Registered Psychiatric Nurses, Partnering with People

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The Other Nurse: Seeking Validation

The Other Nurse: Seeking Validation

Psychiatric Nursing and the Saskatchewan Psychiatric Nurses’ Association, 1930 – 1972

B. A. (Honors) Essay
By Angela Y. Martin
March, 1999

The Other Nurse – Page 1

In the July, 1951 edition of The Psychiatric Nurse, W. L. Pritchard wrote of the challenges to be faced by the relatively new profession of psychiatric nursing:

Psychiatric nursing as a profession of merit is not too well known; it replaces the archaic concept of custody in the midst of regimentation, neglect, and abuse of the less fortunate of our own ‘ the mentally ill. The psychiatric nurse is a professional person – not inferior to the registered nurse, but equally important and equally essential in a changing social structure; each with a definite place, and a definite function. An entirely new concept in an entirely neglected field of operation. In all of this we share credit and future responsibilities! The path will be thorny and strewn with obstacles.1

This was the challenge that the Saskatchewan Psychiatric Nurses’ Association (SPNA) presented to itself. It was also a message to outside parties that this new profession would not only share responsibility in the care of the mentally ill, but also that it would be an equal partner with other medical professionals in planning for the future. The message was clear and so was the mandate. But after reading the material which represents the history of the SPNA, two questions arise. Did the SPNA share the responsibility of planning and strategizing for a better mental health system in Saskatchewan? Secondly, what were the obstacles they faced from their inception until the early 1970s and was it apparent to themselves and others that they were equal partners with the other professionals in the medical field?

In the 25th anniversary history of the SPNA, A Different Drummer, one member reflected on what the SPNA had accomplished and what might be in store for the future. He answered the above questions with what might be perceived as a yes and a no.

Little things that you could call stepping stones along the way, where they got the Act through the Legislature, got recognition by the University and a representative on the Board of Examiners. All these things take long periods of time. The SPNA, over a long period of time, did an awful lot of work – getting people to be able to go to the University and take courses there, to give them extra training where their psychiatric nursing training was recognized as entrance qualifications. These are things that stand out as highlights, things that took an awful lot of years, of meetings, arguing, writing briefs. Regarding the identity of the RPN, people worried so much about the fact that the Saskatchewan Registered Nurses Association (SRNA) was going to take us over. It hasn’t happened yet, and people have been worrying about it for 20 years. Keeping this hassle up is something we could have done without. We could have gone more for cooperation.2

This Honors Essay will review the history of psychiatric nursing and the SPNA from the 1930s to 1972, and will attempt to show that the SPNA did truly share the responsibility of building a better mental health care system in Saskatchewan. The obstacles it faced were many but in the final analysis it will be argued that given all that was done, this group’s viability was constantly challenged by outside parties and decisions over which it had no control. This led to a constant questioning of its identity and its place in a continually changing mental health system.

A review of published and unpublished literature found that although mental health in Saskatchewan has been studied, no works have addressed the topic of psychiatric nurses as a profession in the same way this study has. F. Kahan and Foote, et. al. wrote 25th and 50th anniversary histories, respectively. The 50th anniversary review is formatted like a yearbook, providing a very brief history, but is mostly composed of commentary by long-time SPNA members.3 Kahan’s 25th anniversary book, A Different Drummer, provides a chronological description of the history of the SPNA using SPNA archival records and interviews of psychiatric nurses conducted in 1973. The book, although useful and interesting, lacks analysis and, more importantly, footnote citations.4

Sandra Bassendowski’s M.Ed. Thesis includes a history of the psychiatric nursing, nursing assistant and diploma nursing training programs, showing their evolution from 1929 to 1972. For the most part, her thesis details the origins and development of the ‘core’ concept of nursing education in Saskatchewan. In doing so she identifies the role of the Departments of Public Health and Education in integrating into one program, these three traditionally separate and distinct curriculums, in 1972.5

Paul Nishida’s M.A. Thesis reviews the establishment of Saskatchewan mental hospitals between 1912 and 1940, 6 and Duane Mombourquette chronicles the steps taken by the CCF government as they related to health care in Saskatchewan between 1944 and 1964.7 Both of these works provide an overview of health and mental health in the province, but neither discusses psychiatric nursing in any detail.

Harley Dickinson’s book, The Two Psychiatries, details the nature of psychiatry in Saskatchewan from 1905 to 1984. 8 He traces transitions in psychiatry from asylum to community-based models. Within this context, he argues that over time there was a de-medicalization of psychiatry with a discernible trend toward the de-skilling of psychiatric occupations.

Sharon Baldwin’s M.A. Thesis studies the effect of government involvement on the professionalization of seven different groups in Saskatchewan.9 Although this is an important study in its review of the relationship between government and professional groups, it does not include information on inter-professional relationships which are an important part of the growth of a professional group.

As seen from this summary, much of the history of psychiatric nursing and the SPNA remains to be explained. This essay hopes to add to the literature by looking into the day to day work the Association performed, the struggles it faced, and how it influenced and was influenced by outside and internal forces.

This essay is divided into three chronological sections, each dealing with a different era in the history of psychiatric nursing in Saskatchewan. The first, 1930 to 1948, will review the early history and training of psychiatric nurses and their eventual gaining of professional status in 1948.

The next era extended from 1948 through to the end of the 1950s. During this period the Association dealt with issues of training, and established its own pledge, code of ethics and rules and regulations. It was also faced with a major shift in thinking in the mental health field. This culminated in what became known as the Saskatchewan Plan, which placed greater emphasis on community psychiatric treatment.

 

The Other Nurse – Page 2

The 1960s brought new challenges to psychiatric nurses. As concepts of the care and treatment of the mentally ill continued to change, the SPNA focussed most of its energy on the curriculum used to train psychiatric nurses to meet these changes. By the early 1970s, the SPNA could look back at a decade of changes both in mental health and their role within it. Their role had changed; their institutional training schools had been closed and they were still questioning their own viability as a profession.

Prior to 1930 one of the largest areas of the Saskatchewan government’s expenditure in regard to health matters fell under the jurisdiction of the Department of Public Works ‘ the province’s mental hospitals.10 Saskatchewan’s first mental hospital was opened in North Battleford in February, 1914. By May the Saskatchewan Hospital, North Battleford, ‘one of the most modern on the American Continent,’ 11 had 325 patients. The Saskatchewan government had originally intended to limit the accommodation to 800 patients, but by 1919 the hospital had become so overcrowded that a decision was made to open a second institution in Weyburn. The Saskatchewan Hospital, Weyburn opened in December, 1921.12

By 1929, with approximately 1,000 patients in each institution, the overcrowding became deplorable. Each hospital had a superintendent and two additional medical officers, a ward staff of about 110 untrained personnel and one registered nurse. There was no formal training program.13 This prompted the Saskatchewan government to appoint a special commission to study its psychiatric services with a view to receiving recommendations to resolve the many problems.

The Commission, headed by Dr. C. M. Hincks, submitted its findings in 1930. One of the recommendations was that a training school be started for personnel at each of the mental hospitals with instruction in the areas of psychology, psychiatry, mental hygiene and medicine.14 This proposal led to the establishment of two-year training programs for ward attendants at North Battleford in 1930 and in Weyburn the following year under the direction of the medical superintendents.15

In the meantime, psychiatric nurses continued to work under very difficult conditions. Mrs. Minnie Milne, who began her training at the North Battleford hospital in 1940, also reflected on conditions at the time:

On a 12-hour day there were about 71 patients on 3A, at the most there would be three of us to look after them. They call these patients ‘continued treatment’ now (1973), but in those days we found them the most deteriorated and unclean. The only clothing they wore were strong dresses made of canvas. They slept on beds sometimes two to a bed, sometimes the odd one under a bed. The patients slept on straw mattresses. The hospital had 2,000 patients, but the staff did not realize they were having difficulties. We worked a 12-hour day, from 7 AM to 7PM and on Mondays we worked overtime at a dance, and on Wednesdays we worked overtime at the show. Nobody was paid overtime, of course, it was part of our duties.16

T. C. Douglas’ correspondence files include a newspaper article written by Miss Small who described her job as a psychiatric nurse in the early years at Saskatchewan Hospital, Weyburn.

My chief duty was to guard the door to the day room, allowing no patient entry into the hall or other rooms on the ward. I recall 1A ward particularly well, gray cement floors, gray walls, wooden benches, and huddled on the benches naked, wretched, unclean people.17

The history of formal staff training for psychiatric services in Saskatchewan began in 1947 with the new ward attendant training course. By this time, it was evident that greater numbers of more adequately trained ward staff were required. Three alternative solutions were considered. The first included the creation, in the two institutions, of basic schools for nursing students proceeding to the Registered Nurse (RN) designation. The second alternative called for placing RNs in all supervisory posts including ward charge positions, the remaining staff to be composed of a mixture of attendants and undergraduate nursing students from general hospitals serving a period of three-months affiliation. The third was the creation of a professional group of psychiatric nursing personnel by the establishment of a greatly expanded training program.

The first option was discarded because of the failure of this policy in several states and provinces. The second was impossible because of the shortage of graduate registered nurses and the unavailability of affiliating nursing students. The third appeared to offer the best prospects for success, and so in the fall of 1947 a 500-hour training program began.18

In January, 1947 Dr. D. G. McKerracher, Director of Psychiatric Services, made the decision to establish an expanded training program for psychiatric nurses. Two months later, he set up a committee under the chairmanship of Dr. S. Laycock, a member of the 1929 Hincks Commission, to draft a curriculum and propose methods for its implementation.19

The new program became operational in October, 1947 and immediately encountered a number of problems and setbacks. To begin with, there was no comprehensive term to adequately describe this new type of mental hospital worker. Suggested designations included psychiatric aide, psychiatric technician, and psychiatric nurse. The term ‘nurse’ was ultimately chosen, but it was to cause problems both within the association and with outside groups.

