Mental health in nursing degrees

Image sourced here under Creative Commons license.

“When it comes to mental health, there is insufficient preparation of undergraduate nurses within the Bachelor of Nursing,” … “This is partly because there aren’t available clinical placements in the field, but also because of the stigma perpetuated by some academics and Registered Nurses.”

Professor Eimear Muir-Cochrane in Australian Nursing and Midwifery Federation (SA Branch), January 2019, In Practice, p.5.

Based on my EN experiences and the look on people’s face when I mention I am interested in mental health nursing, I never expected mental health to be a highly popular field amongst nursing students. I even hoped it would make it easier to preference a mental health placement. However I was quite surprised after reading the above to discover there was a complete lack of mental health placements in South Australia. I asked Twitter if this was widespread or isolated to South Australia to discover in some states it is mandatory to undertake at least two weeks placement in mental health, and some universities even offer a mental health major.

I am quite disappointed I will not have a placement opportunity which could help to confirm my interest in the field or help me decide that it may not actually be right for me. Other students may even discover a new-found interest on placement they otherwise would not have been exposed to, or at the very least gain an appreciation of the relevance of mental health care.

Additionally, there appears to be minimal mental health theory taught in some nursing degrees, such as the programs I applied for that do not seem to have dedicated mental health subjects. The federal government has acknowledged the inconsistency across degrees and last year signalled a plan to create a national framework for consistent content, although consistent may not necessarily mean adequate.

Mental health is not a domain only serviced by specialist mental health nurses. All nurses, no matter the field, will care for mental health patients during their career. Physical and mental health conditions do not occur in isolation; the symptoms or treatment of one may exacerbate the other.

Your patient with anxiety may need extra psychological support during a procedure than other patients you have looked after, or your severely dehydrated patient who also takes lithium may require monitoring for signs lithium toxicity. Sometimes acute mental health patients are admitted to general wards while they wait for a mental health bed and they also require competent supportive care.

Similarly, diagnostic overshadowing [1] can have major consequences for mental health patients and I wonder, without a solid understanding of mental health and perhaps experience, how well nurses could ensure they do not succumb to this.

I have come across many nurses whom have so little mental health knowledge they do not know what to do when they are allocated a patient with an acute mental health condition in addition to the physical condition they have been admitted for. On medical wards I have witnessed nurses become distant and provide suboptimal care as they try to avoid their own discomfort. I have seen patients unnecessarily physically or chemically restrained because of staff attitudes (“I’m not in the mood to deal with him today”) and inadequate mental health skills to provide appropriate care [2].

I am undertaking a grad-entry nursing program as I have previously completed a different degree. There are a number of these across the country as either entry into the 2nd year of a Bachelor or as a Master degree. Qualification as an RN requires two, rather than the usual three years of study. For those undertaking a 3-year degree I understand there needs to be at least one initial course allowing students to adapt to university-style learning, however if the rest of first year is seemingly irrelevant to fulfilling the NMBA Standards for Practice, could there not be more mental health content in place of some of this? The small number of grad-entry students would miss out, but the majority would benefit.

I have barely been an RN student for five minutes, have been out of the nursing field entirely for twelve years, and have no teaching or research qualifications in this area whatsoever so may not be particularly qualified to make the comments I have. The situation is probably far more complex than my understanding and if I have misunderstood any of the above, I am more than happy to be corrected. I also understand there are likely to be numerous fields competing for more exposure in undergraduate learning, each with their own importance.

Nonetheless, mental health underpins physical health across the lifespan. Without adequate mental health we cannot look after our physical health. Should understanding and promoting mental health then, be a goal of all nurses and thus form a critical component of both theoretical and clinical training?

Footnotes

  1. Shameless self-plug, however the topic is very important and relevant.
  2. As a new and inexperienced nurse I was too intimidated to speak up to the senior nurses and doctors involved in these cases, when I was not caring for the patients in question. I realise that is a poor effort, however hope that should a similar situation arise I now have the ability to set aside my own discomfort about speaking up to better advocate on behalf of patients.
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The long way around: From Enrolled Nurse to (student) Registered Nurse

Twelve years ago I submitted an application for a double degree in registered nursing and mental health nursing. I planned to up-skill from an Endorsed Enrolled Nurse (EEN) to a Registered Mental Health Nurse. Approximately five minutes before the deadline to change preferences closed, on a whim, I changed my first preference to psychology, not expecting to be offered a place. I was.

Instead of working with people with mental health concerns, I gravitated to the cognitive neuroscience research field, where everything is operationalised and quantified in a precise manner looking for trends across a large number of people. Qualitative research was ridiculed by the academics and individual differences were seen as a hinderance; something to be statistically controlled for so they did not contaminate the data. Emotions were unwelcome and interfered. We were real scientists, with (I am embarrassed to admit) somewhat of a superiority complex. These ideas were drilled into us by senior students and the academics. I had found myself in a very different environment with very different attitudes to where I would have been if I pursued mental health nursing.

