Literature Review

Journal of Mental Health (2000) 9, 6, 575–587

ISSN 0963-8237print/ISSN 1360-0567online/2000/060575-13 © Shadowfax Publishing and Taylor & Francis Ltd. DOI: 10.1080/096382300 20005327

Address for Correspondence: Julie Repper, School of Nursing, University of Nottingham, Queens Medical Centre, Nottingham NG7 2UH, UK. Tel: 0115 924 9924 Extn 42354; E-mail: [email protected]

Adjusting the focus of mental health nursing: Incorporating service users’ experiences of recovery

JULIE REPPER

School of Nursing, Queens Medical Centre, University of Nottingham, Nottingham, UK

Abstract Mental health nursing is currently torn by passionate debate about its proper focus and function, with the two dominant ‘camps’ competing for ascendancy. Although both traditions stress the need to involve service users in their own care, the hegemonic nature of these professional theories tends to relegate the expertise of those who experience mental health problems. This paper considers service users’ views and experiences, particularly their accounts of recovery, and finds a place for both approaches. Users also highlight the importance of strategies for social inclusion (facilitating access to roles, responsibilities, relationships and communities) an area of work that has not been prioritised by mental health nurses in either approach. Service users differ from each other and have a range of different roles in different settings. In developing their own strategies for living they need choices, multiple perspectives, a range of approaches and skills. It is not for us to create single models or fixed ways of acting upon them, but for service users to use a range of resources – including the different strategies that nurses make available – in ways most useful to them. In providing the most helpful environment for recovery, mental health nursing theorists must move from competition to co- operation, from criticising others to self-criticism. We must also incorporate strategies for social inclusion, but if we are to promote diversity in communities, we must first embrace diversity in our own area of work.

Introduction

There has always been debate about the focus, function and form of mental health services: users, their family and friends, the general public, police will all have diff erent views about who should be treated and in what way (Perkins & Repper, 1998). Within mental health professions, the debate is even more heated: there is little consensus either between or within professional groups, but there are passionate convictions about how

things should and should not be done. Such convictions are currently fuelling fierce bat- tles within mental health nursing, driven by perceived threats to the profession as an inde- pendent discipline, and the ongoing quest to define and justify the unique contribution of mental health nurses.

Commentators have offered ways of inter- preting, solving and progressing the debate, but there is no perfect answer, no single way forward. Indeed the difficulty may lie in seeking a single formula; an objective truth,

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in an area which defies objectivity. In much the same way as diff erent users will find different forms of help acceptable and useful, so mental health nurses gravitate towards different forms of practice. But the diff erent theories and practices of mental health nurses have common goals, and there are common themes in users’ accounts of what helps, and how to survive and thrive with mental health problems. This paper draws on this ‘common ground’ to discuss nurses’ roles in achieving goals that are shared by polemic nursing theorists as well as service users. It is not possible here to do justice to the full com- plexities of this area, but particular emphasis is placed on the role of mental health nurses in promoting service users’ recovery and social inclusion.

The ‘proper focus’ of mental health nursing

Mental health nursing is notoriously diffi- cult to define. Unlike other mental health professions it does not rest upon any distinct model or particular hypotheses about mental health problems and their treatment. This is, perhaps, not surprising given the variety of mental health nursing roles: working with people of all ages and cultures, with mental health problems of different kinds and levels of severity, in a wide range of different set- tings. Such variation does not preclude ef- forts to develop a ‘meta-theory’ of nursing (Barker, 1997), yet one of the key debates within mental health nursing lies in whether such a theory does, in fact, facilitate better care (Gournay, 1995; Barker & Reynolds, 1996). This leads to another question: how and by whom should ‘better care’ be defined? This fundamentally affects what will be meas- ured and how (Perkins & Repper, 1998).

