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Research in briefEditors:

Steve Tilley1 & Mary Chambers

Community mental health nurses’perceptions of their practice as a factorin the reform of community-basedmental health services in Nova Scotia

Introduction

In Canada, primary health care (WHO 1978) hasbeen adopted by politicians and health care leadersas an organizing framework for reform of thehealth care system. Initiatives aimed at the promo-tion of individual and community mental well-being require participation by political leaders,professionals and citizens in their development(Health and Welfare Canada 1988). Since commu-nity mental health nurses (CMHNs) assist clientswith a range of mental health problems, it is criticalthat they become allies with other groups in thepolicy-making process. As a first step, they need toarticulate for policy decision-makers the nature oftheir current practice and their ideas for change inpractice.

This brief report summarizes an inquiry under-taken in Nova Scotia in 1992 to determine theextent to which the principles of primary healthcare were embedded in CMHNs’ perceptions oftheir practice. The findings indicated that CMHNsare predisposed to the formation of alliances for theimplementation of primary mental health care. Theprinciples of primary health care were taken to be:an emphasis on health promotion and disease pre-vention; individual and community participation indecision-making processes concerning health careservices; intersectoral cooperation and planning;accessibility of health services; and appropriate dis-tribution of services and technology (WHO 1978).

Method

Nineteen of the 21 CMHNs employed at the NovaScotia psychiatric mental health centres, operatedby Nova Scotia’s Department of Health and Fitness,voluntarily participated in the study. Seventeen

participants provided services in outpatient depart-ments of acute care or psychiatric hospitals; theother two practised in a community clinic for chil-dren. This convenience sample was representive ofthe CMHNs in age, education and years of experi-ence in mental health/psychiatric nursing.

Semi-structured interviews were conducted bythe researcher at the participants’ workplace at atime convenient for them. Each participant wasinterviewed once for approximately one hour. Theinterviews were tape recorded. The schedule designwas informed by the concepts of primary healthcare in that it focused on the nature of the problemsfor which participants’ clients seek help, and onparticipants’ theoretical frameworks for decisionmaking, collaboration among health professionalsin the creation of programs to strengthen communi-ties, and ideas for change in the mental healthsystem.

Data were analysed by content analysis, a methoddesigned to classify words, phrases or sentences in atext into categories chosen because of their theoreti-cal importance (Burns & Grove 1993). The methodwas used to classify the responses into themesaccording to the concepts of primary health care, asdefined above. The frequency of responses withinthe themes was determined. A colleague reviewed asubset of the data to help assess inter-rater reliabil-ity of the classifications. Face validity was evaluatedby the ease with which the responses could beclassified according to primary health care concepts.

Findings

Nearly all of the participants (N=17) stated thatthey worked predominately with individuals expe-riencing anxiety and/or depression generated bysocial circumstances. The clients sought help as apersonal decision or upon the recommendation of aprofessional such as a physician. Specifically, clientsexperienced mental, emotional or social problemscaused by biochemical imbalances as well as bylong-term stresses, interpersonal conflicts, abusive

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relationships, substance abuse or social circum-stances such as unemployment and poverty.

All 19 participants explicitly stated that theirapproach to clients was holistic. They believed thatclients seek help as they face transitions, to gainawareness and to experience collaboration andsupport in decision making. They encouragedclients to learn to change attitudes, behaviouralpatterns or social circumstances to enhance well-being. Managing any biochemical component of amental health problem was only one aspect of theirapproach to caring for clients.

The CMHNs believed that their future roleneeded to include, with other professionals, theprovision of programs and services that fostermental health promotion and the strengthening ofcommunities. Ninety five per cent of the partici-pants (N=18) identified the need to work towardsthe prevention of complex mental health problemsrelated to alcohol abuse, unemployment, poverty,single parenthood and aging. They identified theneed for programs that offer stress management forchildren and adolescents, suicide help-lines, andsocial initiatives for clients with chronic mental dis-orders. As one nurse stated, ‘We need to be reach-ing out to these people’.

Although all participants stated that they coordi-nated services for clients with other professionals asclients sought help, 95% (N=18) reported that thedevelopment of community-based, mental healthpromotive, illness preventive programs throughcollaboration with clients, professionals and policymakers was not part of their nursing practice. Inthe words of one participant, CMHNs are ‘dealingwith [situations] after the fact’.

Discussion

The data indicated that CMHNs perceived a needfor community-based services that aim to promotemental health and prevent illnesses. As well,CMHNs seemed predisposed to alliance formationto facilitate the change in focus.

It appears in 1997 that such alliances have notyet formed in Nova Scotia, in spite of efforts toenhance citizen participation in the reform process.One wonders what conditions might give effect tonew relationships in policy decision-making. Tounderstand that issue, a study is needed to elicitfrom CMHNs whether they are developingalliances with other groups: if so, for what pur-poses; and if not, why not?

It is also recommended that, since the 1992 studywas based on a small sample of CMHNs, nurses inother jurisdictions should undertake a similarsurvey as part of the groundwork for their partici-pation in the development of mental health promo-tive, community-based services in their jurisdiction.

