Nursing in quality space: technologies governing experiences of care

This paper challenges contemporary portrayals in the nursing literature of the spaces within which care of patients in hospital settings is conducted. Within the wider discourse of fiscal restraint on health care spending, professional nursing has cast its disciplined eyes on details of the nurse-patient relationship for the ostensible purpose of repairing that which is treated as individual failings of nurses to practise in ways prescribed by nursing theories. Set aside in this approach to the so-called 'problems' of nursing practice has been an examination of the conditions within which nurses come in contact with patients, and a critical recognition that such contacts represent skilled accomplishments of social action. In this paper, these conditions are treated as resources available to both nurses and patients to generate accounts for the nurse's presence as well as the nurse's absence. Examples from an ethnographic study of nursing practice are used to illustrate how the spaces operating between nurses and patients are not empty voids but are social spaces through which particular meanings about nursing care can be conveyed.     

Mental health nursing: Daring to be different,special and leading recovery‐focused care?

How mental health nursing is differentiated from other disciplines and professions, and what special contribution mental health nurses make to health services, is a question at the heart of contemporary practice. One of the significant challenges for mental health nurses is identifying, developing and advancing those aspects of their practice that they consider differentiate them in the multi‐disciplinary mental health care team and to articulate clearly what a mental health nurse is and does. This paper draws on data from interviews with 36 mental health nurses in Australia who identified their practice as autonomous. Participants were asked the question, “What's special about mental health nursing?” Constructivist grounded theory techniques were applied to the research process. Findings were formulated and expressed as the ‘Ten P's of the professional profile that is mental health nursing’, which are ‘present’, ‘personal’, ‘participant partnering’, ‘professional’, ‘phenomenological’, ‘pragmatic’, ‘power‐sharing’, ‘psycho‐therapeutic’, ‘proud’ and ‘profound’. The combined elements of the findings present a theoretical construct of mental health nursing practice as something distinctive and special. It provides a model and exemplar for contemporary practice in mental health nursing, embracing the role of mental health nurses in the health care workforce as being well placed as providers of productive and effective care.     

Expertise or performance? Questioning the rhetoric of contemporary narrative use in nursing

BACKGROUND: In the early 1980s there emerged in nursing a self-conscious and well-articulated concern to articulate nursing's contribution to patient care. This has fostered the production of a large volume of practice narratives that today form the basis of professional self-understanding. First-person practice narratives are now widely used as the evidence base for nursing expertise, not only in their natural home, the world of interpretative research, but also in the bureaucratic-judicial domain of professional regulation, health care organizations, trades unions and professional associations. AIM: The aim of this paper is to question the use of individual narrative accounts of nursing practice as evidence of nursing expertise. METHOD: We examine the model, method, and continuing consequences of these discursive formations of practice. First, we present a methodological discussion of how personal narratives are produced by the interplay between discourse and subjectivity. Second, we explore clinical narratives of expertise in the work of Patricia Benner and others to uncover the common template for contemporary narrative. DISCUSSION: Narrative production in nursing has led to particular constructions, rather than free representations of practice. It is these particular constructions that we call into question. Rather than viewing these narratives as revelatory of nursing practice, we argue that they place a 'spotlight' on the individual actor - the nurse - with an absence of structural practice context. CONCLUSION: We make the case that treatment of these narratives as individual evidence of expertise fundamentally misunderstands their function and purpose, and reduces the constitution of nursing expertise to the performance of a palatable and highly desirable discourse for a nursing audience.     

Exploring nursing expertise: nurses talk nursing

It has become increasingly important for practitioners to articulate their expertise in modern healthcare settings that demand high levels of accountability and evidence-based practice. The material presented within this article has been interpreted drawing from discourse analysis1 to help explore the discourses that shape and influence understandings of nursing practice. What we present are extracts from four of the 35 participant nurses who applied to take part in the Royal College of Nursing Institute's Expertise in Practice (pilot) Project (EPP). The material presented is used to provide a starting point for exploring how nurses talk about and construct expertise in nursing practice. The four nurse participants' clinical practice areas cover palliative care, mental health, intensive care and fertility care. The material reveals high levels of intensity in the nurse-patient relationship, 'maverick' nursing practices and ongoing reflexivity. All of these aspects appear to capitalize on expertise as a 'catalyst' that alters treatment pathways and maximizes patient-centred outcomes. Exploring a discourse of nursing expertise exposes the tacit situated nature of professional practice that is heterogeneous and most difficult to articulate and explain. It is proposed that expertise tends to be understood from traditional and dominant discourses of medicine, management and technology. Explaining expertise in practice exposes non-conventional practice that in itself can be isolating and challenging to the status quo of contemporary health-care.     

