Commentary 1

Reflecting on times past .

Annie Altschul

At the time I applied for a scholarship of the Commonwealth Fund for Nurses, the General Nursing Council for England and Wales was encouraging schools of nursing to develop 'experimental schemes of training'.

We had made a contract with three schools: Kings College Hospital, Hammersmith Hospital and St. Bartholomew's Hospital, to accept students who had volunteered to spend two or three months of their General Training on a psychiatric placement.

I had no idea at all what to try to teach them during this secondment All my experience was with two or three year courses and my approach to gaining knowledge about psychiatric patients was rather leisurely.

I don't think I had formulated my aims very clearly at the time, but in retrospect I would put them this way: Since both patients and students spent a long time with each other, the first priority was to make the students comfortable and to help the student to become accepting and non judgemental.

Since patients were admitted to hospital because they had difficulties adapting to the demands of society, the business of the ward was to adapt to the patients. What the hospital had on offer to the patients was the opportunity to learn better adaptive modes of behaviour, with respect to the routines of living, with respect to forming relationships with people, both male and female, people of all ages, people over whom they had authority and people who had authority over them. Perhaps because my early psychiatric experience was in a military setting, I accepted the belief that all patients had to have a job, because only then could one judge whether the patient was capable of coping with work related stresses.

All of this seemed to me the function of the interdisciplinary staff team. But I was particularly influenced, I think, by the research I had read about Chestnut Lodge in the USA, where patients seemed to receive an hour's psychotherapy each day, but where the question was asked of what happened to the remaining 23 hours. These hours seemed to be regarded as the responsibilty of the nursing staff. If these hours could not be used therapeutically, then the patient should perhaps not have been there at all.

I believed that only a small amount of the nurses' time, and only with a few of the patients, would be spent in a one-to-one relationship, in what might have been seen as a competitive relationship with the psychotherapist, or at times, perhaps as a complementary relationship. I thought of this aspect of psychiatric nursing as the most difficult part of the job and one which the student could only learn at a late stage of training, at a time when she felt secure in her other functions. I had, however, been profoundly influenced by Peplau's work with withdrawn schizophrenic patients, as illustrated in the film 'Nurse-Patient Relationship', and I had become aware of the apparently mutual avoidance of relationships, as described by Gwen Tudor Wills, and I wondered how the student nurses who were only to have a brief encounter with psychiatric patients were going to cope with these situations.

After considerable consultations, I was advised that Boston University might be a useful place to visit in connection with my search for meaningful short experience for student nurses, and when I was awarded a Fellowship I applied there and was offered a place as a 'Special Student', i.e. I was simultaneously to study the experiences of young student nurses, of their supervisors and of the Faculty members concerned with the teaching during psychiatric placements.

To my amazement, when I was awarded the Fellowship my hospital offered me a full year's leave. £350 was clearly not enough to survive for a year. The State Department of Mental Health for California offered me the opportunity to run a series of workshops for their 'Psychiatric Technicians', which I took up before I went to Boston. Thus I saw the effect on permanent staff of student nurses' one to one work in psychiatric wards, before I had the opportunity of studying the benefits of this experience for students and for patients.

On return to the Bethlem Royal and Maudsley Hospitals, I made much use of the newly found knowledge, but I remained unconvinced that it fitted in naturally in the psychiatric scene as I found it in the UK.

By the time I came to Edinburgh, the 'Wider Basic Training' for all student nurses had been introduced. Students in the new Degree course in the University were just starting their psychiatric experience, so it followed quite naturally to develop my interest in the topic in what was for me a new and welcoming setting.