Registered nurses viewed the training program as a threat to their professional status. They concluded that psychiatric nurses were another group of ‘nurses’ with inferior training, whose members would force the registered nurse out of the mental hospital field. There were also jealousies and hostilities existing in varying degrees between ward attendants and the newly trained staff.20

The objective of the program at its inception in 1947 was to create a highly trained professional staff. The 500-hour course was organized so as to be spread over a period of three years, with lectures given for one to two hours per day during academic terms extending from October to May.21 The rest of the students’ time was service-oriented. It was a long, difficult three year training period, but the students were paid a salary and this, no doubt, was instrumental in attracting students.22

The government obtained the services of Dr. W. Bates, Dr. Lester Bates and Fred McKinnon as Directors of Training in Weyburn, the training school in Moose Jaw and in North Battleford respectively. In the fall of 1947, they began training the first class. By 1951, there was evidence that the training program in psychiatric nursing had greatly improved staff morale, had improved relations between mental hospitals and their communities, and had demonstrated the feasibility of in-service training of ward staff. Consequently, the Saskatchewan Health Survey, in its 1951 report stated:

The Other Nurse – Page 3

The psychiatric nurse training program conducted at the two psychiatric hospitals and the training school has attracted personnel of a higher caliber and has helped to achieve a much improved standard of care for patients. This program should be continued.23

There was also progress on another front. In early 1947, a group of graduates from the previous ward attendant training program in North Battleford met to discuss the establishment of a professional organization for its members. W. J. Vowles was the prime mover in this effort to help psychiatric nurses obtain recognition for their training and their status.24 In April, 1947, on behalf of Mr. Vowles and other graduate psychiatric nurses, Lloyd A. Gardiner from the United Civil Servants of Canada, corresponded with Morris C. Shumiatcher, Counsel in the Premier’s office, regarding a proposed Bill for incorporation of a psychiatric nurses association.25 Shumiatcher responded

I am of the opinion that the proper way for the psychiatric nurses to proceed if they wish to organize themselves into a professional organization is to draft a statute along the lines suggested by existing Acts. This should be discussed with the officials of the Department of Public Health in order that they may approve of the principle. Steps should then be taken to submit the matter to the cabinet together with a petition that a statute be enacted incorporating psychiatric nurses into a Psychiatric Nurses’ Association . . .26

Using the Registered Nurses Act as a model, Vowles made revisions, came up with a draft Act regarding the Psychiatric Nurses’ Association, and forwarded it to Shumiatcher on June 10, 1947.27 After a number of revisions the draft bill was forwarded to T. C. Douglas who on January 22, 1948 suggested, ‘In all probability it will have to be brought in as a private member’s bill. I am quite sure however, that Alex Connon would be willing to introduce it once it has been properly checked.28 ‘According to Vowles’ records, Alex Connon, Member of the Legislative Assembly for the Battlefords, agreed to present it as a private member’s bill.29 ‘The bill was to be placed before the Laws Committee in February, 1948 and I was informed that the Saskatchewan Registered Nursing Association (SRNA) had indicated opposition to both it and the use of the term ‘nurse’.’30 The day the Laws Committee met, the registered nurses were there in full force. Vowles, himself, argued the case for the psychiatric nurses.31In the end, the Committee accepted the bill, and with its passage by the Legislature and Royal Assent on March 25, 1948, the Saskatchewan Psychiatric Nurses’ Association became a reality. Following incorporation, by-laws were drawn up and tabled in the legislature giving recognition to the graduates, the first psychiatric nurses in Canada to receive professional status.32

The next era spans from 1948 to the end of the 1950s. The first order of business for the SPNA was to establish its structure. Organized structure within the SPNA began with the formation of the ‘Seat of Council’. Council consisted of five members who met regularly and dealt with the day-to-day business of the Association. The President, Secretary and Treasurer were elected from among these members. A first and second vice-president were elected, usually from the two larger centers, North Battleford and Weyburn. However, the Vice-Presidents were not involved in the Executive decision-making process to any extent. From 1948 to 1960 the Seat of Council was located in North Battleford. Branches of the SPNA were formed in North Battleford and Weyburn in 1948, Moose Jaw in 1955 and Saskatoon in 1960.33

Another important order of business for the SPNA was to promote itself to psychiatric nurses working at both hospitals. A membership fee of two dollars was levied. Nurses showed some reluctance to pay the fee, but the SPNA was satisfied with the 280 members it enrolled by April 1950.34

Another important project was the development of a seal to represent the SPNA. On April 9, 1948 a pattern for the SPNA seal was presented to Council. According to the minutes of the meeting, ‘It was unanimously approved and admired.’ It was moved by Jack Hoskins, seconded by Mr. McNeill, that a rubber stamp following the pattern presented be used as the official seal of the Association.35

The SPNA also proceeded to seek affiliation with Psychiatric Nursing Associations from other provinces. On February 26, 1950, the SPNA received a letter from the British Columbia Psychiatric Nurses’ Association regarding formation of a national organization. The SPNA agreed to cooperate and become part of the new national group.36 The foundation of a national psychiatric nurses’ association was laid on June 17, 1950 when a meeting of Council members was held in North Battleford with W. Pritchard from the British Columbia Association. The gathering discussed the aims and purposes of the two Associations and explored ways of cooperation for mutual benefit. It was planned to form the Canadian Council of Psychiatric Nurses (CCPN) to set standards and policies for all psychiatric nurses, and to combat common problems. Shortly after, The Psychiatric Nurse, forerunner of the Canadian Journal of Psychiatric Nursing, was published and included a proposed constitution for the national Council.37

The draft constitution outlined the aims and objectives of the CCPN which were to act as a central governing body with a view to:

  1. aspiring to a uniformity in procedure, practice and standards in psychiatric nursing
  2. co-ordinating the activities of provincial associations of psychiatric nurses
  3. allowing for policy-making representation for affiliated organizations
  4. providing for national recognition on a professional level for those engaged in the nursing care of the mentally ill
  5. lending strength through mutual support in the organization and establishment of local and provincial groups
  6. encouraging an active interest in modern trends and attitudes.38

The entire draft constitution was subsequently edited and adopted. The new organization was determined to grow even stronger with the addition of an Alberta and a Manitoba Psychiatric Nurses’ Association in the short term and others further east in the longer term.

By 1951, there were some improvements in the Saskatchewan mental hospitals. Mr. Jones, writing in The Psychiatric Nurse, stated that
The staff ratio is being steadily increased, treatment facilities are being made more readily available and training programs evaluated in conformity with the changing scene. ‘objectives of the SPNA are aimed at bringing about a closer cooperation of the mental hospital nursing staff and stimulating a more active interest in the care and treatment of the mentally ill. We have set the standards and are prepared to accept the challenge as an integral part of a growing profession.39

 

The Other Nurse – Page 4

Still there were problems. ‘Hospitals were overcrowded, many patients were forgotten or neglected by family and friends, and patients were deteriorating,’ wrote G. L. Fitzpatrick, Superintendent of Nursing, North Battleford. She went on to say:
To overcome this, and to help these people return to their rightful place in their community and society, we are trying with our trained staff to carry on patient assignment in nursing or caring for the mentally ill. The aim in patient assignment in hospitals is to make the patients feel the staff cared what happened to them, and would do everything to return them to normal or previous life and environment. Each staff was assigned a number of patients for whom he or she was responsible while routine duties were carried on as well.40

This type of interaction with patients could be seen as a precursor of what was to come in terms of patient care. Up until the mid-1950s psychiatric nurses were little more than custodians, cleaning toilets, scrubbing windows and herding patients to and from meals,. By 1954, however, the introduction of psychotropic drugs revolutionized treatment. Phyllis McElroy reflected on the significant difference this new type of treatment made to her work as a psychiatric nurse:
. . . tranquilizers came in, and then came working with patients in groups, working with them as individuals. . . . we had many patients who responded to it, patients you would never think would be out of here. But month after month of steady group work . . . and making life more meaningful and interesting, gradually some of those patients were discharged. It was really rewarding because, although it was slow, even then, you could see it, and it was nice to work with the patient as a person for the first time.41

Other accomplishments in the early 1950s were the development of a pledge, a code of ethics and the adoption of the practice of wearing two maroon bands on caps and pockets as an insignia of the RPN. These steps occurred smoothly and without hitches. However, a more serious problem arose in 1953 when the SPNA received the contents of the Canadian Nursing Association’s submission to the Sub-Committee on the Training of Nursing Personnel in Mental Institutions. The Sub-Committee had been appointed in 1952 by the Advisory Committee on Mental Health to the Department of National Health and Welfare.

At the time, the organization of psychiatric nursing education nationally was a confused one. The training and status of psychiatric nurses varied from province to province and from hospital to hospital. In British Columbia a graduate of the two-year psychiatric course became a licensed psychiatric nurse. In Manitoba, students in the mental hospital course who spent four months affiliating at a general hospital were eligible for licensing as practical nurses. In Saskatchewan, graduates of the three year psychiatric nursing course were eligible to register as psychiatric nurses after passing examinations set by the University of Saskatchewan Board of Examiners. Other provinces issued certificates or diplomas for the successful completion of courses in mental hospital nursing. Nationally, there was no uniformity in the courses or the status obtained upon their completion.

