PREPARING THE NURSE TO RENDER A SERVICE TO THE MENTALLY RETARDED

Die hoofdoelstellings van ’n diens aan die geestesvertraagde is rehabilitasie in die gemeenskap, of die bereiking van maksimale persoonlike en sosiale onafhanklikheid binne die omgewing van ’n sorgen rehabilitasiesentrum. Daarom moet die verpleegkundige opgelei word om in die normale (of primêre) menslike sowel as die buitengewone behoeftes van die geestesvertraagde te voorsien. Voorbereiding moet op primêre, sekondêre en tersiêre vlak geskied. Dienslewering geskied in sorgen rehabilitasiesentra asook in die gemeenskap. Grondig onderlê in die toepaslike mediese, biologiese en sosiale wetenskappe, asook in die terapeutiese vaardighede van die psigiatriese verpleegkunde, moet die verpleegkundige gemoeid met die geestesvertraagde persoon egter ook leer om die konsep “ normalisering” in haar benadering tot die persoon te bring dit is, in die beraming van sy behoeftes, in die beplanning van sy versorging en rehabilitasie, in die uitvoering van hierdie beplanning en in alle fasette van evaluering.

P rep aratio n for a specific responsibility requires an answer to the following question: W ho is being prepared to do w hat with whom and in w hat location?T he answ er to this question will serve as a basis for set ting fo rth certain guidelines for the educational p re p ara tion for nurses to render a service to the m entally re ta r ded (1, p. 19).
T he answer to who is being prepared, as far as this paper is concerned, is the nurse, because the health ser vices have the responsibility for all m entally retarded children from birth to six years, and after the age o f six years for all those persons who are not suitable for special education or training.The answer to the second p art o f the question is sum m arised in the im posed task, nam ely to render a service to the m entally retarded.The location in which this service m ust be rendered is vast and extends from the com m unity to the C are and R ehabilitation C entres.It includes the preventive, p ro m otive, curative and rehabilitative dim ensions o f m en tal retard atio n .
In the R epublic o f South A frica it is prim arily the registered a n d /o r enrolled psychiatric nurse who is be ing prepared to care for the m entally retarded.
The professional registered psychiatric nurses are trained at different levels o f educational preparation.A t the basic level o f nursing education three courses are o f fered: -A three years and six m onths diplom a course leading to registration as a general nurse and psychiatric nurse.-A three years diplom a course fo r registration as a psychiatric nurse.-The third type o f registered nurses are graduates of different degree program mes in nursing offered at university level.A t the post-basic level after registration as a general nurse there is a one year course fo r registration as a psychiatric nurse.In all the above-m entioned courses m ental re ta rd a tion nursing care form s an integral p a rt o f the psychiatric nursing curriculum .
A ccording to the South A frican N ursing C ouncil directive the form al education in m ental retard atio n should include the following: genetic and congenital causes; classification and clinical varieties; prevention; psychological assessm ent; education, training and all other rehabilitative m ethods; socialisation; com m unity care o f the m entally retarded; legal aspects (8,1).
The m inim um required periods o f instruction for the com plete course in psychiatric nursing, which includes the section on m ental retard atio n , are tw o hundred and forty periods.Surely with such a com prehensive field such as psychiatric nursing the curriculum section on m ental retard atio n co u ld n 't possibly receive at the m ost m ore than one third o f the allocated teaching periods.T h at am ounts to approxim ately eighty teaching periods.In the post-basic diplom a course for registration as a psychiatric nurse the prescribed m inim um required periods o f instruction are even less, nam ely only one hundred and tw enty periods for P sychiatric N ursing Science and A rt III o f which m ental reta rd atio n is a com ponent.
In both the three years and three and a h alf years as well as in the one year basic courses the prescribed period o f clinical instruction and practica am ounts to fo u r weeks only.The clinical instruction and practica period for degree students is a mere tw o weeks.In the a u th o r's opinion the latter two courses were in troduced by the S A Nursing C ouncil with the con tem plated objective to envisage such a new caring p ro fession o f m ental retardation nurses with registered psychiatric and enrolled nurses as its nucleus.
In dealing with the second part o f the postulated question one has to have a closer look at who the m en tally retarded are, their needs, and how they m ust be cared for.
