Schrödinger's Cat: The Mysteries of Mental Health Nursing

My colleagues Professors Foster and Hurley (2024) make a convincing case for the continued recognition and support of the specialty of mental health nursing. In making this case, they argue against the proposition that every nurse can be considered a mental health nurse. In this response, I argue, as I did a decade ago (O'Brien 2014), that there is an important sense that every nurse is a mental health nurse. In this editorial, I argue that such a claim is simply a statement of the scope of nursing and does not undermine or invalidate the professional status or practice of specialist mental health nursing. I address each of the three ‘myths’ outlined by Foster and Hurley and offer an alternative reading, one which I believe allows mental health nursing to be something of a Schrödinger's cat, present or absent depending on the observer, and different depending on why we are talking about mental health nursing.

As Foster and Hurley outline, specialist mental health nursing is critically important for the provision of skilled and professional care of people with severe and complex mental health problems. Such care includes technical skills such as talk-based therapies and non-technical skills such as therapeutic use of self. However, these skills are not the exclusive province of mental health specialists. Almost three decades ago, Olson (1996) identified the contradiction involved in claiming that the therapeutic relationship, so essential to Peplau's theory of nursing, was both fundamental to nursing generally, and the special province of the mental health specialty. Although talk-based therapy is part of the skillset of mental health nurses, it is not a defining feature of the discipline. An abundant literature reports generalist nurses' use of talk-based therapies such as cognitive therapy in care of patients with diabetes (Cuevas et al. 2019) cardiac disease (Holdgaard et al. 2023) and mental health problems such as illness related anxiety (e.g., Safari Mousavi, Ghazanfari, and Mirderikvandi 2019).

Foster and Hurley go further, however, to claim that the existence of a specialty of mental health nursing requires that other nurses resign any claim to be practising mental health nursing. Support for this position draws on historical analysis, professional positioning and the place of the specialty of mental health within generalist nursing discourse. In this response, I offer a different position in support of an argument that mental health is part of the scope of practice of every nurse. The claim that ‘every nurse is a mental health nurse’, at least as I outlined it in 2014, does not imply that every nurse is a specialist mental health nurse, but it does demand that every nurse gives expression in their practice to their mental health skills, in responding to the mental health needs of those they care for. This seems to me to be unproblematic, and in line with the many commitments of the profession of nursing, including those of Foster and Hurley, to provide holistic care.

People experiencing mental health or substance use disorders present in every practice setting, from emergency departments to health services for older adults. In addition, people in every practice setting have mental health needs, regardless of diagnosis. The care provided should not be dependent on the nature of the practice setting, or on whether the nurse possesses status as a specialist in mental health. Nurses in every practice setting have a professional obligation to respond to the full range of health needs of the people they care for, including their mental health needs. Emerging understandings of health emphasise that notwithstanding the need for specialist mental health and addiction services many health problems have a common basis in genetic vulnerability, epigenetic factors, trauma and the social determinants associated with adverse health outcomes. These diverse influences are reflected in the high rates of comorbidity of physical and mental health problems. Nurses in all health settings need to be aware of, and respond to, the multiple factors that contribute to health and illness. We need all nurses to own and practice the mental health skills that are integral to nursing. Anything less is a disservice to health consumers.

For the purposes of undergraduate education, mental health has been incorporated into general nursing, with all graduates assessed as competent, at beginning level, to practise nursing in any clinical setting. Newly registered nurses beginning practice in mental health are considered competent to apply generalist nursing skills in the care of consumers in mental health settings, something we know is critical to the care of people diagnosed with mental health or substance use disorders. Having competence in mental health and generalist nursing skills confers an obligation to apply those skills. This obligation is not dependent on the professional identity of the nurse. It arises from their professional status, something conferred by their regulatory body and assumed by the nurse as part of their acceptance of nursing registration. We know that some mental health nurses are ambivalent about whether responding to the physical health needs of mental health consumers is part of their role. Failure to respond to physical health needs represents a lost opportunity to deliver the comprehensive health care envisaged by integration of the former speciality undergraduate programmes. It is also a lost opportunity to address the serious inequities in health status of people with mental health or substance use disorders. The history of mental health nursing as a separate category of registration, with an education pathway in separate institutions, cannot be an argument for the continued separation of spheres of practice. History informs us of our past but does not bind us to perpetuate it. I would argue that all nurses should embrace their common generalist scope of practice and use their full range of skills to provide the maximum benefit to consumers, in every practice setting.

On the myth of consolidation of general nursing skills before beginning practice in mental health, I agree with Foster and Hurley. There is simply no point in providing generalist undergraduate nursing education if all graduates are advised to practise first in a general setting before moving into mental health. With a more robust commitment to the aims of generalist nursing education, entry to practice, in whatever setting, would be seen as consolidating the full range of skills of the nurse, including mental health and generalist skills. That would mean that graduates beginning practice in mental health would indeed consolidate their generalist nursing skills, but while practising in mental health, not by deferring their move into a specialist area of health. Similarly, graduates opting for generalist nursing on entry to practice should be seen as consolidating their full range of nursing skills, including those related to mental health.

There are increasingly more areas of healthcare in which nurses are expected to use the full range of their competencies. In correctional facilities, for example, rates of physical and mental health comorbidity are extremely high and in many such facilities there is very limited specialist mental health care available. Nurses in these facilities are positioned to provide the holistic health care that nursing philosophy has championed for decades, including comprehensive assessment and such strategies as psychological intervention and judicious use of psychotropic medication. The same is true in student health services where mental and physical health problems frequently co-present and the quality of care relies on one practitioner to respond to the whole person, the person in front of them, rather than to ask that person to make another appointment, engage with another health professional and narrate the story of their health issues again. Similarly, Māori and Pacific services practise holistic models of care that integrate the different specialisms created by Western health services.

The continued existence of specialist mental health services reflects the need for specialised responses to the needs of people experiencing acute and complex mental health and addiction problems. Colleges of mental health nursing in Australia and New Zealand attest to desire of mental health nurses for a distinct professional identity, and to the range of specific issues that requires the focus and resources of a dedicated professional body. Specialist services require nurses with a range of skills and competencies that can address these problems. But these considerations do not mean that nurses in the many other health specialities should not also respond to mental health needs of consumers using generalist health services. To encourage all nurses to respond to mental health needs does not threaten the professional status or specialty skills of mental health nurses. Such a holistic approach should be seen as complementary to the practice of specialist nurses, rather than as undermining the specialty.

There is a rhetorical sense to the claim that every nurse is a mental health nurse. Of course every nurse is not a specialist mental health nurse. Schrödinger's cat might appear when a health consumer in a generalist setting expresses suicidal thoughts, but disappear when a mental health specialist explains that fleeting suicidal thoughts are common in people experiencing acute distress. The skill of the nurse who listens with empathy and responds with compassion is a mental health skill. In that moment, the nurse is a mental health nurse.

The author declares no conflicts of interest.