The Department of Health (DOH 2006) recognises that mental health nurses are the largest profession working within the field of mental health today. In the Chief Nursing Officer’s (CNO 2006), review it recommends that, it is essential for mental health nurses to incorporate the broad principles of core values when carrying out care (DOH 2006). This essay will focus on the key principles of core values of equality and diversity, evidence based practice and the recovery approach. The significance of these within the field of mental health nursing will be discussed. Finally it will explain how these core values impact on people who experience symptoms of psychosis.

According to The Nursing and Midwifery council (NMC 2008) the core principles when carrying out care are to treat people as in individuals and respect their privacy and dignity; not to discriminate in any way against those who are receiving care; to collaborate with others is essential to protect; and promote the health and well-being of those receiving care, their families, carers and people in the wider community. It is imperative to provide a high standard of practice and care at all times. Acting with integrity and being open and honest is vital to uphold the reputation of the nursing profession.

The DOH (2006) recognises equality in health care is imperative to ensure that each person has an equal opportunity to have their needs met. People should be treated the same no matter what their race, gender, disability, age or sexual orientation is (Equality Act 2010). The CNO (2006) says that being equal is not necessarily being the same it is vital that nurses understand the meaning of “Difference and “Diversity” both these promote equality.

The DOH (2010) has set a new framework called “New Horizons” to enable nurses to consider the vulnerable groups of people they care for and aim to provide a high quality of care. One group considered vulnerable is people who experience symptoms of psychosis.

Schizophrenia lies within the category of psychosis (Tsuang et al 2000). Stigma surrounds the term schizophrenia and these misconceptions have lead to much confusion and misunderstanding. Media highlights images of frightening behaviour and violence that leads to stereotyping people with schizophrenia (Byrne 2000). The world Health Organisation (2010) identified schizophrenia as the top ten most debilitating disorders affecting humans. The Disability Discrimination Act (DDA 1995), recognises that a disability is a physical or mental impairment and people with a diagnosis of schizophrenia are covered by the legislation. According to Sayce (2001), the dilemma for these people is whether they wear the label of their diagnosis, or hide it, and lose their civil rights.

The DOH (2010) identifies that stigma and discrimination-surrounding mental illness can be extremely difficult for these people to maintain friendships, seek employment, education and be involved in their community. People with mental health problems are one of the most socially excluded groups. Therefore, it is imperative that nurses work collaboratively to enable them to overcome the difficulties they face.

Working collaboratively with people when implementing evidence based interventions is vital. Evidence Based practice (EBP) is the integration of best available research evidence with clinical expertise and patients values (Sackett et al 2000). Nelson (2010) recognises that there are five steps that involve the process of EBP. These are asking questions to identify the patient’s needs; critique the quality of evidence; apply the evidence in practice; then evaluate the outcomes that are relevant to meeting the client’s needs. According to McKenna et al (2000) EBP does not stop at the implementation stage as to use evidence to under pin practice and not evaluate the effectiveness is short sighted.

There are various sources of evidence some of these are traditional findings these are not research based. They are passed down from one generation of nurses to another and can be considered to do more harm than good. It is felt that the interventions are being carried out because they have always been done that way (McKenna et al 1999). The other types are experience, intuition, service users and their families, audit, protocols and guidelines, research studies, authorities and experts, systematic reviews and randomised control trials (Brooker & Waugh 2007). Many professions consider randomised control trials (RCT) to be the highest standard of evidence, stressing scientific validity over other evidence (Essock et al 2003). King et al (2005) argues that some patients refuse to enter into randomized trials. Therefore this leads to a bias outcome as the patients absence may weaken the findings and restrict the validity of the results. According to Bower et al (2001), there is very limited researched evidence concerning patients finding self help packages acceptable, compared with the conventional therapy treatments and medication.

