Tag Archives: Mental Health Nursing

Unconditional positive regard?

I would like to think a little bit about the use of language within mental health. I have struggled for a couple of years with the kind of language that we use on a regular basis, but don’t really give it much more thought. I know we all have words or phrases that when heard, make your hackles rise. Here is a small selection of mine!  How about “therapeutic relationships” for a start, hands up if you can give a definition? I’m sure we all can, but it will mean something different to everyone. Yet we use it often, how many times do we hear people say, “well, first of all I’d build a therapeutic relationship with the person” No! No! No!

Conversation (click to see photographer)

I noticed that even Jim Chapman and Cheryl Chessum struggled with this concept in their chapter in “The fundamentals of mental health nursing”. Their research shows that Aldridge (2006) states that brief definitions of the therapeutic relationships are scarce, giving only one which is, “Building a genuine human alliance that might begin to address the person’s problems with living.” (Barker & Buchanan-Barker, 2005). Jim and Cheryl say that engagement with the client starts the therapeutic relationship. But does it ever get underway? And if it does, where to then?

Maybe it’s on to “Unconditional positive regard”. The good old statement that says I’m not really troubled that you have been violent and aggressive to people in the past, that you beat up your girlfriend so badly she lost her baby, or that you threw your 9 week old puppy down the waste disposal chute, I’ll accept you as you are now because I believe you were lacking “insight” at the time. But what it really means is that I will try and disguise the disgust I feel for your actions because I’m only human and because I’m told you have a mental health problem – but I’m not promising anything.

Speaking of insight…….The Collins English dictionary defines insight as;

“The ability to perceive clearly or deeply”

 And “a penetrating and often sudden understanding, as of a complex situation or problem. There is also, “3. psychol; The capacity for understanding one’s own or another’s mental processes”

“4. Psychia; the ability to understand one’s own problems, sometimes used to distinguish between psychotic and neurotic disorders”.

Now I consider myself to be a fairly rational, responsible and capable human being, but am I always insightful according to the definitions? I don’t think so! So why do we often hear, “Mr Jones, suffering from schizophrenia, lacks insight”. How dare we? A double whammy there – who says that everyone suffers from or with schizophrenia? I know of many people who have and still do enjoy their experiences.

I’m not so stupid as to think we can, or should get rid of this type of language, but I think we need to consider the implications of using it. Are we really being honest in our use of it? Does it exclude people because we as mental health professionals have a shared, common understanding of its meaning and others don’t? Is it a cunningly disguised way of stigmatising and discriminating against “service users/patients/clients” (there’s another area that we should really get sorted!)

What do you think?

 

(NB Click images to see photographers)

A Question of Suicide?

Henry Wallis (1856-58) Reproduced with the kind permission of Birmingham Museums & Art Gallery
The Death of Chatterton: Henry Wallis (1856-58) Reproduced with permission and ©Birmingham Museums & Art Gallery  (click image for more details)

 

On a recent visit to Birmingham City Art museum I had a look at the painting above ‘The death of Chatterton’ by Henry Wallis (1856). This painting shows the dead body of Thomas Chatterton, an 18th century poet who killed himself by taking arsenic rather than live in poverty.

I suspect that if you weren’t familiar with this picture you wouldn’t guess that it shows an impoverished young man who has died of self administered arsenic poisoning. Although relatively unknown during his life, Chatterton’s death became a well known event because of the romanticised reaction it provoked. As well as this painting, there were poetic responses from the likes of Shelley, Wordsworth, Coleridge and Keats.

When Want and cold Neglect had chill’d thy soul,
Athirst for Death I see thee drench the bowl!
Thy corpse of many a livid hue
On the bare ground I view,
Whilst various passions all my mind engage;
Now is my breast distended with a sigh,
And now a flash of Rage
Darts through the tear, that glistens in my eye

(Monody on the death of Chatterton by Samuel Taylor Coleridge See link)

Arguably, this type of response served to glorify the act of suicide. Certainly, there is evidence of concern about how suicide was portrayed in the media. This essay on the Victorian web looks at attitudes to suicide and fears that media portrayals, especially in the ‘cheap press’ might increase suicide rates. How would we feel if a modern day suicide was to receive a response like this? The National Suicide Prevention Strategy is quite clear that it is necessary to promote “responsible representation of suicidal behaviour in the media”.