Within mental health nursing (as in other fields of healthcare) there are supporters of

nursing as an ‘art’ and nursing as a ‘science’ . On the one hand are those who are primarily concerned with developing an understanding of the process of nursing as a discrete activity based on a relationship between the nurse and the individual person in distress . Contempo- rary leaders of this tradition include Barker & Reynolds (c.f. Barker, 1998; Barker et al., 1995; Barker & Reynolds, 1996; Reynolds & Cormack 1990 ) – who refer particularly to the work of nurse theorists (e.g. Hildegard Peplau) to lend authority to their claims (c.f. Tilley, 1999). On the other hand are those who are concerned primarily with specific interventions or treatment for patients with a diagnosed mental illness. The notable leader of this tradition is Gournay (c.f. Gournay 1995; 1995a; 1996; 1997) who rejects nurs- ing theory in favour of biological and genetic determinist theories, and dismisses discrete nursing activities in favour of multi-discipli- nary approaches to care. He recommends more randomised controlled trials to test the effectiveness of nursing interventions – and authorises his claims with reference to such research (usually conducted by psycholo- gists and psychiatrists in the absence of ‘ad- equate’ nursing research). Rather than focus- ing on the relationships between nurses and service users, the work of nurses following this tradition focuses primarily on ‘extended’ roles (that might be said to emulate or take over the work of other disciplines) such as compliance therapy, nurse prescribing and psychosocial interventions.

Such brief caricatures of the dominant ‘camps’ in mental health nursing do no jus- tice to the complexity, diversity, skill and knowledge base of the key protagonists. They emphasise the difference between the two approaches rather than similarities. But this is how they have been represented within mental health nursing media: reduced to con- frontational headlines, representing oppos-

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ing sides of debates at conferences, and at- tracting followers who gravitate towards mental health nursing based (albeit crudely) on either ‘science/nature’ or ‘art/nurture’ . As Peplau (1994, p. 7) concluded in a review of the challenges for mental health nurses in the current context of change:

‘The age-old controversy about nature vs. nurture, being played out now in the psychiatrist-nurse relationship in mental health care, presents a major challenge to psychiatric mental health nurses in rela- tion to future patterns of their nursing practice.’ The current policy emphasis on clinical

effectiveness, evidence-based practice and clinical governance has unbalanced the de- bate and served to escalate this controversy. Commissioners, education consortia, research funding bodies and service managers – if not mental health nurses themselves – have ac- corded precedence to the ‘scientists’ among mental health nurses. Specific interventions with ‘proven’ effectiveness have gained in- creasing value, and are seen by many to be the essential tools of mental health nursing. This outcome-based approach pervades all aspects of mental health nursing: what cannot be measured is devalued. Indeed in a review of nursing discourses, Tilley (1999, p.293 ) has compared the ‘absence’ of the accountable nurse practitioner with the ‘presence’ of the nurse in research:

‘the nurse ‘present’ in the discourse of nursing researchers, but not in practice, is the deliberate practitioner, referring to the body of knowledge and prof ession- ally accountable. The nurse opposite to this is the one ‘present’ in practice, indis- tinguishable from a layman.’ This last point is important. Nursing is

often equated with a lay caring role – as ‘ordinary’ and ‘common sense’ – partly because much of the experience and process

of mental health nursing is difficult both to elucidate and to represent linguistically. For example it is easy to def ine giving a pill and relatively easy to measure its effect, but it is far more difficult to define the development of a trusting relationship and to measure the extent to which it engenders hope and self belief. These complex and individualised processes are therefore either not reported and not published, or denigrated by those ‘emulating the high kudos, poor fit para- digms of medicine’ (Hicks, 1998).

