ABSTRACT

Keynote presentation by Jan Horsfall, Senior Lecturer, University of Western Sydney Macarthur Division of Nursing Faculty of Health

My aims in this paper are to talk about four groups of people that are central to:

• the preparation of future RNs;
  
• recruitment of undergraduate students into a possible mental health nursing future;
  
• and the provision of effective care in mental health settings.

These groups are:

• undergraduate mental health nursing lecturers;
  
• undergraduate nursing students;
  
• grass-roots nurses; and
  
• consumers of mental health services.
  

I cannot speak for consumers; nor can I speak for nurses at the coal-face who work well with patients, even in the face of multiple constraints. I certainly cannot represent students. However, I will draw on seventeen and a half years of tutoring, lecturing, essay marking, examining, assessing simulated interviews, and receiving feedback.

ON BEING A TEACHER OF UNDERGRADUATE NURSING

Those of you who have graduated in the last fourteen years and have sat in lecture theatres and tutorial rooms with teachers like me will probably have been taught by between one and four experienced psychiatric or mental health nurses. In the university where I work at present, for each undergraduate mental health nursing subject we require between ten and twelve teachers. The number of nurse academics in the 38 Australian universities who teach mental health nursing to undergraduate students at least half-time is not known. Presumably, though, there are plenty of us.

Some mental health nurses continue to say that we are out of touch, we don't know what we are doing, we live in ivory towers. For example, Clinton and Hazelton (2000) in their scoping study of mental health nursing education write that we are 'failing' in our job; our teaching quality is poor; the courses are 'inadequate'; and some lecturers are 'incompetent' (p.3). I don't know how they know this, as I have yet to read the research-based evidence for these claims, but presumably this is what our colleagues have said in focus groups or in written submissions. But, I have not read or heard of the detailed suggested improvements to undergraduate mental health nursing teaching or programs put up by these critics. The most common comment I hear is that there should be more time allocated to mental health nursing. Time is a very blunt indicator of experience or learning: as you know, one can not go to a lecture, daydream in the classroom, or hide in the tea room on clinical. In the meantime, there are no obvious signs of leadership regarding teaching or curricula from these quarters.

In summary, teachers of undergraduate nursing are mental health nurses too and we should be treated with a basic level of respect. I object to other mental health nurses - who have not sat in our classrooms, or who have not been undergraduate lecturers themselves - making claims that cannot be verified, especially if they have not proposed serious practicable alternatives.

Most high profile mental health nursing academics in Australia do not spend six to twelve hours every week of semester in tutorial rooms with a diversity of students in bulging - or empty - lecture theatres. Hence, grass-roots undergraduate lecturers are mostly invisible and silent in the public domain.

Undergraduate teachers are not alone in this: undergraduate students are not visible; grass-roots clinicians are not visible; and the majority of consumers of mental health services are not visible either. By invisibility I mean that the voices of nurses who keep mental health services and courses going on a daily basis are not integrated into or, central to, the public face of mental health nursing in publications, research, or keynote addresses.

LOCALLY PUBLISHED MENTAL HEALTH NURSING ARTICLES

In preparation for this talk I looked at 80 articles in the Australian and New Zealand Journal of Mental Health Nursing from 2000 to 2001 and in the International Journal of Mental Health Nursing since then. This is not an infallible way of investigating what we write about our work, but the evidence is there and it gives us a starting point for discussion.

You may ask: "is what we publish about ourselves important?" I think it is. What is published is documentation of our unique mental health nursing knowledge: our texts represent our reality. More specifically, 'accounts of the social world… are never more than stories we tell whose themes and meanings express the social positioning of the storyteller' (Seidman, 1994, cited in MacCallum, 2002, p.89). And furthermore, what we write about nursing and teaching in the future most likely 'reiterates and reinforces what has been written before' (MacCallum, 2002, p.92). In other words, what we put in print may become perpetuated as fact, whether it is or not.