I was wondering though about how we as professionals really feel about suicide?

Personally, I do feel some uncertainty. I believe that somehow we need to sort out how we as a country are going to work with people who want to end their lives with dignity. There are large numbers of people who suffer from incurable illness and chronic physical and emotional pain who wish to have some control over when their lives will end. I don’t think that this should be left up to families to travel abroad (risking prosecution) with loved ones to assisted suicide clinics. I also think we would be better off if we didn’t have to rely on the likes of this ‘Euthanasia Doctor’ who recently visited the UK.

On the other hand, I spent many years working in in-patient mental health settings where I often cared for people who were considered at risk of suicide. Although we talk about the importance of ‘person centered care’ and working in collaboration with people –  lets be blunt. This involved helping to detain people against their will. There was often (not always) a feeling that the person receiving the care was trying to outwit us. If they succeeded in doing so then a likely result would be the death of that person. Were we right to try and prevent this? – I believe that we were. Is this an ideal way to be treating people? – certainly not – does anyone have any better ideas?

Take a look at this debate (transcript here) with Thomas Szasz, filmed  at Birmingham University. Having read the work of Szasz it seems clear to me that much of his critique of psychiatry and it’s contradictions makes sense. However, it seems quite clear that he wouldn’t approve of working with potentially suicidal people in the manner described above, i.e. “Compulsion is a bad thing”.

Trouble is though, where does this leave all of the people considered at risk of suicide who are currently detained in the UK? What about the people who are doing the detaining? How do we square this with an attempt to treat people with terminal illness’ with compassion and dignity. Lets be clear, I absolutely don’t pretend to have the answers to any of the issues raised above. I am pretty sure that there are no clear answers and certainly no answers that would please everyone. It will be interesting to see what the recent RCN consultation (see also) on the subject of assisted suicide will conclude. How  this will affect people involved in mental health services remains to be seen, I hope it will lead to wider discussion about this subject.

What do you think? – I would be interested to see any comments.

Update 10th June – See comments re an interesting debate on Mental Nurse Blog re Szasz link here & here

Inappropriate?

Often in practice and in teaching, there are situations where the practitioner or tutor makes a judgement about someone else’s work. Sometimes the person has a strong feeling that the other has misjudged something, and sometimes, or maybe often, this other person’s decision is described as ‘inappropriate’.

Things that are inappropriate include jokes, touch, remarks, modes of dress, approaches to others, laughing at funerals. In the language of teenagers, ‘so cheeky!’ but in the language of mental health professionals, ‘inappropriate!’

The message, whether casual or serious, is that the person has transgressed – behaved against cultural or professional norms. Within that though, is an unspoken message, that the person calling ‘inappropriate!’ has the power to decide what’s ok, and what’s not ok, and what’s more, my way is, yours isn’t.

To me this is the exact opposite of how we should be approaching both nursing and teaching. This word has the power to exclude and disadvantage, put the other person on the wrong foot, put one person in a one-up position, the other one-down. Surely this word is the most inappropriate word for us to be using?

A funny joke?

 
 

A funny joke?

 
 

That’s the other problem with it. It doesn’t give much clue as to what was wrong. So when I say the word itself is inappropriate, you only have the barest idea of why I say so. Me saying it, and being a teacher, is that enough? Both values and evidence are implied, but if I don’t feel like explaining, it’s implicit, well, I don’t have to.  I don’t have to account for myself. Well I do and so does everybody else. This word is first of all, undemocratic, and secondly disempowering.

It doesn’t tell us anything, apart from the power differential. So if something is inappropriate, should the other person just guess why? Of course not! So if I was to go into class in a mini skirt and low cut top, there would be reasons that wouldn’t be a good idea. It would be distracting from the messages I would be trying to get across, and could undermine the mutually respectful relationship I would be hoping to establish in class. Perhaps I would also be modelling (I don’t mean this in any fashionable sense) a mode of dress that could lead to difficulties in a clinical area, where service users need clarity of boundaries. But I can imagine if I were to dress like that, I would hear that it was inappropriate. I might realise that I was in the wrong but would not have clear guidance on what was not ok about my behaviour, or how to put it right. So my second point is that inappropriate is lazy.  Teachers need to clarify things for students, likewise nurses for service users, it’s part of our accountability and duty to be there for others’ development. It’s what we’re paid for, and not to do so is fraudulent.

