
0.4%
0.5%
0.5%
0.5%
0.5%
0.0%
0.0%
0.6%
Other Direct Care 2008
7.1%
4.6%
4.6%
7.7%
4.9%
17.2% 5.7%
4.2%
9.2%
6.4%
1.8%
5.4%
10.1%
2012
3.8%
6.7%
14.5% 8.0%
5.5%
34.9% 6.2%
5.6%
8.6%
0.0%
†
†
16.2%
Total Direct Care
Table 2: (Continued)
- 48 -
2008
2,478
2012
2,219
Medical/Surgical 2008
264
2012
295
Psychiatric/Mental Health 2008
144
2012
135
Pediatric 2008
8
2012
10
Maternal/Newborn
2008
8
2012
17
Geriatric/Long Term Care 2008
1,493
2012
1,319
Critical Care
2008
0
2012
0
Community Health
2008
†
2012
14
Ambulatory Care
2008
23
2012
34
Home Care
2008
8
2012
13
Occupational Health
2008
†
2012
†
Operating Room/Recovery Room 2008
24
2012
24
Emergency Care 2008
26
2012
36
Nursing in Several Clinical Areas 2008
183
2012
109
Oncology
2008
0
2012
0
Rehabilitation
2008
51
2012
48
Palliative Care 2008
5
2012
9
Public Health
2008
0
2012
†
Other Direct Care 2008
235
2012
151
Total Direct Care
N.L.
625
614
78
135
72
65
5
†
0
7
224
211
0
†
†
34
36
15
2†
24
0
0
11
1†
8
10
105
64
†
0
2†
13
7
†
0
0
23
15
P.E.I.
3,159
3,614
914
950
197
225
24
21
†
45
1,324
1,532
8
†
160
161
25
36
203
293
†
†
34
42
14
32
48
56
1†
†
100
118
13
1†
0
0
80
68
N.S.
Que.
(Count)
2,599 17,932
2,730 22,200
521
3,278
535
2,654
5†
569
66
526
29
94
36
265
3†
189
48
303
1,089 9,991
1,155 10,481
10
0
19
0
22
0
40
365
14
0
24
0
19
264
34
544
0
0
†
†
62
108
79
260
68
194
87
484
310
0
27†
4,432
20
0
25
99
89
637
79
638
165
274
165
305
0
179
0
40†
86
2,155
65
437
N.B.
26,342
31,937
3,594
3,596
2,331
2,556
321
172
337
476
11,805
13,583
42
27
1,819
389
478
0
0
0
117
96
311
505
232
425
0
0
0
0
1,376
1,538
506
729
0
0
3,073
7,845
Ont.
2,580
2,890
410
528
23
34
25
16
22
23
1,371
1,507
15
24
67
66
56
65
173
205
8
8
8
10
†
3†
280
231
0
†
57
49
1†
17
0
0
45
72
Man.
2,490
2,722
748
815
17
35
33
40
62
7†
610
726
14
12
61
45
25
29
100
140
0
†
78
97
28
48
549
458
19
9
60
69
21
22
0
0
65
100
Sask.
6,122
8,041
1,700
1,553
122
207
121
199
191
238
1,396
2,001
16
23
132
418
426
524
330
477
29
38
110
793
122
206
1,088
869
7
24
200
230
49
92
0
20
83
129
Alta.
6,578
8,594
2,204
2,723
113
18†
34
81
16
32
2,710
3,748
27
147
155
231
49
68
139
329
5
†
56
85
139
194
417
89
21
30
193
307
80
133
0
0
220
212
B.C.
- 49 -
†
†
0
7
†
0
0
†
8
†
0
†
0
0
0
†
38
43
59
77
10
13
0
0
0
0
0
0
0
0
0
0
0
0
†
†
0
Y.T.
0
0
0
†
0
0
0
0
20
16
†
†
0
0
0
†
†
†
†
†
0
0
†
0
0
0
0
0
†
†
0
43
51
93
91
10
9
†
†
71,057
85,729
13,731
13,806
3,646
4,031
697
844
865
1,266
32,094
36,357
132
260
2,421
1,763
1,152
811
1,264
2,066
164
155
802
1,909
840
1,560
2,991
6,590
78
195
2,793
3,096
1,136
1,493
179
430
6,072
9,097
N.W.T. Canada
Table 3: Licensed Practical Nursing Workforce by Area of Responsibility (Direct Care only) and Jurisdiction. Western Provinces 2008 and 2012. Source: Nursing Data Base Canadian Institute for Health Information.
(Percentage Distribution)
2008
100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%
2012
100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%
Medical/Surgical 2008
10.7% 12.5% 28.9% 20.0% 18.3% 13.6% 15.9% 30.0% 27.8% 33.5% 16.9% 10.8% 19.3%
2012
13.3% 22.0% 26.3% 19.6% 12.0% 11.3% 18.3% 29.9% 19.3% 31.7% 16.9% 9.9%
16.1%
Psychiatric/Mental Health 2008
5.8%
11.5% 6.2%
†
3.2%
8.8%
0.9%
0.7%
2.0%
1.7%
0.0%
†
5.1%
2012
6.1%
10.6% 6.2%
2.4%
2.4%
8.0%
1.2%
1.3%
2.6%
†
0.0%
†
4.7%
Pediatric 2008
0.3%
0.8%
0.8%
1.1%
0.5%
1.2%
1.0%
1.3%
2.0%
0.5%
†
†
1.0%
2012
0.5%
†
0.6%
1.3%
1.2%
0.5%
0.6%
1.5%
2.5%
0.9%
†
0.0%
1.0%
Maternal/Newborn
2008
0.3%
0.0%
†
†
1.1%
1.3%
0.9%
2.5%
3.1%
0.2%
0.0%
0.0%
1.2%
2012
0.8%
1.1%
1.2%
1.8%
1.4%
1.5%
0.8%
†
3.0%
0.4%
†
0.0%
1.5%
Geriatric/Long Term Care 2008
60.3% 35.8% 41.9% 41.9% 55.7% 44.8% 53.1% 24.5% 22.8% 41.2% 64.4% 46.2% 45.2%
2012
59.4% 34.4% 42.4% 42.3% 47.2% 42.5% 52.1% 26.7% 24.9% 43.6% 55.8% 56.0% 42.4%
Critical Care
2008
0.0%
0.0%
0.3%
0.4%
0.0%
0.2%
0.6%
0.6%
0.3%
0.4%
0.0%
0.0%
0.2%
2012
0.0%
†
†
0.7%
0.0%
0.1%
0.8%
0.4%
0.3%
1.7%
0.0%
0.0%
0.3%
Community Health
2008
†
†
5.1%
0.8%
0.0%
6.9%
2.6%
2.4%
2.2%
2.4%
0.0%
0.0%
3.4%
2012
0.6%
5.5%
4.5%
1.5%
1.6%
1.2%
2.3%
1.7%
5.2%
2.7%
0.0%
0.0%
2.1%
Ambulatory Care
2008
0.9%
5.8%
0.8%
0.5%
0.0%
1.8%
2.2%
1.0%
7.0%
0.7%
0.0%
21.5% 1.6%
2012
1.5%
2.4%
1.0%
0.9%
0.0%
0.0%
2.2%
1.1%
6.5%
0.8%
0.0%
17.6% 0.9%
Home Care
2008
0.3%
†
6.4%
0.7%
1.5%
0.0%
6.7%
4.0%
5.4%
2.1%
0.0%
†
1.8%
2012
0.6%
3.9%
8.1%
1.2%
2.5%
0.0%
7.1%
5.1%
5.9%
3.8%
†
†
2.4%
Occupational Health
2008
†
0.0%
†
0.0%
0.0%
0.4%
0.3%
0.0%
0.5%
0.1%
0.0%
0.0%
0.2%
2012
†
0.0%
†
†
†
0.3%
0.3%
†
0.5%
†
0.0%
0.0%
0.2%
Operating Room/Recovery Room 2008
1.0%
1.8%
1.1%
2.4%
0.6%
1.2%
0.3%
3.1%
1.8%
0.9%
0.0%
0.0%
1.1%
2012
1.1%
†
1.2%
2.9%
1.2%
1.6%
0.3%
3.6%
9.9%
1.0%
†
†
2.2%
Emergency Care 2008
1.0%
1.3%
0.4%
2.6%
1.1%
0.9%
†
1.1%
2.0%
2.1%
0.0%
†
1.2%
2012
1.6%
1.6%
0.9%
3.2%
2.2%
1.3%
†
1.8%
2.6%
2.3%
0.0%
†
1.8%
Nursing in Several Clinical Areas 2008
7.4%
16.8% 1.5%
11.9% 0.0%
0.0%
10.9% 22.0% 17.8% 6.3%
†
†
4.2%
2012
4.9%
10.4% 1.5%
†
20.0% 0.0%
8.0%
16.8% 10.8% 1.0%
10.4% †
7.7%
Oncology
2008
0.0%
†
†
0.8%
0.0%
0.0%
0.0%
0.8%
0.1%
0.3%
0.0%
0.0%
0.1%
2012
0.0%
0.0%
†
0.9%
0.4%
0.0%
†
0.3%
0.3%
0.3%
0.0%
0.0%
0.2%
Rehabilitation
2008
2.1%
†
3.2%
3.4%
3.6%
5.2%
2.2%
2.4%
3.3%
2.9%
0.0%
†
3.9%
2012
2.2%
2.1%
3.3%
2.9%
2.9%
4.8%
1.7%
2.5%
2.9%
3.6%
9.1%
0.0%
3.6%
Palliative Care 2008
0.2%
1.1%
0.4%
6.3%
1.5%
1.9%
†
0.8%
0.8%
1.2%
†
0.0%
1.6%
2012
0.4%
†
†
6.0%
1.4%
2.3%
0.6%
0.8%
1.1%
1.5%
0.0%
0.0%
1.7%
Public Health
2008
0.0%
0.0%
0.0%
0.0%
1.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.3%
2012
†
0.0%
0.0%
0.0%
†
0.0%
0.0%
0.0%
0.2%
0.0%
0.0%
0.0%
0.5%
Other Direct Care 2008
9.5%
3.7%
2.5%
3.3%
12.0% 11.7% 1.7%
2.6%
1.4%
3.3%
†
†
8.5%
2012
6.8%
2.4%
1.9%
2.4%
2.0%
24.6% 2.5%
3.7%
1.6%
2.5%
†
†
10.6%
Total Direct Care
Table 3: (Continued)
- 50 -
References
● Austin, W., Gallop, R., Harris, D., & Spencer, E.
(1996). A 'domains of practice' approach to the standards of psychiatric and mental health nursing. Journal of Psychiatric and Mental Health Nursing, 3,
111-115.