The Canadian Nursing Association’s submission included a number of recommendations which helped to perpetuate the already strained relationship between the SPNA and the SRNA. Among these was a recommendation that RN’s be in charge of all ward work in mental hospitals day and night for both male and female patients. The Canadian Nursing Association also claimed that because of a lack of affiliation programs for students in schools of nursing, RN’s hesitated to accept positions in mental hospitals, and that in some communities nursing in psychiatric hospitals had less prestige than nursing in general hospitals.

The Sub-Committee noted that the CCPN was established to set up ‘recognized standards of psychiatric nursing on a national basis which would enable trained psychiatric nurses to move freely from job to job in any of the provinces.’ It felt also that a good working relationship between the CCPN and the Canadian Nursing Association was important.

The Sub-Committee recommended that there should be planning for training for auxiliary nursing personnel on a national basis and provision for experience in both fields of nursing for those who wished to transfer from psychiatric to general nursing and vice versa. Significantly, the Sub-Committee also recommended that the duties of the psychiatric nurse should be carried out under the direction of the attending physician and under the supervision of a registered nurse.42

W. Vowles reacted strongly to the Sub-Committee’s recommendations, The results of these plans will be that the majority of the successful candidates choose to remain in the general nursing field and those taking the psychiatric nursing course only have been classed inferior. That is why we have said we do not want the RN’s classed inferior or superior to the PN’s, or vice versa, but that each shall hold equal status in their separate professional nursing fields.43

Relations between the SRNA and SPNA remained cool for the remainder of the 1950s. However, in 1955 the University of Saskatchewan School of Nursing began accepting psychiatric nurses in its Diploma course in Teaching and Supervision. That same year the Act Respecting Psychiatric Nurses was amended to stipulate that all future graduates had to pass SPNA examinations. Two years later, the educational standard for entry into the training programs was raised from Grade 10 to Grade 11.44 In 1957 Vowles noted that, according to the SPNA register, 1,394 licenses had been issued since the inception of the Act, of which 1,006 were current and valid.45

A landmark in the history of Saskatchewan psychiatry was the development of the Saskatchewan Plan. Mental health had always been a concern to the CCF, but by the mid-1950s it was becoming apparent that despite the advances of the previous decade the mental health program was under strain. As early as 1949 there were plans for the construction of a 1,100 patient mental hospital in Saskatoon. Although Dr. McKerracher, Director of Psychiatric Services, repeatedly tried to impress upon the government the urgency of this project, it was never constructed.46

In July 1954, McKerracher presented three options for relieving the pressure on the two main mental institutions. The first was the construction of the 1,100 bed hospital in Saskatoon. The second option included the construction of a 600 bed institution in each of Saskatoon and Regina. The third called for the construction of smaller, regional institutions.47 It is important to note that by 1954, professional attitudes toward the treatment of mental illness were changing. H. Dickinson contends that much of the pressure from McKerracher was intentional. He believed that the best way to convince the government to accept these changes, which came to be known as the Saskatchewan Plan, was to publicly expose the deficiencies of the Weyburn and North Battleford mental hospitals.48

The government did respond and as a result Dr. F. S. Lawson, who took over as Director of Psychiatric Services when McKerracher became a professor of Psychiatry at the University of Saskatchewan, reviewed the options and came up with a report which called for the development of small treatment centers which could be expanded as the need grew. This became known as the Saskatchewan Plan.49

 

The Other Nurse – Page 5

The plan was first publicly presented in 1956 by Dr. F. S. Lawson to the American Psychiatric Association Mental Health Hospital Institute at Denver, Colorado. Briefly, this plan was to bring comprehensive services and facilities to the community with an emphasis on rehabilitation rather than mere custodial care.50

Despite its apparent benefits in terms of patient care and flexibility of cost, despite Lawson’s enthusiastic support for the concept, and despite petitions from all over Saskatchewan to have these smaller centers built in various communities, the government hesitated.51 The reason for this hesitation was because the government hoped to have federal hospital construction grants made applicable to the construction of these hospitals before proceeding with any construction. Hence none had been built by the end of the 1950s.52

In a brief submitted to the Province of Saskatchewan in 1959, the SPNA clearly supported the Saskatchewan Plan:

Although Provincial Mental Health Services have been expanding progressively during the past five years, the problem of providing treatment facilities, space and personnel for the care of our mentally ill still presents a formidable task. The extent of this problem is difficult to judge but it is relatively safe to say that the wide scope of mental illness constitutes the largest hospital problem in Canada today. Mental hospitals are still, rather formidable institutions, housing too many patients under one roof, and in general, inadequately staffed to provide the requisite care and treatment.53

The submission went on to state that ‘The two mental hospitals in Saskatchewan today house some 1,500 to 1,600 patients each.’ The submission also quoted an article which had appeared in Canadian Doctor in April 1959 stating that Ontario had adopted a plan of small, regional hospitals for its mentally ill. In response to this the SPNA wrote,
It would seem as though the province of Ontario has stolen the Saskatchewan Plan before we procured a patient! This is a severe blow to the members of the first professional Psychiatric Nurses’ Association in North America. We cannot believe that our government leaders, who have shown so much foresight in the field of mental health, will accept this without some action. To let the pioneer province in improving conditions for the mentally ill now fall behind, we feel would be a setback for this province and for our profession. Thus we must speak in protest ‘Let us continue to lead ‘ inaugurate the Saskatchewan Plan ‘ Now!!54

H. Dickinson states that initially psychiatric nurses did not support the Saskatchewan Plan as it was seen as a threat to their occupational security. In addition, provincial psychiatrists predicted in 1958 that the transformation of psychiatric work associated with the transition to community psychiatry would lead to the disappearance of mental institutions as they were then known. For many, this was good news, heralding the end of the much vilified psychiatric warehouses. Given that the status quo was the only other option, the SPNA really had no choice but to endorse the Saskatchewan Plan.55

The Saskatchewan Plan was the main topic of discussion at the SPNA’s First Annual Convention at Valley Centre, Fort Qu’Appelle in June 1958. Fifty four delegates attended from the two provincial hospitals, the Saskatchewan Training School and from the psychiatric wards in Moose Jaw, Regina and Saskatoon.56

Lee Sonmor welcomed the delegates, saying that some of the objectives of the convention were to foster professional identity, discuss nursing problems in the different localities, discuss the training program in the Saskatchewan Hospitals at Weyburn and North Battleford, get ideas from those in higher authority, and to become better acquainted with staff from other locations.57

Speaking at the convention was Dr. D. G. McKerracher, then Professor of Psychiatry at the University of Saskatchewan. McKerracher had a significant message to the SPNA and its members. A commitment to the philosophy of the Saskatchewan Plan was apparent in his speech, and he challenged the SPNA to evaluate their place in the mental health system of today and plan carefully for their role in the future. McKerracher reviewed the history of Saskatchewan’s mental health programs and emphasized that

Poor location, poor buildings, overcrowding and understaffing contribute to the mental hospitals’ greatest drawback ‘ adverse public attitude. But public attitude toward mental illness is changing quicker than its attitude toward mental hospitals. People now realize that confusion, depression and withdrawal are evidences of illness and that this illness can be successfully treated like any other illness. So people are demanding that their own mentally ill relatives be treated like any other such person in small modern, well-staffed facilities.58

In support of the Saskatchewan Plan, Dr. McKerracher said,

I believe that Dr. Lawson’s Saskatchewan Plan offers the best practical solution to the battle. The shape of things to come can be seen ‘ smaller decentralized units, more active continued treatment, closer contact with general hospitals and early return of patients to the community. All who look at psychiatry of the future see close tie-up with the community. All see much earlier discharge, more extensive rehabilitation and a much smaller load of chronic patients permanently housed.59

He then asked where the psychiatric nurse fit into this new scenario. As the attentive audience listened, he said, ‘I am certain the prestige of the psychiatric nurse will increase rather than diminish. Better surroundings, recognition of the therapeutic effectiveness of skilled nursing, upgrading of mental disorder to the status of illness, all of these will improve the socio-economic standing of the psychiatric nurse in the community.’60

Then the challenge was issued:

But hurdles exist which must be overcome. As an organization you seem to lack confidence, cohesion and a plan. Somehow you have got to develop more pride in your job. Too often psychiatric nurses think of themselves as a lower grade of general nurse. The way nursing is set up this is not so. The general nurses look after the physically ill and neurotic. But you look after the psychotic and the mental defective. These are different tasks, equally difficult and equally rewarding. To have confidence in yourself and your destiny, you must know where you are going. Then you would be in a position to contribute to the planning of a curriculum which would prepare the psychiatric nurse for her changing role in the changing psychiatry. Your acceptance as a profession will come with your professional competence and maturity. Now is the time to translate this group into action. This takes wise planning. It also takes working in co-operation with other professions. Professional respect cannot be negotiated ‘ it must be earned. 61

 

The Other Nurse – Page 6

Dr. Humphrey Osmond, Superintendent at the Saskatchewan Hospital, Weyburn, echoed McKerracher’s challenge in a paper presented at the convention.

