Editorial

Promoting health and preventing illness: promoting mental health in community nursing practice

Brenda Happell
Director, Institute for Health and Social Science Research, Engaged Research Chair, Mental Health Nursing, CQUniversity Australia, Rockhampton QLD

Michelle Cleary
Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore

PP: 88 - 89

Article Text

Ask a group of your colleagues what they see as necessary for good health.  From our experience the answers will include ways to: ensure a healthy diet, promote sufficient exercise, and achieve good sleep patterns, for example.  Notice something?  They all relate to physical health. There is no denying their importance for good mental health also, but the focus will almost certainly be on the body rather than the mind.  The privileging of physical over mental health has become so entrenched that for many the term 'health' automatically means 'physical health'.

It is a similar picture at the policy level.  There are many public health and media campaigns aimed at promoting good physical health such as the: "Slip, Slop, Slap, Seek, Slide" (slip on a shirt, slop on the sunscreen, slap on a hat, seek shade, slide on some sunglasses), or the "go for 2 and 5", (recommending two serves and fruit and five serves of vegetables per day).  These are just two examples from a long list of physical health promotion and illness prevention strategies that have become part of our daily life. Where is the mental health equivalent?  Where are the ads telling us how many times we should laugh or smile in a day? Hug our children and cuddle our cat? Those little catchy messages that could get us to think about how important it is to feel a sense of emotional well-being and give us permission to take some time out for our own well-being.

Few would disagree with the succinct yet powerful statement by the World Health Organisation: "there's no health without mental health." The relationship between physical health and mental health is now clearly supported by evidence (WHO 2010).  Mental illness and emotional distress are much more common in people experiencing a physical illness or injury and the reverse is also true.

So what does this mean for community health nursing practice?  It might be argued that the care of people experiencing a mental illness should be directed to specialist mental health services leaving community health nurses to work with physical aspects of care, particularly as they generally feel more comfortable in this domain.  The reality is that mental health services are only utilized by a very small proportion (approximately 6%) of people identified as having the symptoms of a mental illness and the largest proportion of people accessing health care for mental illness utilize primary health care services (Australian Bureau of Statistics 2010).   For most people the mental illness is not identified and therefore not treated.  This presents a compelling argument for the important role nurses have to play in the recognition of, and early intervention with mental illness.

While there are many well-considered reasons for separating physical and mental health services, it is important to remember that a person's s health rarely fits neatly into one or the other.  Co-morbidity between physical and mental illness is now the norm rather than the exception. Mental illness may precipitate physical health problems.  Cardiovascular disease and diabetes are far more common in people diagnosed with mental illness, due to lifestyle factors and the side effects of anti-psychotic medication (Scott & Happell, 2011).  Mental illness can also be a response to a physical issue.  For example, severe depression frequently occurs in people experiencing quadriplegia and the emotional distress associated with the anticipated changes to the person's lifestyle and wellbeing.  Addressing the physical and ignoring the mental health needs in this situation would clearly not be in the best interests of the client. 

Mental health is therefore an important issue in community health settings, and the ability to detect and respond to mental health issues needs to be part of nurse's repertoire of skills.  Just as they would routinely assess mobility issues for a person with an above knee amputation, they should also consider its impact on their body image.  The emotional distress likely to result from a loss of limb will be at least as devastating as the physical consequences.  The client may be at risk of substance misuse or suicide.  A comprehensive psychosocial and mental status assessment is a necessary component to provide quality care, ensure safety and facilitate the client's short and long term emotional health and wellbeing.

So how do we know that some one has a mental illness or is experiencing emotional distress?  Unfortunately that is not an easy or straightforward question to answer.  There is no simple test where its presence or absence can be identified with confidence.  It is also not expected that community nurses will be experts in this field, but constant attention to the behavior and actions of a person may give rise to suspecting a mental health issue may be involved. For example the client who is withdrawn and refuses to interact with the nurse, may be dismissed as 'difficult'.  The understandable response may be to provide the necessary care and leave as soon as possible.  This may mean an opportunity to provide good mental health care has gone begging. The client who appears withdrawn may actually have depression or be experiencing emotional distress. She may have been diagnosed with a life threatening illness and be hiding the fear that she will die or her husband will not love her any more.  Lack of sleep and poor diet may exacerbate her sadness.  Whether or not her symptoms indicate clinical depression is not as important as the impact of her distress.  That distress must be acknowledged and the client given every opportunity to communicate with some-one with the confidence that she will be listened to and not be judged.

Nurses without specialist qualifications in mental health nursing often do not feel comfortable providing care for people experiencing mental illness and they frequently share the same discriminatory views as the rest of the population (Horsfall, Cleary & Hunt 2010).  Community nurses cannot be expected to have specialist qualifications in mental health nursing.  They can however, have a genuine desire to promote health and well-being and recognize mental health care as an important part of achieving that goal.

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