There are exceptions to these omissions, of course. Among the 80 feature articles, I found two focusing on students (Fisher, 2002; Mullens & Murphy, 2002); three where grass-roots nurses were centre-stage (Cleary, 2003; Happell et al., 2002; Wynaden et al., 2002); and five where consumer experiences were targeted (Moyle, 2003; O'Brien 2001; Rudge & Morse 2001; Svedberg et al., 2003; and Usher, 2001). That is, no Australian-based specialist mental health nursing publications in the last three and a half years put undergraduate teachers at the forefront, and less than two and a half per cent highlighted undergraduate students. Less than four per cent show-cased nurses on nursing; and just over six per cent focused on patients being nursed. Interestingly, of those ten articles eight first authors are Australian women.

Before I move on to nursing students, I will briefly re-visit psychiatric nursing education in earlier times. I will use my own mid-1960s experience as an example.

HOW DID WE BECOME PSYCHIATRIC NURSES?

I am looking back in time, because when it is said that mental health nursing teaching is not good enough, I think there is an inference that once - when the given speaker was younger - things were better. Is this misplaced nostalgia "for the good old days"?

The hospital I trained in was what sociologists call a total institution, for nurses as well as patients. We spent an inordinate amount of time there (between 60 and 70 hours a week), the shifts were long (13 and 11 hours respectively) and anti-social, as we had one day off after working five. On day shift we ate breakfast, lunch and tea there and we did not leave the grounds. This was total cultural immersion.

Some call this an apprenticeship system: I certainly was not instructed by an expert; and I don't think I was specifically taught to carry out the craft of high-level psychiatric nursing interventions. Probably my only guiding principle was that I believed strongly that I should provide care to every patient. To me this meant that I had to overcome my entrenched shyness and talk and listen to every single person in the ward. In retrospect, I think this is how I taught myself to be a psychiatric nurse.

Consequently I cannot deny the value of self-teaching and learning. Many students and neophytes do well as clinicians, despite uninspiring teacher and peer role models. Furthermore, people do not just swallow information and absorb it, to the extent that what they are told today becomes their own knowledge tomorrow! Nurses and patients are people first (Taylor, 2001). Our attitudes, feelings and behaviours are at least as important as technical information about schizophrenia and psychotropic medication (Davidson et al., 1997). The reality of coming to grips with intense emotional distress, troubling ethical dilemmas, and the limits of one's abilities can only develop through experience and reflection in the clinical milieu (Elliott, 2002).

Societies have changed since the 1960s. A university is not a total institution. Universities provide commodified courses for educated young people who can't get an interesting job, don't know what they want to do in the workplace, or for those who want to get the degree that will best allow them to earn a high income. Universities also offer commodified courses to people from struggling families who are desperate to get a qualification that will provide some future financial security. Seventy per cent of tertiary students are also employed; and the average number of hours worked by each student in 2002 was 14.5 per week (Nelson, 2003).

TEACHING IN UNDERGRADUATE NURSING COURSES

The challenge when teaching undergraduate nursing students is to work with mostly ordinary eighteen year old women, with an average high school education, from diverse cultural backgrounds, to enable them to become eligible for registration as a nurse in three years. This entails them becoming knowledgeable in nursing, physiology, pharmacology, psychology, research, epidemiology, and sociology; being adequately skilled in technical aspects of nursing care, using computers and being able to communicate clearly and assertively. They should also be responsible, accountable people with a commitment to caring, ethical nursing practice, and an awareness of social justice.

I assume that you can see that this is not easy - for students or teachers. Embedded within the nursing curriculum, there is classroom and clinical experience with a focus on mental health and illness. In these subjects, as with others, commonly the underpinning model is medicine not nursing, the language is complex, and student assessments are continuous. From a mental health nursing perspective, every week of teaching is precious (eg, 22 weeks in my present curriculum) as is every hour of clinical experience. Hence, the demands on students, academics, clinical facilitators, RNs and patients are high.

Tutorials enable students and teachers to address nursing practice issues, and draw on more than one perspective when discussing anxiety, mood, substance abuse, personality disorders, and schizophrenia. As well as these we explore mental health nursing ethics, holistic assessment, basic counselling skills, therapeutic relationship challenges, psychosocial development, cultural issues and the Mental Health Act. Many tutors encourage discussion of anything about mental illness that students want to talk about. At this juncture I want to acknowledge Margaret McAllister's (2000) critique of content-driven and teacher-centred styles of teaching abnormal psychology and by implication mental health nursing. McAllister briefly explicates the craft of teaching and the in-built interpersonal and emotional aspects of learning and teaching that are necessary for students to gain authentic mental health knowledge.

