Broad skills for mental health nursing

6 Broad skills for mental health nursing



Chapter aims




• To provide an outline of a range of broad skills utilised in various areas of mental health nursing practice


• To consider how these skills may be transferable to a range of settings



Introduction


This chapter aims to examine the techniques and skills in mental health nursing that lend themselves to working across any area and with any diagnosis. The following discussion considers the skills of communication, facilitating a group, solution-focused working and health promotion. The opportunity to develop these skills should be available in any placement area and will often provide the basis for meeting a substantial amount of your learning outcomes.



Communication skills in mental health settings


This section will explore an intentioned, purposeful and effective approach to communication as it can be used by mental health nurses in different clinical settings. The application of this skill by nursing students will also be examined and discussed.


The first premise made in this section, as inferred above, is that there is something special about the skill of communication as used by effective nurses (Crawford et al 2006). This skill may sometimes be quite different from those used in non-work or social situations. This specialness is rooted in the nurse’s ‘intention’ (Heron 2001) which originates in what the nurse is trying to achieve as part of care management.


Consider a community psychiatric nurse (CPN) calling at a service user’s home for the first time to make an initial contact and assessment. The CPN will have a range of clear intentions. Some of these intentions will be clearly planned and obvious to an observer. Others may be reactive to the immediate situation, more subtle, not so easily detected and may even be such an integrated part of the nurse’s professional personality that they are not aware of performing them until asked to reflect on what they are doing. For example, the skilled CPN is able to often process through a sufficiently comprehensive assessment of a service user, almost as if an everyday conversation is taking place (Bonham 2004). There is no sense of a ‘cross-examination’ or intrusive questioning. Areas of the service user’s experience are examined and assessed with the minimum discomfort for the service user. At the same time, the nurse may sometimes be experiencing, at a deeper level, feelings or emotions which in a social context may be difficult (Bonham 2004). The experienced effective nurse develops the ability to manage these tensions by, for example, clinical supervision. Ask one of your mentors to give you illustrations of this.



image Activity


Review the list of intentions below with one of your mentors. Discuss which they routinely have, which they rarely have and which ones they have that are not listed.


During interactions with service users, the CPN intends to:



image Create a climate of trust and approachability.


image Enable conversation to occur as naturally as possible.


image Keep the focus of the conversation with the service user.


image Explore issues being experienced by the service user.


image Listen intently to the language and delivery used by the service user.


image Support, validate and reassure the service user as appropriate.


image Do the above with any significant others who may be involved.


image Include any coworker (for example, you as a student).


image Limit questions that are asked to those which have a clear purpose.


image Encourage questions to be asked by the service user.


image Involve the service user in any plan of treatment.


image Be aware of timing, in terms of the needs of the service user, and other professional caseload demands.


image Clarify any issues which are unclear to the CPN, the service user or any other involved party, before finishing the visit.


image Leave the service user at least no more distressed, or anxious, than when the visit started, and possibly less so – if at all possible.


image Summarise any action or plan arising as a result of the visit.


image Confirm that the service user understands any action or plan.


image Confirm that the service user understands what is happening next, in terms of any input from the CPN or any other care professional who may be involved.


image Finish the visit at an appropriate point, and in a congruently positive way, if at all possible.


The CPNs you work with may have more intentions, or a few less, than in the examples below, but you will see that the below sequence suggests a thoughtful, deliberate, intentional and strategic approach. This is very different from social interaction with friends, family, neighbours and so on, which is often more spontaneous, less considered and less goal or outcome orientated. The effective mental health nurse will therefore be constantly ‘at work’ within clinical areas. Some of this work may appear to be ordinary everyday conversation (Burnard 2003).


Consider this example. A mental health nurse is sitting with a service user in a secure rehabilitation unit. The nurse is wearing a uniform and has a highly visible personal alarm. Yet, to an outside observer, it looks as if the nurse and service user are at ease with each other. They could almost be friends having coffee together.



image Reflection point




1. What are your impressions of this interaction?


2. What do you think might be the nurse’s intention in this scenario?


Consider though … this is not a social relationship. One person is a service user and one person is a professional receiving a salary. This is a professional being friendly, not a professional being a friend (Murray et al 1997, Jackson & Stevenson 1998). Just like the CPN above, the mental health nurse, in this quite different clinical environment, has a range of clear intentions which could be as follows:



• Be approachable (if you don’t have this, how can you be effective?).


• Use social connectors such as a cup of tea, a newspaper, TV programmes, sport, plans for the day, and so on.


• Be aware of time constraints such as shift changes and meal times.


• Be aware of personal limitations – tiredness, other service users arranged to be seen during the shift, care plans to update, liaison with other professionals.


• Assess. How is the service user at this moment? Different from earlier today, yesterday, last week? If so, in what way?


• Edit. What is going to be added to the care plan as a result of this assessment?


• Be aware of anything that needs to be communicated to other colleagues – the service user is becoming increasingly agitated, the service user is more settled, etc.


