INTRODUCTION

The Nurses Registration Act (Ministry of Health, 1919) instigated

the beginning of a movement which precipitated nursing on a
journey towards professional status. Many changes have taken
place in health care since this Act. There has been a steady
retraction in the number of large hospitals that for many years
were seen as places of 'asylum' for people with mental health
problems and those with learning disabilities. The increase in the
number of older people who require health and social care and
people who have chronic illnesses or disabilities, and the ever
shortening period that people now stay in general hospitals have
led to an increased focus on community care. There has also been a
philosophical shift in health care provision from what was previously
amelioration of illness to a more preventative health-promoting
focus.
One of the major responses that nursing has made to the above
social and health policy changes has been the development of
community health care nursing. Community health care nursing
has developed into eight distinct specialisms to meet current needs:
children, learning disability, mental health, district, occupational health, school, public health and general
practice nursing (UKCC,
1994).
Godin (1996) provides a developmental account of community
psychiatric nursing since the turn of the twentieth century. Two of
the main ideologies which Godin suggests have influenced the
development of community psychiatric nursing have been 'physicalism'
and the 'psychosocial' approach to care. Physicalism is the
development of physical treatments such as major tranquillisers and
the administration of these drugs by 'depot' injections for people
with mental health problems. The psychosocial model emphasises
the psychological and social causation of mental illness, thus
supporting a health promotion focus in mental health care employing
social, environmental and educational interventions.
Both models which Godin refers to are known to influence all
specialists of community health care nursing. Physicalism is evident
in the technological advances in general medicine and surgery which
have led to much shorter stays in hospital by patients followed by
their rapid discharge to community care. Indeed many individuals
are now receiving treatment in the community who previously
would have been admitted to hospital. The psychosocial model
has been an influencing factor on the aims of the report Caring for
People (DoH, 1989), which recognises the benefits to individuals in
all client groups of remaining in their own community when they
require health or social care.
However, a sceptical view, which will not be debated here, would
be that government had other agendas in mind when they pushed
for community care.
The emphasis of this chapter is to suggest that community health
care nurses should focus, or perhaps refocus, on an additional
ideology or model which is based on the philosophy of dialogicalism,
as presented by thinkers such as Martin Buber (1970) and
Gabriel Marcel (1949). The work of existentialist philosophers such
as Sartre (1958) will also receive attention. The issues which these
philosophers have deliberated on relate to the perception of 'self,
the 'self and 'others' and 'presence' with others. These premises
have been debated and written on extensively (whole texts addressing
them) by philosophers, and in a chapter of this size all that can
be provided is an overview of some of their central ideas. This
chapter links very closely with Chapter 3, both advancing a
'relationship'-focused approach to community health care nursing.
Nursing theorists who forward perspectives which are analogous
with the philosophical standpoint of the centrality of human relationships in nursing will be presented. The
mergence of relationship-
focused nursing theories with the ideas of the philosophers
mentioned above will be suggested as an additional human caring
foundation to be used by community health care nurses in conjunction
with (not to replace) the physical and psychosocial models. For
example, it will be suggested that whether a community health care
nurse is providing physical or clinical care 'to' a person in need of
such, cognitive therapy 'to' a person with mental health problems,
or behavioural therapy 'to' a child with learning disabilities, in each
situation care may be viewed as being provided 'with' the other
person and not 'to' him or her.