What can be done? God helps those who help themselves. Psychiatric nursing can only become a fully-fledged profession through the efforts of psychiatric nurses. No one else can or will do it for them. Other professions may advise and give help when asked, but psychiatric nursing has been the victim of unsolicited help for too long. It should dispense with much of this sort of help without delay. The first thing is to find out what psychiatric nurses do and to assume responsibility for doing this and training others to do it without delay. But the impetus to do this can only come from the present psychiatric nurses themselves. Unless they show a lively and determined professional spirit nothing will be done and the prolonged sub-professional status will continue.62

From 1948 to 1959, the SPNA had accomplished some significant things and had suffered some setbacks. Given the challenge by people like McKerracher and Osmond in 1958, and the impetus toward the implementation of the Saskatchewan Plan by the end of the decade, psychiatric nurses faced the challenge of having to re-establish their goals and their place in the new psychiatry. Dr. McKerracher put it, ‘Certainly you can’t stand still ‘ whether you go up or down is up to you.’63

These questions continued to haunt the psychiatric nursing profession throughout the following decade. As they continued to look inwardly for the answers regarding their own identity, other issues surfaced to which they had to turn their attention. The years 1960 to 1972 were, for the most part, committed to writing briefs and collecting data to explain how they were going to fit into the changing mental health field; how they were going to adjust to the new types of working environments, and how they were to train their members to do the work. However, by 1972 the mental health field; the work of psychiatric nurses and where they worked; and the training they completed to perform that work did not, in any way, resemble what it had been at the beginning of this period.

Concepts of the care and treatment of the mentally ill began to change dramatically in the early 1960s. Professionals and lay citizens were demanding better facilities for patients and staff. Hospital psychiatrists were looking at ways of rehabilitating long-institutionalized patients in the community, and beginning to see the potential of psychiatric nurses as group therapists. The new climate began to affect the Association. In April 1960 the SPNA assigned a special research committee the task of keeping abreast of current trends in the care of the mentally ill.

One of the problems the committee faced was to define psychiatric nursing. In an endeavor to clarify the role of psychiatric nurses, both in the present and in the future, the committee sent a letter to doctors, psychiatrists and nurse educators throughout North America, the United Kingdom and the Commonwealth countries. The consensus of the responses was that the main areas of need for psychiatric nurses were in the general hospital, the community and the mental hospital. The psychiatric nurse, it was clear, must be prepared to go out of the mental hospital as a skilled professional who could and should be an integral part of the community.64

At the same time the new President, Fay Sonnergren, presented specific tasks to the SPNA Education Committee. At a Council meeting in May 1960, the question of the SPNA gaining control of the Psychiatric Nurses’ Program curriculum was discussed. It was agreed that the Provincial Council should encourage all psychiatric nurses to avail themselves of opportunities to take post-graduate courses in special fields related to psychiatric nursing, and especially those courses which would prepare them for administrative, teaching and supervisory nursing positions.

At the same meeting it was decided that Council would arrange a meeting with the SRNA Council to establish a post- graduate course that would enable both types of nurses to become trained in both professions. This would involve an evaluation of that part of the psychiatric nursing curriculum pertaining to physical nursing, an evaluation of that part of the curriculum for general nursing pertaining to psychiatric nursing, and the establishment of a post-graduate course to enable both to become dually trained. The Council also agreed to attempt to obtain a seat on the Senate of the University of Saskatchewan for an SPNA representative.65

Unaware of the problems they would meet, the Education Committee began working on its duties immediately. It wrote to the Registrar of the University of Saskatchewan to determine the action necessary to gain control of the curriculum, and outlined a tentative course for a dual training program for RN’s and RPN’s. It also met with the SRNA to discuss its plans. The SRNA did not approve immediately but did promise to give the proposals further consideration. As will be seen, the reason for its reluctance was that, unknown to the SPNA, other plans were being drafted in the area of nursing education.

On May 5, 1961 the SPNA Education Committee met with Dr. F. S. Lawson, Director, Psychiatric Services Branch. He agreed in principle that the SPNA should control its own curriculum and should be involved at the University level. However, he indicated that it would be advisable to work closely with the Psychiatric Services Branch in order to promote cooperation. He volunteered to accompany an SPNA representative to meet with University authorities and make arrangements for the SPNA to gain control of the curriculum. As it turned out the SPNA did not receive total control of the curriculum but it did achieve a place, and thus some control, on the curriculum review committees which advised the University of Saskatchewan, in cooperation with the Psychiatric Services Branch and the Schools of Nursing.66

With regard to nursing education in Saskatchewan, it was made evident to the SPNA at a Council meeting in May 1961 that plans were being developed without its involvement or consultation. Fay Sonnergren reported that she had recently attended a meeting with Hazel Keeler, Professor of Nursing, University of Saskatchewan. Sonnergren reported that at this meeting she had been informed that the SRNA had established an internal Ad Hoc Committee to study the future of nursing education. Keeler divulged that one option involved the discontinuation of all existing schools of nursing in Saskatchewan and setting up central schools, probably in connection with the University of Saskatchewan. The schools would use the various hospitals for clinical experience. One tentative plan for the new curriculum envisioned students enrolling in a basic practical course of one year’s duration and then taking the specializations such as psychiatry, geriatrics or pediatrics.

Sonnergren reported further that Keeler had indicated that she and Dr. McKerracher were presently formulating a plan to establish a diploma course in Teaching and Supervision in Psychiatric Nursing at the University of Saskatchewan. It was intended to have this course set up by 1963.

 

The Other Nurse – Page 7

Sonnergren finished her report by saying:

Thus, it can be seen that nursing in Saskatchewan is at the crossroads and that plans for the care of the mentally ill are being formulated without consultation with the SPNA. It is my opinion that we can have a part in this planning and make an important contribution in the interests of the public and of our Association, if Provincial Council takes immediate action.67

Immediate action included watching the SRNA Ad Hoc Committee with interest. This committee had suggested that a central body be formed to establish standards, and coordinate and supervise all nursing programs closely associated or integrated with the University of Saskatchewan. The central body, it was suggested, should deal with all nursing education programs. Sonnergren, who represented the SPNA at the SRNA meeting when this report was presented in Regina, returned to her own Council with the warning: ‘It is imperative that this Council safeguard the interests of our Association in the planning for nursing education in Saskatchewan.’68 She also offered her opinion that ‘It is likely that the SRNA will ask us to be represented on their Ad Hoc Committee. I am willing to do so. 69

The year 1962 was to be a year of writing briefs and further studying the role of the psychiatric nurse, and attempting to improve training. It was the year that money was allotted for the newly established Prince Albert Branch of the SPNA. It was also the year of province-wide dissension over the introduction of Medicare (on which the SPNA decided not to take a stand). Sonnergren resigned in September and A. Kendall succeeded her. The SPNA was now represented on the Ad Hoc Committee of the SRNA.70

At its fifth annual convention at Valley Centre in May 1962, the majority of the recommendations the Research Committee made concerning the future of the SPNA were turned over to the Education Committee for further study. One recommendation was for the SPNA to sponsor workshops and institutes to increase members’ knowledge, abilities and skills. Another was to enhance the SPNA’s public relations role since it was felt the public was not aware of the importance of the SPNA or of psychiatric nurses.

But the major recommendations dealt with the training program. When the Education Committee explained the SRNA’s proposed ‘central body’ further to the convention delegates, the response was tentative. They wanted to give it the most careful consideration, not wanting to hinder progress, but not wanting to lose their autonomy either. It was also recommended that the Education Committee look at the inclusion in the curriculum of a unit on community psychiatric nursing.71

The Education Committee’s efforts became entirely focused when in 1962 they submitted a brief to the Government of Canada Royal Commission on Health Services. In it they stated that the lack of a sufficient number of adequately trained professional staff was one of the greatest barriers to improved mental health services. The daily average in- patient population in mental hospitals in 1959 and 1960 was 4,480 and the number treated at mental health clinics was 3,224. The total nursing staff in Saskatchewan was 1,900 but of this total, only 600 were psychiatric nurses ‘ a few in psychiatric wards in the general hospitals but none in community mental health clinics. The brief recommended a minimum nursing staff to patient ratio of 1 to 2.5 as desirable for the Saskatchewan Hospitals at Weyburn and North Battleford, but this ratio had not been achieved.

The brief emphasized the importance of community psychiatry, the training of psychiatric nurses and the need for an extension of training programs. It also included a number of other recommendations: a common system of training psychiatric nurses organized on a national basis; a system of providing public information and mental health education utilizing psychiatric staff including nurses; psychiatric nurses having responsibility for the overall planning of nursing services and nursing education in mental hospitals and other mental health programs; and, provision of bursaries to prepare psychiatric nurses for advanced positions in psychiatric nursing.72

During the first few years of the decade, the SPNA also focussed its attention on other business. It had been successful in gaining a seat on the Board of Examiners. This meant that, for the first time, it was involved in the review of all candidates’ papers before the marks were released. It had a plan to offer yearly workshops for members and had accepted a curriculum drawn up by the SRNA which would allow a psychiatric nurse to become a graduate general nurse in fifteen months. It also formed a committee to construct a curriculum which would enable psychiatric nurses to receive training in the field of community health care. The demand for community nurses was increasing as the trend was turning toward the decentralization of psychiatry.73

The SPNA had accomplished much during the first fours years of the decade. But the bombshell was about to be dropped! The Royal Commission on Health Services submitted its report and its conclusions were devastating. It reported that

In the four western provinces’formal programs are offered for the preparation of psychiatric nurses. The graduates of these programs may be licensed according to provincial acts. The programs were instituted to meet the demands for qualified attendants to care for the mentally ill patients in mental institutions. Like the students in the nursing assistant programs, those entering the psychiatric nursing program have qualifications higher than the minimum. We foresee the disappearance of these programs.74

In reaction to this, the SPNA committee studying the report relayed to their membership that

Although it seems we are to die a slow death, this may not be the case, for example, between 1961 to 1971 our projections indicate that, as a minimum estimate, around 20,000 nurses must be added to the supply to match the growing need and to replace those leaving the profession, while the maximum estimate suggests that an additional estimate could approach 42,000. Keeping in mind the PN’s standard of specialization in psychiatry, the committee feels we will be difficult to replace, even provided that all were in agreement with discontinuation of such a program.75

Psychiatric Services officials were not necessarily in agreement with the report’s view of the future of the training program for psychiatric nurses. They fully intended to continue accepting applications to the psychiatric schools of nursing, but did announce their intention to shorten the training program.76 To this end, in September 1965 there was a major change in the education of psychiatric nurses. The Psychiatric Services Branch launched a pilot project, increasing instruction in social and medical sciences to bring the total minimum hours to 608. The clinical period was reduced from 120 weeks to 96.77 One of the reasons for the change was that considerable effort was being given to reducing the number of dropouts It was also desirable to recognize that psychiatric nurse education programs should be more educationally-oriented and the apprenticeship-type educational scheme be phased out, and that psychiatric nursing educational programs should no longer remain in isolation from the general educational stream for nurses.78

 

The Other Nurse – Page 8

The changes were a clear indication of future changes to come and the first official indication to the SPNA that the training of psychiatric nurses in a core program with general nurses might become a reality sooner rather than later.

