The Role of Nurses in Mental Health Recovery

Introduction

It is a known fact that mental illness has a staggering effect on children, adolescents, and family. In 2016, it was estimated that more than 1.1 billion people were affected with the mental disorder. Mental health nursing not only includes its theoretical and physiological basis into practice but also utilizes a wide range of effective interventions for recovery (Borg & Davidson, 2008). This essay addresses the opportunities and barriers faced by adolescents with mental illness in the community. It will examine the Tidal model as a recovery model and assess its positive impact on young adults. In addition, the essay explains several initiatives and strategies used to enhance the quality of health consumers life in society. Ultimately, it describes the role of nurses who possess various skills to work with adolescents with mental health issues and evaluate how well they can enhance recovery and social inclusion.

Adolescents, who are aged between 10-19 years, goes through a transition from childhood to adulthood. According to Erikson's developmental theory, adolescents have the main task of solving the identity versus role confusion crisis. While passing through this phase, adolescents develop their own unique sense of identity and identify the social environment where they can sense the belongingness and enable them to create a meaningful relationship with other people (Chen, Lay, Wu & Yao, 2007).

One of the main barriers that are experienced by adolescents is general or health illiteracy. However, the provision of alternative education for those children who have been excluded from the mainstream education system is an opportunity for such adolescents (Koller, Pouesard & Rummens, 2017). Studies have shown that adolescents with disability face several barriers to social inclusion. Such as loneliness, bullying, being excluded from the community, inability to make peer group (Ministry of Health [MOH], 2018). These negative social experiences lead to identity versus role confusion crisis affecting their autonomy and view of society around them. Eventually resulting in an imbalance in their mental status.

People with mental illness experience extensive stigma and discrimination in a range of aspects of their daily lives (Uttinger, Rapp, Studerus, Beck, & Riecher-Rossler, 2017). Social exclusion and social inequity are interconnected to adults with mental disorder. This is mainly due to their symptoms or side- effects of their medications which makes them recognizably distinctive in the community. These behaviors result in misunderstanding by family and society. Subsequently causing social isolation (Splett, Fowler, Weist, McDaniel & Dvorsky, 2013). World Health Organization [WHO] (2003) describes the prevalence of certain misconceptions about the people with a mental disorder such as they are mentally deficient, unsafe to be with, inefficient to work, unfit to marry and raise children, demanding frequent hospitalization, mental disorders are incurable. Evans, Nizette, & O'Brien. (2016) articulates that stigma associated with mental illness can be mitigated by providing regular and reinforced education to the community regarding the ways to support people with mental illness. The inclusion of causes, symptoms, treatment of mental disease is necessary for community education and educating the public about how to live alongside people with mental distress is vital (WHO, 2003).

Opportunities to the adolescents for social inclusion such as attending regularly to schools, part-time job, inclusion in sports and extracurricular activities, persuading them to volunteer for community services, promoting their interest in music, dance, skateboarding etc. Provision of appropriate jobs for these people helps them to support themselves and their families. School and family play a significant role in nurturing adolescents with support and opportunities. Hence, Bademli & Duman (2016) stress the importance of consistent support from family to adolescents to enhance the feeling of belonging and as a result reducing of social isolation. Wolpert (2013) also points out the significance of school-based mental health services in identifying developmental problems and providing opportunities for active involvement in academics and in various activities.

Undoubtedly, adolescents are the most vulnerable age-group suffering from the highest number of mental ordeals and illnesses. Bulkeley (2010) identified that the depression has affected the academic performance and social relationship of 25% of adolescents in New Zealand. Noting that, among youngsters aged from 10-19 years, depression has been the vital cause for the suicidal thoughts and attempts. Alcohol abuse has increased among this age group in New Zealand (Sellman, Connor & Joyce, 2010). Other negative attitudes commonly seen among adolescents are having low self -esteem, a negative body image, an exorbitant desire to be slim, which may lead to eating disorders, plummeting nutritional status and deteriorating health (Dickie, Wilson & Mcdowall, 2012).

The Tidal Model is a recovery-based model developed by Phil Barker and Poppy Buchanan-Baker. The main intention of the model is to provide guidance to mental health professionals to assist people with mental illness in their recovery journey. Barker (2001) compares the struggles faced by a person in life to unpredictable violent storms. To the person who is experiencing these struggles, it is like drowning and they need lifesavers to protect them. This is carried out by assessing the environment, continuously and cautiously, and rescuing the person when needed. This holistic paradigm is applicable for adolescents because they are passing through the waves of mental and physical changes and Tidal Model refers to these transition period as being more temporary than permanent (Baker, 2001) In the Tidal Model, prominence is given to the person, their lived experiences and the thoughts and feelings as a way of addressing problems. 