● Bedford-Fenwick, E. (1896). On male attendants
Nursing Record 2, 429
● BU President’s Advisory Committee on Baccalaureate Nursing Program (1986, May 9th). [Minutes of
Meeting held at BU in Meeting Room A at 12:00
noon]. CRPNM archives.
● Canadian Institute for Health Information (2014a).
Nursing Jurisdictional Profiles and Health Region
Analysis 2008-2012, Table 49: Registered Psychiatric
Nursing Workforce, by Area of Responsibility (Direct
Care Only) and Jurisdiction, Canada, 2008 and 2012.
Retrieved
from
http://www.cihi.ca/CIHI-ext
portal/internet/en/quick_stats:
● Canadian Institute for Health Information (2014b).
Nursing Jurisdictional Profiles and Health Region
Analysis 2008-2012, Table 12: Registered Nursing
Workforce, by Area of Responsibility (Direct Care
Only) and Jurisdiction, Canada, 2008 and 2012. Retrieved
from
http://www.cihi.ca/CIHI-ext
portal/internet/en/quick_stats
● Canadian Institute for Health Information (2014c).
Nursing Jurisdictional Profiles and Health Region
Analysis 2008-2012, Table 35: Licenced Practical
Nursing Workforce, by Area of Responsibility (Direct
Care Only) and Jurisdiction, Canada, 2008 and 2012.
Retrieved
from
http://www.cihi.ca/CIHI-ext
portal/internet/en/quick_stats
● Crawford, J. A. (2001). Psychiatric nursing and registered psychiatric nurses - Evolution of the profession
in Canada: Context and environment Burnaby B.C.:
B. C. Open University.
● Cutcliffe J. (2005a). A rose by any other name?:
Specialism, genericism, and the diminution of
psychiatric/mental health nursing (Part 1). The
Communicator, Spring, 1-24. CRPNBC: British
Columbia
● Cutcliffe J. (2005b). A rose by any other name?:
Specialism, genericism, and the diminution of
psychiatric/mental health nursing (Part 2). The
Communicator, September, 1-24. CRPNBC: British
Columbia
● Health Canada (2003). Building the future: A national
nursing sector study. Retrieved September 2, 2003
[On-line]. Available: http://www.buildingthefuture.ca/
● Manitoba Association of Registered Nurses (1976).
Nursing education: Challenge and change. Manitoba:
Author.
● Nursing Advisory Committee on the Baccalaureate
Nursing Program (1987). [Minutes of Meeting held on
Tuesday August 11, 1987 at 10:30 AM in BU Brodie
Science Building]. CRPNM archives.
● Osted, A. T. (2009). Some history of psychiatric nursing education in Manitoba. The CRPNM Advisor: Author
● Osted, A. T. (2010, May 21). [letter to Kim RyanNicholls about the history of the relationship between
RPNs and RNs]. Copy in possession of Kim RyanNicholls.
● Purkis, M.E., (2004). [undated public domain response to Kwantlen University College Proposal to
offer a Baccalaureate Degree in Psychiatric Nursing].
CRPNBC Archives.
● Registered Psychiatric Nurses Association of Saskatchewan (2001). Council decision on NEPS. RPNews, 14 (4), 1-12. Author
● Ryan-Nicholls, K. (2004). Impact of health reform on
registered psychiatric nursing practice. Journal of
Psychiatric and Mental Health Nursing, 11 (6), 644653.
● Smith, M. (2011). Canadian psychiatric mental health
nursing: Intersections of history, gender, nursing education and quality of work life in Ontario, Manitoba,
Alberta and Saskatchewan (Unpublished master’s
thesis). York University, Toronto, Ontario.
● Thibaudeau, M. (1986, July 30). [Letter from Canadian Association of University Schools of Nursing to Dr.
J.R. Mallea, Brandon University, President]. CRPNM
Archives.
● The University of Manitoba Faculty of Nursing (1986,
May 9th). [BU President’s Advisory Committee on
Baccalaureate Nursing Program, Minutes of Meeting
held at Brandon University, Meeting Room A, at 12:00
noon]. CRPNM Archives.
● Wiebe, S. (1986, May 26) [Letter from MARN, Executive Director to Dr. P. Letkeman, Brandon University,
Dean of Science]. CRPNM Archives.
● Thorne, S. (2004). [undated public domain response
to Kwantlen University College Proposal to offer a
Baccalaureate Degree in Psychiatric Nursing]. CRPNBC Archives.
- 51 -
Kimberley Ryan-Nicholls is an experienced
psychiatric nurse educator whose career in
education spans in excess of two decades.
Kimberley is currently conducting research
investigating the use of equines to facilitate
learning in persons experiencing mental
health challenges. In addition to being an
Associate Professor within the Faculty of
Health Studies at Brandon University; she is
also an evening supervisor at the Brandon
Regional Health Centre.
An outline of the history of the examinations for mental nurses
organised by the (Royal) Medico-Psychological Association UK
Margaret Hawthorn Williams - Archivist Royal College of Psychiatrists - UK
The Royal College of Psychiatrists was founded at a
meeting in Gloucester in 1841
and was originally named
the Association of Medical
Officers of Asylums and
Hospitals for the Insane. Samuel Hitch, the
Resident Physician at
the Gloucestershire General Lunatic Asylum organised the meeting
Royal Medico-Psychological Associand stated in his letation Mental Nurses Badge 1890
ter of invitation that
his aims were ' that
the Medical Gentlemen connected with
Lunatic Asylums should be better known to each other,
should communicate more freely the results of their
individual experience, should co-operate in collecting
statistical information relating to Insanity and above all
should assist each other in improving the treatment of
the Insane'. (1)
The Association gradually became established and by
the 1860s it was flourishing. The annual meetings were
well attended and held at different asylums throughout
the British Isles, with regular regional meetings in Scotland and Ireland. A Council body was set up in 1865,
quarterly scientific meetings began in 1868 and the
Association's journal, The Journal of Mental Science
(now the British Journal of Psychiatry), first published in
1854, came to be highly regarded.
of the need to recruit 'the best material possible, and to
manufacture out of it the best asylum attendants possible' but the participants seemed to consider that training
should be provided by the asylums (4). After this meeting, an 'Association or Registry of Attendants Committee' was set up but there is no evidence that it ever
reported. Then in 1883, Dr A Campbell Clark spoke on
'The Special Training of Asylum Attendants'. He described in detail the lectures and examinations he had
introduced in the Glasgow District Asylum and the 'elevating influences' that had resulted and suggested that
the Association should consider his plea for 'a more
extended application of the system'.(5)
The result was a Handbook and Training of Attendants
Committee. This worked quickly and proofs of the 'The
Handbook for the Instruction of Attendants on the Insane' were shown to the Associations' quarterly meetings in 1884. The Association agreed that it would be
printed and 1000 copies would be distributed. It was first
published in 1885 and for the next sixty years and more
was known as 'The Red Handbook'
Five years elapsed between the publication of the first
Handbook and the first examinations. Meeting reports
for the late 1880s contain some references to lectures
and teaching and in 1889 Dr Campbell Clark spoke
again of his own examinations for attendants. Once
more the Association appointed a committee, this time
'to inquire into the question of the systematic training of
nurses and attendants in asylums for the insane ' (6)
which soon recommended that attendants should have
two years training, followed by examinations organised
by the MPA. The MPA would also issue certificates and
keep a register. The Committee's scheme for a nursing
proficiency certificate was accepted at the 1890 annual
meeting and the first examinations were held the following year. The first Registrar, Dr Beveridge Spence of
Lichfield, was appointed in 1892.
The Association of Medical Officers of Asylums and
Hospitals for the Insane changed its name to the Medico
Psychological Association (MPA) in 1865. In 1926 it was
granted a Royal Charter and became the Royal Medico
Psychological Association (RMPA). In 1971 the RMPA
was granted Royal College status and became the
The examinations rapidly became established. In 1899
Royal College of Psychiatrists.
Dr Beveridge Spence was elected President of the
The development of the Association can be traced from Association and reviewed what had been achieved in
the reports of its meetings in the Journal of Mental his Presidential Address. Despite 'the new system not in
Science and by the 1870s these reports showed an the beginning being enthusiastically welcomed by many
increasing interest in asylum attendants. In 1870 the of those in charge of asylums, the steady progesss
Journal printed a letter from 'Asylum Chaplain' (probably which has been made of late years is a silent but
the Reverend Henry Hawkins of Colney Hatch, founder eloquent testimony to the fact that a want has been
of the Mental After Care Association) suggesting sys- supplied'. Five or six hundred certificates were being
tematic training of attendants but there is no record of issued every year and candidates from more than a
any immediate response to this (2). Then, at the annual hundred asylums were taking part and the position of
meeting in 1876, Dr Thomas Clouston, the recently asylum nurses had 'unquestionably improved' (7).
appointed Physician Superintendent of the Royal Edinburgh Asylum, spoke on 'The Question of Getting, Train- The Association took its nursing examinations seriously
ing and Retaining the Services of Good Asylum and, despite not having a permanent headquarters or
Attendants' (3). The discussion that followed showed paid staff, retained records of their administration. The
that the Association was becoming increasingly aware general administration of the examinations was the
responsibility of the standing Education Committee.
This committee was first appointed in 1893 when the
MPA was planning its own qualification for doctors but
the attendants' examinations quickly became a large
part of its work. The Education Committee met three or
four times a year, and its reports and the reports of the
Association's Council regularly recorded the appointment of other committees to deal with specific training
matters.
One of the main responsibilities was preparing and
publishing the handbook. This was the basic textbook
for the examinations and was almost permanently under
revision. A revision committee was appointed in 1892
and the second edition appeared in 1893, followed by a
new and revised edition in 1898. Frequent revisions and
reissues followed, prepared by a succession of Handbook Committees, and when a new (seventh) edition
appeared in 1923, it was renamed The Handbook for
Mental Nurses. An American edition was considered in
1892 and in 1906 and printing in Dutch, for South Africa,
was suggested in 1925. A further revision was begun in
1932 but the eighth edition did not appear until 1954,
despite the fact that the Handbook Committee was one
of only two of the Association's committees to meet in
the early years of the War. Much of the stock of handbooks was destroyed by enemy action in 1941 and a
licence for paper to print more copies was refused. The
eighth edition came out in 1954 (preparation having
been so slow that revisions were needed before it was
printed) and the ninth in 1964. Finally, in 1979, nearly 30
years after the RMPA's last nursing examinations, the
College's Education Committee decided there would be
no further editions. Meanwhile, the Association's Advisory Committee on Mental Nursing had begun considering a handbook for mental deficiency nurses in 1928
and the Manual for Mental Deficiency Nurses known as
'The Green Handbook', was published in 1931. This,
too, was soon under revision. Like the Red Handbook,
further editions of the Green Handbook were discussed
after the examinations had been discontinued and a
revision sub-committee was appointed as late as 1965.