The second indication was the result of deliberations of a provincial Ad Hoc Committee on Nursing Education established on July 9, 1965 by the Minister of Public Health, D. G. Steuart. The Committee’s purpose was to study existing systems of nursing education in Saskatchewan and to provide recommendations designed to meet future nursing needs. It was, for example, to study the relationship between hospital schools of nursing and other institutions which trained nurses for various purposes.79

Upon beginning its work, the new committee indicated that it was fully prepared to accept briefs from interested parties. The SPNA, SRNA and the Psychiatric Services Branch all submitted briefs. The SPNA’s brief outlined three problems related to the current psychiatric nursing training and offered recommendations related to each:

  1. Problem ‘ The recent trend to community psychiatric nursing necessitates a revision of our curriculum so that psychiatric nurses will be adequately prepared to function as ‘community centered’ psychiatric nurse. Recommendations: a) the SPNA curriculum hours in social sciences should be increased; b) the student psychiatric nurse should become sufficiently acquainted with community resources, official organizations and private agencies to be able to give maximum help to patients and their families; and, c) more education in casework should be included in the student’s preparation.
  2. Problem ‘ At present, student psychiatric nurses from the three training centers do not receive clinical education affiliation. Recommendation: Establish an affiliation program among the three training centers immediately.
  3. Problem ‘ The SPNA feels that in order to serve this province to our fullest potential, we must have more progressive and directive leadership. Recommendation: For this, there must be available to psychiatric nurses, education beyond the Diploma course level and we suggest a degree program be established at the University of Saskatchewan.

A further recommendation was that the Ad Hoc Committee on Nursing Education recommend the establishment of a sub-committee or a separate commission to investigate the profession of psychiatric nursing in Saskatchewan. 80

The Psychiatric Services Branch’s brief to the Committee, stated that

Knowledge of mental health concepts would benefit all branches of nursing and . . . this point should be considered when planning for nursing education in the future. We should no longer think of psychiatric nursing as a separate function but should work toward a core curriculum common to both. The core curriculum should provide for more efficient utilization of nursing personnel at the diploma level with convenient avenues to registration in the various specialties. In this era of rapid social change, increasing urbanization and population shift, it seems important that the professional nurses have the capacity for mobility.81

The SRNA also favored common training. It stated that the minimum curriculum for the preparation of registered nurses and psychiatric nurses should be amalgamated to produce a well-prepared practitioner.82 When the SRNA presented the final draft of its submission to the Ad Hoc Committee on Nursing Education, it asserted

‘that when the two year diploma course is established, the program for the preparation of psychiatric nurses should be discontinued.’83

When the SPNA learned of this recommendation, it issued an immediate response, published in The Psychiatric Nurse.

Such recommendations by supposedly responsible persons are distressing’where do they get off at recommending that PN’s should give up their profession and become RN’s any more than we should recommend that RN’s should give up their profession and take an extra year to become PN’s. ‘It is incredible that, when it is they who want to practice our type of nursing, that they, rather than seek out extra training for themselves, advocate the discontinuance of our education and our profession.84

More distressing yet was the interim report submitted by the Ad Hoc Committee on Nursing Education on January 11, 1966. It concluded:

In regard to the maintenance of a separate educational stream for psychiatric nurses this Committee tends to think that, if a high quality diploma nursing education program were to be implemented, if greater education were given to psychiatric nursing in the diploma curriculum, and if more students could be attracted into the diploma nursing education program, it would then seem unnecessary to sustain a separate psychiatric nurse education program. There is reason to believe that this merging might be reasonably accomplished in a few years. It is suggested that the Board of Nursing Education [which the Ad Hoc Committee on Nursing Education became] review this situation each year until a firm decision can be taken.85

The SRNA brief, coupled with the recommendation of the Ad Hoc Committee, caused the SPNA great consternation. What spurred the psychiatric nurses into immediate action however, was the information and the challenge which Dr. Fred Grunberg, Director, Psychiatric Services Branch presented to them, at an SPNA Council meeting in October 1966. He predicted that by 1971, the Weyburn hospital would be used for purposes other than hospitalizing the mentally ill. It had been recommended that a Yorkton-type psychiatric centre be built in its place. He believed that the North Battleford hospital would follow the same course, and that a psychiatric centre would be built there as well.

In response to the SPNA’s concern about job security, he predicted that Saskatchewan would need more trained personnel, not fewer, simply because there would be many more community agencies needing staff. ‘The problem appears to be one of job dislocation. The psychiatric nurse must be prepared to move, relocate.’

Further, he advised the group to maintain a unique identity, apart from the general nurse and traditional nursing model, as this would surely lead to the amalgamation of the two programs. To retain their own identity, he advised, psychiatric nurses would have to develop a new curriculum based on a new philosophy.

Think of yourselves as a Mental Health Worker as opposed to a nurse. Psychiatric nurses moving into nursing homes and other such facilities do so as specialists to fill specific needs. They do not or should not move into these facilities as a general nurse. The term ‘nurse’ no longer describes the function of this type of person. The curriculum should determine if you are specialists in the behavioral sciences, or a nurse in the traditional sense.86

 

The Other Nurse – Page 9

Because of the serious implications of Grunberg’s remarks, significant discussion followed. ‘It was subsequently recognized,’ stated the minutes of this meeting, ‘that Council members take a firm and decisive stand and commence total revamping, this to include our role and philosophy, our name and identity and the curriculum.’ A motion was passed ‘That we do not identify ourselves as ‘the’ nurse.’ A motion ‘That we investigate the legal implications for a change of name in the Act,’ was carried. It was also moved and carried that ‘We accept in principle but subject to further consideration a change in name to ‘Mental Health Worker’.’

The Council considered the question of a change of name as urgent, and made plans for a special meeting of the membership to make a decision. A newsletter went out to all members suggesting the title Mental Health Worker, but explained that ‘This was in no way a firm kind of name.’87

One of the members who reacted strongly to this was W. Vowles. In a letter to the Council he stated:

I can fully agree the curriculum may need revising to meet modern changes in the care and treatment of the mentally sick, but I fail to see that this should call for a change in name. Your choice of title is alarming to me. The definition of a nurse is to tend in sickness or infirmity; the definition of a patient is one suffering from an ailment; the definition of a worker is one who works as a labourer.

Vowles felt the proposed changes would destroy the good image psychiatric nurses had built up over the years, and that the Act did not empower the Council to change the name. Further, the change in name would result in having to make changes in the aims and objectives of the Association and in the Psychiatric Nurses’ Pledge. ‘Is it worth all the risk, time and trouble in order to carry out the suggestions made by the Director of Psychiatric Services?’88

On January 17, 1967 SPNA members gathered in bitterly cold weather from all over the province to attend a meeting called for the purpose of discussing the controversial ‘name change’ issue. Kay Fey, President of the SPNA, opened the meeting by stating that

One of the first responsibilities of the elected officers of any association is to protect the interests of its members. In this case, the psychiatric nurse’s rights and privileges to work, function and receive recognition and remuneration as a professional person. The possibility of a change of name is not a new one as some people think, nor have we been stampeded to irresponsible action by the words of one man as others have stated. It is incomprehensible to me that members of this Association could think or believe that Council would do anything blandly detrimental to the psychiatric nurse, for each one of us on Council are [sic] also vitally concerned with our own future in the mental health field.

This motion was then read to the membership:

That the Provincial Council of the SPNA continue their investigation with legal counsel towards preserving the identity of Psychiatric Nurse. If such investigation proves unfruitful, that the Provincial Council be further empowered to take such action as they deem necessary to preserve our identity including the opening of the Act before the Legislature and an eventual change of name upon approval by a mandate of this Association.

