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Out of the asylum

The history of mental health nursing

Mental health nursing has not always been the recognised field of practice it is today. Whilst the debate on what is ‘care’ and what is ‘control’ continues, the tension between the two was more prevalent than ever in nineteenth century nursing practice. Keepers or attendants with little training were subject to a strict regime within the asylum, where custody and order prevailed. Some showed great care for their patients, but had little freedom to develop their practice. Today, the delivery of mental health care looks very different.

This exhibition introduces the early roots of mental health nursing and the changes that have emerged, for better or for worse. Its history is shaped by shifts in education, treatment, the care environment and legislation. Central to the field today, is the building and sustaining of therapeutic relationships with patients and service users.

A selection of old fashioned keys on a keyring. Brass tap keys 19th century. Bethlem. Colourised postcard of the exterior front of a two- storey building, with a central clock tower, covered in ivy. A postcard showing the exterior of Sedgefield Asylum Blue uniform card Black and white cover of the Programme of theatricals

Environment

The setting within which mental health nurses work has changed dramatically throughout history. Increasing demand on the smaller ‘madhouses’ of the eighteenth century prompted the building of much larger asylums in the Victorian and Edwardian era. The move to community care from the 1960s has led to many mental health nurses now being based outside hospital walls.

Nursing roles and responsibilities have changed within those different environments. Few mental health nurses now wear uniforms, making their identity badges one of the only visible distinctions between staff and patient.

Image: Postcard - Danvers Insane Hospital, Hathorne, Mass. c.1900. RCN Archives.

Treatment

In nineteenth century asylums, treatment was largely focused on the setting and surroundings. As well as maintaining order, nursing staff worked alongside patients at facilities such as the laundry and on-site farms. They also provided entertainment with concerts and dances. In the photo above, you can see a printing workshop held at Whittingham Hospital, Lancashire in around 1920.

In the twentieth century, physical treatments also became popular. Nursing staff administered medication and assisted with new practices, like electro-convulsive therapy. Whilst asylum nurses were expected to communicate with patients as much as possible, ‘talking treatments’ such as counselling and Cognitive Behavioural Therapy came much later. Now mental health nurses are trained in a range of psychotherapeutic techniques.

Electro-convulsive therapy machine, around 1960. 

Electro-convulsive therapy machine, c1960

Black and white photograph of three people at the printing workshop at the Whittingham Asylum circa 1920 Black and white cover of the Under the Dome hospital magazine 1889 - 1890/9. Bethlem. Restraint Key. 18th century. Bethlem.

Legislation

Laws and regulations have always shaped mental health nursing practice. Earlier laws were often supplemented by long rule books, which were gradually replaced by codes of practice. Nursing roles were heavily regulated by institutional codes of  conduct and asylum rules. These codes were initiated by regulations  from the various Lunacy Acts throughout the 19th century. Statutes such as the 1845 Lunacy Act and the 1983 Mental Health Act in England and Wales, and the Mental Health (Care and Treatment) Act 2003 in Scotland, have all defined nurses’ working lives. Now, the Nursing and Midwifery Council (NMC) Code of Conduct guides nurses in how to carry out their responsibilities to deliver high quality care. 

Book cover of Brookwood Asylum rule book

Image: Brookwood Asylum Rules for the Guidance of Attendants and Servants. 1871. RCN Library and Archives.

Education

Early mental health nurses learned on the job, guided by colleagues and lengthy rule books. In 1885 doctors responded to the need for more guidance for staff and published ‘The Handbook for the Instruction of Attendants on the Insane’, known famously as the ‘Red Handbook.’ By 1891, the Medico-Psychological Association – now the Royal College of Psychiatrists - had established the first national training scheme for nurses, introducing formal lectures and examinations.

At the turn of the Century, the movement towards state registration for nurses was gathering momentum. Mental health nurses were included in the 1919 Nurses Registration Act, but on a supplementary part of the register. Today, mental health nurses are recognised amongst other fields of nursing and are required to complete a NMC approved degree in nursing.

'Red' Handbook/Asylum attendant handbook

Mental health nursing has been changing throughout the centuries. Today, Nurses work as part of a multi-disciplinary team, alongside other professionals such as psychiatrists, social workers and occupational therapists. These nurses and the wider team play a pivotal role with patients and their families, helping to restore people’s mental well-being and supporting their recovery.

Update your knowledge on the present day mental health nursing by visiting our subject guide.


This exhibition was on display at the RCN Library and Heritage Centre in 2015. It was curated by the RCN Mental Health Forum, the RCN History of Nursing Forum and the RCN Library and Archive Service.