This category addresses participants' experiences relating to their professional role as mental health nurses. In a temporal sense, these experiences are drawn historically and retrospectively from the very outset of participants' embarkation upon pre-registration programmes leading to professional registration, through to their most contemporary issues. It encompasses four sub-categories:
a) Managing role in different settings b) Influence of role models
c) Ongoing learning and professional development d) Career development and anticipation of future roles
Figure 5:12 below summarises the category of 'previous and concurrent professional experience' in diagrammatical form, following which each sub-category is defined and illustrated.
Figure 5.12: Diagram portraying the category of ‘Previous and Concurrent
Professional Experience’
Previous & Concurrent Professional Experience Influence of Role Models Ongoing Learning and Professional Development Managing Role in Different Settings Career Development & Future Rolesa) Managing Role in Different Settings
Though this category overlaps and links with category of 'engaging with dimensions of mental health nursing roles' presented earlier, it differs in that it is concerned with the way in which mental health nurses use previous and concurrent professional experience in a variety of actual settings in an applied and integrated sense, whereas the focus of the category 'engaging with dimensions' focuses upon the individual dimensions. Student mental health nurses are, during their pre- registration programme of preparation, necessarily exposed to a variety of practice placement contexts. These practice contexts focus upon different service user groups in one way or another. While some are defined by age group, other contexts are defined by presenting problems of service user groups, and encompass community-based services, in-patient services, day care services and crisis services. There are also some specific services and/or roles defined within these service demographics such as 'dual diagnosis' (for service users who have co-morbid addiction and severe mental health problems), rehabilitation (helping to move service users from in-patient settings to more independent living circumstances) and forensic (for offenders with co-existing mental health issues). This complex array of practice contexts also represents the range of practice roles within which qualified and registered nurses are deployed.
For student participants, the variety of placements could present somewhat of a 'whistle-stop tour' of mental health provision:
"…it’s hard... changing placement all the time because it’s like you get stuck and used to people... you find your role and where you fit... you’re starting to get on well with everybody, getting to know them, and then ‘bang’, you are out... then you have got to start again." [P.1].
The student participant below indicated that some placement areas are seen as less attractive than others:
"I did older people’s community placement and to be honest, I wasn’t really looking forward to it, but then it’s the thing of when you actually understand something. It’s a prejudice as well; everyone seemed to be regretting, or not looking forward to the older people’s placement... but I really enjoyed it. It’s been probably one of my favourite experiences. Maybe ‘cos I wasn’t expecting to get as much out of it as I did, but it comes back down to the stigma again. I mean, there’s a stigma towards that kind of work, within nursing itself." [P.16].
Student participants varied in their views of where they might like to gravitate to upon qualification and registration. The participant below reflected upon her placement experiences in terms of where she might wish to work once qualified:
"When I first started I would have said CAMHS... and I still think I have an interest, but I don’t think we get much opportunity to actually see what that is all about. And when I first started I was adamant that I didn’t want to work with people with dementia, but my second placement was with people with a dementia assessment ward and that completely changed,
so I am not... I don’t think forensics is for me, I think I know that, but I don’t really have a definitive ‘that’s what I want to do’. I did thoroughly enjoy my time with the crisis team and if I could, have a job on the crisis team when I left university, I would be very happy."
[P.2].
The participant below approached the issue in terms of what areas he definitely would not wish to work within:
"I think I would stay clear of the, I suppose the non-psychosis side of working age adult."
[P.4. Int-1].
Once qualified and registered, some participants had very clear preferences for particular practice contexts. The participant below indicates that working with adolescents became her ambition following a practice placement in the area. This became her area of practice and career development:
"And I chose to go down the adolescent inpatient unit...at that point in time. So I went and did my twelve weeks down there and from that point was hooked... so quite early on in my career I was sort of hooked into working with adolescents." [P.14].
Interestingly, the same participant drew attention to a policy which was, historically, prevalent within large psychiatric institutions up until relatively recently:
"And at that point in time, at that time in the nursing culture, especially at [hospital named] it was that staff nurses don’t stay on a ward more than two years." [P.14].
It was somewhat against this trend that she ultimately secured a role within her preferred area, and remained within that area, developing specific expertise.
