Editorial

The art and science of mental health nursing: Reconciliation of twotraditions in the cause of public health

International Journal of Nursing Studies 46 (2009) 1537–1540

Contents lists available at ScienceDirect

International Journal of Nursing Studies

journal homepage: www.elsevier.com/ijns

We have argued elsewhere (Norman and Ryrie, 2009a)that the identity of mental health nursing in the UK andother developed countries has been shaped by a creativetension between two traditions – an ‘artistic’ interperso-nal-relations tradition which emphasizes the centrality ofnurses’ therapeutic relationships with ‘people’ ‘in distress’and a ‘scientific’ tradition concerned with delivery ofevidenced-based interventions that can be applied to goodeffect by nurses to ‘patients’ suffering from ‘mental illness’.In this editorial we outline these traditions and make thecase for drawing on both to develop a new public mentalhealth nursing role.

The origins of the interpersonal relations tradition is asold as mental health nursing itself, dating back to the‘moral treatment’ philosophy established by 18th Centuryreformers such as William Tuke in the Retreat in York in1792. Tuke replaced physical constraints with moralconstraints based on reason supported by purposefulwork and social and educational activities in a domesticenvironment. Fast forward 150 years to Hilda Peplau who,to the best of our knowledge, coined the term ‘nurse-patient relationship’ and whose book Interpersonal Rela-

tions in Nursing, first published in 1952 (Peplau, 1991)became a classic. Mental health nursing for Peplau involvesnurses working through the medium of their relationshipwith patients (service users, clients) to create conditionsthat promote health and develop patients’ ability to engagewith those around them. Peplau’s ideas were promotedand developed by a number of British nurses amongstwhom Annie Altschul and Phil Barker were particularlyinfluential and the interprofessional relations traditionfinds current expression in Barker’s Tidal Model of nursing(http://www.tidal-model.com).

The ‘scientific’ evidenced-based practice tradition inmental health nursing also has a long history, but hasemerged particularly strongly over the past 20 yearssupported by government policy on mental healthservices, both in the UK and internationally. This traditionreflects increasing confidence in scientifically provenmethods for treating mental illness. It reflects too anassumption that mental health care practices are not

0020-7489/$ – see front matter � 2009 Published by Elsevier Ltd.

doi:10.1016/j.ijnurstu.2009.10.010

sufficiently evidenced based and that nurses, amongstothers, do not stick faithfully to evidenced based proce-dures when working with patients. In the UK KevinGournay, from his base in King’s College London’s Instituteof Psychiatry, was a vociferous exponent of this tradition.Gournay had little time for ‘nursing models’ on the groundsthat they do not reflect the reality of nursing and impedemulti-disciplinary approaches to care and treatment. ForGournay and others in the evidenced based practicetradition a good relationship between the nurse andpatient is taken for granted, for without this the patient isunlikely to take the nurse’s advice. But this relationship isjust one aspect of treatment and not a priority for study inits own right. The priority was to extend nurses’ work toincorporate roles occupied formerly by doctors andpsychologists so they can contribute fully to deliverevidenced based interventions to patients, and to evaluatethe effectiveness of these roles using rigorous scientificdesigns.

Who could object to promoting mental health nursinginterventions that are proven to work as opposed to thosewhich may not? However, some nurses in the interperso-nal relations tradition remain unconvinced. As Barker(2009), puts it:

Many nurses are encouraged to believe that they need to

develop ‘new’ skills or learn ‘new’ therapeutic models, in order

to become effective in mental health care. The Tidal Model

challenges such assumptions . . . Nursing originally meant to

offer nourishment. Nothing has changed across the centuries.

Today, people in mental distress need the nourishment that

nursing can offer. They need the human support that will help

them deal more effectively with the tidal forces which have

rocked their lives. They need help to gain the confidence to get

back in the boat and push off, from the shore, to begin again

the journey on their ocean of experience.

In spite of Barker’s reservations, in the early years of thepresent decade the position of mental health nurses in theevidenced based tradition appeared unassailable. Indeed,when the first edition of the Art and Science of Mental Health

Nursing (Norman and Ryrie, 2004) was published it lookedlike nursing in the interprofessional relations tradition was

Editorial / International Journal of Nursing Studies 46 (2009) 1537–15401538

in danger of being eclipsed. However, this has nothappened and it seems to us that mental health nursingas a discipline, certainly in the UK and possibly inter-nationally too, is more united than it has been for the past20 years.