Over time my depression began to manifest and lead me to become more and more rigid, while amplifying my perfectionism. I surrounded myself with people and a career that somewhat praised these characteristics. I was very successful for my level, further fuelling these feelings and behaviours.

I constantly had to prove myself worthy – in my undergraduate honours year most people conducted a literature review and survey for their thesis research. I completed a systematic review and learnt electroencephalography (EEG) and programming in Matlab to conduct a lab-based experimental study. You were not given additional marks for difficulty, and only gained additional stress.

I continued with EEG for my PhD, but also added some slightly more human elements and worked in a hospital with stroke patients. The more time I spent with the clinical rather than technical aspects of the project the more I became unhappy with the technical. I did not realise it at the time, but I had become incredibly disconnected from my values and being back in a clinical environment may have triggered a small reconnection.

After leaving the PhD I waited 12 months before applying for entry into a nursing degree. I left because nursing did not feel like the right fit for me and wanted to make sure returning was what I really wanted to do. My suicide attempt occurred during this time.

As a consequence, I begun working with a new psychologist and attended a group program at the same facility my psychologist worked, run by a mental health nurse. I thought I needed a few strategies to improve my self-esteem and then all would be well. I was incredibly wrong.

One day I was struggling with a number of things and after the group program the nurse chatted with me in her office for around an hour. She was busy but worried so made the time for me. She helped with a few practical suggestions but mostly she listened and was present. It was the first time I had not felt judged by someone, even the slightest. She was so kind and compassionate when I had lost the ability to be these things for myself. She hugged me afterwards. I think I will carry that conversation with me forever.

That afternoon was my turning point. She had torn a large hole in the wall I had built around me, not letting most emotions in or out; it started to crumble thereafter. It was tough. I spent a lot of time working on my values, allowing them guide who and what I want to be rather than external driven ideas. At times I felt more vulnerable than I ever had but slowly we got there.

As an EEN I was also overly interested in the technical aspects of care – at the expense of truly connecting with people. Again, I was influenced by the close people in my life, those who thrived on technical skills and eschewed compassion – Army trauma doctors and aviation medics… (you get the picture). I was living their interests and forgot who I was along the way while trying to fit in with them.

I am still very academically minded, however now I have started my nursing degree I feel my learning is because I love learning and want to be the best nurse I can, not to be academically better than everyone else and impress them with my knowledge of pharmacology (yes, that actually happened when I was an EEN) in order to gain approval from those above me.

I have taken a very long way around to up-skill from an EEN to RN, however my achievements and the challenges in that time have facilitated the personal growth I needed to realise how important holistic care is. I am incredibly glad I changed my mind and did not try to become a mental health nurse all those years ago. Mental health nursing was my interest and not those around me; I had the right intentions but I was the wrong person. I am still very much interested in mental health nursing, however which ever field of nursing I choose to specialise in after qualifying, I think I may be the right person doing it for the right reasons this time around.

An exercise in self-compassion

Yesterday I completed a Parkrun double header for New Years Day (that is, two nearby Parkrun events that have been timed so you can complete both, one after the other, totalling 10km of running and/or walking).

I ran and walked about equal amounts of the first course and completely walked the second. This was a far cry from the half marathon I was training for months earlier, with the intention of completing one early this year*. Despite this, I am really proud of the effort I put in, even if I literally slept for half the day afterwards.

The start point of my favourite local Parkrun, minutes before I started my first ever event.

I have been too fatigued to run for months. It crept up on me. Slowly my solo runs tapered down, my times were lengthening, and I was starting to skip Saturday morning Parkrun, where I run with a group of friends and have coffee after (this was also the social highlight of my week).

Despite being physically unable to run, I initially thought I was just becoming lazy, making excuses, and in need of a large dose of motivation. I soon stopped trying and was embarrassed to even walk Parkrun while my friends ran. I gained weight after I stopped exercising and this did not exactly help my confidence either.

When depressed, I avoid many things in my life, including those that I enjoy. I wondered if this were the onset of depression, despite being otherwise asymptomatic.

However, a couple of weeks ago I discovered I have a tumour in my neck (at this stage it is assumed to be benign) that specifically causes severe fatigue and bone and muscle soreness due to its location; the perfect combination to make running nearly impossible. I am seeing a surgeon soon and hopefully it will be surgically removed and the symptoms will abate.

This new evidence that my inability to run is not due to laziness has motivated me to tolerate the fatigue (and fear of others judging me) more than I was and to motivate me to do small amounts of running and more walking again. Compared to my previous ability, my current efforts are minuscule, but based on my current abilities, I think it is a good effort.

Yet when I thought I was being lazy I struggled to motivate myself to exercise despite there only being a motivational barrier.

It is interesting how easy it is to ascribe unwanted personality states and traits to ourselves when we do not have a specific “desirable” or “reasonable” explanation for how we feel, to believe that other’s must feel the same way about us, and for this to send our motivation into a rapid downward spiral.

