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- Herausgeber: John Wiley & Sons
- Kategorie: Fachliteratur
- Sprache: Englisch
Comprehensive guide on what it means to be a mental health nurse, with up-to-date clinical perspectives and insightful case studies
Thriving in Mental Health Nursing delivers a 360-degree view of what it means to be a mental health nurse and how to be a resilient, positive, and proactive professional in the field. This book teaches readers to consider their own skills, development needs, and wellbeing while providing an overview of the latest clinical research within the field and what it means for their clients.
While most mental health nursing books focus on clinical skills and patient conditions, this book adopts a holistic approach to the profession by covering topics like managing personal trauma when providing trauma-focused care, understanding, avoiding, and overcoming burnout, and maintaining hope in a post-pandemic staffing crisis.
In-depth discussion, vignettes, relevant case studies, and activity suggestions support learning and engagement for healthcare professionals at every step of their careers, from first embarking on a training course to being an experienced mental health nurse. Special attention is paid to diversity and inclusivity themes including micro-aggressions, allyship, and more.
Other topics explored in Thriving in Mental Health Nursing include:
- Risk in the form of self-harm, suicide, violence, and aggression, with tips on how to take positive risks and manage risk safely when required
- Ethical issues in the field, including key perspectives on detaining individuals under the Mental Health Act (1983)
- Guidelines for identifying and addressing conflict, whether it arises between team members or from clients, including best practices for de-escalation
Thriving in Mental Health Nursing is an invaluable guide for all nurses in the field, from first-year nurses to the most experienced registered nurses, along with students seeking to understand the significant challenges and obstacles they may encounter.
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Seitenzahl: 472
Veröffentlichungsjahr: 2024
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Table of Contents
Cover
Table of Contents
Title Page
Copyright Page
Dedication Page
CHAPTER 1: Introduction
CHAPTER 2: Reflection
Activity
Vignettes
Vignette
Activity
References
CHAPTER 3: Resilience
Activity
Vignette
References
CHAPTER 4: Emotional Intelligence
Activity
Case Study
References
CHAPTER 5: Listening and Communication Skills
Activity
Case Study
References
CHAPTER 6: Working with Trauma
Activities
References
CHAPTER 7: Working with Risk
Activities
References
CHAPTER 8: Diversity and Inclusivity
Activity
References
CHAPTER 9: Managing Therapeutic Relationships
Activities
References
CHAPTER 10: Managing Complexity
Activity
Vignette
References
CHAPTER 11: Conflict
Activity
Case Study
Activity
Vignette
References
CHAPTER 12: Compassion
Activity
Activity
Vignettes
References
CHAPTER 13: Maintaining Hope
Vignette 1
Vignette 2
Activity
References
CHAPTER 14: Self‐Care and Well‐being
Activities
References
CHAPTER 15: Burnout
Activity
Case Study
References
CHAPTER 16: Stigma and Discrimination
Public Stigma Case Study
Structural Stigma Case Study
Courtesy Stigma
Provider‐Based Stigma
Self‐Stigma Case Study
References
CHAPTER 17: Ethical Practice
Activity
Case Study
Outcome
References
CHAPTER 18: Working in Teams
Activity
Activity
Integrating Case Study
Compromising Case Study
Dominating Case Study
Avoiding Case Study
Obliging Case Study
References
CHAPTER 19: Leadership
Case Studies
Activity
References
CHAPTER 20: Supervision Skills
Activities
Case Studies
References
CHAPTER 21: Professional Development
Activity
References
CHAPTER 22: Social Determinants of Health Chapter
Agriculture and Food Production Case Study
Education Case Study
Work Environment Case Study
Unemployment Case Study
Water and Sanitation Case Study
Healthcare Services Case Study
Housing Case Study
Social Prescribing Case Study
References
CHAPTER 23: The Biopsychosocial Model
Schizophrenia Case Study
Biological
Psychological
Social
References
CHAPTER 24: The Stress Vulnerability Model
Case Study
References
CHAPTER 25: Accessing Support
Activity
References
CHAPTER 26: Final Thoughts
Index
End User License Agreement
Guide
Cover Page
Table of Contents
Title Page
Copyright Page
Dedication Page
Begin Reading
Index
WILEY END USER LICENSE AGREEMENT
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Thriving in Mental Health Nursing
Laura Duncan
Senior Lecturer at The University of Chester,Primary Care Network Lead at Cheshire andWirral Partnership NHS Foundation Trust,Nursing and Midwifery Council RegisteredNurse in Mental Health,Teaching Fellow with The Higher Education Academy
This edition first published 2025© 2025 John Wiley & Sons Ltd
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The right of Laura Duncan to be identified as the author of this work has been asserted in accordance with law.
