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Why is mental health nursing unpopular?

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A US study suggests mental health nurses are viewed negatively by other nurses. Lisa Hitchen asks why.

A recent US study suggested mental health nursing is viewed as the least popular specialty by other nurses. What’s more, it found nurses who choose to work in the field are seen as ‘unskilled, illogical, idle and disrespected’.

The survey involved 122 nurses from two hospitals in Ohio, both with psychiatric units. Respondents were mostly female and Caucasian with an average age of 44 years.

The paper, published in Archives of Psychiatric Nursing in February this year, showed that mental health nursing was ranked lowest out of 10 specialties as the area nurses most wanted to work in. Their top preference was paediatric nursing, although they thought society most respected those nurses working in intensive care and emergency departments.

And this attitude does not appear to be confined to the US. Ian Hulatt, RCN mental health policy adviser, believes similar conclusions would be reached if the study was replicated in the UK.

He says it is a concept that has been with us for quite some time and points out that Canadian sociologist and author Erving Goffman was writing about ‘courtesy stigma’ in the 1960s, when he argued that those working with devalued client groups are, by association, regarded in the same negative light. But where exactly are these views coming from?

Mick McKeown, principal lecturer in mental health nursing research at the University of Central Lancashire in Preston, believes they reflect a deeper social problem.

‘It is possible that mental health nursing is seen more negatively than general nursing because of association with pejorative public attitudes towards mental health,’ he says. ‘The idea of mental health nurses being uncaring could relate to some of the contradictions in mental health practice. For example, between wishing to care for people in extreme distress but also being part of a legal system that curtails freedom.’

He adds that the lazy label could be linked to the perception that a hard-working nurse should be busy and active at all times, rather than ‘escaping real work’ by taking the time to talk to patients.

He goes on to say that talking to clients is an essential part of a mental health nurse’s job. ‘I wouldn’t accept any argument that diminishes the skilled aspect of such work done well. Indeed, the emotional labour involved in supporting people in distress is much harder than the mechanical operation of machines and technical practices.’

However, it is the technical skills that capture the respect of public opinion on nursing, he says. ‘Technology, science, patriarchy and capitalism overvalue high-tech contributions and all work is primarily organised to reflect this. Work that looks more like domestic labour, such as emotional work, is undervalued in this sort of economy.’

Abby Earrey, a community mental health nurse at St Luke’s Community Mental Health Centre in Auckland, New Zealand, who trained in the UK agrees. ‘We talk to people. Our equipment is our brains.’

Rachel Munton, executive director of nursing at Nottinghamshire Healthcare Trust, which provides mental health and learning disability services, thinks it is the lack of understanding of other nurses that is contributing to the rubbishing of the mental health nursing specialty.

She says: ‘It is likely to be fear of the unknown and a desire within a profession to promote itself. One way of doing this is by undervaluing other parts of its own profession. Often nurses are dismissive of midwives [and vice versa] for no reason other than stereotypical notions and professional jealously, perhaps.’

Ms Munton went into mental health nursing on leaving school. ‘I loved the variety, the difference and the ability to use myself and my personality to help others. I have been a mental health nurse in one setting or another for 30 years. I am enjoying a fabulous and varied career.’Ms Munton says many people with a variety of life experiences can go into mental health nursing. ‘Often people feel they can use their own life experience and challenges to support others through theirs – a genuine way to choose your career.’

But developing ways to manage stress and keep motivated, and having supportive colleagues and a healthy working environment are key for job survival, she explains. Mary Alabaster, consultant nurse for perinatal mental health services at South Essex Partnership NHS Foundation Trust, has the advantage of having worked in both mental health and non-mental
health settings.

She is trained as a general nurse, a health visitor, a family planning nurse and a therapist but she now works in a mental health trust and sees mothers and expectant mothers with severe depression and other mental health problems. She is in a unique position to see mental health nurses and nurses from other disciplines interact with patients and each other.
Ms Alabaster calls the views in the study ‘disgraceful’. ‘It is only since working in a mental health setting that I realised how stressful it is. Mental health nurses are dealing with the most vulnerable people in society – people who are living chaotic lifestyles, people who are contemplating suicide. They are actually dealing with people’s minds.’

She recommends the field to other nurses. ‘When I came into the mental health setting seven years ago it was unheard of that a health visitor would go into this. It was the best career move I made in my life.’

So what are the solutions to all this negativity surrounding the specialty?

Mr Hulatt is optimistic and says he thinks things have moved forward in recent decades. ‘The public understanding and perception of what we do is improving as we have moved away from institutions but we still have a long way to go.’

But he emphasises the need for more positive images of mental health nursing in the media. ‘There is not a Holby City or a Casualty for people who are considered “mad”. People are relying on outdated images,’ he says.

It is also about education, he adds, with careers advisers understanding little about what mental health nursing is, so they don’t properly advise prospective students.

Ms Alabaster says too that nurse training could go further to enhance understanding of mental illness and mental health nursing across the profession.

‘General nurses, midwives, social workers and psychiatric nurses should have part of their training in the same or similar modules,’ she suggests. For those who are already trained, there should be shadowing of nurses in mental health by nurses in other specialties and vice versa so they all understand each other’s roles.

Mr Hulatt agrees. ‘The point of the current branch system is for people to gain experience across the four branches and get a greater understanding of each other’s specialties. It is not as effective as we would have wanted. Nurses could also have more exposure to mental health lecturers in the core foundation programme, perhaps.’

So, overall, what impact does such research have on mental health nurses?

‘It is pretty demoralising in one sense,’ says Mr Hulatt. ‘When you think that a percentage of the nursing workforce is getting mentally or verbally abused, you don’t really need that from your colleagues.’

But he thinks the mental health nurses themselves can do something to counter this. ‘People have to be loud and proud about their achievements.’

And he says nurses in general should be aware that they are all one profession. ‘In the family of nursing we need to be more respectful of all branches,’ he adds.

Ms Munton thinks the same. ‘As professionals we have an absolute mandate to challenge [the stigma experienced by mental health nurses] and to reflect the reality of mental health experiences in all society. As one in four of us will experience mental health difficulties, we should be less judgmental.’

Mark Melling, a modern matron for mental health services for older people at Sussex Partnership Trust, has another idea. He calls for performance measures around specific areas such as patient satisfaction.

‘I strongly feel that more performance measures are required in mental health nursing to provide a more structured view of what mental health nurses are doing,’ he says.

‘Evidence of good performance can be shared, so you can say, in a meaningful sense: “we’re doing well and getting better at what we do for patients”, he adds. It is also the most robust way of countering the research mentioned.’

How nurses described their colleagues in mental health

‘Unskilled, illogical, idle and disrespected’

‘Introverted, dependent, disinterested and judgemental’

‘Working in an area of nursing least preferred personally and societally’

‘Incompetent and weak’

Source: Archives of Psychiatric Nursing (2008) 22: 1, 20–26

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