Mental and physical health comordibity: political imperatives and practice implications

Insufficient priority is being given to meet the physical health-care needs of people with mental illness. Mental health nurses, as the largest professional group working in mental health care, have a pivotal role in improving the physical health and well-being of people with mental illness. Through health-promotion strategies, alongside recovery-focused support aimed at avoiding deteriorating physical health, mental health nurses can significantly contribute to improving the current rate of premature death experienced by people with enduring mental illness. Drawing from contemporary policy, alongside practical examples taken from the published literature, this paper considers what constitutes recommended best practice in dealing with the physical health-care needs of people with mental illness. The role that UK-based health-care policy plays in shaping care delivery that meets the needs of people with mental illness is explored and placed within the context of global health concerns. Recommendations are made on how mental health nursing can work to provide evidence for a reassertion that nurses are well placed to work across organizational and professional boundaries to deliver person-centred care and a holistic approach to population health and well-being.     

Assertive community treatment (ACT) case managers’ professional identities: A focus group study

Assertive community treatment (ACT) case managers provide healthcare services to people with severe and persistent mental illness. These case managers take on generic roles in multidisciplinary teams and provide all‐around services in the clients’ private homes. This focus group study aimed to gain insight into Danish ACT case managers’ professional identity work by examining their discussions of ethical dilemmas and collaboration in their everyday practice. Data were collected during five focus groups at three ACT teams in the North Denmark Region and subjected to discourse analysis emphasizing how identity work was accomplished through talk. The findings indicated that the case managers constructed professional identities by actively positioning themselves and the particular ACT approach in relation to other mental healthcare professionals and clients. They represented themselves as achieving better client‐related outcomes by being more assertive and persistent, and as responsible caregivers who provided the help that their clients needed when other services had failed to do so. They depicted their services as being focused on the clients’ well‐being, and their persistent efforts to establish and sustain interpersonal relationships with clients were an important part of their service. Basic nursing tasks were described as an important part of their everyday work, and even though such tasks were not distinctive for ACT case managers, the representations of their work seemed to give them a sense of worth as professionals and legitimized a unique role in the community mental healthcare services.     

How do nurses acquire English medical discourse ability in nursing practice? Exploring nurses' medical discourse learning journeys and related identity construction

BackgroundIn Taiwan's hospitals, English medical discourse underpins nursing and medical practice. Much patient care work is done through language work, by both text and talk. This means that when nurses start their nursing careers in the hospital context, where English medical discourse is shared to produce knowledge and engage in practice, knowledge of medical discourse and the ability to use it are prerequisites. In the process of learning and using such specialist language, the formation of professional identities is assumed.ObjectivesThis study aimed to explore nurses' learning journeys relating to medical discourse and the development of their professional identities.MethodsThis research adopted a qualitative approach, using data from 10 nurses working in different hospitals in Taiwan.ResultsThe findings revealed that English medical discourse was employed in Taiwan's hospitals not only for fulfilling professional purposes but also for socialising nurses into the healthcare community. Nurses acquired it through interactions, small talk, relationships, discussions, and nursing tasks. Their professional identities were formed through engaging in meaningful nursing practice based on English medical discourse. However, in the learning process, they encountered difficulties in the areas of listening, speaking, and reading, which raised concerns about patient safety.ConclusionSufficient support is needed to ease nurses' difficulties in learning. We propose having primary and secondary preceptors, establishing a mentorship policy, and creating a learning environment that is supportive of nurses' learning experiences.     

Professional influences on the provision of mental health care for older people within a general hospital ward

Recent policy initiatives within the United Kingdom have recognized that effective care for older people can only be achieved if health care staff are willing and skilled enough to address patient needs in a holistic way. The preliminary stages of the action research project described here focused on the perceptions of nursing staff regarding the factors that impacted on their ability to address mental health needs within a general hospital ward. A phenomenological approach allowed us to identify the experience of addressing mental health needs in this setting from the perspective of the research participants. A focus group was facilitated with nursing staff whose primary professional focus was the provision of physical health care within an older adult unit. Thematic content analysis was used to analyse the focus group data, and four key themes emerged, namely 'disruption', 'role conflict', 'professional resources' and 'professional distress'. These themes provide a focus for the ongoing development of the action research methods and will embed future work in the experience of those charged with ensuring that mental health care is a key element of their practice. This study highlights the urgent need for further work in this area, as we contend that it is only by addressing the professional needs of the staff concerned, that effective patient-centred care can be ensured.     