In attempting to restore some balance to the debate; to re-assert the importance of mental health/psychiatric nursing and to demonstrate the need for (funded) research into the proc- ess of nursing and the experience of being nursed, those opposing the trend towards evidence based, outcome orientated practice tend to resort to the easy reductionism of which they accuse the ‘scientists’ . Rather than considering the relationship building skills necessary to deliver evidence based interventions in an effective manner (Repper, 2000a), or the attention to social networks, culture and skills of engagement necessary for outreach work that service users find acceptable (Smith et al., 1999), psychosocial interventions are rejected wholesale by nurs- ing academics who oppose the ‘rise and rise of nurse brutalism’ [sic] (Clarke, 1999, p. 270 ): ‘an epithet’ earned by those whose ‘methods are as blunt as their scientism lacks humanity’ . Accounts of the actual delivery of psychosocial interventions – being con- c ern ed w i t h n ei th er eff i cac y n or generalisability – do not find their way into academic journals, but they are numerous in professional journals. Here, the practition- ers accused of ‘brutalism’ write about their ‘person-centred rather than technique driven’ work (Ryan et al., 1998) in a cautious, reflec- tive manner (e.g. Ford & Dudley, 1989 – cited in Ryan et al., 1998). Such accounts are

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ignored by the very people who bemoan the lack of recognition of the ‘process’ of nursing in research. This crucial inter-personal as- pect of delivering ‘psychosocial interven- tions’ nursing is also dismissed by those leading a ‘scientific’ approach. They make little attempt to explain how nurses can be more effective, only whether they can statis- tically be shown as such (with effectiveness frequently measured on psychiatry/psychol- ogy-led indicators).

There is nothing new in this process. Baker et al. (1998) characterise debates about the development of nursing knowledge by three phenomena: a tendency for criticism to come from those practising outside the tradition being criticised; a tendency to over-simplify or exaggerate as a way of misrepresenting the position being criticised, and a tendency to focus on two extreme approaches (e.g. randomised controlled trials and phenom- enology) with little attention to distinctions within these broad categories and without attention to more flexible or broad approaches. These authors go on to emphasise the need for more self-criticism, more accurate reflec- tion on others’ approaches, and closer exami- nation of common ground in order to progress nursing knowledge.

This appears to be sensible advice, but as professional theorists vie for the right to define the function and focus of mental health nursing, it is all too easy for the central players – those people who themselves expe- rience mental health difficulties – to become marginalised. This is not through a lack of recognition of the key role of service users’ views: contemporary commentators from both sides of the debate emphasise the impor- tance of users’ views. Thus, for example, Barker and colleagues are developing a model of nursing practice informed by research into what service users want from mental health nurses; it is based on an assessment of the

person’ s own appreciation of their problems and emphasises caring ‘with’ rather than ‘for’ (c.f. Barker, 1998). On the other side of the debate, those who provide training in psy- chosocial interventions also emphasise the collaborative nature of this approach: ‘…. the involvement of service users and their carers in an informed treatment process underpinned with some of the most efficacious interven- tions possible’ (Cannon et al., 1999).

This acknowledgement of the need to in- volve service users might be seen as the common ground in contemporary mental health nursing: an area of agreement that lends itself to careful and respectful critical and self-critical consideration of the contri- bution that both approaches might make to the body of nursing knowledge (as suggested by Baker et al. (1998) above). Yet the values of the separate nursing traditions reveal oppositional understandings of service users. On the one hand they are patients with an illness in need of a specific intervention (of- ten medication) to save them (and society) from themselves, on the other hand, they are people struggling to know and overcome their difficulties in living who can be helped through their interactions with nurses. Such are the differences between the approaches that consensus is unlikely: each seeks to dominate opinion in mental health nursing. The hegemonic nature of both approaches not only make understanding and acceptance of alternative approaches unlikely, it also relegates the expertise of experience. Serv- ice users’ accounts of their lives and needs are accorded less privilege than those es- poused in the professional domains. Yet there now exists a vast literature of users’ experiences describing emotional and cogni- tive difficulties themselves, using mental health services, living with a label of mad- ness, and most recently, of recovery. It is these accounts that might illuminate the

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‘proper focus’ of mental health nursing: whether the profession should follow one or other tradition, steer a middle course or adjust to reflect the priorities of service users in the current social context.