In the confusion that followed, the motion was read a dozen times and it was requested that Fey give her interpretation of the motion. She complied, reiterating what she had said prior to the motion being read. Still not satisfied, the membership demanded her interpretation in writing and she read the following:

My interpretation is that the Act cannot be opened, or, before a change of name can take place, the membership will be requested to state their views in the form of a secret ballot to every member of the Association.89

Following the meeting, five members resigned from the Provincial Council, including Fey, who commented later: ‘It is my contention that the action and demands by the membership was a direct insult upon the intelligence and integrity of their President and Provincial Council Members.’90

On March 1, 1967 a new Executive was elected. The newly elected Secretary, Mel Kruger, upon reflection stated that

Emotions were running high as hell. There are still people who have dropped friendships because of it. This whole issue shattered things for awhile. I’d say it was about two years before we got things really running smoothly again, because of the dissention it caused, and also because of all the new people on Council.91

Psychiatric nurses went back to their jobs to face the world as nurses. The SPNA had the immediate challenge of rebuilding a shattered organization and to address the changes in nursing education that appeared to be both imminent and beyond its control. Over the next two years the SPNA continued its business, organizing a new SPNA central office, restructuring the Council and amending its Bylaws to reflect this change. It also continued to plan a future for psychiatric nurses in the community-oriented mental health field, and continued to explore the establishment of a degree program in psychiatric nursing.92

In September 1969, the Psychiatric Services Branch employed Colvin Peyson to assess the current psychiatric nursing program. He was to examine the training program in meeting the needs of the Psychiatric Services Branch, and to assess the various teaching institutions in terms of methods of instruction, personnel requirements, student selection and types of students entering the courses. His main task, however, was ‘To determine why so many psychiatric nursing students are failing the University examinations for registration in the SPNA.’

The resulting report concluded that there was a great deal of room for improvement in the academic preparation of the instructors and in two of the schools’ programs of clinical supervision and instruction of students. More specifically, the report made a number of recommendations. The first was that supervision and instruction in clinical areas should be instituted by the present instructors at the Weyburn and Moose Jaw schools. The second was that all teaching in junior and senior years should be concurrent, that is, theory should be combined with practice. The third recommendation was that all instructors meet the minimum academic requirements for teaching. The fourth called for a curriculum committee to be set up in each of the schools.93

 

The Other Nurse – Page 10

The SPNA, upon reviewing the report, concurred with all of the recommendations except the last one. In its response to the report, the SPNA recommended that the curriculum committee be a central body with representation from each of the three schools.94

The Deputy Minister of Public Health, S. L. Skoll, also submitted a response to the ‘Peyson Report’.

If we were to closely examine the training courses of the RN’s and PN’s, we would find there is much common ground. In other words, as I see it, after receiving a basic ‘core’ of training the student could specialize in either general nursing or psychiatric nursing. It seems to me that such a proposal, if it could be implemented, would offer every advantage.95

Dr. C. M. Smith, Executive Director of Psychiatric Services, proposed that a two-year program could be set up which would, in some respects, be similar to that for general nurses. But it would include more emphasis on supervised work with psychiatric patients and development of community skills.

In June 1971, Larry Ellis produced a report entitled ‘Psychiatric Nursing In Saskatchewan: A Strategy for Development’, which became known as the ‘Ellis Report’. It was the product of an inquiry undertaken because of concern about the high failure and attrition rates among those aspiring to become psychiatric nurses, and the high cost of their education.96

The recommendations of the Peyson Report opened another long process of negotiation, and the SPNA took the initiative in recommending a major restructuring of the training program to the Psychiatric Services Branch. In some ways, this acted as a catalyst for the Department of Public Health to appoint Ellis to study these concerns. Other factors, however, also led to the study: the fact that the two mental hospitals were rapidly reducing their patient population, the need to find a new location for the training of psychiatric nurses, and the need to introduce new features into the program and to increase the amount of training.97

As a result of responses to a questionnaire developed for the study, Ellis reported that, firstly, there was a ‘lack of a precise functional definition of a psychiatric nurse.’ He also noted:

That both psychiatric nurses and registered nurses are capable of providing fundamental nursing care for both medical and emotional problems of the patients; that student attrition rates throughout all parts of the psychiatric nursing education program were found to be much too high particularly in comparison with general nursing, and that the costs of the psychiatric nursing education program seemed high considering the annual output of qualified psychiatric nurses.98

Ellis had considered the feasibility of developing a core program and reported:

If centralization of the didactic portion of the PN’s training could be in the same location as that of the RN’s, then coring of the curriculum would be possible, mainly in the first year of the two programs.

Related to this, Ellis also recommended that responsibility for the education of psychiatric nurses be transferred from the Department of Public Health to the Department of Education and that a new program be established in post- secondary institutions along with other health science disciplines. The program should be distinct, with its own head who was a member of the SPNA.99

The SRNA disagreed with many of Ellis’ recommendations. It claimed that it could not support the proposal that the head of the psychiatric nursing program be a psychiatric nurse. Further it had difficulties with the proposed program for psychiatric nurses.100

Not surprisingly, the SRNA’s position was challenged in The Psychiatric Nurse. The editor argued that the SRNA had not read the Ellis report in its entirety and that the conclusions in the report were, for the most part, considered true and valid by the SPNA. The SRNA was urged to stop promoting unwarranted recommendations in respect to psychiatric nursing education which were deliberately aimed at thwarting the efforts of others to maintain and enhance an already viable and proven program.101

Although the SPNA endorsed most of the Ellis Report’s recommendations, it did not advocate transfer of authority to the Department of Education. With the release of the report, the SPNA Council called an emergency meeting. Council members contended they had had insufficient time to study the report and that government officials had been reluctant to meet with them. They also agreed that should the proposed transfer occur, there ought to be built-in safeguards to ensure the uniqueness of their profession.

The Council did send a letter to the Department of Public Health explaining its reservations and agreements with the report. It stated that at no time had SPNA advocated phasing out the Schools of Psychiatric Nursing, nor could it visualize the centralization of the school within any one type of facility. SPNA objected to getting ‘everyone into the same boat, an administrative convenience,’ and strongly opposed any move to transfer psychiatric nursing education.102

On November 12, 1971 Walter Smishek, Minister of Public Health in Allen Blakeney’s New Democratic Party government, spoke at a psychiatric nurses’ graduation. He indicated that the gradual reduction (through attrition and failure) of the number of candidates qualifying as psychiatric nurses over the past five years had become a source of real concern. In addition, he told the graduates that the possibility of developing a new centralized educational program was being discussed as a means of dealing with the situation.103

Less than one year later this centralized program at the Saskatchewan Institute of Applied Arts and Sciences in Regina became a reality. November 17, 1972 marked the last graduation exercises held at Weyburn. Twenty-two psychiatric nurses, the final graduating class from the former Saskatchewan Hospital, were honored on this occasion. The last graduation exercises were held in North Battleford and Moose Jaw in 1973.

In September 1972 for the first time in the history of psychiatric nursing in Saskatchewan, students in psychiatric nursing training became, in fact, students. They now had to pay tuition and take all classroom instruction at the Saskatchewan Institute of Applied Arts and Sciences. They were enrolled in the Health Sciences Division which also included Dental Nursing, Diploma Nursing and Nursing Assistant programs. Keith Gannon, a psychiatric nurse, was appointed as the first program head for Psychiatric Nursing at the new institution.104

 

The Other Nurse – Page 11

In conclusion, this essay has reviewed the history of psychiatric nursing and the SPNA in an attempt to answer questions regarding its role in the mental health field; the obstacles the Association faced; and, how it saw itself and was seen by outside parties.

From 1930 to 1972, psychiatric nurses saw many changes in the mental health field which affected the work they did and the training they took. Saskatchewan was a leader in the mental health field, particularly after 1944, and as changes took place psychiatric nurses adapted by developing new skills. Their acquisition of new skills is an important and possibly controversial one. But given the history presented here, it can be argued that as mental health trends changed so did the training and work of psychiatric nurses. Their skills increased from purely custodial in nature to interactive group and drug therapy and then to community-based psychiatric nursing.

The work of the SPNA was integral in facilitating these increased skill levels for its members. While in general the Association had the support of the provincial government, this was most apparent when the CCF was in power. In 1944, T. C. Douglas had a clear agenda to improve health care in the province. Particularly he was committed to improving mental health, and as Premier as well as Minister of Public Health it was apparent that he wanted to personally direct these improvements. His agenda called for establishing a socialized medical care system and improving the care of the mentally ill. This required progressive action and as a result, psychiatric nurses benefited from his government’s support. The government took steps to improve conditions for the mentally ill by implementing the training program for psychiatric nurses, and by supporting their request to establish a professional organization. After all, this was to be a clear signal that it was fulfilling its election promises. The establishment of the SPNA — the first professional psychiatric nursing association in Canada ‘ was one step in the direction of improving health care.

The Liberal government which succeeded the CCF in 1964, although recognizing the interests of the SPNA, had quite a different agenda. By 1968, the economy began to stagnate, and the government needed to curtail expenditures. This had effects on psychiatric nurses in two ways. The first was that cost-cutting measures were sure to include the closure of the mental hospitals in Weyburn and North Battleford. Secondly, if this happened, the training programs would need to be relocated. The SPNA worked hard to prevent these actions by the government, but it became apparent that the government was committed to them. Although more sophisticated in presenting its case, the SPNA was defending a position which, to this government anyway, was out of step with what it believed should happen. In the end, it could be argued, the SPNA had limited control over decisions and actions which were, for the most part, political.

In most historical studies of professions, the professional group is studied in relation to the larger context such as politics, social conditions, or in relation to developments in the field to which it belonged, and not as it related to other professional groups. Both of these elements have been included in this study because to provide a true account of the professionalization and growth of the SPNA, the effect of its relationship with the SRNA must be included.

