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The role of the psychiatric nurse

Margaret Grigg

Objective: To provide an overview of the interdisciplinary team from theperspective of a psychiatric nurse.

Conclusion: Psychiatric nursing has undergone many changes over theyears, including changes to the training and registration of nurses and thescope and location of their activities. Tensions within the interdisciplinaryteam may emerge from a lack of understanding of the skills and abilitiesof the nurse. Nurses bring a breadth of skills to the interdisciplinary team,but often lack depth within individual skills. Models of interdisciplinaryteamwork also need to consider the variety of practice settings that nurseswork within, including residential settings and rural and remote commu-nities.

Key words: interdisciplinary, multidisciplinary team, nursing, profes-sional role, psychiatry.

As a psychiatric nurse who has worked in the clinical area for morethan 15 years, I have witnessed many changes in the delivery ofmental health services, in the relationships between the different

professions and in the relationship of nurses to consumers. This follow-ing perspective of a nurse within the interdisciplinary team is a personalone, but one which may be shared. Throughout this paper the termsnurse, psychiatric nurse and mental health nurse are used interchange-ably; they all refer to a nurse whose major area of work is in the mentalhealth field.

THE PROFESSION OF PSYCHIATRIC NURSING

Psychiatric nursing is one of the oldest disciplines within mental healthand dates back to the asylum era of the 19th century. Traditionally, nurs-ing work occurred within an institutional setting and the scope of the discipline reflected this. Nurses provided care and support to patients overa 24 hour period. The nurse’s role was varied and included the physical,psychological and social domains. Consistent with current treatment models that have shifted the locus of care from hospitals to the commu-nity, nurses have been similarly ‘deinstitutionalised’. A substantial amountof nursing work now occurs in community settings, although nurses con-tinue to work within acute inpatient and other residential services.

Traditionally, nurses were trained within an apprenticeship system thatwas located within hospitals. Many of us learnt our craft from moreexperienced nurses where the practical was valued above the theoreticalor the conceptual. Since the 1980s, there has been a transition to uni-versity training and degree level courses, reflecting both the need todevelop analytical as well as practical skills within the nursing environ-ment and pressure from nurses to obtain ‘professional’ qualificationsequivalent to other disciplines. While there is little debate anymore thatsuch a change has been good for nurses and their patients, it has notbeen achieved without conflict and difficulties within the profession.

In a parallel development, the provision of psychiatric nursing as dis-crete, undergraduate training has diminished with the growth of com-prehensive and post-graduate training. This is also reflected in the

Developed from a paper presented at a joint RANZCP–TheMHSconference symposium

Margaret Grigg St Vincent’s Mental Health Service Melbourne, 41 Victoria Parade, Fitzroy, Vic. 3065, Australia.Fax: (03) 9288 4802Email: griggm@svhm.org.au

THEINTERDISCIPLINARY

TEAM (PART 1)

registration process, with most states not maintain-ing a register of nurses with specialist mental healthqualifications.1 This has led to psychiatric nursingcompeting with other nursing specialties for gradu-ates,2 and contributes to the current shortage ofmental health nurses.1

CONTRIBUTION TO THEINTERDISCIPLINARY TEAM

The nurse can be seen to bring a breadth of skills tothe interdisciplinary team that can be contrastedwith the depth of skills brought by other profession-als. This breadth is reflected in the diversity of activ-ities that the nurse is able to undertake. TheStandards of Practice for Mental Health Nursing inAustralia3 outlines the knowledge, skills, attitudesand practice outcomes associated with psychiatricnursing and reflects the breadth of psychiatric nurs-ing practice.

In contrast, other disciplines can be seen to have agreater depth of skill in fewer domains. Nurses areoften able to do some of the tasks associated withother disciplines, but with less depth and expertise.

The scope of nursing cannot be defined merely by alist of competencies. Nurses have always valued theirunique relationship with patients. In an examina-tion of inter-professional role relations, nurses artic-ulated their contribution to the community mentalhealth team:

“Nurses are ‘traveling companions’ with patients, not‘travel agents’ … the heart [of nursing] is the skills andvalues needed by nurses to establish and maintainhuman contact with patients.”4

While some may not like the metaphor, the valuingof the nurse-patient relationship above technicalskills is at the heart of nursing. The “hidden” workof nursing, the caring and comforting roles of thenurse, are an important part of the nurse’s contribu-tion to the interdisciplinary team.