An addendum to the Handbook for Mental Nurses covering occupational therapy was issued in 1938.
The examinations were regulated by the Association's
Education Committee, Nursing Committees and various
sub-committees. Like the handbooks, the regulations
were kept under review and became increasingly comprehensive. New or revised ones were brought into
force in every decade, including the 1890s, and modifications were agreed for people in the armed services in
1915 and 1939. They covered all general matters such
as eligibility, recognition of training institutions, age at
entry, length of training, conditions for holding examinations, payment of examiners, entry on and deletion from
the register, disciplinary matters, fees, certificates,
badges and medals. Amendments were discussed by
committees and were recorded in varying detail in the
Education Committee minute books. In the early 20th
century the regulations were printed and made available
to candidates; in 1911 it was agreed they should be
printed in a form suitable for display in nurses' homes;
in 1912 they were redrafted and reprinted following
suggestions by the Association's solicitor and they were
issued as pamphlets in the 1920s and 1930s.
The Education Committee minutes occasionally record
discussions about applications for exemption from the
regulations, about cases of misconduct and about attendants whose certificates were to be forfeit for some
reason, such as non payment of examination fees. From
time to time, disciplinary sub-committees were appointed and occasionally their reports to Council are in the
Council minute books. In 1902, the Copying in Examinations Committee not surprisingly recommended improvements in seating and supervision but, in general
few disciplinary incidents are recorded. It is not clear if
this is because they did not take place or because they
were considered the responsibility of the hospital or
asylum concerned.
The extension of training from two to three years was
first recommended in 1897 and began in 1906. A preliminary examination was introduced in 1908. There was
considerable discussion in the 1920s about the length
of training and the precise nature of nursing qualifications. The position of nurses with some general training
entering mental nurse training and the relative position
of asylum and hospital trained nurses became a point of
issue with the GNC.
At first, the names of successful candidates were printed in the Journal of Mental Science. They were issued
with a certificate and entitled to a badge or medal (the
terms seem to have been used interchangeably). After
1918, certificates were no longer issued to successful
candidates in the preliminary examinations; instead, to
avoid them using the certificate to claim full qualifications, their names were entered on a register. Final
certificates continued to be issued. The first Nursing
Badge Committee was appointed in 1893 and the design they agreed on showed Psyche, representing the
soul or spirit. In 1903 the Education Committee gave
figures for the issue of badges and medals and agreed
they would be engraved with the recipient's name instead of their number. In 1909 it was agreed that the
words 'with distinction' would be added where appropriate. In 1926 the design was changed when the MPA
received its royal charter and Psyche was replaced by
the newly acquired coat of arms. At the same time, the
addition of an optional ribbon was approved, blue to
correspond with the colour in the President of the Association's badge of office. In 1928 an additional badge to
be worn on outdoor uniform was suggested. Also in
1928, after much discussion, an honorary nursing medal
and certificate was presented to Princess Mary , who
had shown a keen interest in nurses' training and welfare.
Before the end of the 19th century, the Association
considered extending its examinations abroad, first to
South Africa in 1892 and then to both British colonies
and other overseas countries. It was agreed in 1903 that
the MPA certificate would not be promoted in areas
where training and examinations were already estab-
lished. Candidates from South Africa were soon admitted and although independent South African
examinations began in 1921 the MPA certificate continued to be recognised there. The Education Committee appointed a sub committee in 1916 to consider the
recognition of examinations then being held in southern Australia and this matter became part of the Association's wider discussion on setting up colonial
branches - a regular, if infrequent, suggestion that
never became a reality. Help with examinations for a
mental hospital in Canada was authorised in 1926 and
in 1920 Danish trained nurses were recognised. This
was possibly the only time European qualifications
were recognised although parts of the handbook had
been translated into French when the French were
developing their own training systems.
isfactory' were at first used to describe these meetings,
although by 1928 'a general feeling of goodwill
seemed to prevail' (9).
A separate examination for the nurses of mental defectives was suggested in 1896 and again in 1917 and
the first such examination was set in 1918. Further
examinations for attendants on mental defectives and
a diploma in training medical officers in mental deficiency institutions were discussed in the 1920s and
1930s but were not developed. Much of the administration was covered by the existing regulations and
was carried out by the Mental Deficiency Committee,
the forerunner of the College's present Faculty for
Learning Disability. In 1939, half the committees reporting to Council were concerned with training and
examinations, a reflection of the amount of work, all
voluntary, that was involved.
In 1952, the Registrar, Dr Iveson Russell of York,
informed the Council that a total of 50,021 mental
nursing and 5,256 mental deficiency nursing certificates had been issued and there had been no year
since 1891 when the examinations had not been held.
He continued 'the Association could look back on this
work with some pride. The services involved more
than the organisation of examinations at a time when
no other branch of nursing had any other national
standard or qualification. It standardised the syllabus
of training in all the mental hospitals and mental deficiency hospitals of the country, and was almost entirely responsible for the training of mental nurses before
the passing of the Nurses' Registration Act in 1919'
(10).
While the MPA develop its own training, the movement
for state registration of nurses also grew. A MPA
committee to consider the admission of mental nurses
to the British Nurses Association was set up in 1896.
When a Parliamentary Select Committee was appointed in 1904 Dr Ernest White of the MPA gave evidence
and the MPA President, Dr Outterson Wood, spoke on
this in his Presidential Address in 1905. The Select
Committee reported in favour of state registration and
of recognising the MPA examinations as qualifying for
registration. The need for urgent action by the Association to assure proper representation for its nurses
was repeatedly stressed and when state registration of
nurses became law in 1919 the Parliamentary Committee considered fair representation of mental nurses
had been secured. Asylum trained nurses were included in a supplementary part of the register begun by the
newly formed General Nursing Council. Nevertheless,
in 1916 the Association had passed a resolution that
the proposed College of Nursing should be 'watched'
so as to safeguard the position of mental nurses and
in 1920, the Association, not wishing 'to remain passive or inarticulate when danger appeared' appointed
a committee to 'watch' the General Nursing Council (8).
Soon the position of mental nurses was causing
concern and meetings with the GNC and discussions
on nurses' registration and the position of the Association's examinations were held from the 1920s onwards. The RMPA did not claim to be a registration
authority but wished to remain an examining body;
nevertheless adjectives such as 'inflexible' and 'unsat-
The Association tried hard to retain its own examinations despite a 'revolutionary' resolution submitted by
the Scottish Division in 1937 suggesting that they
should be abandoned in favour of the GNCs. However
in 1945 the Athlone Committee recommended they
should end, the Council reported that relations with the
GNC were improving and an agreement was reached
in 1946. The RMPA received letters of complaint and
regret and the related loss of revenue from fees and
the handbook was criticised but the last examinations
were held in 1951.
For a while the Association advised the GNC about the
syllabus for both the mental nursing and the mental
deficiency nursing examinations, especially on the
inclusion of psychology. In 1954 a committee was
appointed to consider the shortage of mental nurses
and the possibility of starting RMPA examinations
again. It produced a report on the shortage of mental
nurses and it seems that a new examination was
planned.
For a while, too, the RMPA and GNC needed to work
together on disciplinary matters. An RMPA nurse, if
struck off the GNC register, could still in theory use the
title 'nurse' so in 1962 it was agreed the GNC would
take over all disciplinary matters and put in place
unifying procedures.
The Association also briefly ran an occupational therapy examination. Planning began in the 1930s and
there were five successful candidates in 1939. Possibly the war prevented this examination developing.
Although the Association put its view to the post war
Rushcliffe Committee that occupational therapy was a
nursing duty and tried to restart this examination,
negotiations for abandoning had begun by 1946 and it
was abolished in 1947.
In addition to the badges available to successful candidates, two medals were also awarded. The Campbell Clark medal was instituted in 1933 in memory of
- 54 -
Dr Campbell Clark. It was awarded each year in May
and November to the candidate with the highest marks
nationwide in the final mental nursing examination. It
was discontinued in 1951 as the Association's examinations came to an end.
2. Journal of Mental Science, volume xvi, page
The Eleanor Finegan medal was instituted by Dr Arthur
Finegan in memory of his wife and was originally awarded to the nurse, male or female, at the Mullingar District
Asylum, West Meath, Ireland, who had the highest
examination marks. This was later changed so that the
Prize (worth £5 per annum) could be awarded to the
nurse with the highest mark in the examination wherever it was held and this too was discontinued in 1951.
5. 'The Special Training of Asylum Attendants'
310, 1870 (3)
3. Journal of Mental Science, volume xxii, page
381, 1876 (4)
4. Journal of Mental Science, volume xxii, page
499, 1876 (5)
The archives include complete set of Education Committee minutes from 1893 onwards. They cover all aspects of the administration of the nursing examinations
and a prime source for the history of mental nurse
training. It will be clear from the history outlined above
that the Association's reaction to any suggestion or
problem was to appoint a committee. Many of these
special and sub-committees were set up to consider
matters relating to nurse training and examinations and
reported to Education Committee. Their reports are
sometimes inserted in the minute books.
Journal of Mental Science, volume xxix, page
459, 1876 (6)
6. Journal of Mental Science, volume xxxv, page
450, 1889 (7)
7. Journal of Mental Science, volume xlv, page
635, 1899 (8)
8. Royal College of Psychiatrists' Archives: Council minute book, 1914-23 (9)
9. Royal college of Psychiatrists' Archives: Nursing Collection: correspondence with GNC. (10)
10.
Royal College of Psychiatrists' Archives: Council minute book, 1949-54
Other insertions include some of the Education Committee's reports to annual and Council meetings and a few
examination question papers, syllabi, Registrar's reports
and letters.
The Education Committee reported to the College
Council. This met three or four times a year (except in
wartime) and the Council minutes are complete for the
period of the nursing examinations. These too have
been abstracted onto the Meetings Database. The
Council minute books also have some insertions, for
example Education Committee reports and reports from
some other relevant special and sub-committees.
There are also registers of successful candidates for the
mental nursing and mental deficiency nursing preliminary and final examinations, 1891 to 1951. The sequence is complete (25 volumes) but is limited as an
historical source as the volumes include only the candidates names and numbers and the names of the hospitals where they took their examinations. Finding
information can be difficult as, although each volume is
indexed, there is no general index or register of successful candidates. Until the late 1980s the College
received enquiries from hospitals asking for details of
the RMPA nursing certificates and for confirmation that
the qualifications potential employees were claiming
were officially recognised. Now the enquiries come from
family historians.