Neuroleptic medication is effective; however there is still an important role for the use of psychological interventions for people with psychosis (Fowler et al, 1999). According to pinto et al (1999), Cognitive behavioural therapy has an enhanced effect when delivered along side the use of anti psychotic medication. Cognitive Behavioural Therapy (CBT) is a treatment that has been well tested in people with schizophrenia and is of proven efficiency and cost effective (National Institute for Clinical Excellence, 2002). The goal of cognitive behavioural therapy is not force the patient to agree that they have symptoms of a mental illness but to reduce the severity of distress regardless of whether the accept their diagnosis (Turkington et al, 2008). Williams (2002) argues that even though CBT is effective it is in high demand therefore accessing this resource is often limited. Senskey et al (2000), reports that CBT leads to a continual clinical improvement in schizophrenia. However findings from the Cochrane meta-analysis (cormac et al, 2002) found no evidence of an effect in the longer term. Incorporating the principles of equality and diversity and evidence base practice will enhance the road to recovery for people (NMC 2008).

The word recovery has different meanings to people; whilst the word recovery is commonly used in mental health services the true understanding of the word remains limited (National Institute for Mental Health in England 2005, (NIMHE). According to Biley (2010) recovery is a word weighed down with too much expectation and is a desire for something different from that currently available in services. It is term which has caused confusion amongst researchers as they try to differentiate the true meaning of the word.

The Department of Health (2006c) recognises that it is imperative for nurses to incorporate principles of recovery within every aspects of care. This means working collaboratively and holistically with patients towards aims and goals that are meaningful to them, and being positive about change. It is also essential to promote social inclusion for people who use mental health services, along with their carers and other relevant people. According to the NMC (2008) Mental health nurses need to be working within the recovery focus approach working alongside people to support them to live a meaningful and satisfying life as defined by them in absence or presence of their symptoms.

Recovery is a deeply personal process that is distinctive to the person. There are five key concepts that the model of recovery should encompass these are hope, personal responsibility, education, self advocacy and support. It is vital to maximise on the person’s strengths this will endeavour to shift the emphasis on the nurse being the expert (Copeland 2000). Repper &Perkins (2003), suggest that nurses need to listen to patients, who are the expertise in their mental health problems instead of focusing too much on trying to promote insight into patients. Shepherd et al (2007) recognises that recovery does not necessarily mean cure alternatively it is a journey of a person living with mental health problems to build a life for themselves beyond illness. According to Rogers et al (2007) some professionals feel a deep sense of responsibility for the welfare of their patients. Many are uncomfortable in encouraging patients to take substantial risks to reach their self determine goals. This will inevitably conflict with the recovery’s emphasis on hope and empowerment.

There are variations of tools used within the recovery model. Examples of some of these are the Wellness Recovery Action Plan (WRAP) (Copeland 2009) and the Tidal Model (Barker 2001). The WRAP has been developed by a group of people who experience mental health problems. It enables people to identify what keeps them well and use their own wellness tools to relieve difficult feelings to maintain their wellness. It is written by the individual and incorporates an action plan in the event of crisis. Key people can then be identified who can advocate for them when they do not have the capacity to do so. Support time and recovery workers were introduced as part of the government initiative The National Service Framework (NSF 1999) to support people in their recovery empowering them to lead a quality of life.

The Tidal model (Barker 2001) was the first research based model of mental health recovery originally developed by nurses with the support of people who had or were accessing mental health services. The tidal model believes that it should start from the person’s lowest point. It focuses on people who are at their most distressed so they can begin slowly to learn to manage this and identify what support they need from others. The tidal model emphasises on enabling people to tell their stories as this is where there problems first appear and is where any growth and recovery will be found.

In conclusion it is imperative that nurses incorporate the core values when delivering care to people with a psychosis or other mental health problem to ensure they provide a holistic high quality of care. This essay has focused on the key principles of the core values within mental health nursing. It has critically discussed how the core values impact on people who experience symptoms of psychosis.

Massage therapy is the manipulation of the soft tissue on the body by a practitioner through the movement of their hands and arms as well as advanced techniques. Massage has been used to help people relax as well as a way to help treat minor ailments as a complement to other medication or treatment. As A Whirlwind Tour through the entire History of Massage webpage states ‘Massage is a universal instinct. From the day they descended from the trees, humans have known that it helps to rub a sore limb and that to touch is beneficial.’ So since then we have used and developed the skills and techniques through the years into the massage routines we see and use today.

History of Massage;

Throughout ancient history many different countries have been using massage and developing their skills as well as passing these down through the years. They have been borrowed, stolen and shared through different times as well as different places geographically around the world, many of the different types of massages resemble each other as techniques have been copied, borrowed and shared.

