Note: this article was written in 2019, during my first year of qualification and before the CoVid pandemic.
The moment I finally qualified as a mental health nurse I felt deeply and unambiguously proud. It is often not appreciated how difficult it is to train to become a nurse. However, the joy accompanying my initial sense of satisfaction has gone. It didn’t take long. In only a matter of months as a registered mental health nurse my desire to go to work was accompanied by a pervasive sense of dread for which, despite my years of previous experience in nursing services, training and expectation of adversity, I was not prepared.
I was the same person, with the same aspirations and abilities, but I was also exhausted, scared and sad. In an increasing number of interactions with my partner I was appearing withdrawn. More nights than not I had difficulty sleeping. On two occasions I broke down in tears on my sofa at the thought of going back to “that place” where I was spending closer to thirteen plus hours, sometimes four or five times in eight days. I’m pretty sure I experienced my first panic attack.
Why has it been so hard? On one level, it may be the loss of particular support structures. New nurses arrive on wards with a strong sense of comradery having trained as a group for at least two or three years, a time defined by the near-constant sharing of experiences both in and out of the classroom. Upon qualification we are atomised: isolated and scattered across geography and clinical speciality, suddenly stripped of the sense-making apparatus that helped us get to that point. In my opinion, it is this lack of time, space and means to make sense of, reflect upon, and simply talk about, our concerns and experiences that represents the biggest threat to the individual motivations of a newly qualified nurse in mental health services (I imagine this may hold true for other branches, but I cannot speak for my peers in those fields).
There are some more obvious answers too. I began work in an adult psychiatric intensive care unit (PICU) located just off a main arterial road of east London. The workload in PICU comprises a range of challenging emotional, cognitive and physical tasks and takes place within an often over-stimulating environment deriving from the high acuity and unpredictability of patient distress. I have had my first experiences of being the only nurse on shift; being in charge of a team very short of staff; co–ordinating multiple advanced observations; calling a medical emergency; de-escalating racial, homophobic and sexist abuse; initiating and terminating seclusion; and administering rapid tranquillization under restraint. Underlying all this being responsible for patient life and the safety of colleagues. On top of this is the demand to complete various digital and physical paperwork. Despite all of this, and what never stops, is the desire to spend time with patients, and build therapeutic relationships through all these challenges
Another source of acute stress has been the frequent exposure to violence and aggression. It seems a banal thing to say, but neither witnessing nor being a victim of abuse or assault was a normal experience for me. Yet in the first eight months post-registration, this became almost a norm whilst at work. Over a three-week period around Halloween, the ward consultant, the ward manager, myself and another newly qualified nurse were attacked in three separate incidents. One of those was a serious assault that required a visit to an eye specialist. Around a month later, a different colleague was subject to such consistent verbal abuse, centering on their gender, ethnicity and religion, they were moved wards for their wellbeing. Some weeks later I was attacked for a second time, knocked off my feet on a night shift just before Christmas. Another colleague was already off work after being punched the week before. I too was moved to a different PICU following the second attack. After both of my incidents, I returned to work very quickly. I felt unable to do anything else; not because I wasn’t told I could take more time off, but because I didn’t know how to use that time to feel better. There was a third assault before Easter, but by then a slap in the face felt minor, so I stayed to finish the shift.
Before going on, I wish to emphasise that at no point have I used propositions to assign responsibility to any persons for these events. That is not because I don’t believe in agency within the context of personal crisis – for that would make me a non-believer in the possibility of recovery – but I have refrained from this to underline that causality should not entail judgement. This may sound clichéd, but good mental health nursing depends upon the consistent application of the non-judgement principle, or, put more simply, understanding and, when necessary, forgiveness. These are often described as values. That may be, but they are also vital skills that are not straight-forward to learn. Moreover, the causes of violence often go beyond mental states described by diagnosis.
Life on a psychiatric ward is hard and strange. The trauma-informed approach demands that we ask not ‘What is wrong with you?’ but rather ‘What happened to you?’ As a witness to ward life and what it can entail, I wonder if we should also ask, or ask instead, ‘What is happening to you?’
Returning to reflections on my own life, how does being an object of violence reveal the paradox of mental health nursing? On the one hand, I feel I possess a personal history that is well-suited to nursing individuals in distress. I have lived a very calm life. During childhood I felt safe and supported unconditionally in a quiet, financially secure home. I lived in the same town from the age of one to eighteen. Both my nuclear and extended family are almost untouched by addiction, physical or mental ill-health. I went straight from school to university, university to work. Although these facts do not fully determine my personality, interests or range of abilities, I think that such consistent stability has created, to some extent, the capacity to be a vessel of containment for the emotions of others whose lives have been dramatically less stable. Emotional containment is a core feature of caring in mental health services. In my opinion it sits alongside modelling as one of the most subtle but profound roles that nursing teams play in the strange and stressful ward environment.
On the other hand, because of that exact same history, I struggle to comprehend violence and extreme aggression and am therefore perhaps more vulnerable to being seriously affected by them. This struggle is not intellectual but emotional. I know that psychological distress can manifest as violence, not just towards others, but more often towards the self. I understand the rubric and purpose (and limitations) of risk assessments. I am aware of what can cause and result from domestic, urban, sexual and political violence. I do not, however, recognise these as interpersonal phenomena in my own life. Tragically, for many people, including many service-users, these have been both normative and formative experiences. Recognising this is vital if we are serious about preventing, by our actions, further stigma and re–traumatisation.
As a newly qualified nurse, I constantly felt like a site of tension, a locus of many pulling forces. One category of pressure is the political, by which I mean the assignation and discharge of power over others. I did not become a nurse to obtain power or riches. The idea and act of nursing others fills me with a sense of agency and purpose. This feels entirely different, if not opposed to, controlling aspects of other people’s lives, which is something one is tasked with as a mental health nurse.
It is often argued that applying the language and philosophy of rights is a way forward for mental health services. I certainly hope that adopting this paradigm will enable less restrictive practices. However, what may be required to eliminate practices that come close to, if not cross the line between, restriction and compulsion, is a total reorganization, re-evaluation and redesign of the roles, relations and expectations within mental health services. For instance, there is disingenuousness at the heart of a system that (rightly) does not include seclusion – the highest form of restriction – in a care plan, but at the same time limits the form of in–patient life and in–patient care-giving so dramatically that these practices can seem inevitable. If we want better outcomes and experiences, we must start to take seriously what life actually looks and feels like behind locked doors.
My intention here is not to discourage people entering mental health nursing. However, if we really believe in a duty of candour, then I believe this obligation extends to being honest about the challenges of the job. It would be disingenuous to claim that the daily act of nursing others does not bring the individual nurse into various forms of conflict – professional, political, personal and, unfortunately in some instances, physical. When we remember that the original meaning of the word nursing is ‘to nourish’, then nursing others can make it difficult to nurse oneself. I have certainly found it difficult, but not impossible. I hope I’ve made that clear.
This is a sample article from Asylum 28.1 [Spring 2021]. Subscribe to Asylum magazine.