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Limit of Liability/Disclaimer of WarrantyThe contents of this work are intended to further general scientific research, understanding, and discussion only and are not intended and should not be relied upon as recommending or promoting scientific method, diagnosis, or treatment by physicians for any particular patient. In view of ongoing research, equipment modifications, changes in governmental regulations, and the constant flow of information relating to the use of medicines, equipment, and devices, the reader is urged to review and evaluate the information provided in the package insert or instructions for each medicine, equipment, or device for, among other things, any changes in the instructions or indication of usage and for added warnings and precautions. While the publisher and authors have used their best efforts in preparing this work, they make no representations or warranties with respect to the accuracy or completeness of the contents of this work and specifically disclaim all warranties, including without limitation any implied warranties of merchantability or fitness for a particular purpose. No warranty may be created or extended by sales representatives, written sales materials or promotional statements for this work. This work is sold with the understanding that the publisher is not engaged in rendering professional services. The advice and strategies contained herein may not be suitable for your situation. You should consult with a specialist where appropriate. The fact that an organization, website, or product is referred to in this work as a citation and/or potential source of further information does not mean that the publisher and authors endorse the information or services the organization, website, or product may provide or recommendations it may make. Further, readers should be aware that websites listed in this work may have changed or disappeared between when this work was written and when it is read. Neither the publisher nor authors shall be liable for any loss of profit or any other commercial damages, including but not limited to special, incidental, consequential, or other damages.
Library of Congress Cataloging‐in‐Publication Data Applied for:
Paperback ISBN: 9781394202355
Cover Design: WileyCover Image: © Shaumiaa Vector/Getty Images
This book is dedicated to all of the incredible mental health professionals that I have had the pleasure of working with throughout my career. Thank you to everyone for not only the incredible work you do but the support that you give every day.
To my husband Sam, thank you for all that you do to lift me up and encourage me. Without you, this book would not have been possible. To my friends and family, I’m sure you’ll all be thrilled that it is finally complete! Thank you especially to my wonderful parents for your unwavering belief and unending support of me over the years.
Laura Duncan
CHAPTER 1Introduction
Mental health nursing is an incredible profession that I have been proud to have been part of throughout my career. It provides the opportunity to help people in a very real way and that is incredibly rewarding. It is also a very challenging role and this is for many reasons. As Mental Health professionals, we work with individuals who are in distress and experiencing the worst moments of their lives, and this can take a significant toll on us over time. We witness things that no other professional group outside of health and social care usually would, and that is just a standard day at the office. Many books focus on how to understand and support clients better, and this is a part of this text as well, but the much bigger message is how to support ourselves and our teams.
One of the biggest issues facing mental health nurses currently is staffing levels, stress and burnout. The role has never been an easy one but additional pressures and demands have meant that nurses are leaving the profession in significant and terrifying numbers. If we are to protect the profession and clients, we must protect ourselves. Understanding how to manage burnout when we see it in ourselves, and in others, may mean that that individual is able to continue and thrive in the profession. Understanding that we are human and sometimes we need a break is the best way to protect ourselves from the terrible effects of burnout.
The core focus of this book is to help professionals have long, happy, successful and healthy careers. There is a strong focus on our own well‐being and how to recognise the impact of specific issues, such as working with trauma, conflict and risk, as well as what to do about this if it impacts you negatively. It discusses how to recognise and improve key skillsets such as communication, reflection and resilience with a focus not only on being better able to support clients but also on increasing job satisfaction and well‐being for ourselves as well. There will be consideration of how to understand and work effectively with clients across all needs and presentations with particular focus on key models such as The stress vulnerability model and the biopsychosocial model.
‘You can’t pour from an empty cup’ is a phrase we hear frequently in nursing and we all know this to be true. We often say this to others when we know they are struggling but how much time do we spend thinking about how to refill our cup? Self‐care is a key theme within this book, and we frequently overlook the importance of actually caring for ourselves as we spend so much of our time and energy caring for others. If we are to thrive as professionals, we need to proactively care for our own needs but also identify when we may need additional support.
In each chapter, there is a discussion of the key principles of each topic with activities, case studies and vignettes used to apply the theory to practice. The intent of this is to make it feel more ‘real’ and less like a purely theoretical or academic interpretation. The case studies and vignettes are all based on my own personal experiences in clinical practice so they will hopefully be realistic and ‘true to life’. There are reflective activities throughout that are intended to help us to think about our own attitudes, thoughts and approaches in a considered way. Some of these may feel challenging to engage with but will hopefully help to build reflective skills in particular.
Mental health nursing is a unique, challenging and rewarding profession to be a part of. The one thing we can guarantee in this field is that you will never be bored! The variety of roles and the constant development and expansion of these roles means that Mental Health is an exciting and dynamic industry to work in. In comparison to general medicine, we are a new and emerging field. New understanding and developments are happening all the time, and if we reflect on where we were only 10 years ago, we can see how rapidly the profession is changing and adapting.
We spend our careers helping others to understand their thoughts, feelings and emotions. Hopefully, after reading this, we will understand our own and their impact better too. If we are to truly thrive as professionals, we must focus on the well‐being of our clients, teams and ourselves.
CHAPTER 2Reflection
Reflection as a concept is about looking at our thoughts, feelings and actions and evaluating them. It is about analysing our reactions, those of our team and the impact of these upon our clients. Reflection is about understanding what we did well, what we did not do well and how we could improve in the future. Becoming a reflective practitioner who is able to consider our own strengths and weaknesses with a view to continual improvement should be the goal of every registered nurse and healthcare professional.