References:
1. Royal College of Psychiatrists' archives: minute
book 1 (2)
- 55 -
From the Archives of the Royal College
of Psychiatrists United Kingdom.
A history of specialist mental health services
Simon Lawton-Smith and Dr Andrew McCulloch
Mental Health Foundation UK
Many historians such as Roy Porter (2002) and Charles
Webster (2002) have written in detail about the development of specialist mental health services in the western world The following background note attempts to
summarise just some of the main trends in how modern
mental health policy and practice has evolved in the UK
with a view to informing the Inquiry Panel’s analysis.
This note focuses mainly on the period from the second
world war to the present day, and specialist rather than
primary mental health care services.
unregulated and ad hoc local arrangements to a system
which was increasingly segregative, centralised and
managed' (Rogers, A. & Pilgrim, D. 2001). Barnes and
Bowl argue that it was during the Victorian period that
Enlightenment ideas formed in the previous century
were cemented, rational science replacing religious
belief and culminating in the emergence of psychiatry as
a new and distinct discipline (Barnes, M & Bowl, R,
2001).
The era of the asylums
Prior to Victorian times
There is evidence that people with major mental health
problems have been segregated either for care or
containment for centuries. There are various accounts
of the development of the psychiatric hospital in the
“dark” ages. For example, Howells (Howells,J. 1975)
refers to psychiatric care developing as part of general
hospitals in Islamic countries from the 8th century, and
in India from the 10th century. Dedicated hospitals for
people with mental health problems and other conditions in England go back at least as far as the Middle
Ages (The Bethlem Hospital was founded in 1247).
Treatments offered included milieu therapy in therapeutic communities and counselling as well as more archaic
approaches.
Charitable provision developed as society and the economy developed, and further asylums were opened, but
generally most people with mental illness received no
organised systematic care until the 19th century. However, there was a strong tradition of documenting and
describing mental illness by the likes of Burton
(Burton,R. 1621, 2001). There were also some prototypical attempts at community care such as boarding
out from 1750 onwards (Bartlett,P. and Wright,D. 1999).
Early asylum treatments were primitive, usually involving sedative drugs like laudanum, which were administered orally, and baths in various forms as a method of
calming agitated patients (Bewley, 2008). The asylums
provided long term residential care for a wide mixture
of people including people with severe mental health
problems, dementias such as those resulting from
tertiary syphilis, learning disabilities, epilepsy and “moral defectiveness” (e.g. having an illegitimate child out of
wedlock).
The story of modern psychiatric care is relatively well
documented. Modern mental health policy could be
said to have started with the introduction of legislation to
control the governance of lunatic asylums in early Victorian times and has evolved from there. The central
pieces of legislation were the 1845 Lunacy Act and
County Asylums Act, which made compulsory the
provision of public asylums for all pauper lunatics by
local authorities. A few decades later, the 1890 Lunacy
Act gave asylums a wider role, and patients with means
began to be admitted. The emergence of the Victorian
asylum in England was paralleled in most, if not all,
developed countries to a greater or lesser extent,
including France, Italy, the United States and the countries of the former Soviet Union.
After the first world war more modern approaches such
as psychotherapy started to evolve, in response to the
effects of thousands of shell shock cases, which Stone
(Stone, M 1985) argues put an end to 'the monolithic
theory of hereditary degeneration upon which Victorian
psychiatry had based its social and scientific vision’.
Another milestone came in 1926 with the publication of
a report by The Royal Commission on Lunacy and
Mental Disorder which stated that 'mental and physical
illness should now be seen as overlapping and not as
distinct' (Rogers & Pilgrim op cit). After the second
world war charitable and local authority mental health
services, mainly still asylum based, were mostly incorporated into the NHS. Numbers of patients in asylums
peaked in the mid-1950s. The 1959 Mental Health Act
abolished the distinction between psychiatric and other
hospitals and encouraged the development of community care. At its height – in the mid-1950s - asylums in
England accommodated 150,000 people (0.4% of the
total population).
Porter (2002) writes how the end of the 18th century
saw 'the first wave of public asylums', institutions that
sprang up following the growth of the charitable hospital De-institutionalisation
movement. The last years of 18th century and the
beginning of 19th century saw 'a move away from
Asylum-based care was the main model of psychiatric
care for people with a mental illness until the 1960s
when a combination of advances in psychiatry and drug
treatment, greater emphasis on human rights, and advances in social science and philosophy including labelling and institutionalisation theory, combined to start the
de-institutionalisation movement. In England this became explicit Government policy in the 1960s and this
was paralleled in other countries which used administrative policy to gradually close institutions. Some countries such as Italy took stronger action through
legislation (in this case Nuova Legge 180) to abolish the
mental asylum.
and this policy direction was explicitly acknowledged in
Enoch Powell's ‘water tower’ speech in 1961. Almost all
of the old asylums are now closed, depending on how
closure is defined. During the 1970s more detailed and
explicit mental health policies began to emerge dealing
with the establishment of acute psychiatric units in general hospitals and the beginnings of community care.
However, many would argue that during the initial period
of the decline of asylums the needs of people with
severe and enduring mental illness, especially those
with deteriorating conditions, were not well addressed
in policy. There was an erroneous view that, once the
asylums were closed, a new generation of damaged
people who had not been institutionalised would not
develop schizophrenia with concurrent cognitive decline,
perhaps because the cognitive decline was seen as a
consequence of institutionalisation. Initially this group
was not well provided for but in the early 1990s it was
realised they needed particular support. This happened
through a mixture of assertive outreach, 24 hour nursed
care or residential provision depending on severity. So a
comprehensive model had to be adopted instead, closing the mental hospitals and creating a range of community facilities teams, each with complementary functions.
This process is described in more detail below.
Deinstitutionalisation has therefore been one of the primary drivers behind the development of modern care.
It has been defined as “the process of moving patients
from large scale psychiatric institutions towards the community, where alternative psychiatric services strive to
provide care and support in the client’s community,
together with more modern and appropriate treatment
with better outcomes. Its main goal is to empower and
emancipate people with psychiatric and social problems,
enabling them to be fully participating members of society.” (Bauduin,D., McCulloch,A. and Liegeois,A. 2002).
Deinstitutionalisation and community care are also at
the heart of international policy development (WHO The development of modern treatments and
2001, WHO 2005).
care
The development of modern care
Since the 1960s Governments, municipalities and health
care systems across the developing world have worked
to a greater or lesser extent towards the goal of implementing community based mental health services. Reform started early in a number of countries including the
United States, Italy, England, Australia, New Zealand
and the Scandinavian countries. Some of the most
comprehensive models have been developed in countries like Australia where complex sets of teams interact
to provide treatment and support for different groups of
people with different age and need profiles, supported
by some inpatient and residential care and housing and
welfare benefits packages. This “comprehensive model
of care” is necessary to support de-institutionalisation,
because of the complexity of need among people with
more severe mental health problems.. The many functions provided in the traditional asylums - including
health care, housing, food, occupation and leisure,
arguably none very satisfactorily (Goffman, A. 1959) had to be unpacked, and rearranged on an individual
basis after individual assessments by many different
agencies in community settings.
In most European countries, including within the United
Kingdom, the initial aim has been to develop a model of
care based on a combination of some long term provision, often still based in the old mental hospitals, with
acute psychiatric units in District General Hospitals and
community mental health teams within the community
(McCulloch, A., Muijen and Harper. 2000). Across the
UK the asylums started to decline in size in the 1950s
In terms of treatments over the least 50 or so years, the
first were primarily of a somatic type. These included
insulin coma treatment which involved patients being
injected with increasing doses of insulin to induce short
hypoglaecemic comas, which were then terminated
using doses of intravenous glucose. The aim of the
treatment was to make changes to the adrenal system
which was thought to be the physiological root of schizophrenic illnesses (Shives, 2008). The decline of the
therapy was signalled by a 1953 Lancet paper by Dr
Harold Bourne, who claimed that the treatment had no
real effect on schizophrenic illnesses (Bewley, 2008).
Electroconvulsive Therapy (ECT) was used from the
beginning of the 1940s, first in an unmodified form but
then in tandem with muscle relaxants, to prevent injuries
from seizures. The treatment took the form of electrically
induced seizures that alter brain chemistry to rectify
mood or thought disorder. By the 1960s the use of ECT
declined but it is still used up to the present day in
regulated circumstances, mainly to treat severe depression which has not responded to other forms of treatment.
More radical treatments such as lobotomies, originating
in 1936, involved severing connections within the brain
through invasive surgery and were designed to modify
disturbed behaviour and mood. This treatment became
increasingly controversial and its crudeness and inexact
nature caused the practise be phased out towards the
end of the 1950s, at a time when new medications
started to arrive. In the relatively short period time in
which they were used, at least 15,000 of these operations were performed in Britain. (Bewley, 2008)
Policy (1999-2010)
A major change in treatment came with the rise of new
drugs in the 50s and 60s, including the first antipsychotic Chlorpromazine, which was first synthesized in 1950,
and the mood stabliser lithium. The use of these drugs
was a major factor in allowing people to be treated in the
community rather than in hospital. The 1960s also saw
the rise of talking treatments, reflected in an increasing
diversification of mental health professional roles.
Mental health policy from 1979 to 1997
Scotland and Northern Ireland (since 1998) and Wales
(since 1999) have been able to develop their own
mental health policies and service delivery systems
under devolved powers from Westminster. Each has
published mental health strategies and frameworks
outlining these policies. There are many consistencies
between the policies developed across the UK, including reductions in inpatient bed numbers, the development of a wider range community services, more
involvement of mental health service users and carers
in decisions about care, suicide reduction, the growth of
advocacy and peer support services, and a greater
emphasis on the recovery model of care and provision
of psychological therapy. However for the purpose of
this short background paper, we limit ourselves below to
highlighting some of the developments that took place
in England.
Mental health policy during the Conservative administration of this period was primarily aimed at addressing the
consequences of the closure of the old asylums and
expansion of community care. In 1983 a forward-looking
Mental Health Act was introduced which consisted
essentially of a substantial update of the landmark 1959
Act. Reforms included the creation of a Mental Health
Act Commission to defend the rights of detained patients. However in the latter part of the 1980s it became
increasingly clear that the model of providing care via When the National Service Framework for Mental Health
hospital beds and undifferentiated community services (NSF) (Department of Health, 1999) was launched, the
would not succeed in meeting the needs of a core group Sainsbury Centre for Mental Health commented:
of people with severe and enduring mental illness.