The mentally retarded who prim arily would be the responsibility o f the nursing profession are the severely m entally retarded, the m entally retarded children of pre-school age, and secondary all the other categories of m entally retarded in C are and R ehabilitation Centres who need institutionalised care.
A fundam ental concept in rendering a service to the m entally retarded that needs em phasis is that the m en tally retarded are not sick but are handicapped or im paired in their ability to live independently and to meet the critical dem ands o f society, and that the nursing profession, in their caring function, have an obligation to help them live as norm al a life as possible.
The m ajor aims o f a service to the m entally retarded are to achieve rehabilitation into the com m unity or m axim um personal and social independence within a residential setting.
Thus, the nurse has to be prepared to provide for the norm al hum an as well as the exceptional needs o f the mentally retarded.The prim ary needs o f the m entally retarded person are 'hom e' care, education, occupa tional and social training.This concept is consistent with the term encom passed by the 'norm alisation' prin ciple in the Swedish philosophy o f care (5, p .970).
W olfensberger defined the goal o f norm alisation as the developm ent o f behaviours and characteristics by the m entally retarded person th at are average or norm al for the individual's culture.The techniques and en vironm ents used to attain the goal were also to be the usual or accepted m ethods for the general culture (1, p.33).
Nurses should be taught to review their practice and use o f the nursing process; they have to incorporate the concept o f normalisation into their assessment o f the person's needs, planning o f care and rehabilitation, im plem entation o f the care and rehabilitation plan and in to all facets o f evaluation.
A part from the prim ary needs, research has shown that there are some other exceptional needs o f the m en tally retarded.
A survey in 1972 showed th at m any o f the children and adults in institutions for the m entally retarded were very dependent, and require considerable basic care from the nursing personnel: 20% o f those surveyed were severely incontinent, while 23% were reported to need m uch assistance to feed, wash and dress (5, p .970).
These figures confirm that basic care in a care and rehabilitation centre is needed for a significant p ro p o r tion o f the severely and profoundly m entally retarded.But even for these persons skilled and well prepared nurses are required because it has been proven that with the provision o f structured learning experiences and 'n o rm al' social environm ent most o f these persons can acquire basic self-help and can learn to m odify difficult and disturbed behaviours.
Kushlick has reported that " no child has been found to fit the description o f 'helpless idiot', 'vegetable', 'non-responsive' in spite o f the fact that only a m inority have speech or can even score on an IQ-test.All are in need o f or are capable o f responding to individual tra i ning program m es on operant conditioning lines" (5, p. 970).
The care skills and knowledge required by nurses of the m entally retarded to meet these sort o f needs are not ju st those th at are general to nursing.They are also those o f a p arent, a skilled residential social w orker with a wide knowledge o f how individual relationships can be developed and m aintained and an understanding o f group inter-action, and o f specialist educator able to provide carefully structured teaching program m es (5, p. 970).
M cCoull, in a large survey o f 6 258 retarded people living in hospitals and in the com m unity, found that 6,4% were at the time o f exam ination suffering from a chronic illness o f one sort or another.M ost o f the ill nesses reported were ones which did not require skilled nursing care (5, p .969).
To provide for the medical nursing needs o f the m en tally retarded it is essential that the nurse should be skil led at recognising the first signs o f illness, particularly in those too retarded to com m unicate.They should also be equipped to deal with emergencies such as status epilepticus.
F urtherm ore they should have extensive knowledge ab out heart and respiratory disorders and the preven tative m easures necessary to reduce the spread o f com m unicable diseases within a residential situation.N u tri tion, dietetics and psychopharm acology should also be included in the curriculum .
The needs o f the mentally retarded with reference to psychiatric illness have been studied by researchers.C areful exam ination o f the studies by Leek, G ordon and M cKeown, W illiams and M cCoull, suggest that 10%, 11% and 12% respectively, o f the patients surveyed, showed significant psychiatric disorder (5, p. 969).
T herefore a m inority o f m entally retarded do need skilled psychiatric nursing care.
In p reparation for m entally retarded nursing the p ro fessional training o f the nurse should be m atched to the following roles, functions and responsibilities: D eterm ination o f the needs o f the m entally retarded; description and assessm ent o f handicaps; exam ination and utilisation o f the services that will m axim ise per sonal independence and social adjustm ent; as well as organisation and co-ordination o f specialist services for those with special or exceptional needs (5, p .970).
