Mental health articles

OF mental health care and mentally ill

What is mental health nurses?

The problem of articulation of what it is that mental health nurses do is still raised as problematic and the reasons for this remain unclear. The roles that mental health nurses undertake cross the age spectrum from perinatal to older persons and in multiple specialty services. There are mental health nurse practitioners pioneering roles in a range of settings; mental health nurses leading and providing services in primary care settings, psychiatric emergency care units, forensic services, court liaison services, drug and alcohol treatment programs, justice health, a range of psychotherapeutic programs and practices, and of course the inpatient mental health units and community mental health services. I can identify individual mental health nurses working in all of these settings and more, who have in common a dedication to what they do, a passion for providing the best service possible, and who have an amazing depth of knowledge and range of skills, easily identifiable and not at all ineffable. Their knowledge spans mental and physical health and illness, how people respond to emotional stress and illness, what treatments are available and how they impact on the person, and what ameliorates mental and emotional distress. Their focus is the care of people who are in mental and emotional distress, and they apply this knowledge with grace. They would all argue that at the heart of what they do is their ability to care for and relate to people at their most vulnerable in terms of emotion and human experience, and the ability to develop therapeutic relationships even in that extreme of vulnerability. The published work on the centrality of the therapeutic relationship to the role of mental health nursing is abundant and mental health nurses have produced, in this journal from its inception and other publications, a range of scholarly and eloquent articles that address therapeutic relationships and their importance (see for instance Barker & Buchanan-Barker 2008; Bucknell 2004; Delaney & Ferguson 2011; Speedy 1993a; 1993b to name only a few). It has been clearly demonstrated that no matter what the therapy, the most important variable in success of the therapy is the relationship between the person and the therapist. It has also been clearly demonstrated that inpatient satisfaction depends on the relationship with nurses, and that inpatient units where therapeutic relationships are valued use far less coercive interventions and have lower negative incidents. If this is what mental health nurses do, and there is evidence of its value, then why is the question of articulating what we do still asked? Further, why is it asked by mental health nurses? This is a conundrum. At the heart of the problem lies what is valued by us as a discipline and by the mental health services in which we are employed. Perhaps the problem is, at least in part, compounded by the difficulty mental health services have in articulating what they do. Despite the knowledge of the importance of the therapeutic relationship, an emphasis within clinical services on biological understandings of mental illness and pharmacological treatment is prevalent, with a concomitant decrease in an emphasis on the relationship with the person and the need to seek meaning in the experience of the person through therapeutic dialogue. The discourse of care is often around risk, diagnosis, and pharmacology, and arenas that acknowledge and explore the value of the therapeutic relationship are few. One of the flow-on effects of this is the employment of nurses who have very little understanding of mental health, mental illness, or skills in developing therapeutic relationships. Orientation programs for these nurses are often poor, with an emphasis on risk management, medication, and observation, which reflects how the skills of mental health nurses are valued, or rather devalued. However, the adoption of recovery models of care are opportunities for mental health nursing to reclaim its focus on understanding the meaning of the illness experience for the person, through therapeutic relationship and dialogue. To capitalize on this opportunity, we need to ensure that mental health nursing is prepared for the challenge. If the hallmark of mental health nursing is the ability to use the therapeutic relationship and therapeutic dialogue with people who have a mental illness, then we need to ensure that the preparation for mental health nurses holds central the need to develop the knowledge and skills to be able to undertake such therapeutic work. Postgraduate mental health nursing courses need to include a strong emphasis on the theoretical framework for therapeutic relationships, including psychodynamic theory (see Gallop & O’Brien 2003) and also need to include experiential, evaluated skill development. This focus does not discount the importance of understanding neurobiological theories of mental illness, nor does it discount the importance of pharmacological treatments, or other specific treatment modalities, such as manualized treatment programs. The valuing of the therapeutic work of nurses needs to be reflected in the discourse within clinical teams, and nurse leaders need to ensure that there are arenas for discussions of care that reflects the importance of the relationship with the person, and the person’s understanding of their illness and treatment; that clinical documentation reflects the work undertaken by nurses to establish relationships and to use those relationships to develop an understanding of the illness experience, and that clinical supervision is available for nurses. Mental health nursing research needs to extend beyond establishing that therapeutic relationships in nursing are a good thing. We need to rise to the challenge of exploring the complexity of the therapeutic relationship in order to establish a stronger theoretical base and to be able to specify the particular skills and knowledge that are essential, and in what circumstances, with whom, at which stage in their illness, and with what outcomes we use these skills. Perhaps then we will have no need to say that mental health nurses cannot articulate what they do.

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