Service users’ views

People who use mental health services value common characteristics among those who work in those services, and (whilst there are numerous critical accounts of nursing care that can advise improved practice, e.g. Faulkner, 1998) service users do recognise the particular help that nurses can provide. Users of a rehabilitation service identified mental health nurses as providing practical help (cooking, cleaning, budgeting, dressing, bathing) caring (and continuing to care what- ever they did), counselling (talking, chatting, social chit-chat), medication and liaison with other prof essionals (Meddings & Perkins, 1999). Although these users did not consider their ‘talk’ with nurses to be particularly specialised, they did find it beneficial. This ‘ordinary’ talking was also valued in a survey of 516 people who had all been admitted to psychiatric hospital on at least one occasion (and 120 more than six times). Rogers & Pilgrim (1994) reported that nurses were viewed more favourably than other mental health professionals (3 2. 4% respondents said nurses had helped the most, and 59.4% were either satisfied or very satisfied with nursing care). The quality of nursing care regarded most highly was talking, listening and ordi- nary relating; physical care and practical help; and, non-intervention or flexibility – tolerat- ing some rule breaking. Interestingly, stu- dent nurses were preferred as they engaged in seemingly genuine empathic relationships. It is this relationship that marks nurses – as those prof essionals most of ten in closest con- tact, over longest periods, involved in more

areas of their life and in different stages of distress and recovery – as potentially differ- ent from other service providers. The ques- tion is, what nurses should do with and within that relationship.

Read (1996) draws on accounts of what users want from services (c.f. Rogers et al., 1993; Tanzman, 1993; Campbell, 1996) to describe the eight things that users most want: choice; accessibility; advocacy; equal oppor- tunities; income and employment; self-help and self-organisation. In a study of users’ perceptions of their unmet needs, Estroff (1993) found the most common to be: an adequate income, intimacy and privacy, a satisfying sex life, meaningful work, a satis- fying social life, happiness, adequate re- sources and warmth. The same themes were echoed in a study of what users wanted from mental health staff: better information and choice, more accessible help, and practical help with: income and benefits, finding em- ploymen t; housing; daily living skills; childcare; and help in accessing appropriate specialist services (Duggan et al., 1997).

Given the low priority that service users appear to accord ‘treatment’ , it is not surpris- ing that numerous studies have shown differ- ences in the goals of service users and service providers (Dimsdale et al., 1979; Mitchell et al., 1983; Lynch & Kruzich, 1986). Shepherd et al., (1995) also found that service users and service providers had different priorities: us- ers valued help to come to terms with their problems and assistance with housing, fi- nance, social networks and physical health, whilst professionals placed greater emphasis on professional support, treatment and moni- toring.

A series of focus groups conducted to elicit users’ and carers’ views of the core compe- tencies of mental health workers emphasised values and attitudes over skills (IHCD for NHSE NW Office, 1999). The priorities of

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this mixed group included: respect, optimism, ability to manage the power imbalance be- tween users and professionals, belief in the value of a trusting relationship, ability to ‘let go’ of the service user, flexibility, openness, and the ability to work across traditional boundaries. Aspects of knowledge and skills valued by users and carers again placed as much value on social factors as treatment interventions, but skills in preventative strat- egies, recognition of early signs and symp- toms of crisis were clearly prioritised. The latter point echoed the findings of Mueser et al. (1992): in a survey of what users wanted from services, learning about early warning signs and relapse were ranked second out of 40 items.

Service users themselves have provided accounts that come closer to defining that which nurses (should) offer. Lindow (1996) implores community mental health nurses to form alliances with service users to bring about a more healing and helpful service in the community. Campbell (1998) describes practical ways in which nurses can improve their day to day practice in the light of service user’ s response: spending more time with service users – on a person to person basis; improving the environment; reviewing ‘rules’, giving more information and presenting genu- ine choices.