W hat guidelines could be proposed for the educa tional preparation for nurses?
As previously m entioned, the Briggs R eport in its sec tion on New C areer D evelopm ents in m ental handicap, recom m ended the em ergence o f a new caring profession for m ental handicap, with m ental sub-norm ality trained nurses as its nucleus.
A nother m ore recent report, the Jay C om m ittee (1979), proposed the training o f two basic grades of residential care staff for the m entally retarded, i.e.: -qualified care w orkers with a certificate in general residential care and m ental handicap aspects, either children or adults; -in-service trained care w orkers.This group consists o f the nursing and care assistants who would have form al in-service training o f at least two weeks each year.
Because it sees the m entally retarded as needing prim ary residential care rather than treatm ent in the clinical sense, the C om m ittee feels the care sta ff should only be trained in the basics o f residential care.As far as this com m ittee is concerned we thus see that they suggest the emergence o f totally new category of care sta ff w ithout any resem blance to nurse training.
C ritique why the above-m entioned recom m endation o f the Jay R eport will not succeed is ab u n d an t in recent literature and the au th o r tends to agree with som e o f it.O ne such au th o r is J. Bavin -" The C om m ittee m akes the p ro found m istake of thinking that residential care is the fundam ental p ro blem.R ather it is the objective, and the problem is disordered behaviour.
1 can dem onstrate to anyone, at any tim e, num bers of mentally handicapped people who have been in splendid residential care at home and in local authority hostels, and yet have been unable to benefit from these oppor tunities to sample the good community life.They have been transferred to sub-normality hospitals because peo ple could not cope with the problem s o f disordered behaviour, m ultiple handicaps and the burden of physical care.
If on the other hand, I were to draw up a list o f the personal characteristics, knowledge, skills and techni ques required to deal effectively with the problem s o f behaviour presented in profusion by m any m entally handicapped people in hospital, it would leave few people with any doubts as to where the m ain training is needed.
T o give ju st a short list we expect sta ff in hospitals to be expert in behaviour m odification, M akaton, the recognition o f m ental illness, epilepsy, drug actions and side-effects.B ehaviour m odification itself is a technical subject o f som e com plexity, and requires considerable training, to say nothing o f self-control and self wareness (2, p .822).
If residential care is the m ain skill area required to look after m entally retarded people in a hum ane way and a norm al dom estic environm ent, why ca n 't m any parents m anage it? . . .C ertain o f mentally retarded persons have a tem porary or perm anent need for specialized skills, others would apparently need general, paediatric and psychiatric treatm ent which can only be carried out by ap p ropriate trained nursing sta ff" (2, p .823).
T here will always be a need for a skilled, com m itted, professional nursing work force to treat, train and care for, especially th at group o f mentally retarded persons who will be rejected from the educational and social facilities provided by care w orkers from other State D epartm ents.
A fu rth er point in rejecting the recom m endations o f the Jay R eport is th at the m ajor problem with registered psychiatric nursing training has not been the syllabus, which is periodically up d ated , but the inadequate periods o f practical experience in obsolete facilities.
T he last aspect o f the postulated question still needs answ ering nam ely 'in w hat location?'T he function o f the nurse in m ental retardation has three dim ensions -prim ary, secondary and tertiary.The dom ain o f her practice includes the com m unity and the institution, the nurse works with the m entally retarded person in his fam ily circle, his occupational en vironm ent, and in C are and R ehabilitation centres.She is em ployed by m any different em ployers, each of them rendering a service o f some kind to the mentally retar ded.The practising professional nurse who works at m aternity hospitals, ante-and post-natal clinics, at school clinics, child guidance clinics, etc. also plays a role in rendering a service to the m entally retarded.M ental retard atio n nursing education has to encom pass the preventative, prom otive, curative and rehabilitative aspects o f care.
W ith reference to the above discussion the following guidelines are proposed for the educational preparation for nurses to render a service to the m entally retarded.
The curriculum should make provision for the follow ing learning experiences as well as ample provision for the necessary clinical experiences.

See next page for guideline.