In summary, teaching (like nursing) is an art, a science and a craft. That is, teaching and learning styles and methods can be named and described, but every learner's abilities and readiness is unique. Perhaps the art in teaching mental health nursing relates to weaving theory, practice and research into personal and professional actions and interactions. The science involves knowing and understanding a repertoire of educational philosophies and practices. And the craft relates to experience and the use of integrated knowledge to make judgements - about teaching methods and students - in relation to exploring ideas relevant to working with people with a mental illness.

STUDENT FEEDBACK ON CLINICAL EXPERIENCE

One of the structural problems with the present system of classroom teaching and clinical experience is that at times students have not been taught the background knowledge relevant to specific patients in a mental health setting. Another is that clinical learning can remain outside the classroom. Hence, there are at least two challenges for us all: using feedback; and integrating learning regardless of location.

So we need to value feedback: across sectors; between academics and students; as well as between clinical teacher and students. To the best of our abilities we need to integrate classroom learning into clinical; and clinical learning into the classroom. Of course we could all do this better, especially if we had more RNs in clinical settings and more teachers in academic settings!

This year I spent an hour with second year students asking about their mental health nursing clinical experience in the first tutorial after their return (even though this may have been anywhere from a few days to two and a half weeks later). I could do this because we had three hour tutorials.

The following is a summary of positive feedback from 38 students in my tutorial groups on their first day back after a week's clinical experience. In preparation for this presentation, I grouped the student responses into the following headings that best summarise their comments: learning; the environment; RNs; and clinical teachers.

• In relation to learning, students:
  
• increased confidence
  
• decreased fear of people with a mental illness
  
• debunked myths about mental illness
  
• changed attitudes towards people who live with a mental illness
  
• recognised that mental illness does not discriminate regarding age or intelligence
  
• learnt more about specific illnesses
  
• learnt more about specific patients
  
• made connections between events in people's lives and mental illness
  
• better understood the nature of a crisis
  
• learnt more about the Mental Health Act.

In relation to the environment, students:

• felt included
  
• integrated with the team
  
• informed about the hospital
  
• enjoyed the variety of work
  
• liked talking with patients
  
• appreciated intimate involvement with patients.

Students found RNs to be:

• welcoming
  
• pleased to have students
  
• informative
  
• at times explained other more constructive ways of treating some patients.

Students said clinical facilitators:

• provided structured learning
  
• explained interventions.

In 1996, with Alison Bell and Bill Goodin, I carried out a federally funded survey of 339 undergraduate students' experience of mental health nursing clinical in four universities in four different states, with one University functioning as a quasi-control group. Among other results, we found that clinical experience: increased confidence, decreased fear; and facilitated positive attitude changes towards people who live with a mental illness. In that research we also found that RNs in the clinical environment were crucial to successful learning, with students particularly appreciating being welcomed, included in the team, and being informed (Horsfall & Bell, 1998).

Thus, my most recent post-clinical student feedback gained very similar data to that in our unpublished research, even though the information was sought seven years later, in a different university, asking different questions, for different reasons. In an overview of nursing clinical education, Malcolm Elliott (2002, p.75) makes the following points:

• clinical and classroom teaching, publishing, and research should be valued equally
  
• students should be encouraged to create and satisfy their clinical learning needs
  
• RNs and clinical teachers should collaboratively ensure acceptance of students as part of the ward team, whilst acknowledging their level of abilities and limitations.
  

In summary, student needs during clinical experience - above and beyond learning - are really the same as our own would be: to be introduced to relevant staff and patients; be orientated to the setting; be welcomed; be included; and to feel that they have a something to offer consumers (Horsfall & Bell, 1998).

STUDENT FEEDBACK ON CLASSROOM TEACHING

A routine part of university teaching is collecting feedback from students about both the course content and the teaching processes. I usually develop my own evaluation tools, which I change every few years or so.

Last semester I received 38 routine anonymous subject evaluations from 42 second-year students in two tutorial groups after 33 hours of tutorials, 22 hours of lectures and 35 hours of clinical experience. Of the 35 that commented on tutorials, 25 thought they were useful and 10 did not. Of the 17 who commented on the small group discussions, eleven disliked this process, and only six considered it to be an important way of sharing, exploring, and learning. Hence, you can see, that even for experienced teachers these forums are challenging.