Pre-historic people used to practise some forms of therapeutic touch or massage as there has been evidence to suggest that they used to massage their muscles and rub herbs and oils onto their bodies to help with healing or to protect as this has been found in caveman paintings and drawings showing the giving and receiving of massage.

After then the next stage that has been recorded in history to show the major use of massage where the Chinese in around 3000BC in a book called ‘Con Fou of the Tao-Tse.’ As mentioned in the eBook History of Massage, Therapies & Rules in China ‘for years, blind people where the main masseurs.’ According to A Whirlwind Tour Through the entire history of Massage ‘Chinese writing dates from around 1400BC, near the start of the Shang dynasty, and it from around this time that we can reliably date massage.’ It was in China that the first exam in massage was sat about fifteen hundred years later as an addition to the occult studies schools. Around the same times as China the Egyptians also used massage and this has been depicted in tomb paintings of individuals being ‘Kneaded’ by others. The Japanese’s received their knowledge from China through the study of Buddhism and soon customised the techniques which became known as anma, which later became Japanese Shiatsu. According to The history of Massage: Learn How Massage Dates Back over 5,000 Years Ago ‘The primary goal of Shiatsu is to raise the energy level in the patient. In turn, this increased energy level regulates and fortifies the functioning of the organs and stimulates natural resistance to illnesses.’ The practitioners use a variety of techniques to pressure points on the body to balance the energies and work without needles or other equipment to do so.

However, some sources believe India was practicing massage before the Egyptians and the Chinese while others believe they might have acquired it from China a little later so the dates of when India first started to use any forms of massage range from around 3000BC to between 1.800-500BC.

‘Massage in India is referred to in ancient Hindu books such as ‘Ayurveda’ (Art of Life) which was written around 1800BC. It describes how movements such as shampooing and rubbing were used to relieve tiredness, increase energy levels and improve general health.’ Francesca Gould in Body Massage for Holistic Therapists (2004).

After this stage in history the next step in the time line is around 2000BC when the Greeks and Romans first started to use massage in the early foundations of their civilisations. The ancient Greeks used the knowledge from the Egyptians massage techniques, and it was given to the athletes’, women and soldiers as described in History of Massage, Therapies & Rules. The Greeks wrote many books on massage including some written by Homer, Aesculapius, Herodotus and Hippocrates who was the ‘Father ‘of Medicine. It was the Greeks who used to rub up the body towards the heart to help the venous and lymph in that direction, they also used this technique to move sickness towards the centre of the body to where is can be expelled with the waste materials.

The Romans however used massage as more of an indulgence than as a medical therapy; it was saved for those who could pay for it. The Romans received massage from the Greeks and enjoyed bathing before a full body massage and it was said that even Julius Caesar was pinched every day. The Roman gladiators were vigorously massaged before fights to make sure their muscles where warmed up and supple. Galen was the main figure in Rome for massage but he was actually Greek, according to A Whirlwind Tour through the History of Massage he lived from 130AD to 201AD and he acquired his knowledge of anatomy and physiology through working with the gladiators. Massage then was used as an alternative for exercise to help relive their excessive eating and drinking.

Massage was used throughout the different tribes in North America before the Europeans arrived, some tribes would massage/rub down their warriors before and after battle or rub ointments into ailing joints or muscles. Massage has also been seen through a variety of different countries through history including those such as Persia, Kurdistan, Thailand, Tibet, Indonesia and Hawaii.

The most recent history of massage can be seen is western civilisation. The earliest record was written by Ambroise Pare (1510-1590) but he was ridiculed for his publication. However by the time Henrik Ling (1776-1839) became the father of modern western massage it had become less of a ridicule. As the History of Massage, Therapies & rules tell us Henrik Ling once put. “We ought not to consider the organs of the body as the lifeless forms of a mechanical mass,” he wrote, “but as the living, active instruments of the soul.” And through this he finally developed the system known as Swedish massage.