So values too are undermined by use of this word. (I’m getting sick of writing it now, and it’s also quite hard to spell.) By implying something is wrong, we are clearly calling on our value system. I shouldn’t wear revealing clothing in class – but who says, and why not? Well, it would make other people uncomfortable, distract them, and undermine my professional position and relationships. It wouldn’t be fair.

Breakfast on the commode anyone?

When I was a student nurse one of my ‘inappropriate’ decisions was to say (perhaps rather too angrily) to a nursing officer (nowadays a modern matron) that I was not ok about patients eating their breakfasts while sitting on the commode. The sister was very clear to me that this behaviour was inappropriate. Mine that is.

So here the word was used for discipline – in this profession you don’t step out of line, this is the hierarchy, this is your place. The act is not separated from the person, there is no option for inclusion, ‘what you did was not ok, but you are’. The cultural element implied means that the person feels that if you want to be one of us, you have to act just like us. There is not space for non-conformity, alternative opinions, discussion. To me this system is one of the most damaging aspects of nursing, the risk that we reinforce what’s ok and not ok in relation to a vague but strong idea of appropriateness which is culturally reinforced through generations, but because not explicit, is difficult to challenge.

I did learn from this, that if you want to change things in the NHS, it’s better to do it from the inside. At that moment I felt very much the outsider, frowned upon from all quarters. Yet really, the behaviour that was inappropriate here, people eating food on top of … well do you want to tell me I’m inappropriate if I write it? And of course inappropriate doesn’t even cover it – humiliation  injustice and dehumanization, this practice arose because of understaffing and all round under-resourcing. So not only does the word not deal with the issues, it colludes with the cover-up of what’s really wrong.

Equal voices and respect?

So, I’m asking you, my colleagues as teachers, nurses and nurses to be, let’s sack this word, it is harming us, and harming those we are planning to help. It’s disempowering, excluding, unjust, makes things unclear, and contributes to a negative nursing culture. Instead we need to take the long road. This will mean stopping to think about our values, norms and expectations, and whether we can justify these, and taking the trouble to account for ourselves. In the end our destination will be fairer, more equal and inclusive, a nursing culture where we can all challenge supportively and take opportunities to develop as ourselves as a person and a professional, and be there in the same way for other people, aiming for equal voices and respect.

 

Images from Flickr as follows

 ‘I’ Picture by Marron Glacé on Flickr

‘A funny Joke’ Tootdood

Drug addiction?

Flickr click image
Photo by taiyofj : Flickr click image

There have been many discussions on over reliance/ dependence on medication over the years. Personally, I do think that both public and professionals rely too much on pill popping. I certainly feel a degree of sympathy for GP’s who have a few minutes to decide on someone’s illness and treatment plan. The prescription of a drug is likely to work so this becomes a ‘default’ option (and my apologies to any GP’s reading this.  I am aware that this is very simplistic but it does illustrate a point that is true for all professionals. And patients…well, when I see a health professional I will admit to feeling comforted by popping a pill. After all, a pill means that my illness is treatable doesn’t it?

 

Click image)
Medicine (photo KB35 on Flickr : Click image)

But hang on. If this deeply held belief that pills cure illness is flawed, then what is even more flawed is the idea that medication even treats mental illness. Lets look at depression. Depression involves the lowered state of serotonin and so all anti-depressants work by increasing levels of this neurotransmitter through one means or another. But aren’t we missing the point? By increasing serotonin levels all we are doing is dealing with the symptoms of an illness, not the illness itself. Schizophrenia treatment is exactly the same but here it is reducing the elevated dopamine.

My point – we are not dealing with illness eradication, rather we focus exclusively on symptom suppression. But this is the nature of mental health problems. It would be foolish to think that a little tablet taken twice a day will be a panacea for all our ills – unfortunately though, this is exactly what people think.

Birmingham City University – Recovery forum

 

We are planning to start a Recovery Forum at Birmingham City University.  In January I contributed a post about the Hearing Voices module that had been running throughout the autumn term.  The course gave students an introduction to the work of Marius Romme and Sandra Escher, whose work has inspired the Hearing Voices Network.  There are now over 170 Hearing Voices groups in the UK. 

