Using the values identified in the attached book (empathy and importance of self expression) review prepare a 2000 word discussion and analysis of values practice issues within mental health nursing practice.
This essay aims to explore some issues around values and practice in mental health nursing. The essay builds upon a previous piece of work undertaken as a formative assignment, a review of a book read by the author, which raised some key points which may be important in mental health nursing practice. The process of uncovering these issues, in response to reviewing and reading a work of fiction, was one which led to a connection of ideas, from what the book presented, and from the author’s personal experience, life experience, and clinical experience and learning to date.
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The identified issues are to do with compassion, empathy and the importance of self-expression. These are all issues which the author believes are very much taken for granted in everyday life, but which become very significant for users of mental health services, and for mental health service providers, because they affect many areas of the person, their experience, and the therapeutic relationship. This essay will explore these issues in the light of some of the published theory and debate on these topics, and the author’s own point of view and experiences.
It would seem that within mental health nursing, the relationship between the mental health nurse and the client is very important, but this relationship is based on certain values which must underpin nursing care (Eagger et al, 2005), and certain needs or requirements that the client might feel in relation to the nurse. Nurses working within a framework of values is no new thing, and values (and ethics) have always underpinned medicine and healthcare (Eagger et al, 2005). According to Svedberg et al (2003), “Mental health is created by the interwoven process of one’s relationship to oneself and to others”, which would suggest that the relationships the client forms with anyone involved in supporting mental health are doubly important.
The client may find self-expression important for themselves, but also they will require compassion from the mental health nurse. The nurse, in turn, may be challenged by the client’s self-expression, and may find it hard to feel compassion or to empathise with the client at times.
One of the challenges of providing compassionate care and even for the mental health nurse to experience compassion is the supposed relationship which some authors have found between perceived suffering and caregiver compassion. Schulz et al (2007) suggest that there are links between perceived suffering and the level of caregiver compassion. If this is the case, then it could be argued that some mental health nurses who do not feel or display compassion are doing so because on some level they do not perceive or believe the client to be truly suffering, or to be worthy of compassion. This would raise an ethical issue, because all the patient’s needs should be met, no matter what the ‘personal’ response to the client. However, this could be a lack of perception on the part of the mental health nurse.
Akerjordet and Severinsson (2004) discuss the issue of emotional intelligence in nursing, a concept which affects the nurse-patient relationship, particularly within mental health nursing. Salovey and Mayer (1990) define emotional intelligence as “the ability to monitor one’s own and others’ feelings and emotions, to discriminate among them and to use this information to guide one’s thinking and actions” (p 185). In their qualitative study, Akerjordet and Severinsson (2004) found four dominant themes about emotional intelligence in mental health nursing “relationship with the patient; the substance of supervision; motivation; and responsibility.” This would suggest that emotional intelligence on the part of the nurse is important within mental health nursing. Akerjordet and Severinsson (2004) suggest that emotional intelligence “stimulates the search for a deeper understanding of a professional mental health nursing identity” and that “emotional learning and maturation processes are central to professional competence, that is, personal growth and development.” (p 164). Therefore, the mental health nurse would need to develop the emotional intelligence to understand why they are finding it hard to feel compassion for the client, and to take action to remedy this, and to act in a sensitive and supportive way towards the client, even if they do not truly feel compassionate towards them.
Shattell et al (2007) carried out research on the therapeutic relationship within mental health services, and found that clients expressed experiences of the therapeutic relationship under the following themes: ‘relate to me’, ‘know me as a person’, and ‘get to the solution’. “A therapeutic relationship for persons with mental illness requires in-depth personal knowledge, which is acquired only with time, understanding, and skill. Knowing the whole person, rather than knowing the person only as a service recipient.” (Shattell et al, 2007 p 274). This would suggest that the mental health nurse should be motivated to develop an empathy with the client through this knowledge, and should actively engage in seeking out ways to know and to understand the client. This may relate back to the issue of emotional intelligence, because the mental health nurse needs to know themselves very well, and to understand themselves and their professional persona (Akerjordet and Severinsson, 2004) before they can then go on to get to know and understand, and empathise with, the client.
Hamilton and Roper (2007) discuss the concept of insight, looking at its theoretical underpinnings, and the fact that it is problematic in mental health nursing because it can be difficult to have insight into patient’s experiences of mental illness. Insight is seen as part of the process of getting to know and understand the client, and from this, developing a knowledge of their mental illness, including diagnosing their particular mental illness (Hamilton and Roper, 2007). However, developing this insight is made difficult by problems such as the perceived difference in power between caregiver and client, and the expectations of ‘patient behaviours’ (Hamilton and Roper, 2007). This would suggest that the mental health nurse needs to see each patient as an individual, as unique, and to take the time to truly get to know the person and their experience of mental illness. Definitions of mental illness, and labels, can make this harder, for the nurse, and for the client as well, who fears being reduced to his or her disease rather than being seen as a person who is ill (Hamilton and Roper, 2007; Shattell et al, 2007).