A key development which has gathered pace over thedecade is the orientation of mental health policy towardsthe goals of promoting social inclusion and recovery,reducing social stigma and supporting the exercise ofchoice in meeting patient-centred goals. As a result mostmental health interventions are framed within a recoveryoriented approach. By ‘recovery’ we refer to an approach tomental health care which goes beyond managing symp-toms to helping people rebuild or, where possible, retain avalued and satisfying life, by doing the things that theywant to do and leading the lives they want to lead (seePerkins and Repper, 2009). Recovery oriented practiceinvolves nurses working closely with patients through themedium of their relationships to help them achieve theirgoals.

Evidence for endorsement of recovery oriented mentalhealth nursing practice in the UK comes from the 2006Chief Nursing Officer’s (England) review of mental healthnursing (Department of Health, 2006), (the CNO’s Review)which sought to answer the question: How can mental

health nursing best contribute to the care of service users in

the future? Publication of the CNO’s Review was marked bypublication of a Special Issue of the International Journal of

Nursing Studies (IJNS) focused on mental health, whichincluded a series of research and review papers whichhighlighted initiatives in contemporary mental healthnursing practice, policy and education many of whichdemonstrated nurses drawing upon both the art andscience of nursing in their practice.

Published papers included, for example, an investiga-tion of nurses’ views of containment measures (Bowers etal., 2007a) together with an international comparison ofthese measures (Bowers et al., 2007b), a study ofsurveillance by nurses in a community mental healthteams of mothers who suffered from mental illness (Daviesand Allen, 2007) and access to nurses in such teams(McEvoy and Richards, 2007), an international comparisonof the education of mental health nurses (Nolan &Brimblecombe, 2007) and an evaluation of a computerizededucation intervention (Gega et al., 2007). The SpecialIssue included, also, some reviews which provided asynthesis of the evidence on: physical health problemsexperienced by people with mental disorder (Robson andGray, 2007); policy guidance on how to promote diversitysensitive services (Owen and Khalil, 2007); user and carerinvolvement in training health professionals (Repper andBreeze, 2007); and interventions delivered by mentalhealth nurses (Curran and Brooker, 2007).

Also published in this Special Issue of the IJNS were theresults of a national consultation conducted as part of theCNO’s Review (Brimblecombe et al., 2007), which showedthat many nurses were enthusiastic about their relation-ships with patients but also about developing new rolesand skills and applying these in a ‘recovery oriented’ waythrough the medium of these relationships. These findingswere reflected in the recommendations of the CNO’s

Review which described an approach to mental healthnursing practice based on broad mental health policywhich promoted patient centred goals, a recoveryapproach and evidenced based practice.

In his Guest Editorial in the Special Issue Brooker (2007)was critical of the CNO’s Review for being high onaspiration but ‘desperately thin on detail on implementation’and for failure to acknowledge the challenges of imple-menting values such as recovery, equity and socialinclusion in practice. In response Brimblecombe and Tingle(2007) argued that the challenges of implementation, suchas how nurses can offer patients choice at the same time asfulfilling their professional responsibilities, are best left toclinical nurses and their managers rather than be thesubject of national recommendations. However, prelimin-ary findings from the first stage of an evaluation of theimpact of the CNO’s Review provide some support forBrooker’s concerns. The evaluation found that in spite ofranking highly the importance of adopting Recommenda-tions 1 (Applying Recovery Approach values) and 5(Strengthening relationships with service users and carers)mental health service providers and universities havefound these difficult to implement due to factors such ascompeting priorities, lack of funding, and staffing difficul-ties (Baker et al., 2008).

Moreover, whilst the CNO’s Review endorses recoveryoriented practice, which involves application of both theart and science of mental health nursing, it is true also thatthe traditional focus for mental health nursing in the UK,and in most other countries, has been the person with amental disorder, albeit within the context of their familyand friends. ‘Individualized care’ has been the ideal, drivenby the widely adopted problem solving approach, knownas the ‘nursing process’. But insights from public healthand positive psychology raise the question of whether anindividualized approach to recovery oriented practice isreally sufficient.

