psychiatric nursing at the crossroads: quo vadis

1 am honored to present the First Annual Hildegard E. Peplau Lecture. It is a special honor and challenge for me since, as Dr. Peplau’s student in the early 50s, I was at the threshold of what I will term phase two of the development of psychiatric nursing; this phase developing largely from her conceptions.

Peplau’s significant contributions in the early 50s had a formative influence on the past three decades in psychiatric nursing and this period can be termed the Peplau decades. I would like to take the occasion of this conference, with its theme, “PsychiatricIMental Health Nursing at the Crossroads,” to place these years in perspective and to discuss the accomplishments of the past and the opportunities and problems for psychiatric nursing in the future. I do this from the viewpoint,. slightly detached perhaps, of a Dean of a School of Nursing, who always regards her- self as a psychiatric nurse but without the day-today currency to have personal identification as a psychiatric nurse clinician.

Psychiatric Nursing at the Crossroads:

Quo Vadis

by Claire M. Fagin

Phase one in the development of psychiatric nursing as a specialty of nursing occurred prior to 1952. In this phase, psychiatric nursing could be characterized as a blend of kindness, compassion, and firmness practiced mostly in a hospital setting. By the late 40s and early 50s, a variety of theories from descriptive psychiatry and psychoanalysis had been introduced and a number of people were making contributions to identifying psychiatric nursing as a distinct specialty.

Peplau’s significant contribution in the early 50s was to articulate a clear theoretical framework for nursing and psychiatric nursing. Phase two-the Peplau decades-was ushered in as nurses were made aware that such a theoretical framework existed and could be articulated and utilized in practice.

This was the coming of age for a discipline without reference to setting. The Peplau decades saw the emergence of an identifiable group of practitioners, who, utilizing theory acceptable to nursing and others, accomplished the following:

VOLUME XIX NO. 3 & 4 1981 9Q

U Coined the terminology “psychiatric/mental health nursing,” which combined two groups in nursing with distinctly different backgrounds - psychiatry and public health. 0 Established itself as a clinical specialty in

nursing with acceptance of graduate preparation.

U Moved into positions of power in nurshg groups.

U Influenced curricula to integrate psychiatric nursing content using psychiatric nurses in consultant roles to other faculty members. 0 Developed liaison psychiatric nursing as a

viable role in hospital settings, thereby playing a consultant role to other nurses. 0 As a group, psychiatriclmental health

nurses were in the vanguard of the major movements of the period- community mental health, family therapy, use of systems theory in therapy.

n Despite controversy among nurses and opposition from others, psychiatriclmental health nurses established themselves as psychotherapists. 0 And last, but far from least, psychiat-

riclmental health nurses fought for and in many instances obtained third party payment for psychotherapy.

Wonderful no? So why are we in so much trouble? First I’ll define trouble. T o exist as a power- ful group we must have continuity. T o have continuity students must continue to choose our specialty area. In three words-they are not. What has gone wrong?

A brief look at the scene in psychiatry and a somewhat critical examination of the accomplishments I stated in relation to nursing may help explain the past and set a future course.

Psychiatry

American medicine’s love affair with psychoanalysis was perfectly in keeping with what has been described as our futuristic and optimistic approach to the belief in the betterment of man. Psychiatrists had convinced themselves and others that the panacea that was psychoanalysis could change the world. It could change the way children were raised and eliminate adult mental illness. It could cure mental illness when that oc-

curred. It could consult with politicians to help them build a better world. It could solve problems of crime and delinquency and, indeed, cure many physical illnesses. Both the psychoanalytic and community mental health revolutions were for a time warmly embraced by psychiatrists, and their influence in the medical field appeared to have extremely high potential. Relying heavily on the psychotherapeutic relationship and minimally on skills more associated with their medical training, psychiatrists had a hard time defining their unique qualifications in contrast to other mental health professionals. By the 60s, pharmacological developments and administra- tive power changes took much of the luster away from psychoanalytic and community mental health medical people. (Shepherd, 197 1 :302-320)

There has been a great deal of recent attention to the decline in the percentage ofAmerican medical graduates choosing psychiatric careers. Much concern has also been expressed about the diminishing presence of psychiatrists in community mental health with notable absence in leadership positions.