The last question on my feedback sheet was: "Might you think about being a mental health nurse within the next 2-5 years?". There were 12 who said "definitely yes": this is 32 per cent of the students in class on those two days (29 per cent of the total). Not only were 12 out of these 38 third semester students viewing mental health nursing a future possibility; but two more were unsure; and another wanted to work in a community mental health crisis team.

If you had been reading published Australian work published in the 1980s and the 1990s, indeed until 2000 (eg, Wynaden et al., 2000) you could think that I made up those percentages! However, of the 339 students in the research I mentioned earlier, 14 per cent circled "yes definitely" when asked if they have a positive view of mental health nursing. Furthermore, 27 per cent selected the second most enthusiastic of five possible options. That is, more than forty per cent of these students from Adelaide, Bendigo, Rockhampton and Sydney clearly viewed mental health nursing positively.

I must add that I do not sell mental health nursing in the classroom; I point out problems within the profession and in the health care system. On the other hand, it is well known that enthusiastic and knowledgeable lecturers are most likely to impact favourably on student interest. I also want to emphasise that I have never been the sort of lecturer that anybody "sucks up to", or tries extra-hard to please.

FEEDBACK ON CLASSROOM TEACHING FROM MENTAL-HEALTH-INTERESTED STUDENTS

In this section I only put up comments from the 15 students who said "yes" or "maybe" to being mental health nurses. The following are comments they wrote next to declaring their interest in joining the specialty in 2-5 years time.

The following are some of the student comments:

• interesting and challenging, I have been interested for a while
  
• I enjoy dealing with the mind, not the body
  
• It is interesting because I was always learning and it never got boring
  
• I am currently working in the field and will continue when I graduate
  
• I now have made up my mind…because it is really quite challenging
  
• Previous interest reinforced by this subject
  
• Because of the fantastic clinical experience I understand more. It is never boring
  
• I would like to go into mental health after developing my nursing skills
  
• I enjoyed my clinical
  
• I like to use interpersonal skills. It tends to require more cognition. Clinical placement was enjoyable and all staff were easy-going and helpful
  
• I am interested in substance abuse and dual diagnosis
  
• Definitely, especially substance abuse. The best, most interesting placement yet
  
• Not on a ward, but in a crisis team
  
• Maybe, unsure. I thoroughly enjoyed it
  
• Clinical setting was great. Undecided.

One student is presumably studying a nursing degree to enable her to continue work in mental health with a higher qualification; five specifically mentioned their positive clinical experience as part of their "yes" response; three seem to have had a prior interest; and another three indicate that mental health nursing fits with their personality, thinking style, or people skills.

Of the fifteen interested, or possibly interested students, ten were unequivocally positive about the clinical facilitator, and the RNs in the unit. The other five made both positive and negative comments about their clinical experience. The negative comments mostly related to accessibility. They included three statements about the clinical facilitator not being readily available; one student said that the RNs were " a bit unhelpful" because they were too busy; and the final comment was that the RNs were friendly, but they were "very young and inexperienced". Importantly, none of those students made negative availability comments about both the clinical teacher and the RNs on the unit.

To see if there is any overlap between positive comments about being mental health nurses in the future and an appreciation of tutorial activities and processes, I also present a summary of written comments about my tutorials. Amongst the same fifteen students, four had nothing good to say about their thirty three hours of mental health nursing tutorials. Other comments were:

• three students stated that discussions were the best aspect of the tutorials
  
• the tutorials were the best time to learn
  
• small group work helped learning
  
• I liked the teacher teaching
  
• I enjoyed them all, they were interesting and not rushed
  
• the in-depth information was good
  
• relaxed atmosphere with everyone involved, not embarrassed to talk
  
• good explanations helped us learn
  
• group work was like clinical it put you in the picture and increased understanding.

The tutorials is where the more values-based, interactive and personally relevant mental health and illness concerns of the students are discussed, explored and spelled out. In summary, only 69 per cent of those students interested in becoming mental health nurses - who commented on tutorials - made positive comments about them. All fifteen made positive comments about their clinical experience, and five made some negative or qualifying comments as well. Thus, an interest in mental health is not simply associated with interesting tutorial discussions, or perfect clinical experiences.