When I received the tumour diagnosis I think I was able to see the running struggles from a more compassionate lens. I was able to acknowledge that it is okay to struggle to exercise because I am unwell. I will receive treatment and when cured I can resume training. I realised that it was okay to try and do small amounts of exercise, within my current abilities, and it is okay that it is not to the level I was previously capable of, or to simply rest if that is what I need.

I was unable to be this compassionate when I thought there was more of a cognitive/psychological cause. It is frustrating that I would never have these same thoughts towards someone else and would have suggested a more compassionate approach to them, yet could not accept this for myself.

Integrating self-compassion into my life is still somewhat of a work in progress. I had some initial help from an amazing mental health nurse and have been working since with my psychologist. They initially had a difficult job as I was very reluctant and it felt incredibly foreign and uncomfortable for some time. I am much more comfortable with the idea now, and actively working to add more of it to my life. Hopefully I will soon be applying it during motivational slumps too…

If anyone has some resources they have found helpful on self-compassion I would love if you would kindly share. I am starting to find my niche but am always open to learning new techniques and theories.

*I worry this may make me sound like I am a seasoned runner – I am far from that. I tried to make it a habit for around a year but was unable to stick to it regularly. Consistent running became a form of therapy after my suicide attempt and started while I was in hospital last March (why it is so important to me). I am incredibly slow by almost every possible standard. I have a love/hate relationship with running – I hate it most of the time I am running, but love the runners high afterwards, achieving things I never thought I could, as well as the improved fitness and the beautiful locations I am now fit enough to hike or run through that I was not previously able to do.

Fitting in and belonging

I initially created this blog months ago but never posted, although I must have composed a hundred different posts in my head during this time. More recently, I was encouraged to begin a blog as part of a Twitter Blog Challenge and have composed over a dozen more mental posts this past week alone. Getting something on screen however, has been more difficult. 

Deciding what this post, and the blog as a whole, would specifically be about, stirred decades-long conflict about identity and deciphering where I fit in. Am I writing as the person with lived mental health experience or the one with a psychology honours degree? As a former endorsed enrolled nurse or a student registered nurse? Or perhaps as the emerging clinical and cognitive neuroscience researcher who’s career was unexpectedly cut short?

The people I interact with the most on Twitter are professionals with established careers. My qualifications so far are probably a fairly unique combination, however I am far from experienced and only beginning the registered nursing journey. Where do I fit in and what if my thoughts and opinions are completely wrong because I am lacking experience? These thoughts are wonderful fuel for anxiety.

When you are unsure if you fit in so you stand awkwardly at the back of the group.
Photo from my Flickr

Throughout her work [1], Brené Brown suggests that when we try to fit in, we shape and mould ourselves to fit with what we perceive others want. We think there is a need to have a certain characteristic(s) otherwise we will not be accepted into that group. The concept of fitting in therefore, is understandably linked to social connection [2]. For me, it has also been related to loneliness, depression, and anxiety.

Rather than trying to fit in, Brené Brown believes belonging is a more genuine and helpful practice.

True belonging is the spiritual practice of believing in and belonging to yourself so deeply that you can share your most authentic self with the world and find sacredness in both being a part of something and standing alone in the wilderness. True belonging doesn’t require you to change who you are; it requires you to be who you are.

Brené Brown. 2017. Braving the Wilderness: The Quest for True Belonging and the Courage to Stand Alone. Random House.

Earlier versions of this post did not start as something about fitting in or belonging, however the metamorphosis my writing has undertaken has perhaps lead me to the perfect starting point for this blog. My lived experiences are continually evolving and shaping my reemerging professional interests. This is my current area of expertise. 

I have shared only ‘need to know’ snippets of my story with those in my life, other than the health professionals who have helped with my recovery. I have always been wary about stigma and discrimination and have had a disastrous experience with disclosure. Much of this comes back to wanting to fit in (and previously, a very large dose of social phobia). The idea of sharing leaves me incredibly vulnerable and scared so I have mostly avoided this, leaving a heavy burden weighing on my mind, which I would like to reduce.

I hope writing this blog will change my relationship with the anxiety I experience about potentially and actually sharing my story and I will be able to foster my own sense of belonging, while sharing how this has shaped my journey back to nursing and the nurse I will become.

Belonging so fully to yourself that you’re willing to stand alone is a wilderness – an untamed, unpredictable place of solitude and searching. It is a place as dangerous as it is breathtaking, a place as sought after as it is feared. The wilderness can often feel unholy because we can’t control it, or what people think about our choice of whether to venture into that vastness or not. But it turns out to be the place of true belonging, and it’s the bravest and most sacred place you will ever stand.

Brené Brown. 2017. Braving the Wilderness: The Quest for True Belonging and the Courage to Stand Alone. Random House.

Footnotes and references

  1. I do not have a specific reference for this, however if you pick up any of Brené Brown‘s books you will find this is a common theme throughout her work. Brené’s TED Talks provide a great introduction to her work as well.
  2. Walton, GM, Cohen, GL, Cwir, D & Spencer, SJ. (2012). Mere Belonging: The Power of Social Connections. Journal of Personality and Social Psychology, 102(3), 513–532. doi: 10.1037/a0025731