 

The Hearing Voices module encourages participants to begin using Romme and Escher’s Maastricht Interview Schedule with service users.  The Maastricht Interview Schedule is not a quick assessment tool, but rather a way of helping people to talk about voice-hearing.  We also discussed ways that people have found to cope with problematic voice-hearing; and we talked about group work led by voice-hearers themselves, that has been shown to be effective in offering support, hope and meaning to people.   

 

The underlying premise of this work is that voice-hearing itself is not a problem which needs to be eliminated.  Many voice-hearers consider their voices to be positive, or at least an acceptable part of their experience.  Romme and Escher’s work helps people to talk about their voice-hearing experience, to accept that the voices are real – and may have meaning based on life experiences.  This respect for the experience of the person is at the heart of the recovery movement.

 

The recovery process according to the Mental Health Foundation 

  • provides a holistic view of mental illness that focuses on the person, not just their symptoms
  • believes recovery from severe mental illness is possible
  • is a journey rather than a destination
  • does not necessarily mean getting back to where you were before
  • happens in ‘fits and starts’ and, like life, has many ups and downs
  • calls for optimism and commitment from all concerned
  • is profoundly influenced by people’s expectations and attitudes
  • requires a well organised system of support from family, friends or professionals
  • requires services to embrace new and innovative ways of working

The recovery movement has been gaining strength within and outside of mental health services.   Many people with the recovery movement are challenging the traditional language and power structures of psychiatry – and the recovery model is as much user-led and influenced by professionals. 

 

In order to support those who have attended the Hearing Voices module to continue to work collaboratively with voice-hearers, and according to the recovery model we are setting up a Recovery Forum at Birmingham City University.  We anticipate the first session to take place in July 2009.  There will be more details to follow.  Members of university and trust staff with an interest in this area are also warmly invited to attend. 

 

Holistic fantasies revealed

It would be foolish to say that nursing – indeed any health profession I know – offers true holistic health care. Sure, we talk the talk of being holistic. We say that we cater for all needs and care for the individual – a principle that is enshrined in the Code of Conduct. And yes, we have wonderful assessment tools that are designed and tested to identify the areas needing attention. We pride ourselves on how we cater for the idiosyncratic goals of the person being cared for.

 

But do we really offer holistic care?

Or do we hide behind a false veil of ‘professionalism’ and only deal with what we want to deal with rather than dealing with what the person wants?

 

Let me explain.

 

Holistic health care means caring for all health needs. What about sexual health? I, and every nurse I have spoken with, have never asked a patient about their sexual health needs. What a minefield that would be! Imagine the legal problems I would face if I asked a female (or a male for that matter) if she had any sexual needs that she would like me to address whilst she was on the ward. Would my plea of holistic health care be enough to satisfy a judge that I am not a perverted sexual predator? Unlikely. Would the NMC jump to my defence as I have upheld the Code?

 

And please, don’t make me laugh by saying that we at least cater for religious needs. It strikes me that if you are not Christian or Muslim then the health services either cannot or do not want to help you with your religious needs. But even these two religions only have a token gesture made to them. The problem here is that it would take effort to organise and money to pay to allow people to practise their religion – two commodities that are in precious short supply in the health care system.

 

Of course, we have iatrogenic conditions and nosocomial infections – it is particularly worrying that professional caused conditions and hospital acquired infections are so common that we have words dedicated to them. So do we even offer physical health care?

 

Holistic health care is an ideal that we should (and do) strive for. But lets be realistic – it ain’t here yet.

 

 

From Student Nurse to Registered Practitioner – A transition fuelled with Anxiety!

I am delighted to introduce another guest post on the Mental Health Nurse Lecturers Tea party. This comes from one of our soon to be qualified student nurses, Julie Bennett.

Julie describes her feelings on coming to the end of her time at BCU – she has promised to keep us updated about how she gets on after this.

 

 

So, Three years draw to a close and what a wonderful experience. A wealth of friends, university life, fun laughter, tears and tantrums but on we go, pulling each other through with hope and optimism from peers, mentors and tutors alike.

 

More incentive came from the NHS via the generous bursary and dependents allowance, which kept my four children clothed and fed, not to mention the 85% contribution towards the very expensive child care costs, (as much as my rent per month)! Ok, the children haven’t loved going to the child minders some days, but hey, needs must!

 

The practice placement managers and clinical practice allocations staff have been very supportive; my final placements have been in the community, which has meant family friendly hours and have enabled me to complete my training.