We know from work by Friedli (2009) and others thatmental disorder is closely associated with deprivation inall its forms; with unemployment, less education, lowincome and poor material standards of life. The nature ofthis relationship is a question of continuing debate inwhich mental disorder is considered either a cause or aconsequence of inequality; social selection explanationsassume that people who are mentally ill become poor,whereas social causation explanations suggest thatpeople become mentally ill because they are poor. Thereis substantial empirical support for social selectionexplanations, which assume that people become men-tally ill because they are not able to function and competein the job market. But it is now clear that the contributionof social factors (e.g. selective diagnosis in which somesocial groups are at greater risk of receiving a stigmatis-ing label than others, differential access to psychologicaltherapies mediated by ability to pay, differential utiliza-tion of mental health services mediated by differingviews on their trustfulness) in ‘causing’ mental disorderhave been under-recognised (see Rogers and Pilgrim2003).

Important too are insights from positive psychology, onthe benefits of positive mental health or well-being. Keyes

Editorial / International Journal of Nursing Studies 46 (2009) 1537–1540 1539

(2002) proposes a mental health continuum from lan-guishing to flourishing in life. Those who are flourishingare enthusiastic about life, active and engaged with othersand social institutions. In contrast those who are lan-guishing are at increased risk for depression, suicide andphysical illness. Of interest here is Rose’s (1992) popula-tion based approach to health promotion which demon-strates that the prevalence of common diseases in thepopulation is related to the underlying population mean ofunderlying risk factors. Applying this to mental disordersuggests that reducing the risk factors for mental illness insociety will have the effect of reducing the number ofpeople suffering from mental disorder, and reducing theproportion, who are languishing and so at high risk(Huppert, 2005).

What implications do these insights have for the futurerole of the mental health nurse? The present focus ofmental health nurses on providing individualised care forpeople who have serious mental illness is and shouldcontinue to be important. Individualised care counters thetendency to batch treatment, which can so easily occureven in community settings, and those who are mostseriously ill do need the most skilled nursing care.However, insights from the public health field and frompositive psychology points to a rather broader role formental health nurses of the future which involves thembeing much more active than currently in promotingmental health at the level of individuals and communities(see Norman and Ryrie, 2009b for further discussion).

In the UK this broader role is evident in key health andlocal authority policy strands. For example, a recent reviewof the British National Health Service (NHS Next StageReview, Department of Health, 2008) requires local bodies(known as Primary Care Trusts) to commission compre-hensive health, well being and prevention services inpartnership with local authorities. It is recommended thatthese services focus on six key goals: tackling obesity,reducing alcohol harm, treating drug addiction, reducingsmoking rates, improving sexual health and improvingmental health. Related local authority policy guidance ispresented in ‘Creating Strong, Safe, Prosperous Commu-nities’ (HM Government, 2008) with its focus on what arereferred to as Local Area Agreements, Joint Strategic NeedsAssessments and the preparation of Sustainable Commu-nity Strategies.

The health, well being and prevention policy strands inUK health policy present key opportunities for publicmental health nursing. A partnership approach is requiredthrough which the public and mental health service usersare encouraged to take greater responsibility for theirhealth and well being wherever possible, and to engage inbehaviour change when indicated. However, the preciseapproach will differ in terms of the degree to which anindividual or community is ready to make behaviourchange. Nurses need therefore to understand a commu-nity’s preparedness to change and to develop pathways orinterventions for different stages of a change cycle.

Mental health nurses who have worked with behaviourchange in the addictions and related fields will be familiarwith Prochaska and DiClemente’s (1986) trans-theoreticalmodel of change. The model presents behaviour change as

a process with five key stages from ‘pre-contemplation’,where behaviour is not seen as problematic, through to the‘maintenance’ of any behaviour change that occurs. In turn,motivational interviewing has developed as a therapeuticapproach that offers different types of intervention atdifferent stages of the change cycle to motivate or ‘nudge’people towards change (see Kipping, 2009 for furtherdiscussion). For example, there is little point in offeringexercise classes if people are unaware of the need forexercise or live in a culture where such activity is frownedupon. Community engagement, lifestyle assessments andpeer education may provide a more effective route toimproved public health and well being.