Reflection is a core concept within nursing, and it is a key feature of any modern nursing programme. The emphasis on the importance of reflection is fairly recent, and many of us who trained more than 10 years ago will have first completed a written reflection for revalidation when that became a core aspect of the process [Nursing and Midwifery Council (NMC), n.d.], but without this being included in our training, many of us have struggled with formal reflections. My first reflections for revalidation under the NMC standards were deeply unreflective! Reading back now, I can see clearly that they are merely descriptions of a situation without any deeper understanding of them. I have shown these ‘reflections’ to students as a learning exercise and invited critique, the first comment is always ‘they aren’t very reflective’. Now, registered nurses must write reflective accounts every 3 years; they may have ‘reflective practice’ sessions within their clinical team or they may ask student nurses to write reflections after an incident or issue. This is all absolutely fine, of course, but what many don’t recognise is that to be effective practitioners, we should always be reflecting.
Reflection is like any other skill, the more it is practised, the easier and more fluid it becomes. We can start with a theory‐based model to support us through our initial reflections, but many will find this to be a tedious and time‐consuming model with little new insight achieved. It is, however, essential to learn about the reflective models, similar to learning your scales when playing an instrument. Utilising a model such as Gibbs’ reflective cycle (Gibbs and Andrew, 2001) and following the stages of
Description of the event (what happened?)
Feelings (what were you thinking and feeling when the event occurred?)
Evaluation (what was good and bad about the situation and how it occurred?)
Analysis (what else can you find about the situation?)
Conclusion (what else could you have done?)
Action plan (if it arose again, what would you do?)
This can help to build and develop our early reflective skills. Following the cycle of reflection in a structured and repeated way helps to develop and make it into our muscle memory, again, like learning scales! What many people do, however, is only reflect on the big situations, such as an assault or an error that has occurred, and where reflection is, of course, very helpful in these scenarios, we should also be reflecting on the everyday situations and things that have gone well. Sometimes, there may have been a difficult incident that has occurred, and the reflection from it is that actually, this couldn’t have been prevented or handled in a different manner that would have changed the outcome. To become a truly ‘reflective practitioner’, we need to be reflecting almost all the time.
Activity
Think about a scenario that you have been involved in recently that went better than expected.
Follow Gibbs’ reflective cycle steps (above) to analyse the incident.
Focus mainly on your feelings, if you have used a single adjective such as ‘it made me happy’, try and dig into that a little deeper. Was it just happy, or were you ‘proud’ of your work? Were you ‘hopeful’ for the other person? Were you ‘excited’ about the outcome?
Review what you wrote for the ‘Evaluation’ section. The task was to reflect on a positive scenario, is your evaluation more positive than negative? If not, have another think and try and identify more positives in the scenario.
What was your action plan? ‘I’d do it exactly the same again’ is still an action plan; we don’t have to find action points that aren’t necessary if it has been a positive outcome. An action plan could be ‘I’d approach the situation with more confidence next time because I know it has gone well before’ and that would be accurate and effective.
Vignettes
In this chapter, I will use two vignettes to demonstrate the concepts being discussed. I will first explore a reflection utilising Gibbs’ reflective model (Gibbs and Andrew, 2001), as I have tasked you with doing in the activity section. The second vignette will come later and explore more informal reflective principles.
Description of the event
In my role as a lecturer, I support many students during their studies and journey to becoming a nurse. For some students, this journey is not straightforward, and they may need to take a break from their studies for a number of reasons. I recently met with one student who has been having a very difficult time in her personal life, and her mental health was ultimately not good. She was struggling with many things, her mood being very bad, and it was having a negative effect on her studies. I have been a lecturer for a long time and have worked with several thousand students, many of whom have struggled during their programme and I can recognise that this is becoming an untenable situation for this particular student. She was struggling to an extent that she was going to start failing or missing assignments and practice placements. I can objectively see that taking a break from her studies to rest and recover will be more beneficial than struggling and possibly ending her studies because of failing assignments or her placements. We had a meeting, and after discussing all of the options and my concerns for her, she agreed to take a break from her studies and to seek help. She was very upset during our meeting, but we came to an agreement that this was the best way forward and that she can focus on her own well‐being now so that she can return and complete the programme to achieve her dream of becoming a mental health nurse.
Feelings
Going into the meeting, I was very nervous; I was worried there would be a negative outcome to the meeting, that I would cause further distress to the student, and that she could be in crisis if I did not handle this well. I was very conscious of listening to her thoughts and feelings throughout the meeting and being supportive of her when she was tearful and upset. I left the meeting feeling satisfied with the outcome and that this was the most supportive and positive action for her, but guilty that it had upset her. I was concerned for her well‐being and was ruminating on whether I had done the right thing for several days to come.
Evaluation
Overall, it was a positive outcome, and the student recognised that also. It was the right decision as she was not in a good place and could not focus on her studies; taking a few months to seek support, rest, and recover was the correct decision for her to be able to complete the programme successfully and achieve everything she wanted to in the future. I gave her space to be upset and to ask questions and supported her in reflecting on the situation herself to come to the conclusion that taking a break was the right decision. I didn’t rush the meeting; we talked about support mechanisms and what to do if she was further distressed or in crisis, and she agreed that she would seek support. One reflective tool that had a particularly strong effect was asking her what advice she would give to one of her peers who was going through everything she was; after some thought, she responded ‘to take a break’. I think that was a particularly strong realisation for her and supported her to recognise her clinical skills and knowledge.
