The future of community psychiatric nursing: some research findings

A workshop organised by the Research Committee of the College took place on 20 November 1989, in which 14 invited delegates from nursing, psychiatry and general practice presented and discussed the implications of recent research developments in community psychiatric nursing. Papers were given by Helen Hally, Chairman of the Community Psychiatric Nurses Association, on recent developments in the workload ofcommunity psychiatric nurses. Dr Joseph Connolly presented the preliminary findings of the 'Daily Living Project' at the Maudsley Hospital in which comprehensive community care is given primarily by community psychiatric nurses. Professor Brandon outlined some of the difficulties in obtaining data on the working practices of community psychiatric nurses arising from a study in Leicester and this was followed by an account by Dr Alastair Wright, a general practitioner in Glenrothes, Fife, of the typical psychiatric workload of a general practitioner and the ways in which community psychiatric nurses may be ofvalue in treating this without the necessity of referral to psychiatric care. Subsequent papers were given on the comparison between the working practices and treatment given by community psychiatric nurses and mental health social workers by Dr Kate Wooff. This showed considerable uncertainties about the role and responsibilities of community nurses and questioned aspects of their training. Dr Peter Tyrer described the workload of the community nursing team in Nottingham which demonstrated that over half of the time was spent with patients suffering from chronic psychotic disorders and this was perceived as satisfactory by the nurses concerned. Dr John Pearce concluded the formal presentation by comparing two services in the Leicester area for child and adolescent psychiatric problems, one staffed by a consultant psychiatrist and the other by a community based team, mainly consisting ofcommunity psychiatric nurses. A supplementary presentation was made by Mr Browning of the Audit Commission, who emphasised that the successful integration of community resources and the bridging finance necessary to initiate this was a high priority of the Commission. The best way offittingcommunity psychiatric nursing into this integrated model was far from clear. Role and responsibilities ofthe community psychiatric nurse

A workshop organised by the Research Committee of the College took place on 20 November 1989, in which 14 invited delegates from nursing, psychiatry and general practice presented and discussed the implications of recent research developments in community psychiatric nursing. Papers were given by Helen Hally, Chairman of the Community Psychiatric Nurses Association, on recent developments in the workload ofcommunity psychiatric nurses. Dr Joseph Connolly presented the preliminary findings of the 'Daily Living Project' at the Maudsley Hospital in which comprehensive community care is given primarily by community psychiatric nurses. Professor Brandon outlined some of the difficulties in obtaining data on the working practices of community psychiatric nurses arising from a study in Leicester and this was followed by an account by Dr Alastair Wright, a general practitioner in Glenrothes, Fife, of the typical psychiatric workload of a general practitioner and the ways in which community psychiatric nurses may be of value in treating this without the necessity of referral to psychiatric care.
Subsequent papers were given on the comparison between the working practices and treatment given by community psychiatric nurses and mental health social workers by Dr Kate Wooff. This showed considerable uncertainties about the role and responsibilities of community nurses and questioned aspects of their training. Dr Peter Tyrer described the workload of the community nursing team in Nottingham which demonstrated that over half of the time was spent with patients suffering from chronic psychotic disorders and this was perceived as satisfactory by the nurses concerned. Dr John Pearce concluded the formal presentation by comparing two services in the Leicester area for child and adolescent psychiatric problems, one staffed by a consultant psychiatrist and the other by a community based team, mainly consisting ofcommunity psychiatric nurses.
A supplementary presentation was made by Mr Browning of the Audit Commission, who emphasised that the successful integration of community resources and the bridging finance necessary to initiate this was a high priority of the Commission. The best way offittingcommunity psychiatric nursing into this integrated model was far from clear.