Research by Shatell et al (2006) emphasises this point. In their study, clients raised a number of issues around being understood by mental health caregivers, and it was this concept of being understood which seemed most important in developing an effective therapeutic relationship. Some of these concepts include: feeling important; establishing connections, and being on the same level (Shatell et al, 2006). Research by Svedberg et al (2003) found similar results, and in their study “the patients described how the feeling of mutuality in the relationship with the nurse was important for the promotion of health processes. Mutuality was achieved by doing things together and by having a dialogue with each other.” (p 451). This author feels that these ideals can be properly achieved by mental health nurses who take time to get to know the client and who develop empathy with the client through focusing attention on them. The patients wanted to feel understood in Shatell et al’s (2006) study.
“ Feeling important was a major consequence of being understood. Being understood made patients feel like human beings rather than being treated like a number or being treated like in a factory. Participants wanted to be treated like human beings, not as sick, mentally ill persons; like persons, not a set of diagnoses “ (Shatell et al, 2006 p 237).
This could be viewed as a consequence of the compassion and self-awareness of the nurse as a professional, and of their ability to see the client as an individual, to not be prejudiced by anything about them, especially not their illness. This is very important. This author believes that compassion and empathy develop through getting to know the client properly, and that these all enhance the therapeutic relationship. Shatell et al (2006) also suggest that clients feel important when they know the nurse has been thinking of them at times other than face to face contact, and this is something to think of for practice, particularly in relation to the conversations that nurses have with patients. It is also important that mental health nurses develop proper listening skills, which would also allow them to develop compassionate understanding, and support the client in expressing themselves (Freshwater, 2006).
Encouraging self-expression is an important part of nurses getting to know their patients, it would seem, but self-expression is not easy for many people. People with mental illness are often negotiating a range of different sense of what constitutes their ‘self’ (Meehan and Machlachlan, 2008). “ For example, a professional woman becomes a mother and wife or ‘homemaker’ when she leaves the office for home. In changing from one self to another type, her multiple self voices renegotiate their hierarchy and positions and create a coherent self story consistent with the role of mother and wife.” (Meehan and Machlachlan, 2008). These negotiations can be problematic for the person with mental illness, and this just provides one example of how complex understanding the self can be, which makes self-expression similarly challenging. Yet it would be worthwhile to develop activities and actions which would sup port this.
It may be that there are ways that mental health nurses can encourage or support self-expression and the development of caregiver understanding of the client. For example, Raingruber (2004) discusses the use of poetry in child and adolescent mental health, as a means of self-expression, arguing that poetry has the power to allow clients to develop self awareness and to express their feelings. Raingruber (2004) suggests that “The complexity, power, and beauty of language within poetry allow the expression of intense human experiences” (p 14). While there are drawbacks and limitations to the therapeutic use of poetry, it might be that this offers one kind of opportunity for self-expression, on the part of the client, and empathy, on the part of the mental health nurse. “ When an appropriate moment arises, poetry should be used to help clinicians, nursing students, and clients become more aware of and open to possibilities.” (Raingruber, 2004 p 16). However, this author believes that the mental health nurse would need some skills in this area, or to be someone who is perhaps comfortable with using or writing poetry themselves, if they were to use it to any great extent with clients.
Feen-Calligan et al (2008) make similar assertions about using visual art in supporting mental health users who are substance misusers. Feen Calligan et al (2008) found that “As the women learned to verbalize their feelings and reflect on their situations through interpretative interactions with visual art, they gained insight into their feelings and issues they faced in their recovery from chemical dependency.” (p 287). This research seems to show that using visual art and image processing allowed the women to fully express their feelings in ways they had not been able to before (Feen-Calligan et al, 2008). Again, some kind of knowledge or skill on the part of the nurse would be necessary. Both of these examples are of arts-related activities, and relate strongly back to the formative assessment and book review. It might be that there is great scope within mental health nursing to encourage self-knowledge, self-expression and mutuality through the use of creative arts and fiction. Certainly this would provide a way for nurses to relate to clients more readily, to be on their level, and to talk in terms and metaphors that they are familiar with.
It would seem that underpinning mental health nursing are a number of core values which need to be more explicit in the discourses around the profession and in the practices of those within it. Svedberg et al (2003) state:
“The most important goal of nursing care is to promote the subjective experience of health. The health promoting efforts of mental health care nurses must be aimed at creating encounters where the patient will be confirmed both existentially and as an individual worthy of dignity.” (p 448).
The core values of mental health nursing should orientate towards this kind of confirmation of worth on the part of the healthcare provider for the client.
Eagger et al (2005) state:
“Organisations, too, would benefit from a clear, values-based statement that staff at all levels can identify with. Institutions encouraging a culture of care can contribute significantly towards creating a healing environment for staff as well as patients.” ( p 28).
This would be particularly relevant for mental health nursing and mental health services, and might signify and important area for future practice development. Undertaking this exploration has shown to the author the need for self-awareness and emotional intelligence on the part of mental health nurses, as a prerequisite for developing true compassion and empathy. Fostering self-expression amongst mental health services users, providing opportunities for this, and supporting them by paying attention and understanding them, is also important. While some experiences so far might suggest that in certain contexts and situations, this might be difficult to achieve, it should be the goal that we all strive for, and these are core values which should underpin all of our practice.
Akerjordet, K. and Severinsson, E. (2004) Emotional intelligence in mental health nurses talking about practice International Journal of Mental Health Nursing 13 (3) 164-170
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