Nurture: The fundamental significance of relationship as a paradigm for mental health nursing

Perspectives in Psychiatric Care, Jul-Sep 2003 by Raingruber, Bonnie

TOPIC. Whether nature or nurture is the most appropriate paradigm for mental health nursing practice, education, and research.

PURPOSE. To present detailed information that nurture is the most inclusive and sustaining paradigm for mental health nursing.

SOURCES. Published literature.

CONCLUSIONS. Psychological, social, cultural, environmental, biological, and experience-based problems are the root of mental illness. Mental health nursing must have a comprehensive paradigm that honors the relational nature of the nurse-patient relationship, the critical influence of environment, the importance of biological factors, and the way that narrative understanding and history shape behavior.

Search terms: Nurture, nurse-patient relationship, mental health nursing paradigm

Formation of a clear sense of identity is a central developmental task for all people. Professions as well as people need a clear sense of identity to provide guidance to practice, education, and research. Pothier, Stuart, Puskar, and Babich (1990) commented that the decades of the 1950s and 1960s are fondly remembered in mental health nursing as marking "the emergence of the identity of the specialty" (p. 289). Now, debate within the profession illustrates that mental health nursing may be entering its adolescence and a reexamination of the paradigms and sense of identity that previously defined our discipline (Barker, Reynolds, & Stevenson, 1998; Krauss, 2000; Lego, 1997; Liaschenko, 1989; Mohr & Mohr, 2001; Olson, 1996; Orlando & Dugan, 1989; Tolbert, 1992). Such examination and debate are healthy.

A sense of identity is simultaneously both fixed and fluid because it is influenced by past experiences, current needs, and future aspirations (Heidegger, 1962). Taylor (1991) suggested, "Identity is defined by the commitments and identifications that provide the frame or horizon" (p. 27) within which it is possible to evaluate what is good and what one endorses or opposes. Mohr (1995b) agreed that a great deal of identity is tied to the ideals people and professions adopt "but even more so to the values they evidence in their daily activities, choices, and decisions" (p. 30). Dialogue within the profession about nature vs. nurture and the choice of a paradigm for mental health nursing is tied to critical values and enduring decisions. Mental health nursing is at a crossroads: We are being called on to make choices that will shape our identity. Open debate regarding the values of nature and nurture is central to examining the horizons that define notions of what constitutes good practice and to shaping the character of education as well as research for years to come. We must approach the nature vs. nurture debate with an awareness of what the outcomes will mean to future mental health nurses, patients, and families.

Erikson (1963), in presenting the stages of identity formation, described a number of tensions that help us understand developmental processes. Likewise, a series of tensions are relevant when considering whether nature or nurture is a more appropriate paradigm for defining, explaining, and guiding mental health nursing. This article summarizes debates that have been presented in the literature and organizes the discussion considering seven such relevant tensions: (a) holism or reductionism, (b) role differentiation or lack of professional identity, (c) continuity or lack of consistency with practice definitions and historical understandings, (d) work satisfaction and patient trust or burnout and increasingly distant relationships, (e) biophysiology and relationship as a cause or result of mental illness, (f) honoring complexity and free will or adopting linear explanations, and (g) increasing need and decreasing numbers of mental health nurses.

Before examining related points presented within the literature, we should begin with the central thesis of the nature vs. nurture debate, namely that biochemical imbalance and neurological changes are the root cause of all mental illness. This author, in arguing against this thesis, suggests that psychological, social, cultural, environmental, biological, and experience-based problems are actually the root of mental illness. Biochemistry and genetics, although important, do not explain or encompass all mental health problems or treatment approaches. As Flaskerud and Wuerker (1999) stressed, biophysiology does not provide a comprehensive conceptual model for practice. Mental health nursing needs an inclusive philosophy that honors the relational nature of the nurse-patient relationship, the critical nature of the environment, the importance of biochemical factors, and the way that narrative understanding shapes human behavior. A relational paradigm does just that. Within a relational paradigm, however, nurturing must be understood as deriving from a variety of sources such as one's upbringing, as well as from all the human interactions and relationships that extend across life including self-nurturing and attention to biological needs.