The curriculum should also include those biological and medical sciences that provide students with depth of theoretical knowledge to explain causation and related problem s.A nother area of content needed comes from the behavioural sciences, including hum an develop m ent, which enlarges the stu d en t's repertoire of developm ental concepts and provides her with the in tellectual tools for m aking m ore sophisticated assessm ents and com parisons between norm al and de viant o f hum an behaviour and inter-action as well as giv ing the nurse a theoretical foundation for designing en vironm ental intervention directed tow ard behaviour control (3, p .639).
The m ajor effort in the educational preparation of the nurse to render a service to the mentally retarded should be directed tow ards the expression of the poten tialities o f the hum an being, and tow ards m aintaining his integrity, while at the same time conserving these resources so that he can cope with those developm ental crises which originate from deviation in grow th (3, p .634).
The nurse who specialises in the nursing care o f the m entally retarded must be prepared to intervene with a high level o f skill in a caretaking, m aintaining, and sus taining m anner.
Enrolled nurses are the second m ajor category of nurses w ho are being prepared to render a service to the m entally retarded.Their training consists o f a two year course for the certificate for enrolm ent as an enrolled nurse.As part o f their course they specialise in one of five elective courses viz.care o f the aged, nursing care o f m entally defective persons and com m unity health nursing, general nursing, psychiatric nursing.The prescribed curriculum o f the S A N ursing C oun cil fo r the elective course in the nursing care o f m entally defective persons represents a detailed and com prehen sive syllabus on the subject-m atter as well as sufficient tim e for the necessary clinical experience.The field o f m ental retardation nursing includes the follow ing in this course: A w a re n e ss o f b a sic a n d in d iv id u a l n ee d s, psychological m anifestations o f retarded developm ent, intellectual, social and em otional needs and problem s, anatom ical and physiological m anifestations and associated handicaps o f m ental re tard atio n , special therapeutic skills as well as lectures on nutrition and dietetics, first aid, psychotropic medicines, facilities for the m entally handicapped and adm inistrative aspects (8,2).T he m ost recent educational developm ent in prep ar ing the nurse to render a service to the m entally retarded is a post-basic course for registered psychiatric nurses called the A dvanced D iplom a in Psychiatric Nursing Science.This course also m akes provision for electives in which prospective students may specialise, namely: advanced nursing in child psychiatry, advanced nursing in com m unity psychiatry, and advanced nursing o f the m entally retarded.T he above-m entioned courses constitute the basis o f a training program m e for registered and enrolled nurses who are expected to render a service to the mentally retarded.Does this training equip the psychiatric nurse adequately to care for the m entally retarded?The Briggs C om m ittee (7) in 1972, rejected 'nurse' training as ap p ro p riate to the m ajor needs o f the m en tally retarded.They recom m ended the em ergence, in the long term , o f a new caring profession for m ental h an dicap, with m ental sub-norm ality trained nurses as its nucleus.

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or qualification the C om m ittee therefore proposes a program m e o f training with the accent on caring for m entally retarded people, rather than training m ental retardation care staff with the accent on the residential setting.The C om m ittee also decided that the C entral Council for E ducation and Training o f Social W orkers should take over the training o f these care w orkers.They m ain tained that the current nurse training, supervised by the nursing councils, does not place enough em phasis on the social and educational role (4, p .393).
PR IM A R Y D IM EN SIO N or PR EV EN T A TIV E LEVEL Genetic counseling P re-natal C are C are o f the new born C are o f high-risk infants and families early and on-going assessm ent recognition o f m aternal high risk factors ante-natal testing and interpre tation ap p ro p riate interventions patient education neurological assessm ent SECO N D A R Y D IM EN SIO N -Identification -Intervention N eurom otor developm ent: assessm ent and im plications D evelopm ental screening Identification o f the visible'child in the com m unity M axim ising services for the m entally retarded -co-ordinated efforts B ehavioural hom e m anagem ent program s • N ursing interventions in the fam ily approach • support • inform ation giving and health teaching • crisis intervention Counselling C om m unication and collaboration with com m unity agencies and other professionals Institutionalised nursing care • E valuation • N ursing care plans -Nursing Process • Social reorientation continence and personal hygiene dressing m obility self-help in feeding speech appreciation o f num ber and m oney socialising with others work social activities hobbies and sport activities The inter-disciplinary approach Inter-personal skills TE R T IA R Y D IM EN SIO N or R E H A B IL IT A T IV E LEVEL -The transition from institution to com m unity living (1, p p .89-199).CURATIONIS Desem ber 1980