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
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.