Massage has now moved back towards the old holistic attributes instead of the physiological attributes so we are back to seeing massage in the same way as the ancient Chinese, Egyptians and Greeks once saw the therapy. As reported by The Massage Bible, ‘during the first World War injured soldiers were treated with massage, while the Californian bodywork movement in the 1960s combined massage with personal growth.’ There are many different kinds of massage practiced today all over the world and many of them can be received by almost anyone unless they have a specific reason that it cannot be preformed. There are a few different people who have been in the forefront of massage in modern history and those are Cornelius E. Who is the ‘Father’ of massage in the USA, David Palmer, the ‘Father’ of chair massage, Dr Tiffany Fields, the ‘Mother’ of massage research and Jack Meagher the ‘Father’ of sports massage. In figure I. In the appendices is a time line of the history of massage along with the creation and history of other therapies this has been take from the eBook History of Massage, Therapies & Rules.

Massage Principles and Holistic Experience:

To decide if massage is a holistic therapy first of all we need to know what holistic means and according to thefreedictionary.com Holistic means ‘Concerned with wholes rather than analysis or separation into parts.’ And with this definition we shall determine whether or not massage is a holistic experience.

A massage whether it is a Swedish, Shiatsu or any other form of massage moves across the whole surface of the skin missing only a few vital places which are left for either health and safety reasons or due to the intimacy of the area. Most massages that even just incorporate one certain area such as an Indian head massage or even reflexology they all use different points of that area to correspond with different areas or energies upon the body. With different energies running throughout in specific channels which move around the entire body, when a massage is preformed to the whole body or even just a small portion of the body such as the hands, feet or head all the energies are involved which in turn incorporates the body as a whole. With this in mind a massage can be believed to be Holistic as this matches with the definition of holistic in taking the body as a whole instead of a separation of its individual parts.

There is only one reason as to not treat a certain part of the body and that is due to a contra-indication such as pregnancy where you would not touch or massage the abdominal area or is say someone had a fungal infection upon their feet you would not massage their feet and would move onto the next step of the massage itself. These contra-indications could be on a temporary basis or they could be permanent and therefore this client would not be able to receive a treatment. There are some contra-indications such as cancer, epilepsy and a few others which would need a doctor’s approval before a treatment could be carried out upon the client for insurance reasons. For example for epilepsy if you do not know the trigger for a seizure and you had not received a doctors approval for the treatment and the client unfortunately had a seizure upon your table then the client might decide to sue the practitioner for causing this, this is why doctors approval is sought.

Due to the Health and Safety at work act 1974 all employers and employees must maintain a high standard of health and safety in the work place as described in F. Gould’s Body Massage for Holistic Therapists.

‘Employers are responsible for the health and safety of anyone who enters their premises. If an employer has more than five employees, the work place must have a health and safety policy, of which all staff must be aware.’

There are many different procedures in the work place that all employees must adhere to such as the first aid and fire procedures, all employees should know where the first aid kits and fire extinguishers/ exits are located within the building for the safely of themselves and the clients, It is advisable however, that all practitioners are first aid qualified themselves in the event of an emergency. From the clients point of view the practitioner should know these things as well as have a basic understanding of personal hygiene in the sense of washing their hands properly, being of a clean and presentable appearance and be dressed appropriately for the treatment. This is due to the intimate nature of the massage with the close skin to skin contact as strong smelling perfumes or strong body odour can be very unpleasant for the client. A general knowledge of health and safety is beneficial for the example to clean up spillages as and when they happen as to avoid trips, slips and falls of either the client or yourself. A good general idea of protecting your equipment is ideal as oils and creams can become a hazard if left un-cleaned from the treatment table as this could cause a slip or the degrading of your equipment such as the vinyl of the table tops.

For insurance purposes the practitioner must ensure that they do not perform a massage while they are unwell or when the client is contagious due to the spread of infection and should always wear gloves if they have any open areas upon their hands. This is for their own protection and that of the client as to not pass anything between them or onto any other client from the previous client. However it is also important to know if the client is well enough to receive the treatment, for this the practitioner must refer to the contraindication lists to see whether or not the client is acceptable to treat. The client should also be aware that at any point the practitioner is legally allowed to refuse treatment for withholding information or for unacceptable behaviour. The practitioner must also get the permission off the client at all times before a treatment if they can touch the client themselves, and they must ensure the client understands this and what is going to happen during the treatment for insurance purposes for the protection of both the client and practitioner.