Social psychologists and behavioural economists arenow applying these approaches to whole communitiesthrough geo-demographic profiling and targeted pathwaydevelopment. Mental health nurses are well placed tosupport this agenda with their working knowledge ofbehavioural change cycles and the psychology thatunderpins them. As we write, UK primary care trustsand local authorities are grappling to realise this knowl-edge in their public services and we would expect thatequivalent bodies in other countries are engaged with thesame agenda.

Closely related to this opportunity is the need todevelop a range of interventions that support people andcommunities to move along the continuum from ‘lan-guishing’ to ‘flourishing’. We have documented elsewherethe ways in which mental health can be supported, distinctfrom mental illness, at both the individual and communitylevel (see Ryrie and Norman, 2009 for further discussion).Mental health nurses in the UK can use this knowledge towork in partnership with primary care trusts and localauthorities to support the development of programmesand pathways, which are needed for the public but also forpeople with mental health problems and other conditions.

In the UK Local Strategic Partnerships (LSP) are the keymechanism by which these policy strands are to beimplemented at the local level, which provide a platformfor mental health nurses to make their contribution. Thereis now a clear strategic agenda and policy framework,certainly in the UK and in other countries too, for publicmental health nursing to develop as a dedicated dis-cipline. Nursing’s operational positioning is of lessimportance than its operational practice, which will bethrough partnership working across and within LSPs,drawing on the art and science of their discipline to informthe design of innovative programmes and pathways.Equally however, there is a need for all mental healthnurses to develop their awareness of the public mentalhealth agenda. They may be required to advocate onbehalf of patients to ensure that local health and wellbeing strategies take account of their needs and providereal opportunities for recovery.

References

Baker J., Nelson, P., Playle, J., Lovell, K., 2008 An evaluation of the impact ofthe Chief Nursing Officer’s Review of Mental Health Nursing: Stage 1Report. University of Manchester, Manchester. Accessed on 23 Sep-tember 2009 at: http://www.nottingham.ac.uk/nursing/cno-review/resources/Stage-1-report-Dec08.pdf.

Editorial / International Journal of Nursing Studies 46 (2009) 1537–15401540

Barker, P., 2009. Tidal Model website (accessed 26 September 2009), http://www.tidal-model.com/Key%20assumptions%20of%20Tidal.htm.

Bowers, L., van der Werf, B., Vokkolainen, A., Muir-Cochrane, E., Allan, T.,Alexander, J., 2007a. International variation in containment measuresfor disturbed psychiatric inpatients: a comparative questionnairesurvey. International Journal of Nursing Studies 44 (3), 357–364.

Bowers, L., Alexander, J., Simpson, A., Ryan, C., Carr-Walker, P., 2007b.Student psychiatric nurses’ approval of containment measures: rela-tionship to perception of aggression and attitudes to personalitydisorder. International Journal of Nursing Studies 44 (3), 349–356.

Brimblecombe, N., Tingle, A., Tunmore, R., Murrells, T., 2007. Implement-ing holistic practices in mental health nursing: a national consulta-tion. International Journal of Nursing Studies 44 (3), 339–348.

Brimblecombe, N., Tingle, A., 2007. National reviews of nursing: chal-lenges, corrections and cynicism. Response to Brooker (2007) ‘TheChief Nursing Officer’s review of mental health nursing in England anode to ‘motherhood and apple pie’? International Journal of NursingStudies 44 (5), 857–858.

Brooker, C., 2007. The Chief Nursing Officer’s review of mental healthnursing in England an ode to ‘motherhood and apple pie’? Interna-tional Journal of Nursing Studies of Nursing Studies 44 (3), 327–330.

Curran, J., Brooker, C., 2007. Systematic review of interventions deliveredby UK mental health nurses. International Journal of Nursing Studies44 (3), 479–509.

Davies, B., Davina Allen, D., 2007. Integrating ‘mental illness’ and ‘mother-hood’: The positive use of surveillance by health professionals A qua-litative study. International Journal of Nursing Studies 44 (3), 365–376.

Department of Health, 2006. From values to action. The Chief NursingOfficer’s Review of Mental Health Nursing, UK.