The example below captures a point in the participant's career history which illustrates the beginnings of development of mental health nursing roles in a community setting:
"The hospital was the main focal point around that time... I started in 1983. We went along the same loops during our enrolled nurse training.... long-stay placement… very institutional orientated and based. The CPNs around at that time, they were few and far between; they were seen as like the equivalent of the ward manager... charge nurse… an elite kind of bunch at the time... a prestigious role to have. But then obviously with the deinstitutionalisation and things like that... my role changed but essentially from qualifying...there was always the adage that... you need to kind of get a good inpatient experience under your belt to be of any value before you can go on and do anything else, which perhaps was a bit more true then than it is now." [P.18].
For the participant below, exposure to the field of CAMH occurred within an educational setting for continuing professional development (CPD):
"I can remember the day that I decided: that’s where I wanted to be and I was at the university in [City named]... and there was the 603 course, which was the old… CAMHs
course. I thought: 'I’m going to do that' and it was a really strong drive and that’s when I started looking round for CAMHS jobs and then one came up quite quickly." [P.15].
The participant below has worked in a variety of mental health contexts, but had a very clear affinity for working with older people:
"And I have worked with younger adults and I did enjoy it, but I’ve definitely, me, as a person, I’m definitely an older person’s nurse at heart." [P.9].
The participant below presented a very stoical stance to being deployed as needed across a range of settings:
"...I remember when I were... just moved into mental health wards, some people would go off sick rather than be moved to another ward for a shift... I've never been precious about what desk I sat at, or whether I went to another ward for a day or a week... help the cause really, so it's just your nature isn't it?" [P.13].
Participants with longer career histories were more likely to have experienced a range of practice contexts, perhaps indicating a period in the development of mental health services where nursing roles were more immediately transferable between contexts, as in the case below:
"…it was kind of the usual apprenticeship of acute admission wards. I did that a couple of years. Then I moved into drug and alcohol, worked in that for two and a half, three years... did some extra training... worked in what would now be known as CAMHs... for over four and a bit years... with a little bit doing something else in the middle of it not for very long. And then into working in... the university department at the [Hospital named] as was just newly developed then for severe affective disorders." [P.17].
The participant below, though having found her ideal working context (CAMH), still felt her historical experience in other mental health-related contexts was useful:
“I’m glad I’ve had time in adult services... in older person’s services and rehab and day hospital, because I think all that feeds into the knowledge that I know, so if I’m seeing sort of a programme or youngster, I have got an idea of what they could potentially be like in ten years’ time." [P.15].
Re-locating roles to different settings can spring simply from the desire for a change in working context:
"I feel as if sometimes – not in a big-headed kind of way – but you feel as if you outgrow some areas or there’s a necessity for newer challenges or you’ve got ideas that perhaps take you in a slightly different direction..." [P.18].
The participant below outlined how she first qualified, then worked in two roles before finding her 'ideal' role:
"So I did that, as a band 5 obviously, for about two years... and then I applied for the clinical lead post on the female adult acute admission ward... and I did that for about nine month. I found the role of clinical lead to band 5 very different as well... although I was clinical lead I was expected to be the lead of more complex cases... often didn’t have time for that because of the meetings that you would go stand in for if the manager was off…
rotas, dashboards, things like that… which is why I applied for the post in the crisis team because I wanted to work with people." [P.11].
The clinical lead role she referred to clearly did not manifest her expectations in actual practice. In keeping with the issue identified within previous categories regarding leadership roles, engaging with this role led to reduced contact with service users. She added:
"I do, I think, well, I love doing this what I, the crisis role, because it’s so different, it’s so varied and you do, you are dealing with risk and I do like dealing with risk, and you see all sorts of situations and you’re on your feet all of the time." [P.11].
A particular issue of note was participants' anticipation of (students) or experience of (qualified registrants) the transition from the role of student to that of qualified, registered, accountable practitioner. The student participant below expressed this anticipation:
"I can definitely imagine... definitely, I am worried about things but I am still definitely imagining me self doing it, and I know that eventually through experience I’ll be able to be a nurse." [P.6].
Students also encounter newly-qualified nurses during their placement experiences and are able to identify with the transition agenda and potential issues they may encounter through seeing the experiences of others, as reflected by the participant below:
"I still think you need a lot of support as a newly qualified... I remember in my second year, seeing a preceptorship nurse who sort of came on to a ward with all her new ideas... and she was... quite ridiculed really, by some of the more junior staff and it was quite awful to watch from my perspective." [P.5].