Personal safety for the practitioner is also important; these include the correct posture and the compression of the wrists. If either of these are incorrect then the practitioner later in their career could cause themselves more pain due to repetitive strain on the joints and could cause more damage if continued. To help prevent this the right table height should be selected for the practitioner as well as the correct foot wear to help with posture, also the right hand movements should be followed to help prevent the compression of the wrists. The most important piece of safety a practitioner should adhere to is their own safety when working with a client on their own such as a residential call or even in their own rooms at their treatment centre. If doing a residential call then the practitioner should only really perform these on clients that already know, they have a personal phone number for and they should always make sure someone knows where they are at which times and check in after the appointment with either a family member or work colleague to show they are safe. If they get a new client after a residential call they should always follow the rules of asking for the residential phone number and insist upon phoning the day before the treatment to see if they still wish to receive the treatment.

Making the treatment of a client a positive experience is one of the most important parts of making a massage holistic, the practitioner should look after their clients making sure they are comfortable with what is going on whether they are new or long term clients. To be a massage practitioner you should have excellent customer service skills, client care should be the most important thing to remember and should always be used every day with every client, the client should believe that the practitioner cares. The practitioner should always consult with the client and devise a treatment plan to suite the clients and stick to this plan unless anything changes in the circumstances with the client as well as receiving permission from the client for the practitioner to touch them during the treatment. During the treatment the discussion should be at a comfortable level for the client but also low enough for the client to relax and enjoy the treatment. After care should always be adhered to and offered to the client with a small encouragement of lifestyle changes if needed for the client’s needs.

Effects of Massage including the Physiological and psychological effects upon the client:

Massage even though it is a holistic experience has been seen to have an effect of other areas of the human body and not just as a way to relax; a massage has been seen to show that it has both physiological and psychological effect upon the clients. Physiological effects are those which are shown upon the body itself and its function whereas psychological effects are those which manifest themselves in the mind and the emotions of the client. There are many different outcomes which could manifest for both on the anatomy and the body systems. In two different clinical trials that have been preformed independently of each other there is a show of the two different effects received after a massage treatment, one for the Physiological effects and one for the psychological effects.

In the first trial the objective was to see if the early intervention with massage in children with Down syndrome would help with the motor skills and muscle tone. So parents with children suffering from Down syndrome where asked to attend one of two early intervention classes, one class was a body massage session and the other a reading session after a base line had been assessed upon their severity of the syndrome, some children were not used if sever mobility where involved or they had emotional problems as this might interfere with the trial.

Twelve of the children were assigned to the massage sessions and eleven to the control reading session, so in overall there where twenty one children involved in this trial. Each session was scheduled for the same times each week and specific times of the day for both classes, and each session was on an individual basis, the sessions lasted for half an hour each, twice a week for two months, while the reading session was conducted the same way with the therapist holding the child while reading for the half an hour.

This was the treatment that the children received in the following sequence:

‘The 30-minute massage therapy session started with the child lying on a small mat

on the floor. The therapist conducted the following sequence three times with the

child in a supine position: Legs and feet-(a) while forming hands like a letter ‘C’ and

wrapping the fingers around the child’s leg, long, milking and twisting strokes from

the thigh to the ankles; (b) massaging foot by gliding thumbs across bottom of foot

followed by squeezing and tugging each toe; (c) massaging across top of foot by gliding thumbs from ankle to toes; (d) flexing and extending the foot; (e) massaging from ankle to foot and back to ankle; (f) stroking from the ankle up towards the thigh; and (g) back and forth rolling movements (as if making a rope from dough) from the

ankle to the thigh. Stomach-(a) slow, circular, rubbing movements to stomach area

with one hand; (b) using the palms, hand over hand down the stomach in a paddlewheel fashion; (c) starting with thumbs together at the umbilicus, stroking horizontally to sides of body and then twice above and twice below the umbilicus; (d) using fingertips and starting below the umbilicus on the child’s right side, small circular upward movements until even with the umbilicus, then continuing across to the left side, and then down on the left side to below the umbilicus; (e) with one hand

following the other, short upward stroking from right side below the umbilicus, then