While article after article in the medical literature decries the diminishing supply of psychiatrists and their decreasing power in the medical field, it should be noted that there is great similar- ity on this health manpower issue between the report of the President’s Commission on Mental Health in 1978 and the report of the Joint Com- mission on Mental Health in 1958. (Albee, 1979:783-786)

George Albee in a comparison of the two studies commented:

With the exception of the dramatic change in con- sciousness of the need for services for minorities, and the awareness of the paucity of minorities in training programs and professional positions, things have not changed much ... the same personnel shortage problems plague the mental health delivery system, although the locus has shifted from public hospitals to outpatient settings.

Twenty years ago there was a serious shortage of psychiatrists; the shortage continues. The geographic maldistribution of psychiatrists was evident 20 years ago; it is still evidenr. The shortage of psychiatrists who work with poor people, with children, adoles- cents, with the aged, with the organically impaired, and with the physically handicapped, continues today.

100 PERSPECTIVES IN PSYCHIATRIC CARE

Twenty years ago there was growing concern about the difficulty of filling psychiatric residencies ... these problems still exist and are growing even worse today as psychiatry attracts a smaller proportion of the graduates of American medical schools ....(pp. 783-786)

One could pose several reasons for psychiatry’s problems, some of which may have bearing on the problems of nursing as well. The entire nursing profession shares psychiatry’s major problem which is that psychiatrists never made claim to the practice of psychotherapy as a unique function of medicine. Indeed, they were hard put to avoid the encroachment of the entire team on their sphere of activity. With the exception of the ability to prescribe drugs and treat organic problems, there was precious little they could identify that was a purely medical function and that re- quired the background of the physician. While the practice of psychotherapy by non-medical personnel was occurring prior to 1960, the community mental health movement dramatically reduced the dominance of psychiatry in mental health services and increased the participation of other mental health professionals.

Second, during the period of expansion of mental health services the medical field was changing enormously to increase the scientific base for medical practice. Academic medicine was becom- ing obsessed with the notion of the research physician and the need for hard data to support medical decision making. I will not belabor the paucity of hard data to support psychotherapeutic decision making since I would assume that all of you are at least familiar with this problem as I am. What intensive research has been done has usually dealt with the biochemical, genetic, and physiological aspects rather than behavioral aspects.

These problems were compounded when many psychiatrists became identified with various ap- proaches, some of which had been begun by non- medical personnel. Sensitivity training, encoun- ter groups, marathons, TM, and other schools of thought on how to help Americans help themselves did nothing to enhance the status of the psychiatrist within medicine or, for that matter, the status of any other mental health professional. Finally, it should be noted again that psychiatrists, and psychoanalysts in particular, over-

sold themselves, and in not measuring up to the hopes and promises they had encouraged, lost considerable public and professional respect.

Before leaving psychiatry let me make two comments. First, journal articles on the sad plight of present-day psychiatry and its almost hopeless future are the closest I have come to a group which outdoes nursing in dire warnings to itself. (Beigel, 1979:1525-1529; Brill, 1973: 19-26; Nielsen, 1979:632-637; William, 1976: 15-22) Second, the repeated mention of psychologists and psychiatric social workers as inheritors of power in the field led me to question why psychiatric nurses had not maximized their op- portunity to assume a greater role in leadership in the mental health field. This situation is particularly perplexing in community mental health where our background in public health was so much stronger than that of other disciplines. One would think that psychiatricImenta1 health nurses would have focused at least as much on moving into leadership roles in community mental health as on staking a claim to psychotherapy. However, this has clearly not been the case.

Nursing

However, psychiatricImenta1 health nursing’s accomplishments during the Peplau decades- the time period we have just dashed through- were extraordinary. So extraordinary were they that they should have served as a model from which other nursing groups could learn; so extraordinary, that our continued leadership should be an attraction to our specialty for nurses and even to nursing as a profession, if our visibility to the public provided a positive role model.

Let me critically examine the accomplishments that I stated earlier in relation to psychiatric/ mental health nursing and comment on them serially. First, the terminology psychiatriclmental health nursing was in itself a major accomplishment, as it combined two groups in nursing with distinctly different backgrounds and points of view. They were psychiatric nurses and public health nurses. (Programs preparing the latter group were called mental health consultation programs.) Most of you will not remember that there was considerable controversy and competi- tion within the field as to the particular proficien-

VOLUME XIX NO. 3 & 4 1981 101

cies of each approach. It was not a thoughtful col- laboration of the two groups that settled the issue. Rather, it was a win for the one and a loss for the other. The psychiatric nursing group won, and in the struggle to define its sphere of practice melded the two content areas, and very clearly staked its claim to psychotherapy. The community mental health group started as a consultant group to other public health nurses and were themselves little interested in providing any kind of psychotherapy to ill people. The melding of the two groups allowed us to develop depth and breadth in the field and set the stage for our future in community mental health.