To try to address this, the Care Programme Approach
(CPA) was introduced in 1990 to provide a framework
for effective mental health care for people with severe
mental health problems (Mental Health Law Online,
2013). Its four main elements were systematic arrangements for assessing the health and social needs of
people accepted into specialist mental health services;
the formation of a care plan which identifies the health
and social care required from a variety of providers; the
appointment of a key worker (care coordinator) to keep
in close touch with the service user, and to monitor and
coordinate care; and regular review and, where necessary, agreed changes to the care plan.
Much of policy from this point on was about addressing
the needs of this group and responding to inquiries into
homicides by people with severe mental illness (McCulloch and Parker, 2004). The inquiry into the killing of a
social worker by a patient at Bexley Hospital (Sharon
Campbell) was one such event which led to the introduction of obligatory care planning for people requiring
secondary mental health care. Other changes included
the introduction of supervision registers, conditional
discharge from hospital and compulsory inquiries into
serious incidents. This created a new risk management
industry some of it perhaps beneficial and some certainly
not.
Alongside this, there was also a healthy emphasis (if not
always backed by financial resources) on public mental
health in documents such as the Mental Illness Key
Area handbook, part of the Health of the Nation initiative,
and on developing specialist services for groups such
as children and homeless people. Some of this activity
set the scene for the major development programme
which came under New Labour.
"For the first time, Government has set out
a comprehensive agenda for mental health
services which acknowledges that the
whole system of mental health care must
be made to work if we are to succeed in
modernising care." (SCMH, 1999)
Whilst the NSF was radically new in terms of its comprehensiveness and ambition it can be located within a
general attempt to develop health care policy on a more
comprehensive, evidence based way (McCulloch, Glover and St John, 2003). The NSF set out seven Standards which were really key areas for service and practice
development, summarised in the box below. The NSFMH 1999 was for adults of working age (16-65).
Standards for the mental health of older people were set
out in the NSF for older people (2001) and for children
in the NSF for children and young people (2004).
Since 2010
The current Government published a new mental health
strategy for England in 2011. This has not substantively
shifted the overall policy focus, although it has reframed
it under six ‘shared objectives’:
- 58 -
I. More people will have good mental
health. Fewer people will develop
mental health problems – by starting
well, developing well, working well,
living well and ageing well.
Ii. More people with mental health problems Bartlett,P. and Wright,D. (1999) Outside the walls of
will recover. More people who develop
mental health problems will have a
good quality of life – greater ability to
manage their own lives, stronger social
relationships, a greater sense of purpose, the skills they need for living and
working, improved chances in education, better employment rates and a
suitable and stable place to live.
the asylum. London: The Athlone Press
Bauduin,D., McCulloch,A. and Liegeois,A. (2002)
Good care in the community: Ethical aspects of deinstitutionalisation. Utrecht: Netherlands Institute of
Mental Health and Addiction.
Bewley, T. (2008). Madness to Mental Illness: A History
of the Royal College of Psychiatrists. London:
Iii. More people with mental health problems RCPsych Publications.
will have good physical health. Fewer
people with mental health problems Burton,R. (2001) The Anatomy of Melancholy. New
will die prematurely, and more people York: The New York Review of Books
with physical ill health will have better
Department of Health (1999) National Service Framemental health.
work for Mental Health. London: Department of Health.
Iv. More people will have a positive experience of care and support. Care and Department of Health (2000) The NHS Plan. London:
support, wherever it takes place, Department of Health
should offer access to timely, evidence- based interventions and ap- Department of Health (2011) No Health Without Mental
proaches that give people the greatest Health: a cross-government mental health outcomes
choice and control over their own strategy for people of all ages. London: Department of
lives, in the least restrictive environHealth
ment, and should ensure that people’s
human rights are protected.
Goffman,E. (1961) Asylums: Essays on the social
V. Fewer people will suffer avoidable harm. situation of mental patients and other inmates. New
People receiving care and support York: Anchor Books
should have confidence that the services they use are of the highest quality Howells,J. (ed) (1975) A World History of Psychiatry.
and at least as safe as any other public New York: Bailliere Tindall Jones, K. (1972) A History of
the Mental Health Services. London: Routledge.
service.
Vi. Fewer people will experience stig- McCulloch,A., Glover,G. and St John, T. (2003) The
ma and discrimination. Public understanding of mental health will improve
and, as a result, negative attitudes and
behaviours to people with mental
health problems will decrease.
The strategy was widely welcomed, but the economic
recession of the past three years has led to significant
extra pressures on parts of the population (including
threat of loss of job and housing, and increased levels of
debt) that has led to an increase in reported common
mental disorders, and the suicide rate has risen. At the
same time public service spending restraints have led to
cuts in NHS and local authority services that are severely challenging the ability of the new strategy to achieve
its intended objectives.
References
Barnes, M. and Bowl, R. (2001) Taking Over the Asylum: Empowerment and Mental Health. New York:
Palgrave.
National Service Framework: Past, Present and Future.
The Mental Health Review. 8(4) 7-17 2003
McCulloch,A. and Lawton-Smith,S. (2012) Mental health
policy. Chapter in Sandford,T. (ed) Working in mental
health: practice and policy in a changing environment.
London: Routledge.
McCulloch,A. and Muijen,M. (2011) Management issues
in the mental health sector. Chapter in Walshe,K. and
Smith,J. Healthcare Management. Maidenhead: McGraw- Hill: Open University Press.
McCulloch.A., Muijen,M. and Harper,H. (2000) New Developments in Mental Health Policy in the United Kingdom. Int. J. of Law and Psychiatry. 23 (3-4) 261-276.
McCulloch,A. and Parker,C. (2004) Compliance, Assertive Community Treatment and Mental Health Inquiries.
Chapter in Stanley,N. and Manthorpe,J. The Age of
Inquiries. Routledge.
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Mental Health Law Online (2013), accessed 16 April
2013
http://www.mentalhealthlaw.co.uk/Care_Programme_A
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Porter,R. (2002) Madness: A Brief History.
Oxford University Press.
Oxford:
Rogers, A. and Pilgrim, D. (2001) Mental Health Policy
in Britain, Second Edition. New York: Palgrave Macmillan.
The Sainsbury Centre for Mental Health (1999) The
National Service Framework for Mental Health: An
Executive Briefing. London: SCMH
Shives, L.R. (2008) Basic Concepts of Psychiatric-Mental Health Nursing, 7e.Philadelphia: Lippincott Williams
& Wilkins.
Stone, M. (1985) 'Shellshock and the psychologists', in
W.F. Bynum, R.Porter and M.Shepherd (eds), The
Anatomy of Madness, Vol 2. London: Tavistock.
Webster, C. (2002) The National Health Service: A
Political History. Oxford: Oxford University Press.
White, E. (1991) The 3rd Quinquennial National Community Psychiatric Nursing Survey. Manchester: University of Manchester.
WHO World Health Report 2001 (2001) Mental Health:
New Understanding, New Hope. Geneva: World Health
Organization.
WHO Regional Office for Europe. Mental Health Declaration for Europe. (2005) WHO European Ministerial
Conference on Mental Health: Facing the Challenges,
Building Solution; 12-15 January 2005; Helsinki.
Simon Lawton-Smith is the
Head of Policy at the Mental
Health Foundation, UK. His
role is to develop our policy in
respect to the mental health of
the whole population and the
support services that people
with mental health problems receive. Simon has
been with the Foundation since 2008. Prior to his
appointment, he was Senior Fellow in Mental
Health at the King’s Fund from 2003-2008 and
Head of Public Affairs at mental health charity
Together from 1996-2003. Before this, he worked
in the Department of Health and Cabinet Office for
17 years.
Dr Andrew McCulloch was Chief Executive of the
Mental Health Foundation from 2002 to August 2013.
During his time with the Foundation, Andrew has
been an expert adviser to the World Health Organisation and the Council of Europe, a mental health
adviser to National Endowment for Science, Technology and the Arts (NESTA), and a member of the
Hunter review panel looking at mental health improvement work in Scotland.
In September 2013 he was appointed CEO for the
Picker Institute Europe.
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AN BORD ALTRANAIS EIRE (Ireland)
A VISION FOR MENTAL HEALTH NURSING
Thomas Kearns, Education Officer for Bord Altranais
An Bord Altranais is
the statutory regulatory authority for
Nursing and Midwifery which includes Registered Psychiatric Nurses. The role of the Board includes maintaining the register of Psychiatric Nurses, setting the
Standards and Requirements for the Education and
Training of Psychiatric Nurses, operating the Fitness to
Practice process and providing guidance to the profession.
An Bord Altranais acknowledges that Psychiatric/mental
health nurses are the largest professional group working in our mental health service. They make a vital
contribution to providing professional care to service
users across the life span in all settings.
An Bord Altranais supports Vision for Change as a most
appropriate evidence based Policy framework for promoting mental health and the development of a comprehensive person-centred model of mental health service
and quality nursing service provision.
An Bord Altranais supports research into Psychiatric /
Mental Health Nursing that will stimulate support for and
develop capacity in terms of the implementation of Vision for Change.
An Bord Altranais supports working in a recovery oriented way as practice that is based on human values and
their application by the user, the Nurse and the Mental
Health Service to achieve health and well being. In its
mission and role to protect the public An Bord Altranais
acknowledges that a recovery orientated approach requires psychiatric nurses to be competent health care
professionals working as partners, mentors and advocates with those who avail of mental health services.
W e r e q u i r e professional practice to be embedded
in cultural, social, religious and ethnic diversity in a
manner that gives meaning to the person’s identity,
beliefs and circumstances. A recovery orientated way of
working requires programmes of care and treatment that
are developed through negotiation and partnership,
concerned with the provision of responsive services.
Recovery orientated psychiatric nursing practice recognises the uniqueness of the individual, affords real
choices to clients and their families. A recovery orientated approach is founded on the service users experience
and goals and is perceived as a journey; it is an ongoing
process of developing strengths and positive coping
strategies. The tools for working in a recovery orientated way include focusing on choice, hope, meaning,
abilities, knowledge, social support, personal support
and goal setting to achieve positive mental health.
The values and principles that should underpin Mental
Health Nursing should be based on a renewed professional and service culture of positive mental health. A
culture that is service user centred, a service that constructs care programmes in collaboration and partnership with service users and carers, that is developmental
and future orientated. Within this culture the following
values and principles should co-exist, respect, dignity,
privacy, confidentiality, informed consent, choice, hope,
use and access to personal information, an openness
to receive complaints, concerns and compliments, advocacy, the right to refuse treatment and care, participation in care and care decisions, safety, consumer
feedback being sought and addressed, the challenging
of discrimination and the reduction of stigma, partnership
and community engagement and understanding.
