Minimising mental illness among the nursing workforce: mental health coach Jacquie Kidd hopes her PhD will make a difference for nurses who have experienced mental illness during their practice. She wants to assist nurse managers to become better informed about mental illness and to help them create safe working environments for their staff.

Working with nurse managers and nursing organisations to improve the mental health of their staff is the long-term dream of mental health coach and PhD candidate Jacquie Kidd.

Kidd has worked in mental health since she graduated from the then Hawke's Bay Polytechnic in 1990. She began working on her PhD through the University of Auckland towards the end of last year. Provisionally called "I can't pretend anymore", this looks at nurses' own experience of mental ill health while in clinical practice. Through her research she aims to initially develop an understanding of the context of mentally ill nurses, and to explore whether nursing as a profession or nursing work triggers or exacerbates mental illness in its members. But the ultimate aim for the research is to develop strategies for nurses and employers on how to prevent or minimise mental illness in the nursing workforce.

Kidd began working with nurses on their stories in February this year. An initial letter published in Kai Tiaki Nursing New Zealand that same month elicited over 40 responses. From these, she now has 24 nurse narrators participating in the study, most of them women, from all parts of New Zealand and from a variety of practice areas. After undertaking 21 of the interviews, Kidd is even more convinced that nursing can be bad for your mental health.

"Being a nurse means you are responsible for other people's lives and this can be very stressful and demanding, especially if you have high expectations of your own abilities," said Kidd. "I know from my own experience that it can be very difficult to let go of feeling responsible for some patients, even after the shift is over. It isn't uncommon for nurses to phone work to check on patients on their days off. This ongoing stress means the nurse doesn't get the full benefit of being away from the demands of work, and can result in her becoming exhausted. I believe the myth of the 'super nurse' is alive and well, but that trying to maintain that kind of standard is detrimental to our mental and physical health. Nurses facing mental health problems need compassionate nursing leadership, and greater understanding and support to enable them to remain working in a safe environment and to nurse safely themselves. In a shrinking nursing workforce, we can't afford to lose these skilled people."

Kidd believes a high proportion of nurses are likely to experience mental ill health during their working lives, as with the wider population. A study in the late 1980s in Christchurch showed that 65 percent of the population will experience a diagnosable mental illness during their lifetime. (1) "The paradox at the moment is that so many nurses are forced to work towards recovery white hiding their illness. Some feel compelled to leave nursing completely but suffer a great deal of grief leaving a profession that was very much part of their own identities.

"The ongoing stigmatisation around the label of mental illness can mean that everything changes once it becomes known, and the person can feel very unsafe. This could become a significant issue for nurses, as the Health Practitioners Competence Assurance Act requires us all to report impaired practice to Nursing Council Discrimination against people with mental illness is a well known phenomenon and there is no reason to believe that nurses can escape its impact."

In February this year, Kidd set up her own independent practice in Hamilton, Hineira Health Ltd. She recognised there were many people who were being admitted to mental health services who might not have become so ill if their initial distress had been acknowledged and managed proactively. Having worked in education and clinical practice in a variety of settings, she realised that to work in primary mental health, she needed to work independently. The focus of Hineira Health is on mental health promotion, and illness prevention within the occupational health field. Working alongside businesses that want to develop a mentally healthy workforce, Kidd first does a risk assessment on all areas of the business, then draws up a risk management plan to reduce, eliminate or manage stress in the workplace. She follows this up with specifically designed training for both the front line staff and the managers. One of her present clients is the Hamilton City Council and its swimming pool lifeguards, whose jobs keeping the punic safe and coping with people who are sometimes belligerent or drunk can prove very taxing. She would love to do this same work in the workplaces where her research participants have worked or are still working--district health boards, hospices and primary health organisations. Her aspiration is to eventually work with nurses and managers to create a safe and healthy nursing workforce.

