Dear Dan Warrender,
We are a group of 3rd year mental health nursing students in the UK, completing our first field-specific module in the Future Nurse Curriculum. Today we have spent several hours with our tutor discussing your recent paper, Mental health nursing and the theory-practice gap: Civil war and intellectual self-injury.
We found it very striking and there were many elements that the whole group identified with strongly. We have had experiences in clinical placement areas in which nurses are dismissive of the things taught at university, with a ‘this is how we do it round here’ kind of mentality. We also related to the idea of mental health nurses being like the ‘worker bees’ of the service, doing whatever is required of us rather than having a clear separate vision and role. As you put it, we are the biggest profession and yet somehow always the ‘sidekick’. We agreed with your concerns about the Future Nurse Curriculum squeezing out mental-health specific learning at university and also creating a new emphasis on physical care, some of which takes the form of competencies on our placement assessment document that are very difficult to get ‘signed off’ on our mental health placements; it is almost as if there is a mismatch between our assessment and the service that we are being prepared to work within.
We experience the many-facetted parts of being a mental health nursing student as being a complex set of social situations in which the stakes may be high for us. There is a need to fit in and there may indeed be a social cost of being too different, having too many ideas or asking the wrong kind of questions. Within your article we recognised the anti-intellectual dynamic in which ‘thinking too hard’ about service users may be seen as somehow making us not suitable for nursing.
We discussed the issue of ‘quantity over quality’ when it comes to nurse education. In a way, that is a bit insulting to us, but we did agree together that not just anyone can become a nurse. Degree level work is part of that, but nursing is vocational and certain values and sensitivities are needed and not universal.
The parts of your article we debated the most were where you refer to the theory practice gap as being really about the difference between ‘thinking and ritual’ and the split between academia and placements are characterised by ‘one half resisting the other’.
There were several reasons that we felt uncertain about these two statements, even though we did recognise truth in them. It was not easy to articulate all of these concerns, but both felt like a ‘them and us’ that made us feel uncomfortable. Is it really true that nurses in practice are not thinkers and that nurses in universities always are? There are nurses at university that teach in uninspiring ways that seem to have the goal of turning us into a good fit for services more than turning us into strong, independent critical thinkers. We are also not sure that more experienced clinical nurses deliberately squash new ideas. Very often it seems that they themselves have not found ways to make space for them.
We spent some time trying to discuss ways in which this kind of ‘them and us’ mentality may be strongly motivating (‘I’m working to change the system from within!’) but also creates unpleasant simplicities and perhaps prevents us from moving forward by trying to address our problems together, as a whole profession. Are some nurses to be the heroes saving everyone from the rest?! Maybe there is something duplicitous about the way this would present to our service-users, a good cop bad cop routine. Perhaps this is partly why you are keen in another part of your piece to say that the division between academic staff and clinical staff is unhelpful. We agreed in our group that we do recognise the complacency of so many staff and the need for each of us to positively decide to be health-focussed and resist certain ways in which services can work, so perhaps a sense of ‘working to change the system from within’ is only right. And, for all the positive sounding talk of ‘business partners’, maybe we should acknowledge that the business of Trusts is to smoothly deliver services and the business of universities is to promote critical thinking and those two priorities are very different.
In our discussion we also mentioned something else that seems important. We feel that mental health nurses are sometimes defensive because they have to be. We exist in a situation that some might argue is abusive; on the one hand we are degree-educated professionals with our own Code of Conduct, able to be held responsible for our actions. On the other, we are very often that ‘sidekick’ with very little autonomy, also working in teams that are poorly resourced. We feel that when a person is simultaneously made responsible and disempowered, they have to do certain things to survive. Being risk-averse, policy or tradition-driven and uncreative may be some of those things. In this situation, is being closed and defensive best thought of as a failing of those nurses? Are they replicating rituals or are they responding to their experience of power?
Survival is also found through keeping up paternalistic ‘best interests’ thinking. Mental health nurses are required to do things in the ‘best interests’ of service-users that no other nurses seem to have to do, particularly forcing people to take medication. To constantly consider ideas that undermine ‘best interests’ arguments, as we have been doing at university, may be very painful for nurses in practice. Is this their failing? Or is it a failing of nurse leadership or the wider system in some way? Once again we are wondering if the real culprit is not the ‘idealism’ of university, nor the nurses whom you describe as perpetuating rituals, but rather the things which leave those nurses feeling so vulnerable in the first place that they cannot afford to think about what they are doing in ways that leave them with hard questions after the shift.
We finished our discussion sharing the real concern – fear, really – that we will be damaged in some way by the mental health service, unable to hold on to our best values and motivations for the health of our service-users. We have agreed that we need to round off our module with a session in which we seriously discuss how we are going to look after ourselves properly!
Thank you for your thought-provoking article.
Class 0120 Student Mental Health Nurses
Dear Class 0120
I take heart that the next generation of mental health nursing leaders are reflecting deeply upon and confronting our professional dilemmas together. I have been a mental health nurse for 48 years and I have witnessed our profession evolve from custodial domestics through to community nurses and nurse therapists. Towards the end of my career I am witnessing, here in Australia, the devolution of mental health nursing back to custodial care – this time in smaller ‘mainstream’ units where the role of nursing staff is to give pills, restrain aggressive behaviour and spend the rest of our time on ‘observations’ and preventing people escape. Therapeutic and family care have been appropriated by psychologists, occupational therapists and social workers with the acquiescence of nurses who believe they have little time to attend to these areas of practice, but are really unskilled and untrained.
I believe the key responsibility for this devolution lies with university schools of nursing and national nurse leadership organisations who have never really understand our discipline (possibly due to poor experiences during their own student placements in mental health settings). University academics and administrators pushed for an integrated generic Bachelor of Nursing in which I teach the undergraduate mental health component – students are provided with 16 hours of residential school then 80 hours of professional placement. There is no recognised discipline of mental health nursing in our nursing regulatory body. As the skilled and experienced mental health nurses age and retire they are being replaced by minimally trained general nurses.
I find it hard not to slip into an ‘us and them’ mentality or not adopt the role of mental health nursing hero trying to save our profession from others. I am aware that much of my reactivity comes from decades of trauma associated with this discipline – my own experiences of physical trauma, decades of potential vicarious trauma from listening to the stories of our consumers and how they have been hurt by society and/or the mental health system (and my direct involvement with this), and my own experiences of poor senior management using tactics of bullying and abuse in lieu of decent leadership.
What has protected me and enabled me to continue to with my practice has been the support of other mental health nurses, both through individual and peer clinical supervision, and collegiate support through our own Australian College of Mental Health Nursing. It is inspiring to know that your group has come together to explore these issues. Please value the association you have and hold together beyond your undergraduate years. Support each other to take on discipline and service leadership positions. Don’t let ‘them’ take away your direct entry mental health nursing BN – meaningful and effective mental health care in your communities needs properly trained and committed mental health nurses.
My very best wishes to you inspiring people!
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