The second accomplishment I stated was that the psychiatricImenta1 health nursing group established the field as a clinical specialty of nursing with acceptance of graduate preparation. This was a significant accomplishment which has quietly served as a model to other nursing groups but has not yet been fully adopted by many.

Psychiatric nurses were in the vanguard of nursing groups. Psychiatric nurses moved into leadership positions in nursing organizations, nursing education, and nursing practice. However, these positions removed many of these people from leadership in psychiatric/mental health nursing. The same phenomenon did not occur with social workers and psychologists; thus, these groups were able to concentrate their leadership skills within their specialty areas. Nonetheless, this somewhat negative side-effect is ameliorated by having psychiatric nurses identified in extremely visible positions of leadership.

During these decades of accomplishments, psychiatric nurses across the country influenced nursing curricula by integrating psychiatric nursing with social and psychological theories into undergraduate nursing courses. Playing the consultant role to other nurses in curriculum development ran parallel with the development of new roles for psychiatric nurses in acute health care settings. The development of the liaison psychiatric nursing role, where psychiatric/mental health nurses are consultants to other nurses, was an extremely important part of helping nurses to recognize that they could seek consultation from each other rather than from members of other disciplines. This was a crucial step in the growth of the clinical specialist role in nursing. There is

no question that psychiatric nurses were the first to play this consultant role. On the consultee side, however, I have yet to see many psychiatric nurses seeking consultation from nurses in other clinical specialty areas. As other specialty groups have developed, I believe that a lack of mutuality has created a degree of resentment and separatism which has had a weakening effect on the field. In addition, research data supporting the positive outcome for personnel and patients from psychiatric liaison services is notable in its absence. One gets a sense that the consultant roles in curriculum and liaison work have provided tremendous ego rewards to the psychiatric nurse. While possibly helpful to the recipient of the service, the sensitivity to the colleague relationship -vitally important when dealing with others’ interpersonal behaviors - has been less striking. Note that the clinical specialist model in other nursing areas is frequently much more patient oriented than colleague oriented. The focus of the intervention is on the patient; therefore, the staff learnings may be accomplished with much less anxiety and personal threat.

As a group, psychiatric nurses were in the vanguard of major movements of the past 30 years. Before community mental health was clearly formulated, nursing programs were be- ginning to focus on disturbed families in community settings from the standpoint of inter- relatedness of the social, cultural, and psychological components of mental illness. Our interest in family therapy in the community was also demonstrated very early in this movement. Remem- ber we are not talking about individual nursing interests but rather curriculum innovation which occurred in a large segment of nursing’s educa- tional system. In all of the accomplishments I have so far stated, our forward stance was notable both within nursing and compared with other mental health professions. In retrospect, it would appear that our professional maturity at that time was not sufficient to permit us to demonstrate this extraordinary leadership outside of our own group.

Let me handle the last two accomplishments I stated together. Despite controversy among nurses and opposition from others, psychiatriclmental health nurses established themselves as psychotherapists and were able to fight for


and, in many instances, obtain third party payment for psychotherapy. I would like to explore these accomplishments from several vantage points. I think they can provide us with a great deal of food for thought as we examine psychiat- ridmental health nursing’s present and future. The reaction to nurses wanting to do psychotherapy was particularly strong among nurses themselves. While psychiatrists had concern about a variety of health professions, they frequently left nurses off their list of worries and focused mostly on psychologists, with secondary concern for social workers. The reaction to nurses practicing psychotherapy by many nurse authors was close- ly analogous to the latter-day reaction of nurses to primary care-chief among them was the concern about nursing identity.

In an extraordinarily thorough review article on the one-to-one patient-nurse relationship, Lego (1980:67-89) concluded that by the late 60s the roles of individual, group, family, and milieu therapists were firmly established for the clinical specialist in psychiatric nursing and that the question shifted from “does the nurse do therapy [to] ... how.” (p. 72) After a thorough review ofthe literature on this question, Lego concluded:

The area which ranks first in its need for careful study and research is the response to the question, “How does the practice of psychiatric nursing through the one-to-one relationship differ from the practice ofone- to-one relationships with psychiatrists and patients, psychologists and patients, or social worker and patient?” The answer to this is particularly critical now that most psychiatric nursing is, or will be, practiced o

