Broadening our horizons: Seeing beyond the six ‘C’s to capture the depth of mental health nursing

Abstract

Colloquially, notions of the ‘seven seas’ has been around since 2300 BC, and in more recent times, used when referring to all of the world's oceans. Contemporarily, in the UK, nursing has adopted the six ‘C's’: care, compassion, competence, communication, courage, and commitment, the necessary characteristics believed to encapsulate good nursing practice (NHS Commissioning Board 2012). However, if the fundamental tenet of mental health nursing is that of the therapeutic relationship, I would suggest mental health nurses need to look beyond such horizons and move into the unchartered waters of the 12 ‘C's’, adding context (circumstance/culture), connection, confidence, consistency, challenge, and collaboration to the original list. In navigating the 12 ‘C's’ effective relationships, encompassing an emotional human interaction where there is a reciprocal involvement of service user and nurse, the latter offering the former time, serious interest, and sensitivity, are more likely to be established. Mental health nursing is an interpersonal process (Peplau 1952) requiring that the person in distress is understood within the context (circumstantial and cultural) of their life, and how their experiences have impacted on their emotional well-being. Unless we listen to their accounts of the significant events and the context in which they occurred, making sense of their manifestations of illness will evade our understandings. However, sense making needs the nurse to be fully aware of their own need to understand how they have become who they are and how their own history and that of the person is often re-enacted and modified within the therapeutic encounter (Warne & McAndrew 2007). In light of this, providing a physical and emotional connection is fundamental to good mental health nursing practice. Connection through communication needs to be dialogical in nature, ‘listening and speaking with’ to achieve ‘a flow of meaning’ that brings understanding to the person's experience (Bohm 1996). Such dialogue gives recognition to the uniqueness of the person, rather than to a ‘generalized patient’; the latter often being no more than a set of symptoms in keeping with a medical model (Frie 2010). To achieve a dialogical stance, contextualization, for example, family, culture, and immediacy of the situation, is paramount if disconnection with the person is to be avoided. In addition, gestures play an important role in the process of connection, allowing us to reach out and silently explicate the caring inherent in the relationship (Frank 2004). To achieve dialogical communication, the mental health nurse needs the inner capacity to assimilate experience, and to respond in a genuine, spontaneous way to the unfolding significant events in the distressed person's life. However, only those who are confident enough to be themselves will be able to facilitate such telling. It is not easy to accept and validate the experience of another individual whose distress has manifested in such a way that our own security becomes challenged. Such occurrences can leave the nurse feeling emotionally impotent and defensive, and at the mercy of the prevailing psychiatric discourse. Professional detachment, denial of personal feelings, and the pathologizing of what we do not understand are all defence mechanisms commonly adopted by mental health professionals (Gallop & O'Brien 2003). Defensiveness on the part of the mental health nurse might manifest, whereby the medicalized theories of misery and distress, diagnosis, and prescription become harbingers of a safe environment, thus minimizing the moral dilemmas that threaten and challenge their everyday practice (Warne & McAndrew 2007). The utilization of clinical supervision as a platform for challenging our own attitudes and fears, brought to the fore during therapeutic encounters, is crucial in achieving better insight and understanding of unconscious defences. Such insight allows the mental health nurse to avoid perpetuating feelings of self-doubt that can undermine their confidence for therapeutic engaging. Consistency, respect, affirmation, empathy, and staying with and holding the emotional distress will provide an emotional platform conducive to nurturing trust (Isay 2006). Establishing trust through the demonstration of these characteristics will facilitate collaboration, a fundamental component of compassionate human engagement. ‘Compassion’ etymologically comes from the Latin meaning to ‘co-suffer’ or ‘suffering with’. While many mental health nurses are more familiar with the notion of empathy, compassion suggests a more active desire to alleviate the suffering of another, with empathy contributing to a climate of compassion (Orange 2006). Compassion demonstrates resonance and attunement, and our capacity for alleviating distress through therapeutic endeavour (Frie 2010). However, in order to ‘suffer with’, we first need to have an understanding of the person's distress and be able to demonstrate our capacity to share that distress through seeing beyond the horizon to the depths of the 12 ‘C's; the fundamental tenets of good mental health nursing.