The idea of this model is to relocate the person to the epicenter of the caring process. Personal narration or story is used as a tool to access the person's experiences and people are considered as experts in their own lives. This model intends to promote the recovery process by exploring consumers strengths, weaknesses, desires and dilemmas. This can be efficiently carried out by health professionals by actively listening and acknowledging their previous experiences and stories (Brookes, Murata & Tansey, 2008). Adolescents go through several struggles, one such dilemma is an identity crisis. The Tidal Model provides guidance by assisting them to share their confusion and helps them in problem-solving (Brooks, 2008). Selfhood, World, and Others are the domains in the tidal model which are distinct yet interconnected. These domains are used to reflect on the person's lived experiences. While this model focuses on sharing these experiences and it also encourages communication that can unfold the current relationship of the person with the health condition (Young, 2010).

For example, a study was conducted with the aim of understanding the effect of the mental health nursing approach based on the Tidal Model on coping and self-esteem in adolescents with alcohol dependency. The three components of the Tidal Model such as the Tidal care continuum, the Tidal commitments, and the Tidal competencies were used in one-to-one sessions with the participants. The results showed that increased constructive reinterpretation, growth, positive coping, emotional social support, reduction in behavioral disengagement. Overall, positive impact such as increased self-esteem in adolescents was noticed (Savasan & Cam, 2017). Similar results were observed in two separate acute wards in Birmingham and New Castle, where the Tidal Model was implemented for a one-year period (Gordon, Morton & Brook, 2005). Despite that, the main concern raised in the mental health sector regarding tidal model is that its time-consuming approach to the recovery process (Barker & Buchanan-Baker, 2005)

In order to support the resilience and well-being of the young people, the Prime Minister’s Youth Mental Health Project (YMHP) was launched. The essence of the strategy was to focus on adolescents who are at the risk of developing mild to moderate mental health issues. Through this approach more youths benefitted from mental health services in the places where they studied, worked and lived. Effective measures such as early identification and support activities helped in the positive treatment process. YMHP was successful in terms of reaching out to the vulnerable youths in schools and included Pacific and Maori adolescents. However, the YMHP did not target youths who were not in schools, who were experiencing traumatic life situations, LGBTI youths and those with disabilities. Overall, YMHP was found to be effective among adolescents with mental issues by enhancing social inclusion (Youth Mental Health Project, 2018).

‘Stand up', is a school-based initiative developed in 2006 for youths who were adversely affected by alcohol, drugs and substance abuse, with the intention of enhancing their resilience, health, and social wellbeing. Even though this program delivers services to Maori and Pacific consumers, it is not constrained to a culturally specific project but rather is an integrated model. The focus was to encourage the young adults to reduce the influence of substance abuse, to recognize who they are and to be proud. ‘Stand Up' also provides emphasis on identifying their strength and progressively evaluating progress. The evaluation of Stand Up noted no negative outcome, on the other hand, positive impacts such as drug/ substance or alcohol use reduced or remained the same, participants in this program reported themselves to be happier and calmer. Adolescents claimed that they gained confidence and skills for self-care after participating (Stand Up, Programme; Youthline Manukau, 2006.) Thus, this initiative has benefitted adolescents in social inclusion.

SPARX, an online self-help tool, is another initiative which comes under YMHP. It was designed to help adolescents to combat depression and anxiety. Youths are hesitant to meet health professionals in person. Hence SPARX was designed as a game prototype, an online assessment tool. This computer program uses cognitive behavior therapy to teach young adults to cope with negative thoughts and feelings. It provides counseling to youth online 24/7. It was found to be effective among adolescents with depression ranging from mild to moderate, irrespective of their gender and ethnicity. (SPARX: A free online tool for young people, 2018). The positive impact it made on adolescents was it enabled them to connect with the community and thus enhancing social inclusion.

A ‘Strategy to Prevent Suicide in New Zealand: draft for public consultation’ (2017) was introduced with the aim of preventing self-harm and suicide among youths. This strategy focuses on preventing mental health disorders, enhancing the quality of care provided to people with a mental illness related to suicidal behavior and provision of standardized care for young people who make non-fatal suicide attempts. It aims to achieve the set goals by following three pathways, these are fostering well-being throughout the lives of people, acknowledging and relevantly supporting people with mental distress and alleviating the impact of suicidal behavior on people. This strategy has identified that adolescents have a higher suicidal rate. It is effective as it not only aids the affected individual but also the people surrounding them. The effective outcome of the strategy was that it reinforced the positive social inclusion of adolescents to their community (MOH, 2017)

As stigma and discrimination are major obstacles for mental health recovery, the “Like Mind, Like Mine” was introduced in 2014 by the New Zealand Government. It was launched with the intention of removing the false beliefs and prejudice regarding mental illness. The main aim was to listen to the experiences of people with mental distress. This program was found to be successful among adolescents because it not only listened to the distress of young adults but also managed to rule out discrimination or stigma associating them in their surroundings. Through the inclusion of services in school, this initiative provided all pupils with opportunities to learn how to treat people equally and respectfully irrespective of illness, ethnicity and sexual orientation (Like Minds, Like Mine National Plan 2014-2019, 2015). The program was proved to be successful in helping the adolescents in social inclusion.