Mental health services must be accessible, comprehensive, effective, equitable, evidence based, person centred and efficient and economical. Mental Health
nursing practice should establish goals in relation to the
health, educational, employment, social and recreational needs of the client. Within the international literature
the title of psychiatric-mental health nursing is used.
However the orientation of education and training programmes are more focused on mental health in the
broadest context from primary through to tertiary care.
An Bord Altranais would welcome a discussion on the
title psychiatric/mental health nurse.
The Board supports the integration of essential professional psychiatric/mental health nursing capabilities, the
An Bord Altranais Domains of Professional Competence
and the Knowledge, skills and know how and the competencies of the National Framework of Qualifications.
These facilitate the skills required for working in a recovery orientated way which demands competence in
terms of psychosocial rehabilitation, skills in case management, effective referral, shared care, co-joint assessments, intensive case management, problem solving,
brief psychological interventions, psychoanalytical psychotherapy, assisted self-help and the provision of a
seamless nursing service. It requires nursing skills and
competencies to develop realistic goal setting, research
utilisation and clinical (practice) audit to ascertain the
value added by professional mental health nursing
interventions.
Improving outcomes and experiences requires that
psychiatric/mental health nurses develop a range of
therapeutic interventions including comprehensive and
eclectic assessment skills and methodologies, skills in
relation to psycho-education, CBT, solution focused
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therapy, grief therapy, counselling skills, and skills in
relation to the management of anxiety states. While
these skills must be part of the knowledge and competencies of Psychiatric nursing profession, support for
and facilitation of such knowledge and competence
development must be universal across the services in
order to meet policy and service need. An Bord Altranais has planned a revision of the indicative content of
the registration education programmes to support practice developments to meet service need. The Board will
set standards that ensure and effective nursing care that
responds to current and futures driven models of mental
health care provision.
How can RPNs be supported to work in a
recovery orientated way?
An Bord Altranais would support a re-orientation of the
governance of the mental health services and of professional practice locally and nationally. An Bord Altranais
would support the development of a range of in-service
education and CPD activity that addresses the required
cultural change, the required professional commitment
to re-orientate the services and the necessary professional nursing competencies and capabilities required
to deliver a recovery orientated practice. This must be a
supported and supportive process.
Nurse education in Ireland is at graduate level since
2002, the fundamentals for such a graduate programme
are research knowledge and skills and evidence based
practice. An Bord Altranais supports enhancing the
availability of resources to support an evidence based
and research based culture within the Mental Health
Services. Central to enhancing evidence based practice
is the development of strategic alliances between the
mental health services and Higher Education Institutions, for example appointing clinical practice “Chairs”
and clinical research fellows. Such appointments would
help bridge the theory practice gap. The concept of
clinical audit and the audit of psychiatric/mental health
nursing practice is essential to inform the development
and use of evidence based practice locally (increase the
development of evidence locally). A range of research
implementation/utilisation strategies must also be supported and significantly the mental health service must
reduce the common barriers to research utilisation (increase the utilisation of research generated elsewhere).
schools and within community groups, these should be
delivered by service users and carers along with the
nurse.
How can effective leadership be developed
and supported for psychiatric/mental health
nursing?
An Bord Altranais welcomes the focus on effective leadership to champion the protection of the client and user
of the mental health services and nursing practice development. The governance of the mental health services in general and psychiatric nursing specifically must
be re-orientated to ensure a service culture that is based
on the values and principles identified earlier. These
beliefs and values must inform the strategic and operational planning for the mental health services and the
provision of recovery orientated mental health nursing
care. Reflective leadership must continue to be promoted as a core competency within nursing management.
Education and training for leadership positions must be
supported in a manner that is reflective of the demands
for advanced practice. All governance structures within
the service must incorporate the leadership of people
who use the service. An Bord Altranais has developed
requirements and standards for Post Graduate Education and Training and is committed to publishing standards that supports the development of clinical nurse
specialists and advanced practitioners to support the
leadership agenda in mental health nursing.
A focus for RPNs should be the provision of re-orientated psychiatric/mental health nursing services within
primary health care structures to reduce stigma and
enhance integration of services including social welfare,
education, employment support, supporting client access to mental health services within primary care. The
RPN should be central to establishing strong relationships with vocational and social organisations (statutory
and voluntary). Social inclusion could be promoted by
the strengthening the location of mental health services
and RPNs within the Primary Health Care Teams and
be active participants within community groups. RPNs
should promote and facilitate education programme in
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The Myth of Mental Health Nursing and
the Challenge of Recovery.
Phil Barker, PhD, RMN
ABSTRACT: Although the concept of ‘mental
health nursing’ has grown in popularity over the
past 35 years, it remains a myth. People believe
that they know what it is and value it highly, but
cannot describe or define it other than in vague
terms. This paper briefly charts the rise of ‘mental
health nursing’, emphasizing its political implications, and in particular, the drive towards an embrace of a person-centred, recovery-focused
approach to care. If nurses are to realize such
ambitions, they must resolve their historical association with psychiatric nursing. The concept of the
‘mental health nurse’ might signal the emergence
of a new vision for human services, but might also
signal the need for ‘mental health nurses’ to negotiate a formal separation from the traditional ‘psychiatric’ family.
Introduction:
Mental health nursing is a discipline with no obvious
‘purpose’, or at least not one embraced by all who
might lay claim to the title. What are the needs of
people, their families, or society at large that are
met by nurses, and are not otherwise provided by
psychiatrists, psychologists, various other ‘therapists’,
social workers, or other ‘unqualified’ helpers? This
question was first asked over a decade ago (Barker et
al. 1999). Would the answers that then emerged fit
‘mental health nursing’ today?
Over a century ago, ‘mental’ or ‘psychiatric’ nursing was
created by physicians to provide them with particular
forms of support in caring for people in asylums
(Walk 1961). Since the 1950s, psychiatry has
changed dramatically, and nursing has adapted,
slowly becoming more expert and expressing ambitions for a genuine professional identity (Nolan
1993). However, today, in almost every country
worldwide, the nurse’s primary functions remain
much the same as a century ago: to keep people
(and others) safe; to express medical treatment;
and in hospital settings, to ‘manage’ the physical and
social environment’: the stereotype of the ‘housekeeper’.
es, or at least the support of someone offering
what nurses traditionally offer. Most nurses today
also possess university degrees. Many have completed supplementary training, qualifying them to
deliver different ‘therapies’ or even to prescribe psychiatric drugs. However, to what extent do these developments reflect an extension of ‘nursing’ per se?
Are these ‘extended roles’ merely examples of
nurses becoming more adept at fulfilling roles once
the preserve of other disciplines, such as medicine
or psychology?
The Australian Congress of Mental Health Nurses
(ACMHN), later to become the ‘College’, was founded
in 1975 (Martyr 1999), making it one of the first
organizations to use the title ‘mental health nurse’
officially, and therefore, worthy of specific acknowledgement with Almost 20 years later, this title was
recommended officially for nurses working in the
community, hospital, or day services in health nursing’ has spread around the globe, although in
Europe, Horatio still remains an association of
‘psychiatric nurses’ (Horatio 2010). However, the
difference between ‘mental health’ and ‘psychiatric’, or
‘mental’ nursing, still remains unclear (Cutcliffe &
Ward 2006, p. 22). In a very important sense, ‘mental
health nursing’ is a ‘myth’, in the classic sense,
reflecting how nurses would ‘like’ to be: a professional
aspiration, rather than a practical reality. Most of the
writing and talking about ‘mental health nursing’ is mere
‘ideology’: the collected ideals and social aspirations of
some sections of the traditional ‘psychiatric nursing’
discipline (Chambers 2006). However, if nurses
brought this ideology to life, their purpose might
become clearer.
As ideology, ‘mental health nursing’ provides a linguistic means by which practitioners can feel better
about them- selves. In England, Norman and Ryrie
(2004) suggested that this might be its only function:
In part this change in terminology would appear to
reflect a desire by nurses to establish their profession as distinct from the discipline of psychiatry and
also to find a more positive identity as people who
can help people who are mentally ill [sic] become
This might sound like a harsh assessment, since mentally healthy. (p. 67)
it is clear that nurses are almost indispensable;
most services can function even when major gaps Despite its international popularity, the ideological
appear in medical, psychological, or other thera- shift towards ‘mental health nursing’ is often blurred
peutic disciplines, but risk collapse without nurs- by blending ‘psychiatric’ with ‘mental health ‘nursing. For
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Cutcliffe and Ward (2006), this terminological confusion was key to all the theoretical and philosophical debates in the field, leading Collins (2006) to
argue that it might be ‘time to consider whether
psychiatric nurses are nurses at all’. Such a radical
stand would, however, require nurses to split from
their historical roots: ‘free from the influences of the
“medical father” and the “nursing mother” ’ (Collins
2006, p. 50).
The first was: A subservient discipline and an extension of psychiatry’s social control mechanism(s) for
the policing, containment, and correction of already-marginalized people, which carried out a
number of defensive, custodial, uncritical, and often
iatrogenic practices and treatments, based on a
false epistemology and misrepresentation of what
are, by and large, ‘human problems of being’, rather
than so-called ‘mental illnesses’.
The second was: A specialty craft that operates
primarily by working alongside people with mental health problems; helping individuals and their
families find ways of coping with the here and
now (and past); helping people discover and
ascribe individual meaning to their experiences;
(A mental health nurse) holds a specialist and exploring opportunities for recovery, reclamation
qualification in mental health. Taking a ‘holistic’ and personal growth, all through the medium of the
approach, guided by evidence, the mental therapeutic relationship.
health nurse ‘works’ in ‘collaboration’ with people who have ‘mental health issues’, their People considering undertaking nurse training
family and community, towards ‘recovery’ as might wonder if they have a choice to join ‘either’ the
defined by the individual. (p. 5. Emphasis first ‘or’ the second of these ‘camps’. By contrast, a
added)
distinguished nurse leader from the UK said that
‘Mental health nursing’ implies something more meaningful, more egalitarian, more ‘health promoting’, and
therefore, more liberating than traditional psychiatric
nursing. This was signalled in the Australian College of
Mental Health Nurses’ (2010) definition:
mental health nursing covered:
In contemporary international practice, the terms
‘psychiatric’ and ‘mental health’ nursing are used almost
interchangeably. Nolan’s (1993) groundbreaking
‘history of mental health nursing’ referred, in the main,
to ‘psy- chiatric’ nursing, since the concept of ‘mental
health’ nursing was introduced officially into the UK
only a decade before the publication of his book.
However, as Chambers argued: ‘Logically . . . those
nurses working
with the mentally ill should, at the
very least, be called “mental illness nurses” or even
“nurses of the mentally ill[sic]” ’ (Chambers 2006, p. 44).