 

And no council tax! What a bonus….many positives to being a student nurse not to mention discounts in many stores and the cinema!

 

Would it be fair to say that the transition period is full of mixed emotions? Yes, I did it, I stuck it out, jumped through hoops and achieved my ambition, before long that photo of me in my cap and gown will be on my mantlepiece, I am so proud. (if I still have a mantlepiece)!

 

So now for the anxiety part of it all, explained wonderfully by two of my peers during a workshop at the recent Mental Health Conference…..The BIG DIVE! Where is the water? Oh dear, there is none…….

 

Armed with skills and knowledge of  theoretical frameworks, before long my registration number will be in the post and off I go……to the job centre! Via the housing department and the council tax office and the search for a child minder who starts at 6.30am and finishes at 9pm.

 

A community mental health job would be ideal! But band 5 newly qualified nurse in the community? Mmm A prayer or two maybe needed for that one!

 

So what is my predicament? Frustration at my own lack of faith, I am sure though that these concerns are shared by many soon to be qualified nurses. All that hard work for nothing but personal achievement?

 

Unable to find a job with hours to fit in with my children, chuck in the council tax bill child care costs (minus the 85% contribution) and I am actually worse off.  Not to mention the loss of opportunity to develop my skills in an area I am interested in (CAHMS). My final hope of getting some income to keep the roof over my head was working on the bank as a HCA but I am informed, as a newly qualified you cannot work the bank!!

 

Well, it was a good three years, I have met some wonderfully inspiring people and it has all been for a good cause – an experience I will never forget.

 

So, all you young free and single peeps out there, the world is your oyster! Travel the world, get that job and nurse those people who need you, treat students how you would have liked to be treated and reach for the stars! Be Leaders and research best practice all the way, I wish you well.

 

Despite the lack of jobs compared to the amount of graduates (baffles me why they train so many of us when there are no jobs), there is a job for everyone if you can be as flexible as possible, have a supportive family network to look after your kids and a decent car that will get your anywhere!

 

I will remember you all when I look at my graduation photo and never regret my uni days. Oh dear how bleak it all seems!! lol

 

Now…..if you think I am going to give up that easily, you are mistaken! Yes! These are my very real concerns and if I let negativity in it will beat me! My Guardian Angel did not get me this far to leave me stranded, I will continue to pursue my goals and work with service users and their families regardless of how dire the job market might appear, there is something out there for me but I have to get of my ass and find it! (even if it is counselling the  old dear in the post office queue whilst waiting to cash our meagre benefits! Lol)

 

Keep the faith Guys, this transition is make or break, time to “sort the men from the boys” and as my dad would say….”What’s for ya, won’t go by ya!!”

 

Good Luck all you final year Students

 

Julie

Depot medication – the discussion continues.

The latest guest post on the Mental Health Nursing Lecturers Tea party comes from Bob Tummey. Bob is a mental health nurse lecturer at Coventry University and is becoming quite well known as a writer on mental health issues – see for example . In this post, Bob is carrying on an earlier post from Jim Chapman.

 

I would like to continue the rather interesting debate raised by Jim Chapman in an earlier posting. Jim raised concern for the administering of depot neuroleptic medication through IMI into the subcutaneous wall of fat and not the intended dorsogluteal muscle, leading to poor uptake of medication. This raises the question as to whether people receiving the medication this way are actually gaining any effect. (For a couple of research studies see Nisbet, A.C (2006) Intramuscular gluteal injections in the increasingly obese population: retrospective study. BMJ. 332: 637-638 and also Chan et al (2006) Intramuscular injections into the buttocks: Are they truly intramuscular? European Journal of Radiology.)

I was very aware of this issue when working in New Zealand. The depot can be administered into the dorsogluteal muscle but the needle may not reach due the thickness of the subcutaneuous fat wall (which is becoming thicker as the population become larger/obese). However, the medication is still absorbed; it just takes a longer period of secretion into the system. The ventrogluteal is the muscle of choice across USA due to concerns for litigation (hitting the sciatic nerve and so on). Therefore it does seem to be the natural progression for all MH nurse education to consider the teaching of depot IMI into the venrogluteal. However, this does have implications for practice and will require all mentors (for instance) to be competent and taught first.