Few studies report specifically on what service users want from nurses probably be- cause this is a spurious question. People who have mental health problems may be aware of the areas in which they would like help, the attitudes that they appreciate, the type of environment that they find most supportive. But it probably makes little difference whether this comes from a nurse or any other profes- sional or non-prof essional worker, and the same skills/attitudes would probably be val- ued even more highly among friends and family members. Nevertheless, Barker and

colleagues (1999) have conducted a series of focus groups with service users and multi- disciplinary professionals to establish the ‘need’ for psychiatric/mental health nurses. This study revealed that nurses’ intimate knowledge of the person set them apart from other mental health care workers, and the more time they were able to spend with service users, the more ‘ordinary’ the con- tact. Although service users valued ordinari- ness in nurses, they also needed nurses able to adapt their position according to the situa- tion: at times service users need knowledge and advice, at other times they needed re- sponsibility taking from them, at others they wanted a friend: they valued flexibility within nurses, and different people valued diff erent approaches. Nurses were seen to be the translators, working between different pro- fessionals, the person and their family as a ‘bridge’ or a ‘go-between’ . (Barker et al., 1999). The extent to which respondents were identifying the type of personal role that is useful whether or not you are a nurse is difficult to discern in this study. Could peo- ple without a prof essional nursing qualifica- tion provide the same functions? Is the rela- tionship between the nurse and the service user a function of the nurse’ s specific train- ing, or of their role and the time they spend with the service user (both of which might be fulfilled by a mental health support worker)? Should nursing be seen as a set of attitudes and behaviours that are nurturing? Not a job, profession or business, but a function – like supporting – that diff erent mental health workers/professionals can incorporate into their role?

A further question that arises from users’ expressed views about nurses is the extent to which they are referring to the existing role, function and focus of (‘good’ ) nurses rather than proposing a role for nurses that might be more appropriate given the ever changing

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context of mental health nursing. Is it suffi- cient for mental health nurses to focus prima- rily on how to ‘be’ in their relationships with service users, and/or how to utilise specific pharmacological, or psychosocial interven- tions and approaches? Or, are other areas of work and approaches to working relevant? Users accounts of recovery offer further insights into how nurses can help. They go beyond descriptions and opinions based on experiences of using services to distinguish the factors that have enabled people who experience mental health problems to live fulfilling lives.

Recovery

Service users describe recovery as a proc- ess of making sense of what has happened to them, reconstructing a positive identity, ac- cepting, living with and growing beyond the limits of their mental health problems (e.g. Leete, 1989; Anthony, 1993; Deegan, 1993; 1996; Petite & Triolo, 1999; Young & Ensing, 1999). This is not something that can be ‘done to’ a person, it is something that users must do for themselves: a deeply personal process that is unique to every individual. ‘… a matter of rising on lopped limbs to a new life’ (Deegan, 1988).

Ideas about recovery apply just as much to the process of living with physical, sensory or mobility impairments, or the impact of dev- astating life events such as bereavement or unemployment, as they do to living with the cognitive and emotional impairments associ- ated with mental health difficulties (Anthony, 1993 ). Recovery does not mean that all suffering has disappeared, or that all symp- toms have been removed, or that functioning has been completely restored. It is marked by:

‘… an ever-deepening acceptance of our limitations. But now, rather than

being an occasion for despair, we find our personal limitations are the ground from which spring our own unique possibili- ties. This is the paradox of recovery… that in accepting what we cannot do or be we begin to discover what we can be and what we can do… recovery is a process. It is a way of life. It is an attitude and a way of approaching the day’s challenges.’ (Deegan, 1992, p. 8). In proposing recovery as the ‘guiding vi-

sion for rehabilitation services’ , Anthony (1993) summarises some of the common themes in accounts of recovery: � Recovery can occur without professional

intervention, a person’ s own friends, fam- ily and other supports are equally impor- tant.

� A common factor in recovery is the pres- ence of people who believe in, and stand by the individual, who try to listen and understand, who encourage their recov- ery without forcing it or becoming frus- trated when nothing seemed to change.

� Recovery is not dependent upon any par- ticular theory of madness, it may occur with or without medical/psycho-social interventions.