If ‘mental health’ nursing is not simply rebranding – a
piece of linguistic cosmetic surgery – then it must
refer to something different from ‘psychiatric’ nursing.
In an ongoing study, we asked mental health nurses
to provide brief, concise descriptions of what is ‘psychiatric and mental health nursing?’ and ‘how do nurses
‘practice’ it?’ (Barker & Buchanan-Barker 2008) We
offered two-line definitions of medicine, psychology,
and social work, drawn from Web dictionaries, to
act as a guide. Two-hundred practitioners, leaders,
researchers, and educators from around the world
were invited to ‘define’ and ‘describe’ their discipline
in a way that ‘could be understood by the layperson’.
Many admitted that these were ‘difficult questions’,
finding it hard to offer definitions and descriptions
that were not jargon-ridden summaries of eminent
theorists. This led us to wonder how recruitment is
encouraged, if prospective mental health nursing
students cannot be offered a simple definition of its
purpose and function.
Only a few respondents distinguished between
‘psy- chiatric’ and ‘mental health’ nursing. One professor of nursing from the USA said that the field was
divided into two ‘camps’.
A broad and moveable spectrum of roles, responsibilities, and practices defined by the economics,
institutions, and policies of the day, which meant
that this particular branch of nursing could not be
defined.
PATERNALISM AND THE HISTORY OF
PSYCHIATRIC NURSING
Clearly, there are risks in being defined by the ‘economic’, ‘institutional’, and ‘political’ influences of the day. The
nurses who participated in the mass involuntary
euthanasia programme during the Holocaust were
merely con- forming to the social and political standard
of national socialism (Benedict & Kuhla 1999). The
countless number of nurses in psychiatric hospitals
who participated in electroshock, psychosurgery,
enforced sedation, the application of wet packs,
restraints, and seclusion were also conforming to an
image of nursing practice set for them by someone
in authority (Peplau 1994). If nurses do not define
themselves professionally, they risk being defined and
directed by others who might have very different
agendas. Arguably, nurses’ uncertainty over defining
themselves and their inclination to serve almost anyone
in authority lies in their history. In the mid 19th
century, the physician, John Connolly, famously remarked:
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All (the physicians’) plans, all his care, all
his personal labour, must be counteracted,
if he has attendants who will not observe
his rules. (Connolly 1856, p. 37)
Such attitudes led to the development of training programmes for attendants, created by physicians,
largely to meet the physicians’ needs (Walk 1961). In
Cohen’s (1981) view, medical patronage had long
been nursing’s biggest problem: ‘Nightingale defined
the nursing role as handmaiden to the physician,
and it has remained so. Handmaidens are not
professionals’ (Cohen 1981, p. 140). Doubtless, most
contemporary ‘mental health nurses’ would lay a
strong claim to pro- fessional status. However, this
only makes the incon- sistencies and uncertainties
over the definition of the discipline all the more
intriguing.
Few psychiatric-mental health nurses give their
history more than a casual glance, which might be
reasonable, since it is not an attractive story.
When trained nurses replaced Connolly’s untrained
attendants at the beginning of the 20th century,
they continued the attendants’ custodial function,
but also provided more technical support to physicians, becoming the administrators of various ‘patient management’ methods, most of which had
disastrous effects on the people concerned (Whitaker 2001). Given their ‘medical-expressive’ role (Barker
1990; Peplau 1994), nurses were either responsible
for, or assisted in, the delivery of all such ‘treatments’,
the validity and usefulness of which they never
questioned, since they carried the stamp of medical
authority. Unmodified electroshock, insulin coma,
and lobotomy might be history, but forced drug
administration continues, as does the widespread
practice of disinformation and deceit often involved
when nurses try to encourage people to take
psychiatric drugs, which they do not want, or
interpret their problems from a psychiatric perspective (Jackson 2005; Lakeman & Cutcliffe 2009).
A recent Irish study provides a fitting example,
where nurses avoid telling people of the likely effects
of certain drugs for fear that they would stop taking
them (Higgins et al. 2006). Although defended as
‘caring concern’, this was paternalism writ large. The
many ‘side-effects’ of neuroleptic and antidepressant
drugs are well known and include pseudo-Parkinsonism; shrinking of brain mass; increased risk of
impotence, obesity, seizures, and diabetes; enlarged
breast tissue in men; dulling of the intellect; and heart
problems, which might result in death. Before offering
or recommending such drugs, any health-care professional should provide the person with a full explanation of all such risks. Failure to do so would be
dishonest, unethical, dangerous, and illegal. It is only
surprising that there is not more litigation related to the
kind of ‘paternalistic’ practices described in Higgins’s
study.
Misplaced compassion is part of the paternalistic
medical tradition: doing things, allegedly, in the patient’s best interests (Breeze 1998; Szasz 1998), and
nurses might have embraced this tradition even more
fervently than psychiatrists. However, it has become
clear that much of the paternalistic ‘wisdom’ concerning
‘mental illness’ and its ‘treatment’, especially by drugs, is
grossly exaggerated where it is not complete mendacity. Whitaker (2010) noted:
For the past twenty-five years, the psychiatric
establishment has told us a false story. It told
us that schizophrenia, depression and bipolar
illness are known to be brain diseases, even
though . . . it can’t direct us to any scientific
studies that document this claim. It told us that
psy- chiatric medications fix chemical imbalances in the brain, even though decades of
research failed to find this to be so. . . . Most
important of all, the psychiatric establishment
failed to tell us that the drugs worsen long-term
outcomes. (p. 358)
The idea of the ‘chemical imbalance’, first developed in
the 1950s (Valenstein 1998), became the most
popular myth related to of the causation of different
‘mental ill- nesses’, providing a fitting rationale for
drug treatment. The ‘myth of the chemical cure’ was
then sold as a scientific fact to patients and the public
alike (Moncrieff 2009), despite the fact that no evidence existed to support the idea that ‘schizophrenia’,
‘bipolar disorder’, or ‘depression’ arose from such an
‘imbalance’. (Our use of ‘scare quotes’ reflects our
belief that these ‘disorders’ are not legitimate forms of
bodily disease or illness.)
Moncrieff (2009) and Whitaker (2010) illustrated how
drugs offered as a solution became, for many, a cure
that was worse than the hypothetical ‘disease’. Hyman, the eminent US neurologist, was Director of the
National Institute for Mental Health when, with a
colleague, he first described how ‘all’ psychiatric drugs
threw the brain into a state of chemical chaos,
creating ‘perturbations in neurotransmitter functions’
(Hyman & Nestler 1996). Hyman’s view that prolonged
use of such drugs resulted in ‘substantial and
long-lasting alterations in neural function’ showed that
any ‘chemical imbalance’ that might exist in the brain
of people with ‘mental illness’ was produced by
long-term usage of psychotropic drugs, ‘not’ by some
putative ‘mental illness’.
Whitaker’s (2010) review of the scientific literature on
the development of psychotropic drugs formed the
basis of his thesis, that through its rash and unscrupulous advocacy of such drugs, psychiatry had
nurtured an epidemic of ‘mental illness’. Many of today’s
‘mental health nurses’ are either unaware or choose to
Psychiatric Mythology and Psychiatric Nurs- forget that recovery rates from so-called ‘serious
mental illness’ were far better ‘before’ the introduction
ing
of psychiatric drugs in the mid 1950s than they are
- 65 -
today. It is commonly believed that the deinstitutionalization programme was made possible ‘only’
through the introduction of neuroleptics. This is
psychiatric mythology. As Healy et al. (2005, p. 28)
noted, few people are aware that the asylum population in Japan ‘quadrupled’ following the introduction
of chlorpromazine, rather than leading to the closure
of the institution. More importantly, numerous
longitudinal studies (e.g. Harding et al. 1987; Harrow
& Jobe 2007; Jablensky et al. 1992) demonstrated that
people with diagnoses of ‘schizophrenia’ and ‘bipolar
disorder’ fared better in the long term if they ‘did not’
receive psychiatric drugs or gradually ‘discontinued’
their use. Despite this evidence, the European Convention on Human Rights, for example, exempts people
with mental illnesses from its protection (Warne et
al. 2010), with the result that, in most countries,
people with ‘serious mental illness’ can be forced by law
to take psychiatric drugs, which might cause them
permanent and disabling physical damage.
little in the way of active resistance. This might well be
typical of their traditionally conservative outlook. As
Nolan (1993) observed, psychiatric nurses ‘have
embodied traditional values of subservience to the
system and preservation of the status quo. Theirs has
been a ‘victim role’ and by deflecting responsibility for
the failures of psychiatry onto doctors, patients, or the
institution, have made themselves, some would claim,
obstacles to progress’ (p. 159).
Much of the traditional discourse on psychiatric–mental
health nursing remains focused on the treatment or
management of ‘patients’. Having coined the term ‘nurse–
patient relationship’, in her last major paper, Peplau
(1995) turned her attention away from ‘patients’ to the
subject of ‘persons’:
Nurses claim that advocacy for patients, and
consideration of their needs and interests as
persons, having dignity and worth, are primary
values inherent in the design and execution of
nursing services. In keeping with these claims, it
Many mental health professionals would argue that would behove nurses to give up the notion of a
drug companies have delivered ‘new and improved’ disease, such as schizophrenia, and to think exdrug treatments, especially those who have developed clusively of patients as persons. (p. 2)
sophis- ticated programmes to nurture adherence to
drug treatment regimes, who argue, for example, that Peplau might be the most cited author in the nursing
‘poor adherence increases morbidity and reduces a literature, but few nurses today practice what she
patient’s quality of life’ (Anderson et al. 2010, p. 341). preached at the end of her life. The most cursory
trawl of any psychiatric–mental health nursing journal
This is not the place to rehearse these arguments in
reveals that many nurses are reluctant to give up the
any detail. However, Lakeman and Cutcliffe (2009)
notion of ‘patients’, ‘diseases’, or ‘illnesses’, such as schizohave at least prefaced the case against ‘pharmaco- phrenia. However, Peplau might have anticipated the
centrism’ which bedevils contemporary ‘mental health ‘person focus’ of recovery (Barker 2001), only beginnursing’.
ning now to be embraced, officially, by mental health
nursing. In a highly-significant development, the Stand‘Schizophrenia’ and ‘bipolar disorder’ are frequently ards of Practice for Australian Mental Health Nurses
characterized as ‘malignant’ forms of ‘mental illness’, 2010 articulated five core values underpinning pracrequiring prompt medical intervention through drug tice. These included:
treatment, usually for the rest of the person’s life. If
evidence existed that a significant number of people . . . acknowledging the personal experience and
with physical malignancies, such as carcinomas, expertise of the individual, supporting their potential
could recover ‘without’ either surgical or drug treat- for recovery and assisting them to achieve optimal
ment, then the sci- entific and public view of cancer quality of life. (ACMHN 2010, p. 5)
would change irrevocably. Yet a significant number
of people ‘recover’ from ‘schizophrenia’, ‘bipolar disor- This implies that at least one purpose of nursing is
der’, and drug and alcohol ‘addictions’, either through the to help people live their lives in the way they see fit.