In 1971, Henry and his colleagues in a book called “The Fifth Profession,” proposed that all psychotherapists are alike. (Henry, Sims, Spray, 1971) Leaving out the nurse, he stated that psychoanalysts, psychiatrists, clinical psychologists, and social workers are all doing the same thing. Critics of this book have raised questions such as whether or not these various groups carry on the same kind of psychotherapy, see the same types of patients, are equally effective and so forth. I would suggest that to some extent the lack of present influence of psychiatric nursing on the profession has to do with the notion that the autonomous role that they developed was one

which could not be easily duplicated by other nurses. While proclaiming a desire to maintain a nursing identity, the apparent use of medical models for psychotherapeutic practice moved psychiatric/mental health nurses out of the mainstream of nursing and proclaimed separatism and difference.

It is interesting to note that the systems approach to individual groups and families could be characterized as a nursing approach which would require a range of collaborative efforts among nurses and other mental health professionals. The identification of models psychiatric nurses choose in the 80s will probably characterize the third phase of our development.

Nonetheless, the somewhat defensive posture, with respect to the medical psychoanalytic model, should not mask one of the benefits of having adopted this model during phase two of our development. An appropriate approach at this time would be to identify those factors which made it possible for nurses to establish themselves as autonomous and independent psychotherapists and, in some instances, to receive third-party payment for such practice. In this process, other nurses might be helped to establish strategies to obtain the same end.

Why have psychiatric nurses been more successful than most other nurses in this area? I see two reasons for this relative success. First, they established minimal qualifications and declared these qualifications as at least equivalent to meet the mental health needs of patients as were those members of disciplines then considered the psychiatric team; that is, psychiatry, clinical psychology, and psychiatric social work. There was no attempt to make an egalitarian claim that all nurses must be reimbursed for psychotherapy. Second, there was never an attempt to differenti- ate nursing practice for reimbursement. A little reflection should make it clear that where nurses have been successful in receiving third-party reimbursement for direct patient services (which are neither private duty nursing nor community health nursing ordered by a physician) the case of substitutability for a physician is clear. Psychiat- ric nurses, midwives, and nurse anesthetists are seen by the public to be performing substitutable services which would be paid for were they performed by a physician. I have come to believe

VOLUME XIX NO. 3 & 4 1981 103

that our quest to establish our nursing identity should not be done as part of our quest for third- party payments, or by seeking an umbrella for nurses prepared at all levels as we go forth with recommendations. Ifwe did not succeed with this approach during a more generous spending era, the chances for success at this time are nil. I will say more on this as we address the future. Before turning to the future, however, let me summarize this critique of our accomplishments of the past three decades.

There is no question that psychiatric nursing was in the vanguard of the profession and of the mental health field for at least 15 of the 30 years under study. Power in the profession and estab- lishment of the specialty as a peer of other mental health disciplines should have brought us through the next 15 years with a high degree of success despite the changing views toward psychiatry in our society.

Future Directions of Psychiatric I Mental Health Nursing

Before recommending future priorities for the development of psychiatric/mental health nursing, it is important that I mention that no future course can be chartered without regard for the re- alities of our society. Funding for mental health in the hture will be both cut and altered. President Reagan’s proposals to shift responsibility to states through the use of block grants are accom- panied by proposed extreme spending cutbacks. Although states will have the flexibility to fund programs of extremely high priority, the cuts will jeopardize many programs in which we are invol- ved. The community mental health system faces drastic cuts. Some aspects of mental health research and special education for all handicapped children, including the emotionally and mentally disturbed, will also be hard hit. How successful President Reagan will be in achieving all his goals is hard to say, but a high degree of success is an- ticipated. If reduction in funding would help mental health problems go away, we would only have to worry about our own personal futures. However, it has been found that instabilities in the national economy have been the most important source of fluctuation in mental hospital ad- mission rates in this country over the past 127

years. “As economic activity decreases and the economy contracts, overall social stress increases and mental hospitalization increases.” (Brenner, 197545 1) The question must also be raised as to whether we will see a marked increase in hospitalization because community mentai health services will be so sharply reduced. In any case, economic factors affecting our society over the short and long term must be examined as we look at our profession and plan for our future.