The Nurses role in mental health is a demanding one. In mental health nursing, nurses are required to provide nursing intervention for the management of both acute and chronic mental problems. They are responsible for the daily needs of both individuals with mental illness and to the people associated with them. (Bradshaw & Pedley, 2012). For the effective provision of service in the field of mental health nursing, nurses require skills such as positive attitude and behaviors, maintaining the therapeutic relationship, building trust and developing good communication (Loukidou, Ioannidi & Kalokerinou-Anagnostopoulou, 2010).

 Building a therapeutic relationship with the clients have found to be the effective nurses' role in facilitating the recovery process and for social inclusion. Implementing and maintaining professional boundaries is the sole responsibility of nurses while establishing a therapeutic relationship. Emotional intelligence, advocacy, trust, empathy, and rapport are the characteristic skills necessary for nurses to develop a therapeutic relationship. Nurses to involve the clients and their family members in decision making and in the care planning process. Nurses are required to guide the relationship towards a professional interaction based on clients care and needs. Creating good rapport builds trust which in turn accelerates the recovery process. By building a therapeutic relationship with adolescents and their whanau, nurses can encourage a healthy lifestyle and therefore enhancing social inclusion of adolescents. (Roberts, Fenton & Barnard, 2015)

One of the exemplars for skills or knowledge that nurses need to possess in order to work with adolescents is digital knowledge. Technology has become irreplaceable in healthcare and nurses play a vital role in the usage of digital media in empathetic nursing practice. Nurses can utilize digital devices as a tool for providing quality care for health consumers especially adolescents. As is it common knowledge that young adults hesitate to approach health centers, hence establishing a therapeutic relationship through digital media has become a norm in nursing practice (Bradshaw & Pedley, 2012). Best practice example is regarding a school nursing team using an interactive mobile app to convey information and advice regarding health issues especially about emotional well-being and mental health. 

This strategy was found to be successful because it provided a safe and discreet platform for adolescents to get health information. With the gained information regarding health, adolescents can associate with health professionals to enable them to formulate an intervention for their recovery. O’Keeffe and Clarke-Pearson (2011) state that digital media platform provides opportunities for adolescents to learn, understand and empathize with others. Moreover, they can utilize these technological tools to cooperate and exchange ideas and thereby encouraging social inclusion. Young adults should be given positive feedback for using these tools for their well-being (Chassiakos, 2016). As these impacts positively on the recovery process by enhancing their self-esteem and feeling of being recognized thus encouraging social inclusion.

Motivational interviewing is another example of nurses' role which has found to be successful while intervening with alcohol-dependent adolescents. In motivational interviewing, nurses are required to develop a partnership with the adolescents. This can be achieved by mutual trust and respect. Empathy and understanding of adolescents' experiences through reflective learning are building blocks for this relationship. Nurses being confrontational or direct persuasion have proved to be ineffective in changing adolescents' behavior. Through motivational interviewing, nurses provide support to their self-efficacy and autonomy in order to decide to change their negative behavior. In this role, nurses provide education and advice to the peers and family members regarding the alcohol misuse and importance of social inclusion of adolescents for their recovery and betterment in life (Kiernan, Ni Fhearail &Coyne, 2012)

Conclusion

Especially young adults face many barriers for social inclusion in their day to day life. These barriers can be linked to the childhood developmental stage of identity vs role confusion. Furthermore, social deterrents such as stigma and discrimination can lead adolescents to isolate themselves from the community. Increased opportunities for these young adults are necessary for their social inclusion. Therefore, the Tidal Model appears to be the preferred model, especially for the adolescent age group since it aids them to express their problems and to determine strategies for solving issues for themselves. 

This model promotes selfhood, integrity, autonomy among young adults and impacts on their well-being. New Zealand government and non-profit organizations have launched various initiatives and strategies to encourage the inclusion of Tangata whaiora. The role of the mental health nurse holds a unique place in consumer care acting as a source of connection between clients and society. Therapeutic, holistic and comprehensive nursing care forms a basis for the recovery process. In conclusion, it is necessary to acknowledge that people with mental disorders are inseparable from society and it is their legitimate right to be included in society.

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