• Create, sustain or finish a professional relationship.


• Maintain continuity – in terms of being clear to the service user that you will be back on duty tomorrow/next week/not at all.


Again it is clear that the nurse in this setting has some similar intentions, but some different intentions, from the CPN in the earlier example. Intention is, therefore, a function of the complexities of the clinical setting, the desired outcomes of the service user and for the service user, combined with the personality and desired outcomes of the nurse. This is perhaps why, despite having carried out what appear to be little more than a series of social interactions (but in a clinical setting), most effective mental health nurses find the work demanding and tiring, but also often very satisfying.


If the above range of intentions is examined more closely, they can be separated into identifiable skills. Most of these can be found in the body of literature on therapeutic interventions, communication skills, counselling and so on. This confirms the existence of a robust evidence base for the skills and attributes. These can be considered and discussed in the classroom, then practised in placement. As confidence and proficiency increase (this is a slow process for most people, by the way), the skills can be combined and blended into each other. They will become less conscious and more a part of your natural professional personality (Benner 1984).



Intention as separate communication skills and attributes ‘Clusters’


Much of the literature on ‘beginner’ communication skills separates verbal from non-verbal skills. That separation will be apparent in the descriptions below, but you will also see how the two can be skilfully combined to form an effective, integrated whole. The following descriptors are the qualities you will see demonstrated by effective mental health nurses (and other mental health professionals) you will meet. They are not the raw communication skills you will see listed in most other texts. For instance, skills such as use of eye contact, touch, body positioning, voice tone and so on are discussed in the beginner literature. These areas will be discussed in classroom sessions during your time as a student nurse. Once you have considered basic separate skills, however, it is essential to refocus on the purpose of them and learn how to integrate them together.



image Activity


Discuss with your mentors how basic skills can be used to start to achieve the following more meaningful communication skills and attributes:



image Approachable


image Honest


image Encouraging clarity


image Consistent


image Transparent


image Optimistic


image Ordinary


image Knowledgeable


image Reliable


image Thoughtful


image Confident


image Empathic


image Assertive


image Accepting


image Use of language


image Pitch


image Eye contact


image Demeanour


image Touch


image Levels


image Proximity


image Tone of voce


image Gesture




Approachable


This is where it all starts (Bonham 2004). As a professional mental health nurse you are, in effect, being paid to be approachable. Other mental health professionals can use unapproachability to maintain distance between themselves and service users. It is a primary function of the mental health nurse to close that distance, professionally and skilfully. Not all service users wish to engage with mental health professionals, or even be friendly. If you are not sure what the individual components of approachability are, think about the colleagues you have met on placement. If you are just starting your career as a nurse, think of people you know who have this quality. What is it that seems to give them approachability? You’ll find that the answer to this often lies in what they do, as much as in what they say. (Also consider – do you want to be approachable all the time?)



image Activity


Consider with your mentor, or other students on your course, the skills cluster required to achieve approachability. Some components are the following:



image Suitably engaging eye contact (Egan 2002).


image A friendly or open demeanour (Bonham 2004).


image Professionally available body language.


image Manipulation of the environment, such as an open office door, or the deliberate positioning of oneself within the service user group rather than the professional group.


image Choice of clothing that suggests equality rather than superiority or striking difference, together with clarity of boundaries, i.e. the clarity has to be meaningful for the service user.


Identify with your mentor how you might demonstrate approachability and the opportunities which you might have to reflect and gain feedback on your approach.



Honest


This personal characteristic is a good example of the difference between professionally outcome-driven strategic communication as a skill, and social communication. In social situations you are at liberty to be deceitful, avoiding or open and direct to the point of brutality. You can ‘call a spade a spade’.


In professional situations it is essential, for the safety and care of service users and your own professional credibility, that you are more considered and careful about what you say and how you say it. This pre-editing of your natural spontaneity can sometimes feel like avoidance or professional economy with the truth. The mental health nurse will often be in the situation of knowing more about certain issues than the service user. Often information is withheld from the service user as it is deemed to be ‘… in their best interests’ (Nursing and Midwifery Council 2008). This view needs very careful consideration and must be the result of a multiprofessional consensus whenever realistically possible. Reflect with other students and your mentors on how to best manage these situations.



Encouraging clarity


This is a skill rather than a personal characteristic. As above, its use can be very different in professional situations compared to social situations.



image Reflection point


Consider this example:


A social setting …


Your friend: I hate this kind of situation.


You: Yeah. So do I.


A professional setting …


A service user: I hate this kind of situation.


You: What do you mean, you hate it?



1. What is the difference between the first example and the second?


2. How do you think the way you respond to the service user might impact on their reaction?


In the first example no effort is made to explore the nature of the word ‘hate’, the nature of the situation and the reasons for this view. In the second example the nurse has a strategy or intention to clarify. It may not be achieved immediately, during the next exchange, but the nurse is making a professional effort to tentatively (Bonham 2004) find out more, as part of a longer term assessing or monitoring, perhaps. It is important to note here that the above phrase ‘What do you mean, you hate it?’ can have many different impacts depending on how the words are delivered by the nurse. Try rehearsing some of these with another student and experiment with tone of voice, eye contact and general demeanour, to see the effect on the other person.



