nursingforsocialjustice

Have you ever read something and wondered what the actual motivation of the author(s) was? I will contextualize this for you. Right now I am preparing to write my comprehensive exams. The preparation involves a lot of reading and a lot of writing. I read an article today that was published in a Social Work journal and could not help but think, something more was happening here than just wanting to propose a potential change to make mental health services better. The author makes quite a few assumptions about the education of generalist nurse preparation. This made me think, the peer reviewed research process is quite interesting because there is a lot of reliance that both the person who submitted an article and the people reviewing it have academic integrity and also, that they know the substantive area that is the content of the article they are reviewing.

The article left a bad taste in my mouth because the gist of it is: Registered Nurses have a lot of mobility, mental health specific services (particularly inpatient) are stigmatized and undergrad programs don’t have a lot of mental health specific curriculum so we shouldn’t rely on a mental health system designed to require nurses as an integral role of care. Instead train a mental health specific discipline that can be a consistent supply. And…that will change this system that we have that continues to rely on a medical model? That will decrease stigma? Or that will solve a perceived staffing crisis? Or should this be about understanding the reasons why nurses choose mental health and leave mental health specific places in the first place?

Some of the insight that Hayes and Collins¹ offer seem like distortions of the data. A table is included with the percentage of RNs/RPNs separated by east and west in Canada. The higher percentage of nurses overall who work were employed in mental health is identified as supportive of a mental health specific entry to practice level but there’s no further break down of the actual number nor what these percentages mean. Is the shortage actually less in Western Provinces? Because, for example if there is less of a shortage of nurses in Eastern Canada then maybe the model isn’t working in Western Canada? Or is that something we can even conclude without a more in-depth statistical analysis? Are there other factors that have to be considered, for example, rural versus urban, the number of nursing schools, curriculum standards, etc? Assumptions are made that care must be better in Western provinces because of more hours of mental health specific curriculum. But what is the content of this mental health specific curriculum? Especially in 2008, there were not studies exploring curriculum content, and certainly no comparisons about if patient outcomes were better: East versus West.

We can’t assume that the sole factor that is underlies workforce shortages is education structure. What about the workplace itself? What about the changing relationship of women and professional work?

At the end of all of this I think an important question that must be asked is: what is it about inpatient mental health that make it more of a challenge to recruit an retrain? It’s not just nurses who are tough to recruit and retain in mental health services, nursed are just the most numerous professional group. And is this shortage more profound compared to other areas like long-term care? There was a time, not so long ago when almost half of people who were in hospitals in Canada were in mental hospitals. But, when this was happened a lot of people who would not today fall within the realm of a DSM-5 diagnostic type of mental illness classification were in the mental hospital, including people with dementia, people with complications of syphillis, people living with epilepsy, people living with developmental issues, etc. were in the mental hospital. So, in some ways I am not sure if we have an less nuanced understanding of who accesses mental health inpatient services. I am not sure if there is also a nuanced understanding of who gets forced into involuntary treatment.

Perhaps we need to re-think this. And by re-think I mean re-frame and dig deeper. I think there might not be as nuanced understanding of how the moral distress that nurses sometimes feel working in a care area that is so deep a mismatch between what we say is the philosophy of care (ie recovery orientation practice, strength-based care, trauma and violence informed practice, collaborative care, person and family centred care) and how it plays out in practice impacts choice of nurses to work in those areas. Other questions must be asked, for example, what is the retention like of entry to practice psychiatric nurses? Do generalist RNs who enter mental health services stay in it, or do they leave, and why? Why do RNs come to mental health areas after not initially starting in mental health specific services?

It’s a problematic assumption to make that if a generalist educated RN does not start in mental health then they will never ever want to work in mental health. It is also a problematic assumption to make that mental health nursing and mental health nurses are segregated to mental health specific spaces. On some level, is the stigma actually being perpetuated by this idea that inpatient mental health is so different and so removed from “nursing” that only a specialist nurses can work there? I say this because I often wonder. when we have a patient who has just been diagnosed with a terminal illness, we might work in oncology but does that mean that there’s not mental health knowledge that we use to guide our nursing practice? If this is so, that’s a problem.

I am having trouble getting over this idea that the separation between general nurse and psychiatric nurse in 2021 is something that extends beyond staffing issues. That is my bias but that is also my understanding of the evolution of nursing as a discipline from the perspectives of theorists like Parse, Fawcett, Peplau, Rogers, Watson, Roach, and so on and so forth. Maybe we have to take a different route here and really embrace that the general public might not know, even in 2021, even in a place like Canada, even in a historical moment when nurses are celebrated as heroes in the COVID crisis, what a nurse does, what their education is, what their scope of practice is, what their role in in healthcare is. I get it. Physicians are the face of healthcare. There are almost 440 000 regulated nurses in Canada. Maybe we should also be the face of healthcare? And not in a supportive, silent, seen but an understood way in which the public image of nursing is about nursing and our role in the healthcare system.

At the end of the day is a better question ask: is the current model of mental health service delivery, where the main options are specialized community services exist for those flagged as needing “psychiatric” services manageable in the community, and inpatient hospital services for those who are identified as at high risk of harm to themselves and others certified under provincial mental health acts?

Peace,

Michelle D.

1. Hayes, E. W., & Collins, J. (2007). A Proposal to Reduce Psychiatric Nurse Shortages: Or Does ‘Nursing’ Really Serve the Cause of Mental Health?. Social Work in Public Health, 23(1), 129-142.