MENTAL HEALTH NURSES ON MENTAL HEALTH NURSING

Some of the hoary chestnuts in nursing and mental health nursing are questions such as: "what do we do?"; "how can we explain it to others?"; and "how are we different to other mental health professionals?". Personally, I have had not much difficulty with these, as they were the very questions I particularly asked myself in 1986 during my first year of lecturing. I believe that the first two questions must be able to be answered by any one seriously involved in teaching students or RNs in classrooms or in clinical settings. The final question about how do we differ from other health professions only becomes an issue, I think, if the medical model underpins our practice: in that case the answer must be "some sort of inferior doctor". If we are nurses and consider that our responsibilities are to support and assist patients to improve their daily living skills, reclaim their sense of self and confidence, and manage their illness and medication, then it is clear who we are and what we do.

Late last year I was writing a chapter on nursing people who are depressed. As I had written about depression off and on between 1989 and 2000, I decided to interview some expert RNs, so that I could incorporate their up-to-the-minute viewpoints. One nurse worked in an acute unit; one in the community; one in a child and adolescent unit; and another in rehabilitation. It is possible that one or more are here today! I was very impressed by the complexity of the knowledge that all four nurses shared with me. These mental health nurses had no trouble clearly saying what they did. They explained: how they assessed patients in an ongoing way; how they understood what they were doing; the reasons for the approaches they took; and the aims they had in collaboratively working with consumers.

One nurse highlighted the personal aspects of nursing depressed people: the need for self-awareness; sharing our humanity; using imagination; and leading a balanced life. She spoke of listening carefully; tuning into the patient; bearing witness to the person's pain; and sharing a few laughs. Those two sentences roll off my tongue, but to try to teach someone else about just one of them would take hours and even then I would not know if the person would be able to carry out such an activity when they next met a depressed person.

The second RN talked about patiently and persistently developing rapport, trust and a therapeutic relationship with a depressed person who had rejected help from a nurse before. Here bridging a cultural and religious gap was a facet of the challenge, along with assessing for suicidality without information from any other people because of the client's social isolation. The person felt abandoned by and alienated from their religion, in part because God had allowed a family member to commit suicide, and partly because this deep loss had not been grieved. It is my view that nobody other than the mental health nurse herself could have taught her to successfully make such assessments and intervene so subtly and effectively.

Another nurse was also challenged by age and cultural differences between himself and the patient. Immigration losses, cultural practices and transgenerational expectations all fed into the severity of this person's depression and the length of time required to lift it. The person's family was integral to the nurse's education about loss, illness, family relationships, behavioural expectations, and the expression of distress.

The spectrum of care that the fourth nurse provided to a depressed in-patient within a period of a few weeks was astonishing. The severity of depression was such that eating, drinking, sleeping, getting out of bed, occupying himself and taking medication all had to be addressed in the beginning. As with the other interviewees, this RN reminded herself that no matter how many depressed people we have worked with, we cannot make assumptions about them. Later on the nurse was helping the patient analyse his patterns of thinking and attribution; as well as both supporting and confronting him, to facilitate better self-understanding and assist in making decisions about lifestyle adaptations. The transitions within the therapeutic relationship and the repertoire of skills the RN used, were truly impressive.

It is this type of detailed mental health nursing from the grass-roots that I would like to see more of in publications. Remember that less than four per cent of those recent articles provided in-depth information about how mental health nurses say they provide care for consumers. I know that RNs are overworked and that it is likely that many clinical settings do not highly value nurses writing about nursing for nurses. But it is important that mental health nursing insights, approaches and clinical thinking are made available to students, new graduates, and peers.

There are mental health nursing professors who have promoted the idea of a centralised national research focus. If research is funnelled through one centre of excellence, the topics pursued will inevitably become narrow as one project will build on the back of those that have gone before. This is because the usual way of getting funding is to provide empirical evidence that you have an excellent knowledge base; that you have managed a research project before; and that you have the resources, personnel, and time to do so.