The point could be argued that the animosity between the SPNA and the SRNA was merely the result of ‘turf wars’. Indeed, it was a ‘turf war’, with the SPNA protecting its professional status and its autonomy, and the SRNA thinking psychiatric nurses should fall under its own umbrella of control. The nature of this relationship cannot be underestimated, particularly as it relates to the professional development of the SPNA. Because of this animosity, it could be argued that the SPNA had two main adversaries. The SRNA constantly questioned the quality of psychiatric nursing training and the fact that the work they did was actually nursing. The second was the psychiatric nurses’ own internal struggle with their identity and self-image. This struggle is evident throughout the Association’s history. The result of constantly being put into a defensive position by the SRNA shadowed the development of the SPNA. Even though they believed their work was that of a nurse in the true sense of the word, the doubts cast upon their professional status caused them to second guess their role as equal to that of the general nurse.

Nonetheless, psychiatric nurses maintained their status throughout the period and indeed were equal partners in the planning for a better mental health system. The work they did was integral to the system and to the care of their patients. They used everything in their power to influence decisions outside of their control. Where inquiries were related to a better mental health care system, the rights of their members, improved training for their members or planning for the future, their voice was always heard. Even though they did not always agree with the final decisions taken, they realized they were for the betterment of care for the mentally ill. Therefore, in the final analysis, they could be seen as valid mental health care professionals.

 

The Other Nurse – EndNotes

  1. W. L. Pritchard, ‘The Psychiatric Nurse and the Public’, in The Psychiatric Nurse (Sapperton, B.C.: Canadian Committee on Psychiatric Nursing, 1951), n.p.
  2. F. H. Kahan, A Different Drummer (Regina: Saskatchewan Psychiatric Nurses’ Association, 1973), p. 109.
  3. Delores Foote, et. al., Fifty Years in Review (Regina: Registered Psychiatric Nurses Association of Saskatchewan, 1998).
  4. Kahan
  5. Sandra L. Bassendowski, ‘Development of the Core Curriculum in Nursing at Wascana Institute of Applied Arts and Sciences, Regina, Saskatchewan,’ M.Ed. Thesis (Regina: University of Regina, 1988).
  6. Paul Susumu Nishida, ‘The Establishment of Saskatchewan’s Mental Hospitals: 1912-1940,’ M.A. Thesis (Regina: University of Regina, 1988).
  7. D. J. Mombourquette, ‘A Government and Health Care: The Co-operative Commonwealth Federation In Saskatchewan, 1944 ‘ 1964,’ M. A. Thesis (Regina: University of Regina, 1990).
  8. Harley D. Dickinson, The Two Psychiatries: The Transformation of Psychiatric Work in Saskatchewan, 1905-1984 (Regina: Canadian Plains Research Center, 1989).
  9. Sharon M. Baldwin, ‘Self-Interest and the Public Interest: Professional Regulation in Saskatchewan, 1905-1948,’ M.A. Thesis (Regina: Canadian Plains Studies, 1998).
  10. Mombourquette, p. 12.
  11. Government of Saskatchewan, Annual Report of the Department of Public Works (Regina: John A. Reid, King’s Printer, 1912), p. 81.
  12. D. G. McKerracher, ‘Historical Development in Saskatchewan, Some Aspects of Psychiatric Development’, in Ten Giant Steps (Regina: Canadian Mental Health Association, Saskatchewan Division, 1959), p. 3.
  13. Ibid.
  14. Kahan, p. 1.
  15. M. C. Schreder and Colin M. Smith, ‘The Training Program for Psychiatric Nurses in Saskatchewan’ (Regina: Saskatchewan Psychiatric Nurses’ Association, 1972), p. 2.
  16. Kahan, p. 3.
  17. Saskatchewan Archives Board, Papers of the Hon. T. C. Douglas, File R33.1, XIV(554) ‘Mental Institutions and Psychiatric Services, January 1960 to February 1961,’ Memo with newspaper clipping from H. G. Ferraby to T. C. Douglas, February 20, 1961.
  18. McKerracher, p. 4.
  19. W. J. Vowles, ‘1960s Archives’ (Regina: Saskatchewan Psychiatric Nurses’ Association Records, 1964), n.p.
  20. J. D. Ward, ‘Ward Staff Training’ in The Psychiatric Nurse (Sapperton, B.C.: Canadian Committee on Psychiatric Nursing, 1951), n.p.
  21. Schreder and Smith, p. 2.
  22. F. Lester Bates, Patterns of Change: Changing Patterns of Care of the Mentally Retarded in Saskatchewan (Regina, 1977), p. 147.
  23. Saskatchewan Health Survey Report, 1951, p. 98.
  24. Kahan, p. 11.
  25. W. J. Vowles, ‘1960s Archives’ (Regina: Saskatchewan Psychiatric Nurses’ Association Records, 1964), n.p.
  26. Saskatchewan Archives Board, Papers of the Hon. T. C. Douglas, File R33.5, III(109), ‘Psychiatric Nurses April 1947 to March 1948,’ Memo from Schumiatcher to Gardiner, April 14, 1947.
  27. Saskatchewan Archives Board, Papers of the Hon. T. C. Douglas, File R33.5, III(109), ‘Psychiatric Nurses April 1947 to March 1948,’ Letter from Vowles to Schumiatcher requesting he review the first draft of the bill regarding the Psychiatric Nurses’ Association, June 10, 1947.
  28. Saskatchewan Archives Board, Papers of the Hon. T. C. Douglas, File R33.5, III(109), ‘Psychiatric Nurses April 1947 to March 1948,’ Letter from Douglas to Gardiner, January 22, 1948.
  29. W. J. Vowles, ‘1960s Archives’ (Regina: Saskatchewan Psychiatric Nurses’ Association, n.d.), n.p.
  30. Ibid.
  31. Ibid.
  32. Ibid.
  33. Foote et. al., pp. 9-10.
  34. Kahan, p. 18.
  35. Saskatchewan Psychiatric Nurses’ Association Records, ‘Council Minutes,’ April 9, 1948.
  36. Ibid.
  37. Kahan, p. 18.
  38. Thelma H. Davis, ‘Needed ‘ A National Council for Psychiatric Nurses’ Association’ in The Psychiatric Nurse (Sapperton, B.C.: Canadian Committee on Psychiatric Nursing, 1951), p. 7.
  39. Frank Jones, ‘The Saskatchewan Psychiatric Nurses’ Association’ in The Psychiatric Nurse (Sapperton, B.C.: Canadian Committee on Psychiatric Nursing, 1951), p. 15.
  40. G. L. Fitzpatrick, ‘Patient Assignment In Psychiatric Nursing’ in The Psychiatric Nurse (Sapperton, B.C.: Canadian Committee on Psychiatric Nursing, 1951), p. 45.
  41. Kahan, p. 31.
  42. Ibid., pp. 23-25.
  43. W. J. Vowles, ‘Canadian Council of Psychiatric Nurses,’ Letter from Vowles to W. R. Butcher, Secretary- Treasurer, CCPN, who had been corresponding to the Federal Department of Health and Welfare regarding the Sub- Committee’s recommendations. (Regina: Saskatchewan Psychiatric Nurses’ Association Records, 1955), n.p.
  44. Kahan, pp. 26-27.
  45. Ibid.
  46. Mombourquette, p. 124.
  47. Dickinson, pp. 138, 155-156.
  48. Ibid.
  49. Mombourquette, p. 126.
  50. M. Schreder, ‘Psychiatric Nursing In the Community’ (Regina: Saskatchewan Psychiatric Nurses’ Association, 1985), p. 3.
  51. Mombourquette, p. 127.
  52. Dickinson, pp. 154-155.
  53. Saskatchewan Psychiatric Nurses’ Association, Submission to the Government of the Province of Saskatchewan (Regina: Saskatchewan Psychiatric Nurses’ Association, 1959), p. 1.
  54. Ibid., pp. 1-3.
  55. Dickinson, pp. 145-146.
  56. Saskatchewan Psychiatric Nurses’ Association, Report of the First Saskatchewan Psychiatric Nurses’ Association Convention (Regina: Saskatchewan Psychiatric Nurses’ Association, 1958), Preface.
  57. Ibid., p. 3.
  58. D. G. McKerracher, ‘The Psychiatric Nurse in Psychiatry’s Changing Picture’ in Report of the First Saskatchewan Psychiatric Nurses’ Association Convention (Regina: Saskatchewan Psychiatric Nurses’ Association, 1958), p. 9.
  59. Ibid., p. 10.
  60. Ibid.
  61. Ibid., p. 12.
  62. Humphrey Osmond, ‘The Psychiatric Nurse and the Mental Hospital’ in Report of the First Saskatchewan Psychiatric Nurses’ Association Convention (Regina: Saskatchewan Psychiatric Nurses’ Association, 1958), p. 17.
  63. McKerracher, ‘The Psychiatric Nurse in Psychiatry’s Changing Picture’, p. 12.
  64. Kahan, pp. 31-33.
  65. Ibid., p. 33.
  66. Ibid., pp. 34-37.
  67. Saskatchewan Psychiatric Nurses’ Association Records, ‘Council Minutes,’ Sonnergren’s report to Council, May, 1961.
  68. Kahan, p. 37.
  69. Saskatchewan Psychiatric Nurses’ Association Records, ‘Council Minutes,’ Sonnergren’s report to Council, November, 1961.
  70. Kahan, p. 41.
  71. Ibid., p. 39.
  72. Saskatchewan Psychiatric Nurses’ Association, Submission to the Royal Commission on Health Services (Regina: Saskatchewan Psychiatric Nurses’ Association,1962), p. 7.
  73. Kahan, pp. 42,48.
  74. Government of Canada, Royal Commission on Health Services (Ottawa: Queen’s Printer, 1964), p. 279.
  75. Saskatchewan Psychiatric Nurses’ Association Records, ‘Education Committee,’ Report of the Education Committee to the membership, May, 1965.
  76. Kahan, p. 49.
  77. Schreder and Smith, p. 5.
  78. Kahan, p. 50.
  79. Bassendowski, p. 81.
  80. Saskatchewan Psychiatric Nurses’ Association, Submission to Ad Hoc Committee on Nursing Education (Moose Jaw: Saskatchewan Psychiatric Nurses’ Association, 1965), p. 8.
  81. Government of Saskatchewan, Ad Hoc Committee on Nursing Education, Brief #13, 1965, p. 10.
  82. Bassendowski, p. 89.
  83. Government of Saskatchewan, Ad Hoc Committee on Nursing Education, Brief #25, 1965), p. 1.
  84. Anonymous, The Psychiatric Nurse (New Westminster, B.C.: Psychiatric Nurses’ Association of Canada, 1966), p. 11.
  85. Kahan, p. 58.
  86. Ibid.
  87. Ibid.
  88. W. J. Vowles, ‘1960s Archives,’ Letter from Vowles to Elmer Sauvie (Regina: Saskatchewan Psychiatric Nurses’ Association Records, 1966)
  89. Kahan, pp. 60-62.
  90. Ibid.
  91. Ibid.
  92. Ibid., p. 65.
  93. C. Peyson, An Evaluation of the Psychiatric Nursing Training Program (Regina: Department of Public Health, Psychiatric Services Branch, 1969), p. 2,30.
  94. Kahan, p. 71.
  95. Bassendowski, p. 91.
  96. Ibid., p. 92.
  97. Kahan, p. 74.
  98. L. T. Ellis, Psychiatric Nursing In Saskatchewan, A Strategy for Development (Regina: Health Manpower Studies Unit, Research and Planning Branch, Department of Public Health, 1971), p. 5.
  99. Ibid., pp. 55-57.
  100. Bassendowski, p. 93.
  101. Linda Lee, Editor’s Comments, The Psychiatric Nurse, (Winnipeg: Psychiatric Nurses’ Association of Canada, 1972), p. 3.
  102. Kahan, p. 76.
  103. Bassendowski, p. 94.
  104. Kahan, pp. 79-81.