Department of Health, 2008. High Quality Care for All: The NHS NextStage Review Final Report. DH, London.

Friedli, L., 2009. Future directions in mental health promotion and publicmental health. In: Norman, I., Ryrie, I. (Eds.), The Art and Science ofMental Health Nursing: A Textbook of Principles and Practice. OUPress, Maidenhead, pp. 43–61.

Gega, L., Norman, I.J., Marks, I.M., 2007. Computer-aided vs. tutor-deliv-ered teaching of exposure therapy for phobia/panic: Randomizedcontrolled trial with pre-registration nursing students. InternationalJournal of Nursing Studies 44 (3), 397–405.

HM Government, 2008. Creating Strong, Safe, Prosperous Communities.Statutory Guidance. Communities and Local Government Publica-tions, Wetherby.

Huppert, F.A., 2005. Positive mental health in individuals and popula-tions. In: Huppert, F.A., Baylis, N., Keverne, B. (Eds.), The Science ofWellbeing. Oxford University Press, Oxford, pp. 307–340.

Keyes, C.L.M., 2002. The mental health continuum; from languishing toflourishing in life. Journal of Health and Social Research 43, 207–222.

Kipping, C., 2009. The person with co-existing mental health and sub-stance misuse problems (‘dual diagnosis’). In: Norman, I., Ryrie, I.(Eds.), The Art and Science of Mental Health Nursing: A Textbook ofPrinciples and Practice. OU Press, Maidenhead, pp. 490–519.

McEvoy, P., Richards, 2007. Gatekeeping access to community mentalhealth teams: a qualitative study. International Journal of NursingStudies 44 (3), 387–395.

Nolan, P., Brimblecombe, N., 2007. A survey of the education of nursesworking in mental health settings in 12 European countries. Inter-national Journal of Nursing Studies 44 (3), 407–414.

Norman, I., Ryrie, I. (Eds.), 2004. The Art and Science of Mental HealthNursing: A Textbook of Principles and Practice (1st edition). OU Press,Maidenhead.

Norman, I., Ryrie, I., 2009a. Mental health nursing: origins and traditions.In: Norman, I., Ryrie, I. (Eds.), The Art and Science of Mental HealthNursing: A Textbook of Principles and Practice. OU Press, Maiden-head, pp. 62–85.

Norman, I., Ryrie, I., 2009b. Future directions: taking recovery into society.In: Norman, I., Ryrie, I. (Eds.), The Art and Science of Mental HealthNursing: A Textbook of Principles and Practice. OU Press, Maiden-head, pp. 749–766.

Owen, S., Khalil, E., 2007. Addressing diversity in mental health care: areview of guidance documents. International Journal of NursingStudies 44 (3), 467–478.

Peplau, H.E., 1991. Interpersonal relations in nursing: a conceptual frameof reference for psychodynamic nursing. Springer, New York (originalwork published in 1952).

Perkins, R., Repper, J., 2009. Recovery and social inclusion. In: Norman, I.,Ryrie, I. (Eds.), The Art and Science of Mental Health Nursing: ATextbook of Principles and Practice. OU Press, Maidenhead, pp. 86–112.

Repper, J., Breeze, J., 2007. User and carer involvement in the training andeducation of health professionals: a review of the literature. Inter-national Journal of Nursing Studies 44 (3), 511–519.

Robson, D., Gray, R., 2007. Serious mental illness and physical healthproblems: a discussion paper. International Journal of Nursing Stu-dies 44 (3), 357–466.

Rose, G., 1992. The Strategy of Preventive Medicine. Oxford UniversityPress, Oxford.

Ryrie, I., Norman, I., 2009. Mental health. In: Norman, I., Ryrie, I. (Eds.), TheArt and Science of Mental Health Nursing: A Textbook of Principlesand Practice. OU Press, Maidenhead, pp. 3–21.

Ian NormanKing’s College London, Florence Nightingale School of

Nursing and Midwifery, James Clerk Maxwell Building,

57 Waterloo Road, SE1 8WA, London, UK

Iain RyrieR&E Consultant, Office for Public Management, UK

E-mail address: ian.j.norman@kcl.ac.uk.