Consistent


Again, this aspect of communication can be very different in professional mental healthcare settings as compared with social situations. It does not mean ‘sticking to your guns’ regardless of changing circumstances around the care of the service user. The term means to be considered in your behaviour and attitude. These are two personality traits by which your effectiveness may be measured by service users and colleagues.


Both nurses in the examples above will be assessing, planning, implementing and evaluating the care they give (Norman & Ryrie 2009) as part of a consensus team approach. Even the CPN, who is more autonomous in terms of needing to make decisions about the care given, has to refer back to a team for support. That team will continue to give consistent, planned and agreed care. The original direction of this care may have come from the early meetings between the service user and the CPN. The team supports the carrying through of this care. So, to be consistent, the nurse must be empathic (Rogers 1951) to service users and colleagues, assertive with both, an effective listener to what is said and what is not said by both, sensitive to cultures and environments, a lateral thinker (de Bono 2009) and be open-minded to the ideas of others.



Transparent


Some other terms that can be linked to this are honesty, congruence, genuineness and authenticity (Rogers 1951). Like many of the attributes discussed in this section, transparency is not just something that is used in your interactions with service users. Some examples of transparent practice are the following:



• Fully including service users in all aspects of the management of their care, even the unpleasant or difficult ones, such as restricting their movements or unwanted adjustments to medication.


• Giving service users access to information written about them.


Just a little experience as a mental health nurse will tell you that the above examples of practice can sometimes be very difficult to carry through, and may actually have a negative effect on nurse–service user relationships. It can be difficult to judge an appropriate level of transparency when taking into account the immediate needs of a service user and the consequences of accessing or denying those needs. Transparency is something that is aspired to, but not always achieved.



Optimistic


Your work as a mental health nurse means that you are a professional optimist (Bonham 2004). In your personal life you may be pathologically pessimistic. In your professional life there is always hope for the service user you are working with. Looking at the caring role of the nurse at a very basic and pragmatic level, if you cannot visualise any hope for the service user you are working with then perhaps it is in the service user’s best interests to minimise therapeutic contact with them. This might mean asking a colleague to take over the care of the person, referral to a more suitable care agency, arranging clinical supervision to reflect with another how hope might be found or a team consensus may be to no longer engage with that person. An example of this is the person who continually self-harms despite, and regardless of, a range of therapeutic interventions by different concerned professionals. There may come a point when the input starts to become counterproductive. It may be more caring to withdraw support in a planned way, to try to foster independence, rather than dependence. This is in line with contemporary ‘recovery’ approaches (Repper & Perkins 2003) (see Ch. 3).



Ordinary


This is sometimes seen as a rather strange attribute for a mental health nurse – the ability to be ordinary or to possess ordinariness. It could be argued that this is a re-presentation of Rogers’ core condition of congruence (or genuineness, honesty, authenticity). It is not. Ordinariness is a separate entity. To a large extent, within healthcare literature, clear references to ordinariness are few. The term is used in passing as the focus of the text is foregrounding something else. Occasionally it features in its own right as an attribute that some nurses have (Burnard 2003, Bonham 2004), and that is appreciated by service users. This does not just apply to mental health settings. Oblique reference to ordinariness can be found across the complete spectrum of health care (Dunniece & Slevin 2000, Blomqvist & Edberg 2002, Giske & Artinian 2007, Hopkins & Niemic 2007). To paraphrase these ideas, the nurse who has this therapeutic attribute can use their ordinariness to consolidate any stage of the therapeutic relationship. It can manifest itself in the following ways:



• Just ‘being’ with service users.


• Not necessarily needing to ask questions.


• Talking about self.


• Sharing food and drink.


• Being non-intrusive and consistently respectful of service users’ space.



Knowledgeable


Even students who are at or near the end of their nursing course express the idea that they don’t know enough to work effectively. Becoming deeply knowledgeable can only ever be a gradual process. Clinical experiences can accelerate and deepen knowledge in relatively narrow or specialised areas. For example, a mentor or a tutor with a particular interest or enthusiasm can help develop a focused knowledge within students. Thus, the nurse can become knowledgeable in the specific characteristics of the narcissistic personality disorder, but not know where the pharmacy is. Service users and colleagues usually do not expect even experienced staff to know everything. The key piece of knowledge for the student or newly qualified nurse is how to find out where the pharmacy is, what ward visiting hours are, when the consultant holds review meetings and so on, and then actually do it.

Related posts:

  1. The practicalities of mental health placements
  2. Working with people to make choices about their treatment
  3. Working with people who hear voices or express unusual beliefs
  4. The service user experience

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Feb 25, 2017 | Posted by in NURSING | Comments Off on Broad skills for mental health nursing

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