Personal experience of mental illness

Kidd, who is of Nga Puhi descent, has firsthand experience of mental illness, having suffered severe post-natal depression after the births of each of her four children. Since 1990, Kidd has worked at lake Alice Psychiatric Hospital, in Dunedin Hospital's mental health services, including time in emergency psychiatric services and over two years in Maori mental health in the Otago region with Te Oranga Tonu Tanga. During her years in Dunedin and while working full-time, she completed her bachelor's and master's degrees, becoming one of Otago Polytechnic's first master of nursing graduates in 2002. From 2002-2004, she lectured in mental hearth and research at Wintec in Hamilton.

This year, as well as developing her own business and working on her PhD, she is doing some postgraduate teaching at the University of Auckland and teaching the first mental health in primary care paper to post-graduate students. She and Auckland University mental health lecturer Tony O'Brien jointly developed this paper, which is delivered to skilled and experienced mental health nurses who are expanding the boundaries of mental health nursing into the primary care arena. She is also academic lecturer for nine mental health new graduates in the Waikato region, meeting with them once a fortnight for lectures and mentoring.

Talking to people and building long-term relationships with them is what attracts her to working in mental health. "I love listening to people and try always to accept what I hear without making any judgements about them," she said. "I also enjoy the unpredictability of the work. People have described me as 'naive', which is something I am quite proud of. In mental health, you have to be able to take people at face value and I believe being naive is a necessary and helpful quality."

Before beginning her PhD studies, Kidd had assumed that interviewing nurses who had experienced mental ill health at work would be a theory-based exercise, resulting in some dispassionate analysis. However, once embarking on the interviews, she soon realised that holding herself at an emotional distance was not feasible or appropriate. "I now see myself as a 'decentred' researcher whose main task is to value the voices and stories I am privileged to record. The nurse narrators in this research are not the objects of the study, but form the fens through which nursing and its relationship to mental illness is studied. The data collection has developed into co-constructed narratives from the nurses who have been mentally ill The nurses and I work as a team to produce stories that portray what the nurse wants to say."

Kidd has been very careful not to become another health professional seeking to reframe the nurses' experiences. "A person with a mental illness can end up reefing colonised as their thoughts and feelings are interpreted and changed by others so they conform to society's expectations. I don't want to be the next person to do that to them. The nurses are putting a huge amount of trust in me to treat their stories with the respect they deserve. Talking to the nurse narrators is an amazing and humbling experience, and I am now working on a range of themes that are beginning to emerge." Although it is too early in the research process to formally present any findings, she is eagerly looking forward to engaging in the analysis in the new year and to sharing her findings with the nursing community.

Kidd intends completing her interviews this year (helped by a grant from the Nursing and Education Research Foundation), finishing her analysis over the next 12 months and submitting her PhD by March 2008. Originally she intended taking seven to eight years to complete her PhD working on it part-time, but as she has gathered the data, she has felt a growing responsibility to get the stories out into the public arena and to make recommendations from her findings as soon as possible. "I want to produce a PhD that will make a difference for nurses. The only way to do that is to make sure these stories are published sooner rather than later, along with my recommendations.

"I believe we need a national framework for nurse managers on how to assist nurses experiencing mental ill health. Nurses with previous mental health problems could also work out advance directives or care plans with their employers so they are aware of early warning signs and can know what to do to help. Advance directives would also be helpful for the nurses themselves. "Nurse managers need to inform themselves about mental illness. It's not a fife sentence. Nurses who have been mentally unwell are just as bright, capable and safe as anyone else. In fact, they have particular gifts and experiences to offer their patients and their families that other nurses may not have. The answer is for managers to tackle the issues that trigger mental ill health before they get too big. They must build a safe working environment where nurses will feel safe enough to admit to problems, should they arise."

Reference

(1) Oakley-Brown, M. et al. (1991) Christchurch Epidemiological Study. Australia and New Zealand Journal of Psychiatry, 89, 23:327-340.