Role Emergence

The role of psychiatric nursing began to emerge in the early 1950s but it was not a smooth path. An article by Bennett and Eaton in the American Journal of Psychiatry in 1951 identified the following problems affecting psychiatric nurses:

These psychiatrists believed that the psychiatric nurse should join mental health societies, consult with welfare agencies, work in outpatient clinics, practice preventive psychiatry, engage in research, and help educate the public. They supported the nurse’s participation in individual and group psychotherapy and stated, “Despite the fact that most psychiatrists seem to ignore the role of the psychiatric nurse in psychotherapy, all nurses in psychiatric wards do psychotherapy of one kind or another by their contacts with patients” (Bennett and Eaton, 1951).

Also in 1951 Mellow (Mellow, 1968) wrote of the work she did with schizophrenic patients. She called these activities “nursing therapy.” One year later, Tudor published a study in which she described the nurse-patient relationships she established, which were characterized by unconditional care, few demands, and anticipation of her patients’ needs (Tudor, 1952). These articles were some of the earliest descriptions of the nurse-patient relationship and its therapeutic process. As nurses engaged in these kinds of activities, many questions arose: Are these activities therapeutic, or are they therapy? What is a therapeutic relationship or a one-to-one nurse-patient relationship? How does it differ from psychotherapy? These questions were addressed by Dr. Hildegard Peplau, a dynamic nursing leader whose ideas and beliefs shaped psychiatric nursing.

In 1952 Peplau published a book, Interpersonal Relations in Nursing, in which she described the first theoretical framework for psychiatric nursing and the specific skills, activities, and roles of psychiatric nurses. Peplau defined nursing as a “significant, therapeutic process.” While she studied the nursing process, she observed nurses functioning in various roles, such as those listed in Box 1-3. She wrote, “Counseling in nursing has to do with helping the patient remember and to understand fully what is happening to him in the present situation, so that the experience can be integrated with rather than dissociated from other experiences in life” (Peplau, 1952).

Two other significant developments in psychiatry in the 1950s also affected nursing’s role. The first was Jones’ publication of The Therapeutic Community: A New Treatment Method in Psychiatry in 1953. This method encouraged using the patient’s social environment to provide a therapeutic experience. The basis of the therapeutic community was that each patient was to be an active participant in care, become involved in the daily problems of the unit, and help solve problems, plan activities, and develop the required unit rules. Therapeutic communities became the preferred environment for psychiatric patients. The second significant development in psychiatry in the early 1950s was the use of psychotropic drugs. With these drugs more patients became treatable, and fewer environmental constraints such as locked doors and straitjackets were required. Also, more personnel were needed to provide therapy, and the roles of various psychiatric clinicians were expanded, including nursing.

Evolving Functions

In 1958 the following functions of psychiatric nurses were described (Hays, 1975):

Peplau further clarified psychiatric nursing’s position and directed its future growth. In Interpersonal Techniques: The Crux of Psychiatric Nursing, published in 1962, Peplau identified the heart of psychiatric nursing as the role of counselor or psychotherapist. She clarified the differences between general practitioners, who were staff nurses working on psychiatric units, and psychiatric nurses, who were specialists and expert clinical practitioners with graduate degrees in psychiatric nursing. Thus from an undefined role involving primarily physical care, psychiatric nursing was evolving into a role of clinical competence based on interpersonal techniques and use of the nursing process. For her contributions to the specialty, Hildegard Peplau is often called the mother of psychiatric nursing (Figure 1-1).

In the 1960s the focus of psychiatric nursing began to shift to primary prevention and implementation of care and consultation in the community. These changes lead to a shift in the name of the specialty from “psychiatric nursing” to “psychiatric and mental health nursing.” The Community Mental Health Centers Act of 1963 made federal money available to states to plan, construct, and staff community mental health centers and resulted in a growing awareness of the value of treating people in the community and preventing hospitalization whenever possible. It also encouraged the use of multidisciplinary treatment teams by combining the skills of many professions to treat illness and promote mental health. This team approach continues to be negotiated as issues of territoriality, professionalism, authority structure, consumer rights, and the use of peer counselors are still being debated.

The 1970s saw psychiatric nurses emerging as the pacesetters in specialty nursing practice. They were the first to do the following:

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