Analysis
This is a scenario I have been in many times and will likely be in again and so reflecting upon it is important. I think the meeting itself went as well as it could have done; I believe the student understood that I cared about their well‐being and their future, and that is a really positive outcome from the situation. Recognising the student’s knowledge and skills was important and hopefully, this was empowering for her. I was very conscious of being positive and future focussed on how she would feel better, return to her studies, and thrive as a mental health nurse, which I truly believe is the case, and I think that maintaining that hope for her when she maybe couldn’t feel that herself at the moment was important.
Conclusion
I found myself worrying after the meeting had occurred, whether I had done the right thing, said the right things, etc., but completing this reflection has helped me identify that this was always going to be a difficult conversation that would be emotional in nature. I demonstrated my commitment and care to her studies and achievements throughout. A separate reflection to complete would be about whether, in the months preceding this, I had recognised that her mental health was deteriorating and if I could have intervened sooner to support her. I think my clinical skills in nursing were important as I was able to help her reflect, process her emotions with her and maintain hope for her.
Action Plan
I will of course keep in contact with this student to support her, particularly when she returns to the programme, as that may be challenging for her. I will have more confidence in my skills in similar scenarios moving forward and will try and identify sooner when students may be struggling to try and put measures in to support them earlier.
As you can hopefully see from the reflection above, I focussed mainly on my thoughts and feelings. This can be very challenging, often because as mental health professionals, we can struggle to accept our own emotions and feelings are part of any interaction. It would have been emotionally easier to focus on the student’s emotions within the reflection and they are, of course, important and acknowledged within the reflection; however, this is a reflection about me as the lecturer and professional in this scenario. The process behind the situation was very straightforward and something I have done several hundred times, so a functional focus would not have been particularly beneficial as the process is always the same and instructed by university policy. It is difficult to acknowledge my feelings in this scenario; however, this is an important aspect of processing these feelings as after completing the above reflection, I feel more confident that I acted appropriately, in a supportive manner, and ultimately handled the situation well. There are of course learning points, and a key action point would be trying to identify how to support students who may be struggling sooner, which, of course, is a significant challenge. Acknowledging that I had actually been ruminating on the situation – ultimately due to guilt of not identifying the seriousness of the situation sooner and causing further upset to the student – was something that I hadn’t actually recognised until completing the reflection. It can be difficult to notice or recognise that we are having ongoing feelings or reactions to particular scenarios that have occurred. and sometimes these can present in different ways. When something is playing on my mind, as this scenario did, I find I can become snappy and irritable about small things but after reflection, can identify it is because of something else much bigger that I haven’t been able to fully process and move forward from.
As we have explored above, Gibbs’ reflective cycle (Gibbs and Andrew, 2001) can be very helpful as a formal reflective model, particularly when we need additional prompting to explore our thoughts and feelings in relation to a situation but there are other models of reflection that can also be very helpful. One such model is Driscoll’s Model of Reflection (2007) in which there are just three stages:
What? (Describe the situation/scenario. What exactly happened? What did you do? What did others do?)
So what? (Why is it important? What happened, and how was it resolved? How did it make you feel?)
Now what? (How do you move forward? Are there any further actions to take to resolve the situation? Do you need support or to escalate the situation? What have you learned? What could you do better to prepare yourself for similar situations in the future?)
Driscoll’s (2007) model is possibly the simplest reflective model in terms of its structure and so becomes a frequently used and cited model. The simplicity of the model does not mean that the reflection it prompts from the clinician or practitioner is any less detailed or in‐depth; however, the individual reflecting and utilising this model will need to challenge themselves more to reflect in an effective, detailed and in‐depth manner.
Vignette
As discussed above, we will now explore more informal reflective principles, utilising Driscoll’s (2007) model.
At the beginning of my career in mental health nursing, I worked in a psychiatric intensive care unit and then a triage assessment unit within the same mental health unit. I lived approximately a 30‐minute walk from work, and I would normally get the bus to work but would always walk home from my shift. During my walk home, I would think about the shift that had just happened, and although I wasn’t utilising Driscoll’s (2007) model at the time (as I wasn’t aware of it!), it could be argued that I was following the core principles.
During my walk home, I would think about what had happened during that shift (What?), had there been any incidents? Had there been any challenges? I would then think about my reactions to them (So what?); had I acted correctly? Had I responded quickly enough? Had I read the warning signs correctly? Had I followed the appropriate policy? Had I documented thoroughly enough? Then, I would think about what I would do differently on the next shift (Now what?); did I need to raise anything with my supervisor or ward manager? Did I need to ask for help in understanding something better? Do I need more training? Are there any improvements within the team I could identify?