Anther professor of nursing has said that one research method is the best. Again, I disagree. If we all become experts in one type of research, our findings will be limited by the type of knowledge that must be gained by asking those types of questions in those ways. Therefore I say, let there be diversity of method. And there should be parallel research agendas - providing researchers share information and acknowledge the prior work of others.

POSSIBLE TYPES OF APPROACHES TO MENTAL HEALTH NURSING

From their research in Norwegian acute care settings Hummelvoll and Severinsson (2001) ascertain that there are four approaches to mental health nursing. These are:

the pragmatist fits in with present day realities of quick assessments, moving patients on, and not opening up anything new (an abscess metaphor);

the idealist is committed to the humanist principles of supporting patients to draw on strengths, make informed choices, and improve their problem-solving abilities;

the traditionalist focuses on relationships, patient self-understanding and growth;

the enforcer is concerned with policy and practice reform and consists of two sub-types, (i) the entrepreneur who aims to stimulate change and (ii) the implementer who emphasises quality control and improvements in treatment effectiveness.

Hummelvoll and Severinsson (2001) say that 'it is important that each of these roles is represented, because their function is complementary as well as corrective''(p.23). Thus, in acute care settings they consider that a mixture of mental health nurses with a diversity of practice orientations is needed for effective nursing care.

Because of her broad research into acute mental health settings, Michelle Cleary's (2003) published work picks up on pragmatic, idealist and traditional nursing. The other two Australian mental health nursing practice focused articles explored medication (Happell, et al., 2002) and seclusion (Wynaden et al., 2002), respectively. Consequently patient turnover, staff availability and short time-frames - the pragmatic aspects of mental health nursing - were more evident in those studies.

Researchers, who are mostly academics, rather than grass roots nurses or consumers, usually determine what will be studied. The research topic may therefore depend on funding, time, and the ability to produce results that are valued within nursing and mental health at present. I want to offer a brief plug for researchers who have the commitment, and make the time, to pursue more holistic mental health nursing research topics. These are usually doctoral students - another temporarily invisible group? If we only publish mental health nursing information on sharply focused research targets, then the richness of practice-based knowledge will be either absent, or fragmented and hidden.

CONSUMERS: THE RAISON D'ETRE OF MENTAL HEALTH NURSING

Forgive me for coming to consumers last. In my own defence, consumers and their families were the focus of my first published article (Horsfall, 1987); consumer needs and articulated concerns are raised in the first chapter in the textbook I co-authored (Horsfall & Stuhlmiller, with Champ, 2000); and my last solo-authored article (Horsfall, 2003) asks if mental health nurses are listening to what consumers have said, and continue to say.

Louise O'Brien's (2001) study of female clients' views of their relationships with community psychiatric nurses captures both the idealist and traditional approaches mentioned earlier. These consumer comments include:

• nurse acceptance and development of trust - even in the face of resistance
  
• nurses and consumers working together to uncover meaning, and the nurse seeing difficulties from the client's perspective
  
• nurses being resources to check out reality and clarity of thinking
  
• nurses acknowledging clients' practical, financial, and living constraints
  
• nurses validating client strengths and achievements
  
• working as partners on the tensions between dependence and autonomy.

Wendy Moyle (2003) asked hospitalised depressed clients about nursing care, and in particular their experience of being nurtured. Immediately after admission most of the patients viewed the mental health nurses as listening, reassuring, being there, creating a safe environment, drawing them out, taking time to explain their thoughts, feelings and behaviours, offering comfort, and decreasing their distress.

However, there was a contradiction between the support received on admission and the experience of distance thereafter, and some patients wondered whether the nurses actually had a therapeutic role to play. Some interviewees were not supported, let alone nurtured, especially one man whose gender may have been central to the nurses' difficulties with him. And worse some clients were treated with disrespect, yelled at, and not apologised to when a mistake was made. Instead of humane or healing approaches, some consumers said that the nurses recognised their fear and other strong emotions, but avoided them, did not listen, or just said "you'll be ok".

When we ask patients about their experience of being nursed, we need to be prepared for both positive and negative feedback, without resorting to easy excuses. Some nurses in Cleary's (2003) research said that they separated negative behaviours from the humanity of the patient and clients in O'Brien's (2001) study mentioned the nurse accepting them as they are. Both of these skills are fundamental to effectively nursing people who are hospitalised with a mental illness.

