Actitudes eclécticas en la asunción identitaria

Recovery principles can be seen to focus on the service user’s goals, potential for change and growth, and a transparent and collaborative relationship with health care professionals (Barker & Buchanan-Barker, 2005). Indeed, the importance of the interpersonal relationship between professional and service user is well documented (Smith, 2000), with a central component of reciprocity (Bigwood & Crowe, 2008). However, inherent in recovery principles is the notion of risk taking (Ramon, Healy & Renouf, 2007). A challenge therefore exists in the implementation of a balance between a focus on the risk a service user is seen to pose, particularly in areas where risk to others and self is involved, and the development of “a respectful and considered therapeutic relationship [which] assists the patient to achieve a sense of ownership and responsibility for their mental illness, treatment and risk management” (Kelly, Simmons, & Gregory, 2002, p. 208).

105 When considering the role of the mental health nurse in acute inpatient settings, it has been found that they perceive limit setting interventions to be key, seeing their role as corrective with an emphasis on changing the service user through external control (Salias & Fenton, 2000). Muir-Cochrane (1996) has further found that coercive practices, such as seclusion was used rather than relational strategies. In these studies it seems that a framework of power and control underpins the nurses’ perceptions of their role, which is in contrast to recovery oriented philosophies. However, this is reflective of the wider perception of the purpose of acute inpatient units, which is to minimise risk. Practices used under the Mental Health Act, such as restraint and seclusion, as well as the perception that nurses’ have of their role indicate that it is perceived that the service user lacks capacity to make appropriate judgements that will keep themselves and others safe, and that control therefore needs to be taken from them. Indeed, such practices are associated with an expectation in the culture of the acute inpatient setting that nurses need to maintain control (Bigwood & Crowe, 2009).

Some perceive that the work that mental health nurses carry out in this setting, especially under the Mental Health Act, is a custodial activity with the work of mental health nurses is embedded in a larger narrative of psychiatric medicine and its social control function (Morrall, 1998). Examining the literature, it seems that the attempts to move mental health nursing from a primarily custodial activity to a therapeutic one has a long history. As the threshold for admission to acute inpatient units has risen as a result of a move to the community model of care, the ward environment has become increasingly disturbed, chaotic and over-occupied (Quirk & Lelliot, 2001). There seems to be a consensus that ‘humane custody’ (Goodwin, 1997), which was hoped to reduce as a result of de-institutionalisation, has not been diminishing as a result of

106 these changes. Deacon (2003) argues that custodial nursing means that service users are not free to come and go on acute inpatient units, even those who are not formally held by law. If nurses were not to know where service users were, their practice may be called into question by their employers, and the public. It could therefore be argued that all service users on acute wards are, to varying degrees, in custody, and therefore nurses are their custodians (Deacon, 2003).

Given that one of the key tasks of mental health nurses in this setting is the formation of a therapeutic relationship, whilst also being required to enforce ‘humane custody’, a relationship that is built upon collaboration and trust may be difficult given that the partners are overseen and over-seer (Watkins, 2001). As Clarke (1999) outlines, mental health nurses are therefore confronted with the dilemma of having the intention to care for service users, whilst having a requirement to police them. A custodial approach, aiming at reducing risk and at prevention at any cost is not appropriate, given that it is likely to impact on the therapeutic relationship which is so important within the setting (Duffy et al., 2004).

Morgan (1979) has written of ‘malignant alienation’ whereby a number of his own inpatients appeared to have killed themselves following a progressive deterioration in their relationship with others, including ward staff. Duffy et al., (2004) hypothesise that one of the reasons for such deterioration in relationships is counter transference, where by negative attitudes of unconscious malice or aversion are communicated to the patient by staff who are responding to feelings of anxiety or helplessness which the patient has awakened in them (Watts & Morgan, 1994). However, this highlights the importance of the quality of the therapeutic relationship between the nurse and service user. A relationship characterised by a preoccupation with risk and thus control may lead to low self-esteem and morale, exacerbated due

107 to communication of distrust, infantilisation and denial of personal rights, whereas if care is emphasised without appropriate vigilance then the results may be tragic (Duffy et al., 2004).

Nurses themselves have spoken about their perception of controlling practices. Bigwood and Crowe (2009) found that although they perceive controlling practices, such as restraining service users, to be part of their job, they are still uncomfortable with their use. Thus nurses seem to be caught between trying to be therapeutic whilst having to maintain the safety of service users and staff.

Therefore, there seems to be a tension between nurses needing to minimise risk by maintaining safety, which can entail using controlling practices including implementing boundaries with a service user or in the environment to limit a behaviour. This is in contrast however to recovery oriented practices in which professionals are required to promote choice, freedom and independence which would entail relaxing the relational boundaries around their professional role.