I would allow myself to ruminate on all of these things throughout my walk home, including allowing myself to feel whatever emotion occurred. Did I feel unsupported? Was I angry at something that had happened? Had something upsetting or distressing happened? I would feel my feelings and think of what I needed to do next time I was on shift all the way home, and then I would close the door. I would close the door literally and metaphorically – and once I was at home, work was done – and it would not be allowed in. I was semi‐cognisant of this approach and that I used the door as a way of maintaining my work–life balance, but that was pretty easy in that role. No work came home with me, I didn’t need to check my emails when I wasn’t on shift, and I couldn’t in any way ‘work from home’ so that definitive boundary was very easy to maintain. What I didn’t fully recognise or appreciate at the time was that I was informally reflecting all the way home and that having such a firm boundary and switching into ‘home Laura’ as soon as I was through the door was an incredibly healthy way of processing an emotionally difficult and demanding role.
Reflecting upon my informal reflection style at the earliest part of my career, I can recognise that without having the awareness of reflective models such as Gibbs’ (Gibbs and Andrew, 2001) or Driscoll’s (2007), I was actually doing quite a good job of reflecting! Completing this reflection has made me realise why I have found it so challenging to ‘switch off’ from work since the COVID‐19 pandemic began, and that is primarily due to working from home the majority of the time for the first time in my career. I think this became a particular challenge for me due to a heavily increased workload and not finding a replacement for that ‘walk home reflection’ that I used to have and having no clear boundary between work and home life. There are several solutions to this, such as going for a walk after finishing work, switching where you physically work at home so that you can ‘close the door’ on your work or working at a completely different location all together but the key point is that I needed to reflect on why I was struggling with work–life boundaries, recognise that it was because I had always used my commute to reflect on and process my working day and find an appropriate solution to this.
Reflecting after the fact, as above, is known as ‘reflecting on action’ but as practitioners, what we sometimes struggle to identify is how much we ‘reflect in action’. Reflecting on/in action relates to Schon’s (1991) theory presented in his seminal book ‘The Reflective Practitioner’ (Schon, 1991). Reflection in action is something that we may do unconsciously and involves considering the situation at present, making a decision and acting in the moment. Some of the questions we may ask ourselves when reflecting in action could include:
Have I been in this situation before?
If so, what did I/we do to manage the situation?
Did that go well?
If so, will the same approach work in this situation?
If not, what could we do differently?
We can reflect in action as a team by asking these questions aloud or asking ‘what are our options?’. By doing this and then evaluating each option with our previous knowledge and experience is quintessentially, reflecting in action. As an experienced clinical practitioner, you may find it easy to quickly reflect in action and identify the best solution to a problem or situation. Still, you can support peers and those less experienced at reflecting in action by simply asking the above questions to them and supporting them to find the most appropriate answers.
Reflecting on our clinical practice is vitally important for all of the reasons discussed above. However, what is sometimes less considered is how we can develop our professional identities through reflection. This can be quite simply by asking the question ‘what kind of practitioner do I want to be?’.
Activity
Take some time to really consider that question; ‘What kind of practitioner do you want to be?’
How do you want your colleagues and clients to see you?
How would you want junior staff or students to view you?
The response to the above activity will, of course, be very personal and individual, but many practitioners may want colleagues or clients to view them as kind, supportive, patient, knowledgeable and so on – all of which are positive attributes we would like to see in ourselves and in our colleagues. The next step is to think about your interactions. Do you think you have demonstrated those qualities within your interactions within the last week? If not, what do you think you could do differently next week? This may seem very simple, but this is very much how we develop our professional identities. Role‐modelling is an important component of this, you may have a colleague you have worked with who you thought always demonstrated a caring approach, think of what they did and how they acted for you to see them that way and then think how you could replicate that as well. Role‐modelling is something that we should always consider within our clinical practice – both in terms of looking to others for inspiration and as being a role model. I have been lucky enough to work with some incredible nurses during my career, and I have always tried to understand their approaches to be able to adopt them into my practice. If we consider all aspects of reflection, reflection in action, reflection on action, reflection on our professional identity and reflection in relation to role‐modelling, we can see how reflection becomes a 360° all‐encompassing aspect of our practice and professional identity.
References
Driscoll, J. (2007)
Practising clinical supervision: A reflective approach for healthcare professionals
. Edinburgh: Baillière Tindall Elsevier.
Gibbs, G. and Andrew, C. (2001)
Learning by doing: A guide to teaching and learning methods
. Geography Discipline Network.
The Nursing and Midwifery Council (n.d.)
Revalidation
. Available at:
https://www.nmc.org.uk/revalidation/
(Accessed: 6 April 2023).
Schon, D.A. (1991)
The reflective practitioner: How professionals think in action
. Aldershot, U.K.: Ashgate.
CHAPTER 3Resilience
You can’t pour from an empty cup …
Resilience is a term that is referred to frequently in nursing, always emphasizing how important it is. When we consider the demands of working in healthcare, long shifts, high clinical caseloads and emotionally difficult work, we can understand why resilience is such an important consideration but what does it actually mean? How do we understand our resilience? How do we build resilience when we feel overwhelmed? This chapter will explore some of the key considerations around resilience, how we can understand our needs and build resilience for ourselves and others.