Psychotropic medication is of great interest to mental health nurses, as one of the nurses-on-nursing articles focused on medication, so did three articles about consumer perspectives. The eleven consumers who shared their experience of taking depot medication with Svedborg and colleagues' (2003) viewed the medication as a 'necessary evil'. The reasons for the medication being 'necessary' are that it allows them to feel more 'normal' and enables them to gain more control over their thoughts, feelings and behaviours. The 'evil' aspects of the psychotropic medication are the troublesome side-effects, and feelings of diminished creativity.

As well as saying that they wanted to be more like others and commenting on side-effects, Usher's (2001) ten research participants also deemed that medication helped them take more control over daily activities to minimise stress. But they also felt that they had lost a part of themselves. Rudge and Morse's (2001) reporting of interviews with two consumers called Alex and Vida, uses their experience of taking newer anti-psychotic medications as a platform for an exploration of living with schizophrenia for ten and twenty years, respectively. Alex and Vida speak of the emptiness of time, geographical relocation, stretching and losing friendships, and the way schizophrenia permeates their mind, body and sense of self.

IN CONCLUSION

These two clients, along with those in Moyle's (2003) study, and all consumers in hospitals and the community who are sent to mental health settings unwillingly, or who hopefully seek out mental health nurses, are the reason we are employed. Mental health consumers are the people we learn from, forge relationships with, and whose interests we must have to the forefront of our daily mental health nursing practice, research and teaching. I can do no better than to end this paper with a quote from Tom Olson a mental health nurse who found himself catapulted into an episode of mental illness characterised by distressing intrusive and obsessive thinking. Olson (2002) says: 'I ...have learned that real hope truly is as much about the clinician as it is about the client'(p.443).

REFERENCES

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Clinton, M. & Hazelton, M. (2000). Scoping mental health nursing education. Australian and New Zealand Journal of Mental Health Nursing, 10, 2-10.

Davidson, P., Merritt-Gray, M., Buchanan, J., & Noel, J. (1997). Voices from practice: Mental health nurses identify research priorities. Archives of Psychiatric Nursing, XI, 340-345.

Elliott, M. (2002). Clinical education: a challenging component of undergraduate nursing education. Contemporary Nurse,12, 69-77.

Fisher, J. (2002). Fear and learning in mental health settings. International Journal of Mental Health Nursing, 12, 128-134.

Happell, B., Manias, E., & Pinikahana, J. (2002).The role of the in-patient mental health nurse in facilitating patient adherence to medication regimes. International Journal of Mental Health Nursing, 12, 251-259.

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Horsfall, J & Bell, A. (1998). Student experience of mental health nursing clinical. Unpublished manuscript.

Horsfall, J., Stuhlmiller, C., with Champ, S. (2000). Interpersonal nursing for mental health. Sydney; MacLennan & Petty.

Hummelvoll, J. K. & Severinsson, E. I. (2001). Imperative ideals and the strenuous reality: focusing on acute psychiatry. Journal of Psychiatric and Mental Health Nursing, 8, 17-24.

McAllister, M. (2000). Lisa's lessons: A case study of mental health teaching and learning. Australian and New Zealand Journal of Mental Health Nursing, 10, 29-41.

MacCallum, E. J. (2002). Othering and psychiatric nursing. Journal of Psychiatric and Mental Health Nursing, 9, 87-94.

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Mullen, A. & Murray, (2002). Clinical placements in mental health: Are clinicians doing enough for undergraduate students? International Journal of Mental Health Nursing, 11, 61-68.

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Rudge, T. & Morse, K. (2001). Re-awakenings? A discourse analysis of the recovery from schizophrenia after medication change. Australian and New Zealand Journal of Mental Health Nursing, 10, 66-76.

Svedborg, B., Backenroth-Ohsako, G., & Lutzen, K. (2003). On the path to recovery: Patients' experiences of treatment with long-acting injections of anti-psychotic medication. International Journal of Mental Health Nursing, 12, 110-118.

Taylor, B. (2001). Overcoming obstacles in becoming a reflective nurse and person. Contemporary Nurse, 11, 187-194.

Usher, K. (2001). Taking neuroleptic medications. A phenomenological study. Australian and New Zealand Journal of Mental Health Nursing, 10, 145-155.

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