Demographic changes in our society are equally important as we project professional needs. Some say the greatest problem for children’s services over the next 20 years will be the elderly in our country as funds are redirected from children to the geriatric population. It is estimated that more than 30 million people will be over 65 years of age by the year 2000. The incidence of mental illness rises with age, and the elderly are more prone to such illness than the general population. (Brotman, 1973:21-38; Butler, 19752393) While social services are extremely important, nurses and physicians will need to review (perhaps reintegrate) medical background and seek consultation when working with these elderly patients. “Of the elderly not in institutions, 86 per- cent have at least one chronic health problem, and multiple problems in the same individual are common.” (Jacobson, 1978:568-572)

Areas of research, including expanding and re- fining data on psychotherapeutic effectiveness, are essential. It can be expected that the ratio of costs and therapeutic effectiveness and, in particular, cost-effective short term psychotherapy will be emphasized. Psychiatric epidemiology can be expected to emerge as an important area of study. The progress of the 60s and 70s was in other areas of psychiatric research such as psycho- pharmacology, genetics, and neurobiology. Weissman and Klerman state:

... the future direction of psychiatric epidemiology will produce rates for discrete mentai disorders, a greater separation of the independent variables (risk factors) from the dependent variables (discrete psychiatric disorders), and a greater exploration of causal relationships. The new scientific knowledge of psychiatric disorders will have important implications both for professional practices in medicine and public health services, training, and research. (Weissman and Klerman, 1978:705-712)


Both the epidemiological approach and cost- effective psychotherapy are extremely viable op- tions for competitive research proposals from public health oriented psychiatric nurses as well as physicians.

It has been said that the reduced participation of psychiatrists in community mental health cen- ters was economically related in that costs could be lowered by the minimal use of psychiatrists and the maximal use of professionals who were paid less. We can expect that in the coming few years this trend will heighten, if anything, and that psychiatric-mental health nurses’ awareness of the cost-effective argument will enhance both their private practice and employee status. That is, unless nurses believe that their income should be the same as physicians. I will leave that argument for you to develop.

Let us remember that the decline in popularity in psychiatric/ mental health nursing preceded, by some years, the decline in nursing school en- rollment and funding cutbacks for psychiatric nursing education. In fact, the decline occurred as undergraduate nursing programs were growing and when funding possibilities for people choosing psychiatric nursing in graduate programs were far superior to available dollars in other specialties. At the University of Penn- sylvania, for example, until last year, master’s students in psychiatric/ mental health nursing were receiving full tuition and stipend, whereas full-time students supported by traineeships were receiving less than half of the $6,000 academic year tuition. While our programs have continued to be extremely successful, national figures tell us a very different story. Although there are some parallels between nursing and medicine here, I don’t believe we can use all the excuses of physicians to explain why the status of our field has declined. While the societal factors do obtain, the power and prestige of the psychiatric nursing faculty member in the nursing school continue at a extremely high level. How faculty members participate with undergraduate students is, however, another question. Various curriculum issues have con- tributed to the decline of popularity of psy- chiatridmental health nursing as a distinct specialty.

While mental health integration strengthened

curriculum content it seems to have led us to minimize our direct role in teaching psychiatric nursing to undergraduate students. In many instances, we demonstrated the belief that our consultant role was somehow more important than the actual teaching of students in the psychiatric setting. I said earlier that the rewards received from mental health integration were at least as great from the standpoint of the egos of psychiatric nursing instructors as from the actual success of the curriculum work. It was one of the ways we used to establish ourselves as leaders in nursing. But somehow this leadership is not getting through to our prospective students, perhaps because we have not demonstrated the strengths of such a model in our own work with acute and chronic patients. It should be clear that a major effort is in order to analyze and correct the causes of this situation.

I mentioned earlier that one of our colleagues believes that the area that ranks first for us in research over the coming years is to identify how the practice of psychiatric nurses differs from the practice of others in psychotherapy. Studying this question will have to be done on our own time and at our own expense, since no funding group would find this a suitable area for funded research. On the other hand, if we can show with hard data from whatever model we choose that we are doing more for less, this could be a significant national contribution. I said earlier that third-party payers, when they pay us at all, pay us for a substitutable service. Nurses’ practice of psychotherapy is legitimate and practical. We should then study our successes in this area and identify the strategies that have worked. Helping our colleagues in nursing recognize the need to base our claims for national reimbursement on generic roles performed by prepared credentialed practitioners would be a major leadership contribution that we can make to nursing at this time. Looking at the problem of the future, it may be predicted (and a systems view would demand) that we will need the strength and resources of other specialists in nursing as we face the future needs of our clientele. Such an interface will have mutual benefit as well as enable us to maintain our distinct specialty role while strengthening the common and collegial bonds in the profession.

