A unique headspace

'What’s special about mental health nursing?’

This question launched a three-year study into the nature, scope and consequences of nurses’ work in the mental health sector.

“The question [was] posed in the context of what constitutes distinctive practice and how this contributes to positive outcomes for the clients it serves – in short, is it special?” says conjoint senior lecturer at the University of Newcastle and PhD candidate at the University of Tasmania, Peter Santangelo.

“It was clear to me that role definitions did not adequately define the profession’s essence. Also, much of the research involving mental health nursing is bio-medical focused rather than nursing focused, and there was a need to develop theory based on practice.”

Three years on and Santangelo, who is a credentialed mental health nurse and the immediate past president of the Australian College of Mental Health Nurses, said the study raised and identified opportunities for future research on practice, education, leadership and identity.

“It has provided, for me, a springboard to pursue future research, either directly or vicariously through other nurse researchers, in any of these areas but are as yet undefined. It certainly has revived my passion for seeking and contributing to new knowledge in this profession.

“As I listened to mental health nurses recounting their work and articulating the way in which they saw and related with their clients, it reinforced my admiration for those nurses who modestly and humbly execute their skills with such competence and commitment, [which is] often not understood or appreciated for its gravity.”

Nursing Review spoke to Santangelo about the study, his findings and what they mean for the sector.

NR: You are speaking at the upcoming Mental Health Nursing Conference on Shaping recovery-focused mental health nursing for the future: report on a grounded theory study. What prompted your work on this particular project?

PS: The motivation for pursuing this research stems from an enduring inquiry by mental health nurses, who struggle, at times, to articulate clearly what a mental health nurse is and does. That is, the essence of this activity that makes it distinctly mental health nursing remains a contested issue within the profession.

Despite a distinct profession of nursing with specific regulation, standards, codes and educational preparation, and a defined workforce of mental health nurses, debates continue. They include issues around how it’s named – that is, whether its practice is psychiatric or mental health – its role definition, its professional practice, its professional identity and self-image, and its sustainability in the workforce.

These expressed concerns reinforce the importance of defining a rightful identity and place for mental health nursing that acknowledges its distinct contribution. Clarity of these issues is vital for esteem, integrity and motivation to enhance practice towards improved service delivery.

You started with the question: ‘What’s special about mental health nursing?’ What answers have you found to this throughout your process of inquiry?

I used a constructivist-grounded theory methodology to explore this question in the context of the nature, scope and consequences of mental health nursing. I interviewed 36 mental health nurses working predominantly in a community-based and/or primary care setting, five of their clients and one healthcare colleague.

What emerged from this data, augmented by the literature, were major categories reflecting the nature, scope and consequences of mental health nursing, consolidating into a core category that I called “co-constructing care towards recovery”. From this, further analysis and conceptualisation generated a theoretical construct titled “Being in the here and now, side by side, co-constructing care: a substantive grounded theory of recovery-focused mental health nursing”.

This proposes that the identity of nursing is rooted in the notion of service to others. This perspective, along with intimate caring, brings a peculiar sensitivity to the holistic needs of the clients fostered by a relationship with them grounded at their level.

This is translated into practice, which unsurprisingly places importance on the relationship with the client as the catalyst for therapeutic caring. It acknowledges and responds to the idiosyncrasies of each client and each encounter. It is collaborative, flexible, enduring and persistent and in sync with a nursing ethos adapting its knowledge and skills in the service of others. This construction of practice sensitises mental health nurses to engage in a therapeutic and beneficial coupling that is concurrently humanistic and professional, co-constructed and contractual, collaborative and purposeful, and empowering and power-sharing.

The consequences of this care are positive outcomes that place the client as an equal partner in negotiation, generation and execution of therapeutic interventions. Care is delivered and adapted through a process of co-construction between the mental health nurses and their clients, using whatever other resources, directly or indirectly, to achieve the agreed upon outcomes. Mental health nurses use their special professional skills to provide the co-ordination of this care, which is both complementary to other [professionals’] contributions and, at the same time, distinct in its own contribution.

What are the take home points you have learnt about the specialty over this time?

The theory generated in this research has 10 attributes, expressed as 10 ‘P’s.

The nature of nursing depends on being present with the client to affect care, which connotes physical engagement and also experiencing the immediacy of the client’s physical, psychological, social and spiritual being. The intimacy of this encounter engenders a sense of the personal for both players.

The closeness of the relationship in which this takes place is a special part of the nursing care work environment in which nurses are active participants in the care relationship, rather than distant observers. It is a participant partnering that is derived from the nature of nursing work and which is the genesis of a therapeutic engagement that allows interventions for care to be co-constructed.

Mental health nursing is professional in its foundational knowledge and in its expressed practice. It requires specialist qualifications in mental health in order for nurses to apply established evidence-based interventions as well as [use] their distinct position in working with clients to generate alternate sources of evidence for intervention. At the same time, it is phenomenological, stressing all domains of experience. Inclusion of the lived experience of the client’s perspective of mental health and illness – as well as the lived experience of the nurse’s background and achievements in this partnership of care – are essential. Blending professional and experiential knowing is an acquired skill and approach that characterises the nursing lens.

Mental health nurses’ pragmatic approach to care facilitates this. Their concern with practical and positive consequences for their clients drives this approach and is in accord with a client-focused recovery agenda. This encourages a broad, holistic view, acknowledging that the ordinary activities of living are interwoven with illness expression that may be any combination of biologically, psychologically, socially and spiritually based or determined. Real and present issues are addressed by a therapeutic relationship grounded at the client’s current level of readiness and capacity to engage, sufficiently flexible to accommodate change and variance, and purposeful in its therapeutic intent.

Power sharing is also a crucial element that aids this process. The credibility of mental health nursing expertise is not built on prescribing care, but rather on participatory care that creates equity in the power dynamic of the nurse/client relationship. In particular, and in sync with recovery principles, mental health nurses acknowledge the need for those with lived experience of mental health issues to have influence and control over their experiences in mental health services.

There is also a targeted focus on psychotherapeutic outcomes, which is inherent in these nurses’ remit as specialist practitioners. Psychotherapeutic interventions are informed by traditional, evidence-based knowledge and practice but also are executed in the context of the nursing paradigm described above and tempered by the needs, wants and aspirations the client brings to the process.

These attributes constitute a distinct contribution that makes mental health nurses stand proud as a confident and distinguished professional identity in the context of multidisciplinary mental healthcare. The consequences of this special contribution are profound, demonstrated by the positive outcomes that this orientation of care brings and adding a credible and distinguished contribution to the meaning and understanding of professional caring relationships.

What are the main ways you have found that mental health nurses can meet current challenges?

The substantive theory this research has generated is derived from mental health nurses practising in a contemporary setting and working within, but also to the edges of, their professional boundaries of practice. They have expressed practice that is distinctly nursing in orientation and execution. Irrespective of the setting, the essence of its practice, as expressed in this theory, provides a model that is quintessentially nursing, with which any mental health nurse could identify.

The 10 ‘P’s highlight aspirations for recovery-focused care, collaborative partnerships, inclusive and accessible care, and a special person-centred approach that [uses] relational skills as its core. The national agenda in Australia for improvement and reform of mental health service delivery also has these aspirations. This synchronicity of aspirations augers well for acknowledging the special place of mental health nurses in meeting these agendas.

Peter Santangelo will present findings at ACMHN’s 40th International Mental Health Nursing Conference, October 6–9.

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