‘administration’ of social support or simply by ‘talking’ This is developed further in Standard 3:
about their problems. Despite this evidence, the
received view endures that these states are manifes- . . . the Mental Health Nurse develops a therapeutic
tations of ‘illness’ or ‘disease’ requiring medical treat- relationship that is respectful of the individual’s choicment. It is difficult to counter the argument made by es, experiences and circumstances. This involves
Whitaker (2010) and Mosher et al. (2004a), among building on strengths, holding hope and enhancing
others, that the ‘pharmaco-centrism’ in contemporary resilience to promote recovery – later defined as a
mental health services is a function of successful subjective experience, defined by the individual.
marketing by drug companies, rather than deriving (ACMHN 2010, p. 10)
from scientific research.
Although much of this emergent critique of psychiatric
GRASPING THE NETTLE OF THE
practice is focused on psychiatrists, it implicates
psychi- atric nurses, without whom the machinery of RECOVERY ETHIC
psychiatry could not operate. Where psychiatric
nurses are not active advocates of Lakeman and
Cutcliffe’s ‘pharmaco- centrism’, they appear to display
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Although necessarily vague, the ACMHN standards
represent important examples of attempts to
articulate the ‘purpose’ of mental health nursing. We
singled out for consideration some of the ACMHN
standards, since they represent the expressed
views of members of the disci- pline itself, rather
than ambitions made on behalf of the discipline by
politically-elected or otherwise politically- motivated
groups called upon to conduct ‘reviews’ of nursing,
as so often prevails in other countries (e.g. Department of Health 2006). Moreover, the ACMHN standards also appear to distinguish ‘mental health
nursing’ from the traditional practice of ‘psychiatric
nursing’. This is expressed most perhaps by the emphasis on ‘values’.
Another psychiatrist, Ed Podvoll, was the inspiration for the Windhorse projects in Colorado and
Massachusetts, which realized what Podvoll
called a genuine nursing of the mind (Podvoll
1991). Distressed people were helped to live ordinary everyday lives with nothing more than careful
support of caring companions.
The ACMHN standards and their underpinning values
signal an ambition to reinforce, or perhaps establish
officially for the first time, a different kind of nursing
for people experiencing the problems in living, commonly called ‘mental illness’. This initiative is laudable,
but not without potential problems. As Glover (2005)
noted, it is one thing to embrace the recovery ethic,
The ACMHN concept of ‘mental health nursing’ ap- and quite another to shift towards a recovery-based
pears focused on helping people live their lives ‘on their paradigm. In the context of the ACMHN’s expressed
ambition to locate ‘recovery’ at the heart of ‘holistic’ menown terms’, echoing Barker’s concept of ‘trephotaxis’:
tal health nursing practice, a number of questions might
Although we may help people to change in some be asked. These might include the following.
way, we do not change people directly. Certainly we
do not heal people, or otherwise make them whole;. I Could a ‘mental health nurse’ fulfil the ACMHN standhave come to accept that while helping people ards ‘and’ be involved in:
always involves change, it never involves a return
• The administration of psychiatric drugs or
to previous functioning: it is always a forward
any other form of treatment ‘against’ a
change. I have called this approach trephotaxis,
person’s expressed wishes?
which in the original Greek would mean the ‘provision of the necessary conditions for the promotion of
• The use of coercive or constraining practices,
growth and development. (Barker 1989, p. 138)
such as ‘control and restraint’ or ‘seclusion’?
This contrasts starkly with ‘psychiatric nursing’, which
• Any programme that encourages individuals
appears to be
focused
primarily
on
the
or their families to adopt a psychiatric view of
management of some hypothetical ‘mental disease’ or
their ‘symptoms’ of ‘mental illness’, rather than
‘illness’, and usually involves ‘treating’ the person by
assist people to develop their own understandsome medical means, and if necessary, by force. In
ing of their problems in living?
this sense, ‘mental health’ and ‘psychiatric’ nursing
could not be more different.
The ideal at the heart of the ‘mental health nursing’
‘ideology’ embraced by the ACMHN standards, re- CONCLUSION
flects an understanding of nursing in its purest
sense. The English word ‘nursing’ derives from the
Old French ‘nourice’, meaning to nourish. Therefore, Over 20 years ago, Barker (1989) said that his
nursing implies the provision of the conditions nec- articulation of ‘trephotaxis’ served: ‘little other function
essary for a person to thrive, grow, and develop than symbolic protection from those who would define
(Barker 1989), using whatever resources are avail- our art for us’ (p. 140). Perhaps the ACMHN standable, complemented by the nurse’s compassionate ards represent a significant advance on that ‘symbolic
protection’, as the College seeks to mould the discisupport (Barker 2000).
pline in the image of the ideas it values most.
We searched the psychiatric–mental health litera- However, the emphasis given to valuing the active
ture for models of practice that met the criterion of ‘person focus’ of partnerships, personalized notions of
‘nourishment through interpersonal caring’. The recovery, and respect for human rights might fly in
examples that exist are more often than not the face of contemporary forms of ‘evidence-based
provided by psychiatrists and psychologists who practice’, which remain ‘patient focused’ and paternalhave moved beyond the limits of their core disci- istic, where they are not actually coercive and dehupline. Arguably, the most famous example of ‘nour- manizing.
ishing nursing’ was Loren Mosher’s work with the Soteria
project in California in the 1970s and 1980s (Mosher The ACMHN standards appear to represent an
et al. 2004b). Mosher showed how compassionate important step forward in clarifying the fundamental
caring, without the use of psychiatric drugs, could purpose of mental health nursing. However, that
help people grow and develop through the experi- step might also require the discipline to reconsider
its relationship to ‘psychiatric’ nursing, if not also the
ence so-called ‘schizophrenia’.
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traditional family of psychiatry, which might not atric and mental health nursing. Journal of Psychiatric and
Mental Health Nursing, 8, 233–240.
share the value base of mental health nursing.
Five years ago we surveyed 100 colleagues in
different countries around the world. Our question was
simple: Could someone with a ‘conscientious objection’
to ‘any’ form of coercive practice, train ‘and’ qualify as a
mental health nurse? The unanimous response was
‘no’. Several educators said: ‘Such a person could
study and qualify, but if they confessed such a view
at interview, they would be unlikely to gain employment
in “mainstream practice” ’.
We are not sure if the people who framed the
ACMHN standards intended to make a radical
statement about mental health nursing and mainstream practice. At least on paper, the standards raise
many challenging questions about the relationship
between the College’s vision for the future of mental
health nursing, the shadow cast by psychiatric nursing
of old, and their common roots in the mental health
field. Whatever its potential, however, ‘mental health
nursing’ remains a ‘myth’ in the sense that the concept
reflects how nurses would ‘like’ to be: a professional
aspiration, as expressed by the ACMHN standards
perhaps, rather than a widespread contemporary
reality. What is clear, beyond dispute, is that the days
where nurses debated what to call themselves
appears to be over.
Now nurses appear to be begging the question: ‘What
do we “do?”’ to merit the title ‘mental health nurse’ and
‘Why do we do this, rather than anything else?’ The
answers to such questions signal a future form of
practice that might
differ significantly from the conservative traditions of
the psychiatric nursing past.
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Dr. Barker’s nursing career stretches back over
thirty years. He became one of the country’s first
nurse psychotherapists, one of the first nurse clinicians to gain a PhD and the first professor of
psychiatric nursing practice, at Newcastle University. Given an honorary doctorate at the Oxford
Brookes University in 2001, he has long been both
a distinctive and controversial figure in nursing. The
author of 14 books - often in collaboration with
others - he developed the Tidal Model, which has
been adopted by mental health nurses in numerous
countries. In 2002, he decided to give up his post
at Newcastle to concentrate on writing, lecturing,
and not to mention, returning to his first love, painting.
The Registered Psychiatric Nurses of
Canada (RPNC) is an incorporated body
with a Vision of Optimal Mental Health for All
People of Canada. The RPNC exists to provide leadership for the profession of psychiatric nursing by working collaboratively on
regulatory issues in the public interest, by
achieving common standards in education,
registration and practice; and by being a
voice, nationally and internationally for excellence in the profession.
www.rpnc.ca
This website has been provided by the Registered Psychiatric Nurses of Canada to provide
information about the profession of Registered Psychiatric Nurses in Canada
- 70 -
Your donations
help fund
Scholarships for
RPNs and Student
Psychiatric Nurses
in Canada
www.rpnf.ca
Social Justice & Nursing until April 2015
Registered nurses from around the world are needed to participate in
a research study to help us learn more about social justice...
Please explore this site to learn more about the researcher, the study, a $50.00 U.S. gift
card for participants (as a token of appreciation), and how you can get involved.
This international study explores nurses' experiences with- and thoughts about- social
justice. Your story is key to developing a rich and complete understanding of the
nurse's role in this important work.
If you are a registered nurse who is currently- or has ever been- actively involved in
social justice, there is an exciting opportunity for you to be involved in a unique study.
Contact:
[email protected]
Dr. Jessie Colin
Barry University Faculty Supervisor:
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- 72 -
Provincial Regulatory
Psychiatric Nursing Authorities for Canada
British Columbia
Alberta
Saskatchewan
Manitoba
Registered Psychiatric
Nurses of CANADA
ICN’s Definition of Nursing - June 2014
Nursing encompasses autonomous and collaborative care of individuals of all ages,
families, groups and communities, sick or well and in all settings. Nursing includes
the promotion of health, prevention of illness, and the care of ill, disabled and dying
people. Advocacy, promotion of a safe environment, research, participation in shaping health policy and in patient and health systems management, and education are
also key nursing roles.
The ICN Code of Ethics for Nurses, most recently
revised in 2012, is a guide for action based on social
values and needs.The Code has served as the standard for nurses worldwide since it was first adopted in
1953.
The Code is regularly reviewed and revised in response to the realities of nursing and health care in a
changing society. The Code makes it clear that inherent in nursing is respect for human rights, including
the right to life, to dignity and to be treated with respect.
The ICN Code of Ethics guides nurses in everyday
choices and it supports their refusal to participate in
activities that conflict with caring and healing.
To obtain a hard copy of the ICN Code of Ethics,
please contact [email protected]
CALL FOR PAPERS
A peer-reviewed open accessed e-journal that reflects the increasing global
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