Mental health in nursing degrees

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“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.