The participant below was re-interviewed one year into his qualified registrant status, and reflected upon his transition:
“I have sort of settled in really quickly and I am... performing above my experience level... sort of initial I suppose honeymoon period if you like is starting to wear off... the politics of other staff are starting to wear us down a little bit now." [P.4. Int-2].
The final example below illustrates how participants with longer career histories were able to reflect upon their experiences in comparison with the way in which transition is managed in the contemporary context:
"It was really difficult... because then you didn’t have the preceptorship support that you’ve got now... I often joke: one day you’re wearing a white dress as a student; the next day, you were kind of a staff nurse with a blue dress on and suddenly people were asking you your advice and your opinion… and that was really, really quite alarming and scary."
[P.9 ].
In summing up the key points for this sub-category, mental health as an arena of practice is, in reality, a myriad matrix of services and contexts.
Student mental health nurses are exposed to this variety of contexts during their preparation for registered practice via time-limited periods of experience in each, with some opportunities to gain insight into associated services as part of their placement experience. They also have the concurrent agenda of increasing expectations in terms of responsibility as they move through the placements across their period of preparation. There is then the transition from the student role to the qualified registrant role. Students are aware and anticipate that they face the task of transition at the end of their initial preparation. Participants with a longer time period since qualification and transition reported less structured processes to enable the transition.
In terms of preference and affinity for particular practice contexts, some student participants recognised very early in their programmes where their affinity lay. Others consciously defer expressing preference until they have experienced the variety of settings within their placement schedules. A similar picture was evident amongst qualified and registered participants. Though the initial context which individuals begin their registered practice within might be restricted by availability of posts, those with firm aspirations to work within particular mental health contexts can, within a period of time, position themselves to move to a more preferred role. Some had identified their particular preference early within their careers (or whilst they had been students) and gravitated toward this. Others had gravitated to a number of roles prior to establishing their preferred practice context, and still others might take opportunities to 'move on' after a period of time simply for a change of context.
This variety of contexts within which mental health nurses practice brings the debate concerning generic/eclectic approaches and specialist interventions explicitly into focus. This will be addressed more explicitly in chapter six.
b) Influence of Role models
Given the practice-based nature of the discipline of mental health nursing, and the emphasis upon learning experientially in practice as well as academically, it is not surprising that most participants were able to recount particular individuals and/or incidents which had influenced their own professional development in some way.
At a general level, such influences are not necessarily critical, earth-shattering incidents. The student participant below outlined what she felt to be the influence of competent practitioners within practice placements:
"I think it’s about being able to reflect on somebody else’s practice... in an analytical way and take the good bits that you would like to take on board and develop into how you
would want to practice in the future and take away the negative bits, because nobody is perfect, so you could have the best nurse in the world but there is going to be some negative part to what they do, so it’s trying to pick out the bits that are best for you…"
[P.2].
This was echoed by the participant below, who suggested that influence can be a gradual, building process and may take place cumulatively over a period of time rather than a particular episode:
"...just being able to observe their behaviour and their attitude... and talking to them... like I probably spent a week with one lady and it wasn’t even a week, it was like a couple of hours on one day and like a couple of hours on the next... at the end of the week... you just sort of build that respect for that person and you see, and you watch them work and that’s where you like respect them as a practitioner…" [P.3. Int-1].
However, all practitioners have strengths and weaknesses within the dimensions of their practice, as pointed out by this participant:
"...every person I have worked with I tried to take strengths from and some people have had a lot more strengths than others... I worked with a nurse who I didn’t feel was particularly confident... and was very defensive in her practice but her record keeping was brilliant and stuff..." [P.4. Int-1].
Some of the above participants recognised that there are weaknesses as well as strengths for all practitioners, including role models. Student participants had encountered individuals who were very poor role models. The participant below drew two extremes of comparison:
"I mean, you know, people that are so passionate about what they do that it virtually seeps out of every pore in their body and then you have got other people who, ‘well, three years, two days and ten minutes and I will be retired it doesn’t really matter’." [P.2].
A particularly negative example was given by the participant below:
"...that mentor in particular I think she was just really burnt out… and like on my first day she said ‘you’re here to spark enthusiasm in me’ and I thought ‘right, that’s not why I am here like’... before I left, she was saying she was thinking of moving to doing something different." [P.1].
Participants did recount a lot of good practice which they had seen modelled, and some nurses in practice placements were particularly inspiring:
"Say for example, the addictions placement I had, where I just visited, that mentor there would bend over backwards to help patients. He really did. He was very, very good. I’ve