To over‐simplify the term, resilience can be understood as our natural or learned defences to stressful situations and our ability to recover from these. We all have the capacity to deal with stress and stressors, but as we know, not all stressors are created equal! Holmes and Rahe in 1967 published their ‘Social Readjustment Rating Scale’ which assigned a numerical value to various stressful life events and in their research found that those with a score of over 300 were 80% more likely to experience health issues in the following two years (Holmes and Rahe, 1967). To contextualise this, the highest‐ranking stressor was the death of a spouse, which scored 100 on the scale, retirement scored 45, and a ‘minor violation of law’ scored just 11. Many of us could look at the rating scale and question whether we would find that situation stressful, such as divorce (which scores 73). If someone were in an abusive marriage, for example, surely the more stressful thing would be to remain in the marriage? Retirement may be a significant life event but many of us eagerly await the day we can enjoy our retirement! There are many examples like this where individual perception would be a significant factor in the impact of different situations and scenarios however, the important factor with the Holmes and Rahe Scale (1967) is that it very much establishes a link between stress and health. Stress is a core concept in mental health nursing that will be returned to many times throughout this text, but the link between stress and health will be explored in much greater depth in the chapter focussing on ‘the stress vulnerability model’.
When we consider ‘what is resilience?’ it is difficult to separate any definition from the concept of stress. Many consider resilience to be about coping with adverse experiences, whereas some view resilience as an inherent personality trait (Henshall, Davey and Jackson, 2020). However, this presents many challenges as an attitude to resilience as it implies that some are resilient and others are not and that this is an unchangeable status of being. Which, quite simply, it is not. Thinking of resilience as something that can have peaks and troughs leads to a more empathic understanding of ourselves and others. For example, think of a time when you have had a particularly bad night’s sleep. How did that affect your mood? Did you find yourself more or less able to cope with stress the next day? Most people can empathise with how a single night’s poor sleep can have a detrimental impact on your mood and stress levels, which then impacts your resilience. If we have been feeling stressed or overly tired, our resilience will be less than if we are generally feeling calm, supported and well rested. We can also reflect on when we were experiencing something challenging in our personal life, such as a bereavement or separation. That will have a significant impact on our work–life balance, we may not be able to work at all (particularly in the acute stages of a significant life event) and if we do continue to work/return to work, our quality and standard of work may not be of the same level as when we were not going through a difficult time in our personal life. After all, we are human and can only cope with so much stress, no one has unending resilience. Although we can develop strategies to identify when our resilience may be challenged and how to improve this, we must also recognise the importance of limits and boundaries. We frequently extend empathy to others but not ourselves.
Nursing as a whole is considered a stressful occupation; however; research (Foster et al., 2020) identifies that mental health nursing as a profession is particularly challenging due to factors such as increased levels of verbal and physical aggression and ‘moral distress’. Moral distress can come from engaging in practices you ethically disagree with; even if you agree practically, it is the most appropriate action, such as utilising seclusion. Healthcare professionals in all areas and fields could be the victims of violence, abuse, or moral distress/injury, whilst we are focussing on mental health nursing, we must be mindful that we are not the only profession that experiences these challenging work environments. Mental health nurses reported that the most challenging workplace stressors were violence and aggression, followed by challenges with colleagues and organisational factors such as workload demands (Foster et al., 2020). This highlights the negative impact working in environments with high levels of violence and aggression has on clinicians and that ultimately, those who engaged in the research are effectively saying that their workload issues (which would include long shifts, staffing issues, high caseloads, etc.) is not as stressful or challenging as the presence or threat of violence and aggression. The second most common source of stress was collegiate, and nurses are frequently faced with adversity as part of their role, but it is surprising how frequently bullying appears within the literature as a significant source of stress for nurses (Henshall, Davey and Jackson, 2020; Foster et al., 2020). You would anticipate working in healthcare to be a supportive and kind environment but this appears to frequently not be the case. It is difficult to understand why bullying is so common within the profession and if in fact it is more common than in other professions. It is particularly shocking when you consider the current staffing crisis facing all fields of nursing and that feeling bullied or ostracised would be a strong motivator for nurses to leave the clinical area or even the profession. Increasing our personal resilience is obviously a positive factor within this; however, this highlights the importance of supporting our colleagues and peers to develop their resilience through supervision, compassionate practice and leadership. This, however, does not replace the need for organisations to improve support and healthy working environments for their staff (Henshall, Davey and Jackson, 2020). Developing improved resilience should be seen as a fundamental cultural and organisational issue (Henshall, Davey and Jackson, 2020) that should be a high priority for every organisation and leader within clinical services. Embedding positive attitudes and approaches to developing and improving resilience across teams and organisations would positively impact individual staff and may improve staff retention.