� Recovery can occur even though symp- toms remain or reoccur. Recovery is about living a valued and valuable life with diff iculties; finding ways of under- standing and coping with problems, as much as getting rid of them.

� Recovery is not a linear process, it in- volves setbacks and sudden periods of growth and insight.

� Recovery from the consequences of men- tal health problems can be more difficult than recovering from the difficulties them- selves. The barriers and discrimination that people experience as a consequence of their difficulties can limit a person’ s life far more than their cognitive and emo-

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tional problems (c.f. Koehler & Spaniol, 1994).

In describing their own journeys towards thriving (rather than merely surviving) with mental health problems, service users offer a wealth of expertise that, if recognised, under- stood and valued, can inform mental health nursing. Clearly being on the receiving end of mental health services and mental health nursing is very diff erent from administering it. Anyone seeking to def ine service users’ experiences, categorise their symptoms, pre- scribe and evaluate their treatment might be seen as detracting from the proactive role of each individual in their own recovery. Yet, these accounts do not discount help, rather, they illuminate the nature of support that best facilitates their own journeys. They do not def ine the role of nurses (or any other profes- sional group), rather, they characterise the values, attitudes, supports, facilities, and re- sources that they require - within and outside mental health services – for recovery.

The role of the mental health nurse in recovery

It was suggested earlier in this paper that a fundamental concern for users’ views was ‘common ground’ in the ongoing debate in mental health nursing, yet differences be- tween the two ‘camps’ were epitomised in their oppositional values concerning service users – leading to conflict and competition. Service users’ accounts challenge this con- troversy. Their recovery does not depend upon any particular view of madness or its treatment, and it applies to all levels and types of mental health problems. Their experi- ences do not distinguish one mental health nursing approach or set of skills from an- other, both have a place so long as they are not applied oppressively. However, the chal- lenge described by people who experience mental health difficulties does extend the

current debate within nursing. Recovery involves both coping and living with the difficulties themselves, the domain in which mental health nurses (from both ‘camps’ ) have traditionally sought to help, and dealing with discrimination and exclusion, a rela- tively new and undeveloped area of mental health nursing.

Clearly there are two areas of work for mental health nurses. The first lies in helping people to adapt to the challenges that face them. In a study of users’ experiences of recovery, Young & Ensing (1999) identified a distinct process of recovery which included grieving what has been lost (a label of mental illness requires readjustment however tem- porary the symptoms), finding new sources of hope, learning about their difficulties, de- fining themselves and what they can become, actively taking responsibility for their own problems and lives, and finding new mean- ing, direction and purpose. There is no right way of providing help in these areas. Deegan (1996, p. 96–97) writes from her own experi- ences:

‘Choice, options, inf ormation, role models, being heard, developing and ex- ercising a voice, opportunities for better- ing one’s life – these are the features of a human interactive environment that sup- port the transition from not caring to caring, from surviving to becoming an active participant in one’s own recovery process… Each person must find what works for them. This means that we must have the opportunity to try and to fail and to try again. In order to support the recovery process mental health prof es- sionals must not rob us of the opportunity to fail.’ Of paramount importance is the nurse’ s

belief in the person’s capacity to recover – whatever the manifestation and seriousness of these problems; willingness to be clear,

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honest and informative; desire to learn from each individual what they feel, think and want; and, an ability to use this information in the manner most helpful to that person. It is likely that both nursing ‘camps’ would agree that these are important qualities. Service users value ordinary conversation (Meddings & Perkins, 1999), friendliness (Coursey et al., 1995), trust, a willingness to help with practical tasks and someone to support them through good times and bad times: an ‘ally’ (Repper et al., 1994; Perkins & Repper, 1996). But, it is the complexity of this role that is difficult to specify and describe: how can the nurse fan the spark of hope that Deegan refers to? Is this a function of role, training, a particular approach or personal qualities?