The credentialing issue leads me to comment

VOLUME XIX NO. 3 & 4 1981 f 05

on the pervasive quality of this problem in all other nursing problems. The entry level question must take a high priority if we are to have any hopes of improving nursing’s attractiveness, vi- ability as a profession and of attracting applicants to psychiatric/mental health nursing programs.

I’d like to summarize briefly and restate my conclusions for future direction. The Peplau decades were years of extraordinary accomplishment for psychiatric/mental health nurses. Achieving status in the profession and colleagueship with members of other disciplines should have brought us to the 80s with a high degree of confidence about our present and future. Declin- ing enrollments in our graduate programs have undermined that confidence.

I have tried to examine critically the accomplishments of the past 30 years and pose some future directions. These are:

1. Economic and demographic factors in our society must be examined as we plan our profession’s and specialty’s future. In-patient care and care of the elderly are areas that will undoubtedly require our attention.

2. Epidemiological research and research focusing on cost-benefit ratios of short term psychotherapy should be explored from the nursing perspective.

3 . Attracting nurses to our field inevitably re- lies on first attracting students to nursing. Our participation is crucial in the dis- incentives to nursing student recruitment such as the entry level problem.

4. Curriculum issues on the undergraduate level must be addressed by psychiatric/mental health nursing faculty. Teaching psychiatric nursing to undergraduate students by our most talented faculty must receive a high level of priority.

5. The building of intra-nursing colleagueship requires a recognition that separate and better than equal has not served us profes- sionally even if it has given us personal satis- faction. The generic role of the psychothera- pist should be no more separatist from nursing than other newer nursing roles. Articu- lating with our non-psychiatric nurse colleagues the similarities and strategies which have been successful will re-establish our avant garde position and advance the profes-

sion as we advance our specialty. Both the curriculum issue and the intra-nursing issue must be resolved within the context of an appropriate model for psychiatric nursing practice: the phase three task.

6 . Finally, we need to maintain and strengthen

I

our stance with other disciplines by increas- ing our visible participation with them in ad- dressing the major mental health issues of the period. Our visibility in the mental health world will be a clear measure of our maturity.

believe we are ready.

References

Nbee, George, W., Ph.D., “Psychiatry’s Human Resources: Twenty Years Later,” Hospital and Community Psychi- atry, Vol. 30:ll (November 1979), pp. 783-786.

Beigel, Allan, “Psychiatric Education at the Crossroads: Issues and Future Direction,” American Journal of Psy- chiatry, Vol. 136:12 (December 1979), pp. 1525-1529.

Brenner, M.H., Mental Illness and the Economy, quoted in Hospital and Community Psychiatry, Vol. 26:7 (July 1975), p. 451.

Brill, Norman, “Future of Psychiatry in a Changing World,” Psychosomatics, Vol. 14 (January-February

Brotman, H.B., “Who are the Aging?” Mental Illness in Later Life, Busse, E.W. and E. Pfeiffer (eds.), Washing- ton, D.C., American Psychiatric Association, 1973. pp.

Butler, R.N., “Psychiatry and the Elderly: An Overview, American Psychiatry, 132:893, 1975.

Henry, William E, John H. Sims, and Lee S. Spray, The Fifh Profession, San Francisco: Jossey-Bass, 197 1.

Jacobson, Seymour B., “Geriatric Psychiatry Today,” in Bulletin New York Academy of Medicine, Vol. 54:6 (June

Lego, Suzanne, “The One-to-one Nurse Relationship,” Perspectives in Psychiatric Care, Vol. 18:2, 1980, pp.

Nielsen, Arthur C., “The Magnitude of Declining Psy- chiatric Career Choice,” The Journal of Medical Educa- tion, Vol. 54 (August 1979), pp. 632-637.

Shepherd, Michael, “A Critical Appraisal of Contemporary Psychiatry,” Comprehensive Psychiatry, Vol. 12:4 (July

Weissman, Myrna M. and Gerald L. Klerman,“Epidemiol- ogy of Mental Disorders,” Archives of General Psychiat- ry, Vol. 35 (June 1978) pp. 705-712.

William, J. Ivan and E.J. Luterbach, “The Changing Boundaries of Psychiatry in Canada,” Social Science and Medicine, Vol. 10, Pergamon Press, 1976, pp. 15-22.

1973), pp. 19-26.

21-38.

1978), pp. 568-572.

67-89.

1971), pp. 302-320.


psychiatric nursing at the crossroads: quo vadis

Documents