Now we’ve considered what resilience is and why it’s important, we will now consider what it is not! Many professionals wear their resilience as a badge of honour, and while we should support and praise people for overcoming challenges and adversity, this can lead to a negative impact on that same individual and those around them. Imagine there has been a difficult incident on the ward, and one team member was injured. That team member may be very resilient and may feel they are fine and can continue with the shift; other members of the team may praise them for this and positively reinforce this behaviour. What if later they start experiencing more pain? If they’ve been praised for staying on shift and ‘powering through’, they may feel unable to say they are now struggling and need to go home. What about the other team members who were distressed by the incident but think that because they weren’t physically injured, they can’t say anything or ask for support as it will look like they aren’t resilient? Presenteeism and ‘hustle culture’ are certainly not unique to nursing but the consequences within healthcare of presenteeism can be significant and severe. The definition of presenteeism is attending work when not physically or psychologically well enough to perform normally and one of the core reasons for presenteeism is the fear or concern of your colleague’s being overloaded in your absence (Santos et al., 2022), however the evidence demonstrates that presenteeism causes decreased productivity, increased errors and poorer patient outcomes. One example of this is continuing to go to work with a cold. By doing so, you are risking passing this on to colleagues and patients. Now, your team all become unwell when this could have been avoided by staying at home when unwell. Logically, we all know we would not want our team members to come to work if they were physically unwell, but many still continue to do so. Physical health presenteeism has an obvious ‘knock‐on’ effect but what about when someone is psychologically not well? Put simply, continuing to go to work when psychologically impaired (this could be from personal life or work–life stressors) can lead to burnout. Burnout is a crisis facing nursing currently, and ultimately, burnout starts as stress. Ongoing and chronic workplace stress leads to poor job satisfaction, distress and care standards becoming affected; staff can also experience vicarious traumatisation (Foster et al., 2020), and all of these factors can culminate to cause burnout.
In summary, resilience is not continuing to work regardless of what has happened or how you feel. One of the critical aspects of resilience is recognising your own boundaries and when you need to take time to rest and recover. Experiencing a difficult scenario that challenges our resilience is much like having a cold; by taking time to rest and recover at that moment will ultimately mean we feel better and able to continue with our work sooner and in a healthier manner.
It can be challenging to recognise our resilience; ultimately, this is part of our reflective skills. Developing our abilities in reflection will enable us to better understand and build our resilience throughout our careers and this should be seen as an ongoing commitment such as continuous professional development and lifelong learning.
Activity
Think about something that you found mildly challenging in your work life in recent months; take some time to make notes on what it was about that situation/scenario that you found challenging and how you overcame this.
Imagine yourself 10 years ago, where were you? Were you at school? University? Working?
How would the recent scenario have affected the you of 10 years ago?
How do you think you would have felt? Would you have managed the situation in the same way? Would you have found it more challenging? Would you have had more of an emotional response?
When undertaking that activity, many people would feel that the ‘them of 10 years ago’ possibly wouldn’t have handled the situation as well/competently/efficiently as present‐day them. This is because age and experience do naturally build our resilience, and it is important for us to recognise how our resilience has developed. Research supports this as younger mental health nurses appear to be more adversely affected by stressors than those who are older and more experienced in the field (Foster et al., 2020) which could account for the high attrition rate for early career nurses and demonstrates the importance of providing better support for newly qualified nurses in particular. The fact that resilience builds with experience is a valuable takeaway, as many may feel that if they feel un‐resilient, that that will never change.
To improve our resilience, we need to reflect on when we have felt un‐resilient. What was happening? What was the situation or scenario, and was this an ongoing feeling over a period of time or something you felt for a brief period? We may find that upon reflection, we identify that similar scenarios challenge our resilience and these will be unique to each individual. Some may find working with a client who has recently harmed themselves very challenging and upsetting, for example, and if we can identify that self‐harm is an area that we find challenging then we can focus specifically on this and develop strategies such as ensuring that there is a de‐brief with a colleague you are comfortable with following any incidents that involve self‐harm. Our mindset is also crucial to identifying and developing our resilience, and research suggests that some of the factors and attributes that can improve resilience are seeing challenges as an opportunity, accepting our limits, having a good sense of humour and crucially, accepting help from others (McDermott et al., 2020). All of these factors are things we can identify and improve on if we want to strengthen our resilience (yes, even humour!). They inherently need our skills in reflection to help us identify which ones we could improve and when. Being goal orientated in our work and studies can also aid with resilience (McDermott et al., 2020) as this can help focus our mindset on recognising that stress and challenges are temporary and, if we want to achieve our goals, must be overcome.
Accepting help from others and recognising when to ask for help is an important aspect of improving our resilience. Still, to develop positive cultures in working environments then there must be reciprocity in that we offer that support to our peers and colleagues as well. We need to recognise that mental health nursing is a stressful profession, and interestingly, in Foster et al.’s research (2020), they found that no mental health nurse reported zero workplace stressors; in fact, the majority reported 15 or more stressors, and experiencing verbal aggression was reported by 98% of respondents. Suicide and self‐harming behaviour were very prominent stressors in Foster et al.’s (2020) findings and were particularly emotionally demanding and distressing for mental health nurses. This highlights the importance of effective and consistent strategies to support nurses within their roles however even when there are good support mechanisms in place for clinical staff such as reflective practice and supervision, these are frequently sacrificed when there is a clinical issue (Henshall, Davey and Jackson, 2020) such as staffing shortfalls or an incident. Whilst this may sometimes be necessary when there is an immediate issue, if they are not promptly rescheduled, it further evidences that the needs of staff are sometimes at the bottom of the priority list in clinical areas leaving people feeling devalued and unsupported. As individuals, our crucial role within this should be to recognise when these supportive mechanisms, such as supervision, are being missed, offer ad hoc support to our team members, and escalate our concerns to our seniors if this is a consistent and persistent issue within our clinical team. This does not just apply to line‐management arrangements; we do not need to be senior to a colleague to offer ad hoc or informal supervision to support their emotional or well‐being needs.