 

The Other Nurse – Bibliography

SASKATCHEWAN PSYCHIATRIC NURSES’ ASSOCIATION RECORDS

Provincial Council Minutes 1948-1972
Branch Minutes 1948-1972
The Psychiatric Nurse 1951-1972
‘1960s Archives’ Binder
Graduation Records 1950-1972
Curriculum and Examinations Files
Briefs File
Canadian Council of Psychiatric Nurses Records
Report of the First Saskatchewan Psychiatric Nurses’ Association Convention. Regina: Saskatchewan Psychiatric Nurses’ Association, 1958.
Submission to Ad Hoc Committee on Nursing Education. Moose Jaw: Saskatchewan Psychiatric Nurses’ Association, 1965.
Submission to the Government of the Province of Saskatchewan. Regina: Saskatchewan Psychiatric Nurses’ Association, 1959.
Submission to the Royal Commission on Health Services. Regina: Saskatchewan Psychiatric Nurses’ Association,1962.
I would like to thank the staff of the Registered Psychiatric Nurses’ Association of Saskatchewan ‘ Marion Rieger, Executive Director, Sharon Rooney and Linda Jesset.

SASKATCHEWAN ARCHIVES BOARD FILES

Sessional Paper No. 27, Report of Commission C. M. Hincks, 1930.
Department of Public Health, Annual Reports, 1930-1972.
Department of Public Health, Psychiatric Services Branch, 1944-1972.
F. H. Kahan Papers for SPNA 25th Anniversary book, A Different Drummer
Papers of Premiers and Cabinet Ministers,
Honorable Thomas J. Bentley
Honorable Allan E. Blakeney
Honorable William G. Davies
Honorable Thomas C. Douglas
Honorable Jacob W. Erb
Honorable Woodrow S. Lloyd
Honorable Walter Smishek
Honorable David G. Steuart
Honorable W. Ross Thatcher
Honorable John M. Uhrich

GOVERNMENT OF SASKATCHEWAN

Annual Reports of the Health Services Planning Commission 1944-1951
Ellis, L. T. Psychiatric Nursing In Saskatchewan, A Strategy for Development. Regina: Health Manpower Studies Unit, Research and Planning Branch, Department of Public Health, 1971.
Government of Saskatchewan. Ad Hoc Committee on Nursing Education, Brief #13, 1965.
Government of Saskatchewan. Ad Hoc Committee on Nursing Education, Brief #25, 1965.
Health Services Survey Commission: Report of the Commissioner. Regina: King’s Printer, 1944.
Health Survey Committee. Saskatchewan Health Survey Report, Volume One: Health Programs and Personnel. Regina: King’s Printer, 1951.
Health Survey Committee. Saskatchewan Health Survey Report, Volume Two, Hospital Survey and Master Plan. Regina: King’s Printer, 1951.
Peyson, C. An Evaluation of the Psychiatric Nursing Training Program. Regina: Department of Public Health, Psychiatric Services Branch, 1969.

GOVERNMENT OF CANADA

Royal Commission on Health Services, Ottawa: Queen’s Printer, 1964.

 

The Other Nurse – Other

Anonymous. The Psychiatric Nurse. New Westminster, B.C.: Psychiatric Nurses’ Association of Canada, 1966.
Archer, John H. Saskatchewan, A History Saskatoon: Western Producer Prairie Books, 1980.
Baldwin, Sharon M. ‘Self-Interest and the Public Interest: Professional Regulation in Saskatchewan, 1905-1948,’ M.A. Thesis. Regina: Canadian Plains Studies, 1998.
Bates, F. Lester. Patterns of Change: Changing Patterns of Care of the Mentally Retarded in Saskatchewan. Regina, 1977.
Bassendowski, Sandra L. ‘Development of the Core Curriculum in Nursing at Wascana Institute of Applied Arts and Sciences, Regina, Saskatchewan,’ M.Ed. Thesis. Regina: University of Regina, 1988.
Davis, Thelma H. ‘Needed ‘ A National Council for Psychiatric Nurses’ Association,’ in The Psychiatric Nurse. Sapperton, B.C.: Canadian Committee on Psychiatric Nursing, 1951.
Dickinson, Harley D. The Two Psychiatries: The Transformation of Psychiatric Work in Saskatchewan, 1905 ‘ 1984. Regina: Canadian Plains Research Center, 1989.
Fitzpatrick, G. L. ‘Patient Assignment In Psychiatric Nursing,’ in The Psychiatric Nurse. Sapperton, B.C.: Canadian Committee on Psychiatric Nursing, 1951.
Foote, Delores, et. al. Fifty Years in Review Regina: Registered Psychiatric Nurses Association of Saskatchewan, 1998.
Friesen, Gerald. The Canadian Prairies, A History. Toronto: University of Toronto Press, 1984.
Jones, Frank. ‘The Saskatchewan Psychiatric Nurses’ Association,’ in The Psychiatric Nurse. Sapperton, B.C.: Canadian Committee on Psychiatric Nursing, 1951.
Kahan, F. H. A Different Drummer. Regina: Saskatchewan Psychiatric Nurses’ Association, 1973.
Lee, Linda. ‘Editor’s Comments,’ in The Psychiatric Nurse. Winnipeg: Psychiatric Nurses’ Association of Canada, 1972.
McKerracher, D. G. ‘Historical Development in Saskatchewan, Some Aspects of Psychiatric Development,’ in Ten Giant Steps. Regina: Canadian Mental Health Association, Saskatchewan Division, 1959.
McKerracher, D. G. ‘Nursing In Saskatchewan,’ in Ten Giant Steps. Regina: Canadian Mental Health Association, Saskatchewan Division, 1959.
McKerracher, D. G. ‘The Psychiatric Nurse in Psychiatry’s Changing Picture,’ in Report of the First Saskatchewan Psychiatric Nurses’ Association Convention. Regina: Saskatchewan Psychiatric Nurses’ Association, 1958.
Mombourquette, D. J. ‘A Government and Health Care: The Co-operative Commonwealth Federation In Saskatchewan, 1944 ‘ 1964,’ M. A. Thesis. Regina: University of Regina, 1990.
Nishida, Paul Susumu. ‘The Establishment of Saskatchewan’s Mental Hospitals: 1912-1940.’ M.A. Thesis. Regina: University of Regina, 1988.
Osmond, Humphrey. ‘The Psychiatric Nurse and the Mental Hospital,’ in Report of the First Saskatchewan Psychiatric Nurses’ Association Convention. Regina: Saskatchewan Psychiatric Nurses’ Association, 1958.
Pritchard, W. L. ‘The Psychiatric Nurse and the Public,’ in The Psychiatric Nurse. Sapperton, B.C.: Canadian Committee on Psychiatric Nursing, 1951.
Robinson, Marguerite E. The First Fifty Years. Regina: Saskatchewan Registered Nursing Association, 1967.
Schreder, M. ‘Psychiatric Nursing In the Community,’ Regina: Saskatchewan Psychiatric Nurses’ Association, 1985.
Schreder, M. C. and Colin M. Smith. ‘The Training Program for Psychiatric Nurses in Saskatchewan,’ Regina: Saskatchewan Psychiatric Nurses’ Association, 1972.
Sheppard, Michael. Mental Health in the Community. London: The Falmer Press, 1991.
Ward, J. D. ‘Ward Staff Training,’ in The Psychiatric Nurse. Sapperton, B.C.: Canadian Committee on Psychiatric Nursing, 1951

 

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