OPPORTUNITIES FOR, AND BARRIERSTO, EFFECTIVE TEAMWORK

Amongst nurses, there is considerable variation inthe knowledge and skills of individual nurses reflect-ing the diversity of training and experience. Otherdisciplines may have difficulty in understanding thisvariation and conflicts may emerge. Differences ineducation and training can be individualised andpersonalised with some nurses being over-valuedwhile others may be stigmatised within the team.These differences also provide opportunities forteams, particularly if there is an investment in theprofessional development of team members. Manynurses are able to take on expanded roles if they

receive the appropriate training, support and super-vision.

Over the past 50 years there has been a transitionfrom predominantly institutional models of treat-ment for the mentally ill to the development ofcomprehensive community based services. However,significant numbers of nurses continue to workwithin institutional settings. While many otherteam members are now located within the commu-nity service, nurses continue to be the largest profes-sional group providing inpatient care. While therhetoric often describes an inpatient setting as ateam, the reality is often different. Wide spread dis-satisfaction of the interdisciplinary team by nurses,particularly within inpatient units, has beenreported with concerns including that nurses are notlistened to by other members of the team and thattheir expertise is not recognised.1 Significant num-bers of nurses are effectively excluded from teamprocesses either because of the dominance of hierar-chical structures and/or the difficulties in includingshift workers in inter-disciplinary teams. The chal-lenge for many teams is to develop processes thatinclude the nurses working within inpatient set-tings. Creative strategies as well as commitmentfrom other professionals is required if this is to beachieved.

The difficulty of recruiting mental health practition-ers in rural and remote areas often leads to theexpansion of the nurse’s role. Many nurses effectivelywork as sole practitioners in areas with few, if any,alternative mental health services. The nurse maytake on roles more frequently associated with otherprofessionals, providing much of the assessment,treatment, counselling and rehabilitation services.Interdisciplinary team work models should not onlyinclude those models associated with urban areas andthe representation of all professional groups, but alsoother models where the team may consist of only thenurse, the local general practitioner and the psych-iatrist who visits monthly. The recent developmentof Nurse Practitioner Projects within Victoria pro-vides a framework for developing and credentiallingthis expanded role and provides opportunities forteams to recognise advanced nursing roles.

Nurses frequently work in management and leader-ship positions within services and thus exert consid-erable influence over the functioning of the team.While this may be a result of the large number ofnurses employed in mental health services, never-theless nurses are often team leaders or managers.Tensions may occur within teams if nurses are seento disproportionately occupy positions of power.Different professional groups come from differentmodels of leadership and the hierarchical modelsoften associated with nursing may be at odds withthe more egalitarian models of other disciplines. TheA

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result of this tension may be a split between ‘clinicalinter-disciplinary teams’ and ‘managers’, with theformer accused of being obstructionist and the latternot understanding clinical needs.

There are opportunities for teams to rethink teammanagement. Models that emphasise leadership andpartnership between disciplines may provide a newparadigm of team work. While some nurses mayoperate within hierarchical models, many are at theforefront of fostering innovation and creativitywithin teams.

CONCLUSION

Nurses are, and will continue to be, integral mem-bers of the interdisciplinary team. However, while itmay be useful to explore the workings of the team,along with many of the tensions and contradictions

within team models, it is also essential that we main-tain a focus on our central task, the treatment andcare of individuals with mental illness. The interdis-ciplinary team is only a means, not the end we seek.

REFERENCES

1. Clinton M, Hazelton M. Scoping practice issues in the Australian mental healthnursing workforce. Australian and New Zealand Journal of Mental Health Nursing2000; 9: 100–109.

2. Happell B. The implications of legislative change on the future of psychiatric nurs-ing in Victoria. Australian and New Zealand Journal of Psychiatry 1998; 32:229–234.

3. Australian & New Zealand College of Mental Health Nurses (1995) Standards ofPractice for Mental Health Nursing in Australia, ANZCNHN Inc., Greenacres, SA.

4. Peck E, Norman I. Working together in adult community mental health services:exploring inter-professional role relations. Journal of Mental Health 1999; 8:231–242.

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