Consideration, support and training specifically around resilience should begin during nurse education, particularly when we consider that nursing students face many stressors whilst undertaking their studies including intensive academic and practical workloads in clinical practice (Drach‐Zahavy et al., 2021) and experienced nurses can sometimes forget how challenging undertaking a nursing programme truly is. Many have argued the need for specific focus and training on resilience within nurse education (McDermott et al., 2020), and that during education, nurse academics have a specific role in providing resilience‐related learning, being supportive to nursing students during stressful situations, and supporting students in reflecting on challenges positively and constructively. Suppose we were to embed resilience training throughout preregistration nursing programmes collectively, we may see significant benefits in terms of retention of student nurses in the first instance but then more resilient nurses who are better prepared for the profession's challenges. This may also lead to a more supportive workforce overall, which would improve the experience of not only the clinical team but also service users as well as the overall well‐being of the nursing workforce is crucial to their capacity to provide safe, person‐centred and effective care (Foster et al., 2020).
Vignette
To protect the identities of those involved, I will be deliberately vague about some of the details of the scenario from my clinical practice. This vignette is provided to support linking theory to practice and share a reflective account that will hopefully help you in your own reflections.
I had only been qualified as a nurse for about 18 months when I moved teams, and due to some fairly complex contractual reasons, I was working within a team who were all from a different organisation to me, meaning they had no management responsibilities over me. I have always been a good team player and thrived in inpatient teams but this team was very small and well established before I had started there. I have reflected upon my early days/weeks/months there many times and have frequently asked myself, ‘What would I have done differently?’ and each time, I have drawn a blank. The reason for that is not because I see myself as the perfect practitioner but instead because I approached that team with kindness and openness and that is simply something that I will not regret. I worked in that team for a year in total and it was the absolute worst year of my career. One member of that team would be fine to work with; nothing would have happened and nothing would have been said, but then a few hours later, I would get a call from my line manager telling me she had made a complaint against me for something that had no basis in fact. I have never and will never understand her motivations and it took me a very long time (and several counselling sessions!) to name it as bullying.
All of the accusations she made were bizarre and made little/no sense. They included examples such as me saying ‘as it’s quiet, I might pop down to introduce myself to “x” team as my manager told me to do that when I could, is that ok with you?’, her replying ‘yes that’s fine, I did that too when I first started here’ and then my manager later called me after she called her manager, who called my manager to ask why I’d said I was going to work in a different team, in a different location. Obviously, I hadn’t said that as that wasn’t the case, she knew that wasn’t what was said but chose to make a complaint about it for what reason? Her lies and malicious complaints led to me frequently being shouted at first thing in the morning by her line manager, often before I’d even managed to take my coat off.
I explained the situation to my manager (who was also somewhat fed up with the constant phone calls!), who was supportive and told me she was escalating the matter further. Every month at my line‐management supervision, I begged to be transferred, but there was always a reason that couldn’t be facilitated.
This went on for a year and had an incredibly negative impact on my well‐being and mental health. I never felt comfortable or that I could relax, I was watching every word I said and tried to guess how it could be misinterpreted or manipulated and was constantly on edge. That workplace was a 2‐hour commute via train, and most nights, I would be sobbing on the train home. The situation culminated in her calling me on a day off and basically implying that I was going to get arrested as a client I had assessed had been arrested and named me as the reason they hadn’t complied with their bail conditions. Despite experiencing her lies for a year, it didn’t occur to me that this was also a lie, so before calling the police officer who wanted to speak to me ‘and go to the station for an interview’ I called my line manager for advice. She calmed me down and advised me to call the police officer and ask how I could help, and we would go from there. I did that, and they asked me some questions about this client if I had any acute concerns, etc., and after about 15 minutes, I asked if I was in trouble or needed to come to the station. The officer was shocked because what had actually happened was that they told my colleague that they were aware I’d put a robust support package in place and they would just like to ask me about it and if there were any other services the client should be referred to.
The situation continued deteriorating until I was eventually moved to a different environment to work alongside a new team that was very supportive and professional.
So, what does this mean about my resilience? Well, first, I’d suggest I was very resilient to continue to show up and do my job when working in an environment as toxic and hostile as that! Second, I learned some very valuable lessons that I have taken forward in the rest of my career. When I reflect back on how young I was, how newly qualified and inexperienced (from the perspective of myself now) I was, I am amazed at how professionally I handled that situation. I never retaliated; I continued to behave like a professional; I was respectful and utilised the appropriate mechanisms, such as my management team and supervision arrangements. I cried, a lot, but always outside of the environment. Never letting her see how upset and distressed I was will always be a source of pride.
Reflecting on how I actually was incredibly resilient to continue functioning in the face of such challenges has made me appraise my ability to cope with future issues more positively. I have frequently found myself thinking ‘well it’s not as bad as “x” that’s for sure!’ and knowing that I would ultimately be fine. It did take me time and an excellent counsellor to be able to frame it as an experience that I learned and grew from and could ultimately be proud of myself for.