References

Burns, N. & Grove, S. (1993) The practice of nursingresearch. Saunders Company, Toronto, Canada.

Health and Welfare Canada (1988) Mental health forCanadians: Striking a balance. Ministry of Supply andServices, Ottawa, Canada.

World Health Organisation (1978) Primary health care.World Health Organisation, Geneva, Switzerland.

NORMA J. MURPHYAssistant Professor

Dalhousie University/School of NursingHalifax

Nova Scotia B3H 3J5

Views on community care for peoplewith mental health problems: adiscourse analysis of argument andaccountability in a Scottish community

Introduction

As the drive towards community care for peoplewith mental health problems has increased inmomentum, organizations attempting to set upcommunity mental health facilities in differentparts of Britain have encountered public opposi-tion. Indeed there is now sufficient anecdotal evi-dence to suggest that there is widespread publicresistance to the resettlement of mentally ill peoplewithin local communities. It has been argued thatthis resistance is due, in part, to the attitudes heldby the public towards members of this client group.Policy makers and practitioners who have a respon-sibility to plan for, implement and deliver commu-nity care will therefore be best placed to do so ifthey have a knowledge and understanding of publicattitudes towards mentally ill people and their carein the community.

Background to the study

Despite the anecdotal evidence, the findings of pre-

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vious UK studies of community attitudes towardsmentally ill people (e.g. Brockington et al. 1993,Wolff et al. 1996) suggest there is reason to be opti-mistic about the willingness of the public to acceptmembers of this client group in the context of com-munity care provision. There is therefore a markeddiscrepancy between the empirical findings and theexperiences of those involved in community careimplementation and delivery. The above studiesemployed traditional approaches to attitude researchthat have a number of theoretical and methodologi-cal limitations, which may account for this discrep-ancy. In particular, they used survey approachesand hypothetical situations. These fail to takeaccount of the rhetorical richness and complexityof the attitudes likely to be expressed on occasionswhen mentally ill people are moving into specificcommunities.

Methodology and Methods

The study reported here used discourse analysis, atheoretical framework and method for analysingspoken and written language (e.g. Potter &Wetherell 1987), to explore the views expressedabout mentally ill people. Taking this approach, itwas possible to take account of the constructednature of participants’ views and the various sub-tleties inherent in their expression. Moreover, theviews expressed by participants were studied in areal-life community care context. Specifically,people’s views were explored in the contexts of thearguments they used to challenge or advocate asupported accommodation project for mentally illpeople in their community. Three main data sourceswere used. These were: written text, comprisingletters written to the local press by objectors andsupporters of the project, and a written statementcompiled by objectors; group discussions held withthe writers of these documents; and interviews withrepresentatives of the organization setting up theproject.

Findings

The analysis was concerned with both the topicsand the form of argumentation. Objectors to the

supported accommodation project constructedtheir views around a number of argumentativetopics which they characterized as issues of publicconcern. These were: the lack of prior consultationwith local people and the secrecy they claimed sur-rounded the plans for the project; the claimedunsuitability of the project’s location; and the typeof tenants who would take up residence there.Supporters criticized objectors for their opposi-tional stance and expressed their views on theissues raised by objectors in formulating their caseagainst the project. Supporters also constructedarguments around broader issues such as humanrights. It was noteworthy, however, that there wasno specific argument in favour of community carein this particular community. In the course ofarguing either for or against the supported accom-modation project, participants constructed a numberof different versions of people with mental healthproblems. In addition, they formulated their argu-ments in such a way as to attend to various issues of accountability; for example, to avert potentialcharges of prejudice and to protect their argumentsfrom potential rebuttal. Participants constructed thejustifications and criticisms they used to supporttheir views and to undermine counter claims aroundsocial common-places. Along with the various argu-mentative forms and rhetorical devices identified,these common-places constitute a set of culturallyavailable argumentative resources.

The findings of the study have the potential to beof practical use to policy makers and practitionersinvolved in the planning and implementation ofcommunity care for mentally ill people. In particu-lar, they may be used in devising consultationstrategies and in developing education programmesaimed at mental health practitioners. Such pro-grammes could be incorporated into existing edu-cation and training programmes with the aim ofproviding practitioners with a knowledge of thekinds of arguments likely to be encountered in localcommunities when implementing and deliveringcommunity care. A knowledge of these and theresources drawn upon in order to formulate them,can enable practitioners to develop strategies forentering and engaging in local debates about com-munity care for mentally ill people.

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References

Brockington I. F., Hall P., Levings J. & Murphy C.(1993) The community’s tolerance of the mentally ill.British Journal of Psychiatry 162, 93–99.

Potter J. & Wetherell M. (1987) Discourse and SocialPsychology: beyond attitudes and behaviour. SagePublications, London, UK.

Wolff G., Pathare S., Craig T. & Leff J. (1996)Community attitudes to mental illness. British Journalof Psychiatry 168, 183–190.

SUE COWANLecturer,

School of Social and Health Sciences,University of Abertay,

Dundee, UK

62 © 1998 Blackwell Science Ltd, Journal of Psychiatric and Mental Health Nursing 5, 59–62

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