In UK, New Zealand and Australia, best practice dictates the use of the dorsogluteal (upper-outer quadrant) but mainly due to tradition and training offered (For the NZ and Australian focus please see, Wynaden, D et al. (2006) Best practice guidelines for the admin of IMI in mental health settings. Int. J MHN. 15: 195-200.) This muscle is also supported by the drug companies which I suspect is due to their dated research and the product information they share. I believe all drug trials for depot medication have used the dorsogluteal muscle, although these trials now need updating.

Another point for discussion I would like to raise is on the ethical issue of actual site. If the ventrogluteal is reportedly the best site then should we not be evidence-based and comply? However, coming from another angle, when I worked as a nurse specialist in NZ I came across a number of NZ MH nurses who administer the depot every week/two weeks into the deltoid (upper arm) muscle with the IMI needle. This ensures direct penetration of the muscle and absorption of the medication….. The UK nurses in NZ would not provide IMI this way, but maybe some research needs to be undertaken to consider any benefits to treatment. From a brief look at policy in the UK it seems that the deltoid is only to be used as a one-off/stat dose into the less-dominant arm and mainly for adolescents. However, ethically is this right? Or indeed, should we consider its use to ensure effective treatment? One thing seems quite certain, the use of the dorsogluteal IMI is now redundant.

In a recent MHN conference I attended in NZ the most subscribed plenary session by far was about administration of depot injections, facilitated by Dianne Wynaden. It is an interesting debate, but what are the answers….

Please share your thoughts and experiences.

 

Bob Tummey

 

 

A sporting yarn

There was once a cricketer who enjoyed his sport and got rather good at it. One day, the cricketer bumped into a footballer and said“Hello, I’m a professional sportsman just like you!”

A jolly good cricketer!
A chap playing cricket

The footballer looked at the cricketer with great disdain.

“No you’re not”
“Yes I am” cried the cricketer in dismay.

The cricketer went away and thought long and hard about what the footballer had said. He had spent years studying and practising his sport and wanted to be respected as a professional sportsman. How could the footballer treat him so? To prove his merit as a professional sportsman, the cricketer decided to learn to play football – if he could do this then he will be respected as a professional sportsman he thought.

After some time, the cricketer had indeed learnt to play football. He found the footballer and said:

“Look, I can play football just like you! Now do you see me as a professional sportsman?”

The footballer still had the look of disdain and said sneeringly

“OK. Whatever you say.”

And the cricketer continued to play football.

The cricketer stopped being a cricketer. He forgot to do what he was supposed to do. And the relevance….have nurses forgotten the nursing role? Are we trying to be every other profession (and one in particular) because we suffer with a pervasive lack of professional confidence? It seems to me that as a profession, we are ashamed to admit that we are a caring profession. Perhaps that nursing is the only health related profession where the entry level is not graduate (yes it will be changing shortly) has left us feeling a little embarrassed?

Some other chaps playing footie
Some other chaps playing footie

Mental Health Nursing – Time to flex our muscles?

Last I looked at the NMC statistics there were over 100,000 Registered Mental Health nurses in the UK, Isn’t it time that we flexed our muscles and got our voices heard?

Mental Health Nursing in the UK is beginning to adapt to the 21st century. As a professional group we are facing some fascinating opportunities and challenges. Increasingly we are required to consider Human Rights v Responsibilities v Risk. This is interwoven with the Mental Capacity Act, the reviewed Mental Health Act alongside Nursing & Midwifery Council changes to pre-registration and post-registration education, New Ways of Working, The Darzi Review, Nurse prescribing, The National Dementia Strategy and greater demands for evidence based practice just to identify a small selection of the policy drivers in mental health nursing and services.

As a mental health nurse educator of many years I would contend that not only do we need high quality initial and continuing education but Mental Health nurses need to demonstrate their worth and value and expertise to mental health service users, carers and services through recognised research processes. We need to engage with high quality, large, random controlled trials (these are the Department of Health Gold Standard) which examine and specifies what we do, how, why and when we are effective in practice.

Looking over the pond to the example of our American colleagues in the American Psychiatric Nursing Association provides some useful strategies that mental health nurses in the UK could employ to enhance our practice. An effective national organisation for mental health nurses might be a start alongside a commitment to promoting rigorous doctoral level programmes for mental health nurses into their practice – too ambitious, I would welcome responses.