Realities of Mental Health Nursing Practice in Rural Australia

Mental health nursing as a distinct speciality has been in decline in New South Wales (NSW), Australia, for two decades. Arguably, this decline has worsened both consumer outcomes and the workplace experiences of mental health nurses. This article reports on a study designed to ascertain the nature of contemporary mental health nursing practice in New South Wales. The study utilised focus group research methodology, with participants recounting the realities of their day-to-day professional practice and perceptions of their professional identity. The findings indicate a contracting, if not moribund, profession; a decrease in the value attached to mental health nursing; and a pattern of persistent underfunding by successive governments of mental health services. An analysis of present and historical trends reveals there is a pressing need for a restructure and re-formation of mental health nursing in rural areas. This article links the shortage of mental health nurses in NSW to the closure of the mental health nursing register, a shift to comprehensive/generalist nurse education models, a perceived lack of nurses’ professional standing, and natural attrition without suitably qualified replacements. Mental health nurses in this study perceived that they were not valued by other health professionals or by their own managers. Participants in this study reported mental health nursing in rural areas was an unattractive career choice. These findings are important to the understanding of recruitment and retention issues in rural mental health nursing in Australia.     

The importance of emancipatory research to contemporary nursing practice

When considering the significant changes that continue to transform nursing practice, a focus on evidenced-based practice has clearly placed nursing research at the forefront of professional practice. The aim of this paper is to highlight the important contribution that emancipatory research methodologies can make to the ongoing development of contemporary nursing practice. A research example demonstrates how an emancipatory framework was applied to a recent doctoral study undertaken with Australian community nurses who provided palliative care. The research focus was on exploring the relationship between the nurse's emotional well-being and their professional practice. The research was epistemologically located within a critical and feminist framework. Emancipatory research is well situated to address the subjective experiences of nurses and to contribute strongly to the future of nursing practice.     

Gender and professional identity in psychiatric nursing practice in Alberta, Canada, 1930-75

This paper examines gender-specific transformations of nursing practice in institutional mental health-care in Alberta, Canada, based on archival records on two psychiatric hospitals, Alberta Hospital Ponoka and Alberta Hospital Edmonton, and on oral histories with psychiatric mental health nurses in Alberta. The paper explores class and gender as interrelated influences shaping the work and professional identity of psychiatric mental health nurses from the 1930s until the mid-1970s. Training schools for nurses in psychiatric hospitals emerged in Alberta in the 1930s under the influence of the mental hygiene movement, evolving quite differently for female nurses compared to untrained aides and male attendants. The latter group resisted their exclusion from the title 'nurse' and successfully helped to organize a separate association of psychiatric nurses in the 1950s. Post-World War II, reconstruction of health-care and a de-institutionalization policy further transformed nurses' practice in the institutions. Using social history methods of analysis, the paper demonstrates how nurses responded to their circumstances in complex ways, actively participating in the reconstruction of their practice and finding new ways of professional organization that fit the local context. After the Second World War more sophisticated therapeutic roles emerged and nurses engaged in new rehabilitative practices and group therapies, reconstructing their professional identities and transgressing gender boundaries. Nurses' own stories help us to understand the striving toward psychiatric nursing professionalism in the broader context of changing gender identities and work relationships, as well as shifting perspectives on psychiatric care.     

What should be the future focus of mental health nursing? Exploring the perspectives of mental health nurses,consumers, and allied health staff

The landscape of mental health care and service delivery is changing, as is our understanding of the underlying causes for mental distress. It is now apparent that biogenic explanations have been overstated and instead experiences of trauma and adversity constitute the main contributor to people’s experiences of mental health challenges. The shortcomings of treatments traditionally used in mental health care are also evident, and with a contemporary focus on person-centred care, the utility of diagnostic labels has been called into question. Taking all this into consideration, this study sought to explore, what should be the future focus of mental health nursing? Three separate focus groups were conducted. One with a sample of senior clinical mental health nurses, one with a sample of consumer representatives and another with allied health professionals. The common theme across all three focus groups was the centrality of the therapeutic role of mental health nurses (MHNs). Consumers and allied health participants, in particular, advocated for a de-emphasis on medications, psychiatric diagnoses, and custodial practices. The MHNs role in health promotion, working collaboratively with consumers, being hopeful, understanding the individual perspective, and appreciating the social determinants of mental health were all highlighted in framing the future focus of MHN practice.     