Role and responsibilities ofthe community psychiatric nurse
These papers emphasised that the community psychiatric nurse was expected to be a model of versatility who should be able to assess psychiatric status, set up treatment programmes in family and behaviour therapy, have a good working knowledge of psychotherapy and dynamic principles, understand the principles of case management and be aware of developments in rehabilitation. These responsibilities have grown piecemeal and have not been part of any systematic programme of development. Evidence that community nurses were getting an increasing number of referrals in primary care has led to uncertainty as to which referrals should take priority. As more long-stay psychiatric patients were discharged into the community, the service would need to be expanded and an increase in the number of community psychiatric nurses would be needed. There was little evidence that this demand has been anticipated.
Several of the papers suggested that the expectations and perceptions of community psychiatric nursing by its practitioners were not being achieved in practice and that independent therapeutic initiatives by nurses were rare. This led to a lively debate which was handicapped by the paucity of research into the typical day-to-day working of community nurses. It was noted that in a typical psychiatric urban practice most of the patients seen by community nurses were suffering from one of the major psychoses in chronic form and that 'long-term support' was a major component of the treatment given, although it is far from clear exactly what constituted the elements of such support. Although it appears that many nurses were satisfied with this part of their work there was little attention given in the training ofnurses to accommodate the monitoring and maintenance of long-term psychotic disorder. As this group characteristically tends to be neglected by both society and medical services, it was important to acknowledge this role in training.
The expectations of the referrers to community psychiatric nurses were also very different. Whereas most psychiatrists at the meeting felt that it was right for the community nurse to be involved mainly in the only be implemented if community psychiatric nurses agreed that they were necessary.

Recommendations
The following recommendations were agreed at the workshop about further research into community psychiatric nursing: (a) studies to establish the relative importance and effectiveness ofdifferent skills, including those ofsupport, housing advice and budgetary skills as well as the more obvious clinical disciplines of assessment, monitoring of medication, case management, behaviour therapy and psychotherapy (b) investigations of the value of further specialisation within community psychiatric nursing because ofits widening remit (c) evaluation of the current training and refresher courses for community psychiatric nurses (d) studies of the cost-effectiveness and costutility of the work of community psychiatric nurses similar to recently reported studies (paykel et ai, 1982;Ginsberg et ai, 1984) (e) introduction of a standardised recording system ofthe work ofcommunity psychiatric nurses that could form the basis for an audit of the service.
Thefuture ofcommunity psychiatric nursing care of major psychiatric disorder, this was clearly not the expectation ofthe general practitioner, exemplified in Dr Wright's presentation. His survey established that the patients which the general practitioner would most like to refer to the community psychiatric nurse were those with neurotic disorders, particularly with a common mix ofanxiety associated with somatisation, tranquilliser dependence, and patients requiring non-pharmacological treatments for depression. Patients with the major psychoses made up less than 100/0 of referrals. Community nursing teams who operate an open referral system were therefore being asked to select patients from groups that showed very little overlap and it was difficult to know what criteria should be adopted in selecting patients and whether referrals should be prioritised.
There seems little doubt that the psychiatric are of the non-psychotic patients referred from GPs is less stressful than that of the more severely mentally ill. This was particularly exemplified by Dr Connolly's account which showed that community psychiatric nurses as part of a special team were extremely 'successful in reducing the duration of admission of psychiatric patients with major mental illness. This benefit was achieved only by placing heavy demands on the nurses concerned. Attitudes towards experimental projects of this nature could be changed overnight by tragedies involving patients and some of these and their implications were discussed. Community teams usually work on a close multidisciplinary basis and it was uncertain what were the different levels of responsibility held by members within the team and how these responsibilities should be bounded.
There were particular advantages in community psychiatric nurses working closely with other di~ci plines when this could be agreed mutually. ConfUSIon and difficulties arose when community nurses competed for referrals with other psychiatric disciplines. Continuity ofcare and sharing ofexpertise were prevented by having separate systems and this led to unnecessary interprofessional rivalry.
The meeting acknowledged the professional commitment of community psychiatric nurses and the importance of their work, and also recognised their status as an autonomous discipline. Some suggestions for change were made at the meeting in the spirit of constructive collaboration, but these could