‘[We do not remember when] the small and fragile flame of hope and courage illuminated the darkness of our despair. We do remember that even when we had given up, there were those who loved us and did not give up. … They were pow- erless to change us and they could not make us better … They did not over- whelm us with their optimistic plans for our futures but they remained hopef ul despite the odds. All of the polemic and technology of psychiatry, psychology, social work, and science cannot account for this phenomenon of hope…[it] is the turning point that must be followed by the willingness to act’ (Deegan, 1988, p. 14). People who have recovered speak of not

wishing to be rushed, nor fitted into formulas, nor living up to others plans. They do want to be in control of their symptoms and they may find specific strategies helpful in this regard. For example: help to recognise the triggers and warning signs of relapse; construct an action plan to avert relapse if certain circum- stances occur; develop coping strategies for disabling symptoms, compile an advance

directive to inform treatment if relapse does occur. Such strategies are taught under the rubric ‘psychosocial interventions’ but they were not invented by professionals, rather, they developed from the experiences of users – and are now part of user-led self-manage- ment training. The essence of their success lies in tailoring them to the unique wishes and needs of every individual, again service users appear to want the values and skills espoused by both of the nursing traditions to be avail- able:

‘Self-management is a jigsaw of many techniques. Each person decides not only how many pieces there are, but also which pieces are appropriate to them’ (Harris, 1999: p. 12). The second aspect of helping a person to

live with mental health problems has been emphasised by ‘community care’ and has escalated as the media has fed the public’ s fear of ‘madness’ (Repper et al., 1997). Tack- ling social disability – the extent to which a person is disabled by the expectations of those around them – does not entail changing the individual to fit those social expectations. It involves helping people negotiate an often hostile world and gain access to those roles, relationships, activities and facilities that they need to rebuild their lives and move beyond the limits of their problems (Perkins & Repper, 1996). This area of work is not accorded privilege in the research and theories of either the ‘nature’ or ‘nurture’ tradition in nursing, but it does reflect the priorities expressed by service users.

There are numerous different ways in which access to a decent income and housing, work, friends, intimate relationships can be facili- tated. Mental health nurses should begin by examining their own beliefs and attitudes towards people who have mental health prob- lems. Service users continue to experience

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prejudice from the very people professing to help them (c.f. Faulkner, 1999; Chadwick, 1997), but it is only when nurses genuinely believe in the rights and abilities of service users that they can positively promote and achieve social inclusion. Too often social inclusion is not recognised as a legitimate nursing goal: it is the goal of the occupational therapist, the social worker, or the commu- nity (rather than inpatient) team. Or, social exclusion is blamed on structural barriers (benefit disincentives, inadequate legal pro- tection for people with mental health prob- lems), and negative attitudes (‘the neigh- bours would object’ ; ‘his family wouldn’ t understand’ ). Clearly there is much that needs to be improved (Sayce, 1998), but this does not diminish the importance or the im- pact of every mental health nurse promoting social inclusion (Repper, 2000b).

Service users value help with practical tasks in a manner that is sensitive to their wishes and culture – such as sorting out housing problems, paying bills, choosing furniture. This work can improve their quality of life and give them a chance of being accepted within their community. Indeed, such work is often the way to engage and maintain contact with people who particularly resent having to use mental health services (Repper et al., 1994; Jackson, 1999). It is also practi- cal work with individuals (accompanying them to the pub, or church; negotiating sports activities or education; organising employ- ment experience) that is most effective at changing public attitudes. Whereas the ef- fect of public education about mental illness appears to be limited; public attitudes appear to be more amenable to personal acquaint- ance with one person who has found ways of coping with their mental health problems (c.f. Repper & Brooker, 1996, 1997; Repper et al., 1997).