Massage and Down syndrome 401 across the umbilicus to the left side of the body, and then down on the left side to below the umbilicus; and (f) cupping or holding sides of knees, bending both knees simultaneously towards the stomach and holding for three to five seconds. Chest-(a) with palms of hands on child’s sternum, stroking outward across chest; (b) starting at sternum, stroking upwards and over tops of shoulders and down the sides of the ribs; and (c) starting at the right thigh, stroking diagonally through the chest to the opposite shoulder and back down to the same thigh; repeat starting at the left thigh; Arms and hands-same as legs and feet (i.e. replace ‘legs’ with ‘arms’ and ‘feet’ with ‘hands’). Face-(a) making small circles to entire scalp (as if shampooing hair); (b) with flats of thumbs together on midline of forehead, stroking outward towards the temples; (c) stroking gently over the eyes and brows; (d) starting at the bridge of the nose, stroking across the cheekbones to the ears; and (e) making circular movements under the chin, around the jaw line, around the ears, to the back of the neck and the rest of the scalp. The following sequences were done after placing the children on their stomach (in a prone position). Back-applying oil to the hands: (a) starting at the top of the spine, alternating hand strokes across the back working down towards the tail bone (never

pressing the spine) and reaching over to include the sides; (b) hand over hand movements from upper back to hips with flats of hands and then continuing to feet; (c) using circular motion with fingertips, from neck to hips stroking over the long muscles next to the spine and retracing on the other side of the spine; (d) making circular strokes with the palm of the hand to rub the tops of the shoulders; and (e) ending with long gliding strokes from the neck to the feet.’ As was described in the journal Children with Down syndrome improved in motor functioning and muscle tone following massage therapy (2006).

The trial was held at the children’s early intervention pre-school centres, while the test was run by the university of Miami school of medicine. The results of this trial show that there was a greater gain for the results of the children who where massaged in their sessions than to those who where read too. The improvements were shown in the gross motor skills and fine motor skills development of the children as well as a marginal effect in their language development. This then showed that through the early intervention with massage it could help children with Down syndrome enhance their motor development at a faster rate than if they were left to mature in their own way.

These results help to show that massage can have a physiological effect upon the body in helping to produce and enhance muscle tone. However, there is the argument that another control group could have been added into the trial to help show whether this is successful or not is a control group that uses light stokes instead of a pressure massage to help with the ethical problems of withholding the intervention from those in the reading session. This was all shown in the clinical trial journal of Children with Down syndrome improved in motor functioning and muscle tone following massage therapy (2006) which is located in the appendices.

The second trial is to determine whether or not massage can have a psychological effect on the client and for this the trial was preformed for the Association of Paediatric Haematology/Oncology Nurses (2009). The aim of this trial was to reduce symptoms of children with cancer and to reduce the anxiety of their parents.

‘Children with cancer, ages 1 to 18 years, received at least 2 identical cycles of

Chemotherapy, and one parent, participated in the 2- period crossover design in which 4 weekly massage sessions alternated with 4 weekly quiet-time control

Sessions.’ As described in the article Massage Therapy for Children with Cancer (2009).

To determine if the massage was helping to relieve the psychological symptoms of anxiety in the parents and the symptoms of the children while the trial was progressing they measured everyone’s heart and respiratory rates, blood pressure, and salivary cortisol level as well as their pain, nausea, anxiety, and fatigue levels.

According to the results of this trial the massage was more effective in reducing heart rate than quiet time in the children, the anxiety in the children aged fourteen and older and the anxiety in the adults. The clients all commented upon how the massage rather than the quiet time helped with their anxiety and helped them feel better. So due to their result it is feasible to massage children with cancer and their parents to help relieve their anxiety. Therefore this result helps to show that massage to the body can have a psychological effect upon the client in this sense it has reduced the anxiety of the both the children and the parents although in the younger babies the results did vary a little more than the other ages, but the results of the older children and the adults help to prove that just a massage on its own can have a psychological effect upon the human body. The trial that this assessment was based upon is located in the appendices as clinical trial 2.

So both of these trials show that massage can had a successful outcome on the physiological and psychological effects portrayed on the body, they both proved that through a short massage the body can manifest its effects through muscle tone or motor function progression as well as to reduce anxiety in both children and adults. Neither of these two trials have a negative out come and therefore both are a success but there shall be a few trials where massage has not appeared to be successful at all or shows that it is a little less successful than anticipated, these however are normal and show both sides to an ongoing argument about whether massage is actually good for the body, mind and spirit on a whole or if it just theoretically works on the body.