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Student nurses beginning their clinical experience in psychiatric–mental health nursing usually find the discipline to be very different from any previous experience. As a result, they often have a variety of concerns; these concerns are normal and usually do not persist once the stu-dents have initial contacts with clients.Some common concerns and helpful hints for beginning students follow:
No one magic phrase can solve a client’s problems; likewise, no single statement can significantly worsen them. Listening carefully, showing genuine interest, and caring about the client are extremely important.
A nurse who possesses these elements but says some-thing that sounds out of place can simply restate it by saying, “That didn’t come out right. What I meant was . . .”
In the mental health setting, many familiar tasks and responsibilities are minimal. Physical care skills or diagnostic tests and procedures are fewer than those conducted in a busy medical–surgical setting. The idea of “just talking to people” may make the student feel as though he or she is not really doing anything. The student must deal with his or her own anxiety about approaching a stranger to talk about very sensitive and personal issues. Development of the therapeutic nurse–client relationship and trust takes time and patience.
Students sometimes fear that clients will reject them or refuse to have anything to do with student nurses. Some clients may not want to talk or are reclusive, but they may show that same behavior with experi-enced staff; students should not see such behavior as a personal insult or failure. Generally, many people in emotional distress welcome the opportunity to have someone listen to them and show a genuine interest in their situation. Being available and willing to listen is often all it takes to begin a significant interaction with someone.
Students often feel awkward as they imagine themselves discussing personal or distressing issues with a client. It is important to remember that questions involving per-sonal matters should not be the first thing a student says to the client. These issues usually arise after some trust and rapport have been established. In addition, clients genuinely are distressed about their situations and often want help resolving issues by talking to the nurse. When these emotional or personal issues are addressed in the context of the nurse–client relationship, asking sincere and necessary questions is not prying but is using thera-peutic communication skills to help the client.
The behavior and statements of some clients may be shocking or distressing to the student initially. It is im-portant to monitor one’s facial expressions and emotional responses so that clients do not feel rejected or ridiculed. The nursing instructor and staff are always available to assist the student in such situations. Students should never feel as if they will have to handle situations alone.
Some clients have difficulty recognizing or maintaining interpersonal boundaries. When a client seeks contact of any type outside the nurse–client relationship, it is important for the student (with the assistance of the instructor or staff) to clarify the boundaries of the pro-fessional relationship . Likewise, setting limits and maintaining boundaries are needed when a client’s behavior is sexually inappropriate. Initially, the student might be uncomfortable dealing with such behavior, but with practice and the assistance of the instructor and staff, it becomes easier to manage. It is also important to protect the client’s privacy and dignity when he or she cannot do so.
Often students have had little or no contact with seri-ously mentally ill people. Media coverage of those with mental illness who commit crimes is widespread, leav-ing the impression that most clients with psychiatric disorders are violent. Actually, clients hurt themselves more often than they harm others. Staff members usu-ally closely monitor clients with a potential for violence for clues of an impending outburst. When physical ag-gression does occur, staff members are specially trained to handle aggressive clients in a safe manner. The stu-dent should not become involved in the physical re-straint of an aggressive client because he or she has not had the training and experience required. When talking to or approaching clients who are potentially aggressive, the student should sit in an open area rather than in a closed room, provide plenty of space for the client, or request that the instructor or a staff person be present.
In any clinical setting, it is possible that a student nurse might see someone he or she knows. People often have additional fears because of the stigma that is still asso-ciated with seeking mental health treatment. It is es-sential in mental health that the client’s identity and treatment be kept confidential. If the student recog-nizes someone he or she knows, the student should notify the instructor, who can decide how to handle the situation. It is usually best for the student (and sometimes the instructor or staff) to talk with the cli-ent and reassure him or her about confidentiality. The client should be reassured that the student will not read the client’s record and will not be assigned to work with the client.
Students may discover that some of the problems, family dynamics, or life events of clients are similar to their own or those of their family. It can be a shock for students to discover that sometimes there are as many similarities between clients and staff as there are differences. There is no easy answer for this concern. Many people have stressful lives or abusive childhood experiences; some cope fairly successfully, whereas others are devastated emotionally. Although we know that coping skills are a key part of mental health, we do not always know why some people have serious emotional problems and others do not.
Self-awareness is the process by which the nurse gains recognition of his or her own feelings, beliefs, and attitudes. In nursing, being aware of one’s feelings, thoughts, and values is a primary focus. Self-awareness is particularly important in mental health nursing. Everyone, including nurses and student nurses, has values, ideas, and beliefs that are unique and different from others’. At times, a nurse’s values and beliefs will conflict with those of the client or with the client’s behavior. The nurse must learn to accept these differences among people and view each cli-ent as a worthwhile person regardless of that client’s opin-ions and lifestyle. The nurse does not need to condone the client’s views and behavior; he or she merely needs to accept them as different from his or her own and not let them interfere with care.
For example, a nurse who believes that abortion is wrong may be assigned to care for a client who has had an abortion. If the nurse is going to help the client, he or she must be able to separate his or her own beliefs about abor-tion from those of the client: the nurse must make sure personal feelings and beliefs do not interfere with or hin-der the client’s care.
The nurse can accomplish self-awareness through reflection, spending time consciously focusing on how one feels and what one values or believes. Although we all have values and beliefs, we may not have really spent time dis-covering how we feel or what we believe about certain issues, such as suicide or a client’s refusal to take needed medications. The nurse needs to discover himself or herself and what he or she believes before trying to help others with different views.
· Keep a diary or journal that focuses on experiences and related feelings. Work on identifying feelings and the circumstances from which they arose. Review the diary or journal periodically to look for patterns or changes.
· Talk with someone you trust about your experiences and feelings. This might be a family member, friend, coworker, or nursing instructor. Discuss how he or she might feel in a similar situation, or ask how he or she deals with uncomfortable situations or feelings.
· Engage in formal clinical supervision. Even experienced clinicians have a supervisor with whom they discuss personal feelings and challenging client situations to gain insight and new approaches.
· Seek alternative points of view. Put yourself in the cli-ent’s situation and think about his or her feelings, thoughts, and actions.
· Do not be critical of yourself (or others) for having cer-tain values or beliefs. Accept them as a part of yourself, or work to change those values and beliefs you wish to be different.
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