Although mental health nurses as an occu- pational group are only just beginning to recognise the role they could play in promot- ing social inclusion; creative practitioners have always used inclusive strategies. Bates (1999) has developed an ‘ABC of strategies for inclusion’ , including over 60 ways of supporting people to participate in commu- nity life. These range from formal approaches (such as creating a support team or circle of friends to provide ongoing support for an individual, and appointing ‘bridge-builders’ to provide an expert link between care set- tings and specific community settings such as voluntary work or education), to more intui- tive strategies (such as ensuring that a person maintains contact with friends and family when they are admitted to hospital, and al- ways following up positive initiatives within the community – with both the service user and the host setting – to reinforce support offered, provide support and advice). Like many other aspects of mental health nursing, however, these strategies have not been ‘named’; their effect has not been measured, so they have not become valued or claimed as a core role of mental health nursing. Indeed, while the efficacy of services is measured predominantly in terms of impact on symp- toms and bed use, strategies for social inclu- sion – however highly valued by service users – will not be deemed effective, and thereby under-valued. If mental health nurs- ing is to incorporate the values that service users experience as conducive to recovery, then its efficacy must be measured against these values: the quality of users’ experience of relationships with nurses; the adequacy of information given; the availability of choices in treatment, explanations and location of care; the adequacy of help to maintain rela- tionships and roles, and their success in achiev- ing adequate housing, employment and edu- cation.

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Conclusion: multiple roles, multiple perspectives

Everyone has multiple roles in life, in one they will be competent and responsible, in another more dependent, in another hopeless and despondent. We all live in communities where we relate to many different people in different ways and for different reasons. Peo- ple with mental health problems are no dif- ferent. Neither a single prof ession, nor a single individual can provide every perspec- tive, type of support, help or explanation that another person needs, nor should they try. However, mental health nurses are the natu- ral allies of those people they seek to help. They can offer that consistent day to day relationship that can foster hope and growth. They can provide practical help to maintain or promote valued or desired relationships, roles and activities. They can also help service users to construct their own under- standing of what has happened to them, but not by imposing a sense of order that is disconnected from the persons’ own experi- ences and renders their own explanations inferior. None of these qualities are depend- ent upon a particular theoretical approach to mental health nursing, they may (or may not) be provided by whatever theoretical values the mental health nurse holds. Although the values underlying the ‘nurture’ approach ap- pear to reflect service users’ wishes more closely, many skills offered by those practis- ing psychosocial interventions explicitly ad- dress areas of importance for service users.

Service users value nurses for their ‘ordi- nariness’ but this is no easy task. It demands extraordinary sensitivity, acute listening skills, a willingness to put oneself in the place of another, to be creative and flexible in proposing ways forward, yet prepared for such suggestions to go unheeded. There are times when service users want nurses to be

less ‘ordinary’ and more ‘professional’ (c.f. Barker et al., 1999). For example, to: help them understand the diagnosis that they have been given, the possible causes and progno- sis; give information and support to achieve an acceptable level of medication; help them cope with their beliefs and voices; work with them to identify signs of relapse and develop plans to avert crises; plan ways of coping when crises do occur. Clearly both of the dominant ‘camps’ in mental health nursing have a place. However, in addition to these skills – which essentially involve changing the individual in some way – mental health nurses need to work towards changing com- munities. This requires intimate knowledge of community resources, an ability to work with family, friends and community agencies in a culturally appropriate and sensitive man- ner: strategies to create environments that enable people to live fulfilling lives.

If mental health nursing is to meet the needs and wishes of service users it must fulfil multiple roles, provide multiple perspectives and promote social inclusion (that relies on the co-existence of a multitude of views and abilities). Rather than seeking an objective mental health nursing knowledge base that attempts to fix the world in a given way and allows us to act on those seeking help, we must embrace diversity within the practice, research and explanatory theories of our pro- fession. We bring particular skills with us, but whether and how and when they are used will differ for every individual. Of para- mount importance is that these skills and values are not used oppressively – either with the people we seek to help, or in the ongoing mental health nursing debate. Mental health nursing owes its existence to those who expe- rience mental health problems. The majority of these people have no interest in the theo- ries underlying mental health nursing: they do not need the certainty of those who think

586 Julie Repper

they have all the answers, or the blanket condemnation of those who disagree.

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