Abstract
Psychiatric nursing is built on the premise that the interpersonal relationships we have with clients and the development of caring therapeutic relationships allows nurses to use their “perceptions, thoughts, and feelings in the identification of patient needs” (Redknap, Twigg, Rock, & Towell, 2015, p. 262). This complex relationship is based on psychiatric and developmental knowledge, the theories of psychiatric nursing leaders such as Travelbee (1971) and Peplau (1991), and the knowledge that the nurse brings her/his interpersonal knowledge to a healing relationship with a client. Quite simply, it is this relationship that contributes to maximized health and recovery. There is no question that the psychiatric nurse is a key player in psychiatric treatment in all mental health settings and in general medical settings, especially primary care. Who cares for the psychiatric nurse and how is this accomplished in this era of a dwindling workforce and increasing need for psychiatric nurses at all practice levels?
Shelton (2015) wrote about emotional health and caring for psychiatric clients. She notes the shift toward advocacy in mental health care that has been strongly influenced by policy initiatives for several decades. These include the Mental Health Parity Act, the Americans with Disabilities Act, and, most recently, the Affordable Care Act. These programs have had a significant impact on the provision of care for individuals with psychiatric issues. Caring for vulnerable populations also requires an increasing educational focus for caregivers on recovery, influence of stigma, and prevention. Shelton (2015) notes that “psychiatric clinical nursing research and its dissemination has not kept pace with patient care needs” (p. 2). As nurses are required to provide increasingly sophisticated treatment models to vulnerable populations, the following questions must be asked: Are we preparing them for this from an educational perspective? Are treatment environments ensuring that nurses receive the support they need to care for clients? Are we providing the emotional support they need to do their jobs?
Happell et al. (2015) conducted a qualitative study of nursing students’ attitudes about individuals with mental illness. Their findings, with predominant themes of fear and power, emphasized the need to face the fear about mental illness, demystify it, and identify the role of power in consumerism. They found that involving individuals with mental health challenges in nursing education contributed to recovery-focused mental health services with reduced misconceptions and fears. The authors emphasized the need to demystify psychiatric issues with all nurses who work in any setting since psychiatry is a commonality of all practice environments. This study also raised the question of why nursing students avoid psychiatry. Does it take too much emotionally to effectively provide care to psychiatrically ill individuals? Are the structural supports in place in educational settings for nurses to help them understand the emotional demands of a career as a psychiatric nurse? Does this differ from nursing care provided to other populations? Are the interpersonal demands, the self-examination, and the daily encounters with stigma against individuals with mental illness too much to consider handling as a student or new graduate?
This has enormous implications for the ongoing discussions of workforce development and how the need for psychiatric nurses is outpacing those who choose this profession. In a landmark article in 2012, Hanrahan, Delaney, and Stuart outlined a blueprint for developing the psychiatric nurse workforce. They emphasized the following domains: broadening the concept of workforce, strengthening the APRN-PMH (advanced practice psychiatric-mental health registered nurse) workforce, and creating structural supports for the workforce. This links with an article by Redknap et al. (2015) describing efforts to attract and retain psychiatric nurses in Australia. They address more specific strategies such as nurses owning their practice environment and emphasizing leadership that addresses conflict resolution and engagement. Others note that there has to be an investment in leadership development, a key driver contributing to nursing satisfaction (Roche, Duffield, & White, 2011). In all three articles there is an emphasis on leadership development beginning at the undergraduate nursing education level and continuing through doctoral preparation. While not specifically stated, there is also a need for specific structural supports that assist the nurse dealing with the reality of caring for psychiatric patients. If the nurse psychologically owns the practice, knows the clients, and, on a daily basis, uses self as the tool to restore health, there is a cost to that nurse. Nurses willingly pay that price to see that their clients receive excellent care. They choose to put themselves on the emotional line of investing in their clients. Who fills up the blank and provides the affectively supportive underpinnings that allow those nurses to be effective while maintaining emotional equilibrium and their own mental health?
Delaney (2016) notes that as we move forward while the “health care landscape transforms, practice standards, payment structures, staffing models, and metrics are changing” (p. 128), we have to pay equal attention to the effect of these changes on the individual nurse caring for clients in the hospital or clinic. It is essential that paying attention to the emotional needs of the workforce becomes just as important as shaping the political influences on practice at all levels in all environments. In order to retain nurses in psychiatry these individuals will need to feel valued, empowered, and independent. That is the challenge to all of us involved in the array of changes influencing and changing our health care system. We need to grow our psychiatric nursing workforce and also support and retain those who continue to practice with stigmatized, difficult populations. Understanding the systems’ issues influencing nursing practice while simultaneously acknowledging the interpersonal stresses inherent in the psychiatric nursing role have to occur if we are going to attract nurses to this specialty and then grow and keep them within psychiatric nursing. All the exciting and rapidly changing health care reform currently occurring will crumble if the nursing workforce does not remain strong and functional as they perform the incredibly difficult job of caring for individuals with psychiatric illness. We have to pay attention to who is caring for the nurse.