What mental health nurses have to say about themselves: A discourse analysis

Mental health nursing is largely invisible within public discourse. When mentioned at all in news media, it is usually a signifier of an occupation connoting where a nurse works. There is rarely a presumption of expertise in any sphere or articulation of a unique skill set or defining features which differentiate the mental health nurse from other nurses. This paper sought to examine the professional discourse around mental health nursing as inferred from a review of papers published in the International Journal of Mental Health Nursing in 2019. A discourse analysis of full‐text papers (n = 117) was undertaken exploring references to mental health nurses or nursing and what this communicated about the field. The discourse clustered around three themes: The invisible or absent mental health nurse, ambiguous and blended identities, and a group of low attributed value and sophistication. There were few examples of authors presenting mental health nurses in a way which counters stereotypes of the dominant discourse about mental health nurses as a lesser skilled occupational group. Academics, editors, authors, and practitioners are urged to contribute to the construction of discourse around mental health nursing expertise which differentiates it from other branches of nursing and other distinctive disciplines.     

Redressing the balance in mental health nursing education: Arguments for a values‐based approach

ABSTRACT: Evidence‐based practice (EBP) has become a dominant epistemology in nursing education, and has devalued the complex interpersonal components of mental health nursing. A curriculum for mental health nursing, which values the personhood of service users, should focus on those processes that promote recovery within a therapeutic relationship committed to collaboration and respect for diversity. These relationships become possible where the preparation of mental health nurses for practice includes an examination of self in terms of beliefs and values and their consequences on others. The combination of action and reflection in praxis provides a means by which self‐examination and professional obligation can be examined in order to construct a moral identity, which is responsive to the needs of people with mental health problems. Praxis is more than a means of reflecting on practice: it draws together skill, practice knowledge, attitudinal style, and moral reasoning. For this reason, ethical values have a vital role to play in the development of contemporary nursing praxis.     

Avoiding Paternalism

Ethical problems have always been a feature in mental health nursing, partly due to the association with the system of traditional psychiatric care. This paper examines the issue of paternalism and how it lingers from past nursing practice and can impede contemporary practice. Finally, some paths for positive engagement are examined, along with strategies to determine how paternalism could be minimised in modern mental health nursing practice.     

The place of the unconscious in mental health nursing

ABSTRACT:  This paper acknowledges the concept of the unconscious in psychiatric discourse and explores the importance of this for mental health nursing practice. Mental health nursing practice has always been strongly influenced by psychiatric discourse because of its dominance in the clinical setting. The most recent edition of the American Psychiatry Association's Diagnostic and Statistical Manual has signalled that the concept of the unconscious is re-emerging in psychiatric discourse. This re-emergence provides the opportunity for mental health nurses to re-affirm or develop their psychotherapeutic skills in the nurse−patient relationship. The psychotherapeutic relationship could focus on ways for the patient to find meaning in their lives that recognize and value difference and multiple ways of being.     

Seeking and defining the ‘special’ in specialist mental health nursing: A theoretical construct

In the context of an enduring debate about the distinct identity of mental health nursing, this qualitative study explored the nature, scope and consequences of mental health nursing practice. Data for interpretation were generated through interviews with 36 mental health nurses, five of their clients and one health care colleague, each of whom were asked to speak in as much detail as possible about what they believe is special about mental health nursing and what had influenced them to arrive at this understanding. Using a constructivist grounded theory approach, the study generated a substantive theory of recovery‐focused mental health nursing expressed as ‘Being in the here and now, side by side, co‐constructing care’. The study revealed that the distinct nature and identity of mental health nursing provides the foundation that primes and drives practice scope and consequences. Conceptual interpretations of the data emphasized the mental health nursing perspective of care as an acquired lens founded in nursing as a profession and enhanced by the relational interplay between the nurse and the client that facilitates the nurse to adopt recovery‐focused practices. This theoretical construct holds the potential to be the mediating connection between client and mental health nurse. By situating mental health nursing and its central role in practice as something co‐constructed, findings from this study can be expanded beyond the Australian context, particularly in terms of mental health nursing's distinct professional identity and practice.     

Managing risk: clinical decision-making in mental health services

Risk assessment and management is a major component of contemporary mental health practice. Risk assessment in health care exists within contemporary perspectives of management and risk aversive practices in health care. This has led to much discussion about the best approach to assessing possible risks posed by people with mental health problems. In addition, researchers and commentators have expressed concern that clinical practice is being dominated by managerial models of risk management at the expense of meeting the patient's health and social care needs. The purpose of the present study is to investigate the risk assessment practices of a multidisciplinary mental health service. Findings indicate that mental health professionals draw on both managerial and therapeutic approaches to risk management, integrating these approaches into their clinical practice. Rather than being dominated by managerial concerns regarding risk, the participants demonstrate professional autonomy and concern for the needs of their clients.