Challenges – this link takes you to more specific challenges association with learning.
Brief description of Mental Health Difficulties
The term mental health describes a sense of well being. It implies the capacity to live in a resourceful and fulfilling manner, having the resilience to deal with the challenges and obstacles that life and studying present.
Depression, stress and anxiety are the most common types of mental illness experienced by students, and it is common for students to lack confidence and have low self-esteem despite having the same full range of intellectual abilities as the population as a whole.
Nursing and Students with Mental Health Difficulties
The mental health of students in the caring and related professions has attracted particular concern because of their future potential impact on others. Although a doctor, nurse, social worker or teacher with psychiatric problems is much more likely to represent a risk to themselves, the spectre of potential harm to patients, clients or pupils has led to strict protocols for the management of students of these professions who develop mental health problems.
Medical students are the most frequently studied of the health care professions. Although relatively few have serious mental illnesses, studies have shown that medical students report higher levels of psychological symptoms than the general population and that levels of distress increase progressively during the course of medical studies. Roberts et al (2001) found that a quarter of a large sample of US medical students suffered symptoms of mental ill health. Students perceived the need for personal health care, but ‘feared reprisal from seeking help’.
Medical practice demands the highest standards of performance and conduct. The study and practice of medicine is stressful, however, and both medical students and doctors are vulnerable to mental health problems, especially anxiety, depression and substance misuse. There might be an association in some cases between stress, mental ill health, and personal or professional misconduct.
In the USA and Canada, health promotion programmes for medical students have been established to reduce the effects of stress (Wolf & Scurria, 1995). ‘Wellness electives’ have been shown to reduce stress and improve coping strategies. In London, the Royal Free and University College Medical School has developed a peer tutoring project, academic advisers meet students several times a year and clinical advisers operate walk-in surgeries to track student progress.
Medical education involves much more than the acquisition of knowledge and skills. It involves development of ethical understanding and professional responsibility. The General Medical Council’s revised framework for medical education, Tomorrow’s Doctors (General Medical Council, 2002a), emphasises the acquisition and demonstration of the attitudes necessary for achievement of high standards of medical practice, including in relation to the doctor’s own personal development. This implies the need for medical students and doctors to be capable of applying their knowledge and understanding to their own attitudes and behaviours.
Mental Health Screening and Nurse Training
The Clothier Report, an independent inquiry into the deaths and injuries caused by children’s nurse Beverly Allitt, recommended stricter criteria for selection to and progress in nurse training (Clother et al, 1994). Eight of the report’s 12 recommendations relate to tougher screening procedures. It endorses the advice of the Chairman of the Association of NHS Occupational Physicians, who suggested ‘excessive absence through sickness, excessive use of counselling or medical facilities, or self-harming behaviour such as attempted suicide, self-laceration or eating disorder are better guides than psychological testing’. It was also stated that ‘applicants who show one or more of these patterns should not be accepted for training until they have shown the ability to live an independent life without professional support and have been in stable employment for at least 2 years’.
These stringent criteria might make sense if the clinical picture is indicative of a severe and potentially dangerous personality disorder, but interpretation of any exclusion protocol will need to take into account the requirements of the Disability Discrimination Act 1995 as it now applies to higher education.
Although the Royal College of Nursing supported the Clothier Report’s recommendations in general, it has published health assessment advice for the profession to help address these concerns. The College acknowledges that there are limitations to health assessments, but asserts that the aim is to ensure that the applicant is fit to carry out their job without a significant risk to their own health and safety or that of the patient. The College advises that health assessments should:
- only be carried out by qualified occupational health nurses and physicians
- be careful with regard to the confidential nature of the information disclosed
- not exclude an applicant on the basis of information supplied on a questionnaire alone
- allow a clear appeals procedure and an independent second opinion.
Following a later inquiry into the actions of another nurse, the Bullock Report advocated that the recommendations of the Clothier Report be extended to cover all health care professions (Bullock, 1997). An appendix to the report sets out an exhaustive questionnaire which, although it could throw up false positives, has been adopted by other occupational health services. Subsequently on the 17th November 2005 Amanda Jenkinson was totally exonerated by the Court of Appeal, she was cleared of all wrong doing by the court.
If the consequence of disclosing a mental health problem such as an eating disorder was inevitable exclusion from training in a health profession, it could deter individuals from seeking help from either professional agencies or self-help groups. Any attempt by the potential student to hide a significant mental health problem, however, could be viewed as a dishonesty unworthy of a responsible professional person. Most mental health problems, including personality disorders and substance misuse, are treatable if detected early and addressed constructively. Screening and risk assessment in the higher education context needs to be highly sophisticated and mindful of the interests and rights of the potential student.
These expectations in relation to selection, education and registration highlight the dilemmas surrounding confidentiality in relation to health care students with mental health problems. The General Medical Council’s expectations of doctors who treat medical students with serious mental illnesses are quite clear: disclosure of the student’s illness may be necessary in the public interest. ‘Doctors should not disclose information, without the student’s consent, unless the risk posed to patients is so serious that it outweighs the student’s right to privacy’ (General Medical Council, 2002b: paragraph 5, ‘Student Health and Conduct’). The Student’s consent for disclosure should be sought by the responsible doctor, of course; but if it is refused, the student may have to be informed that disclosure is unavoidable. University counsellors and non-medical academic staff are not bound by the General Medical Council’s code, but might appropriately follow its principles. All who work with students who present with mental health problems might be encouraged to consult with colleagues about any potential overriding of confidentiality.
Information taken from The Mental Health of Students in Higher Education. Council Report CR112. The Royal College of Psychiatrists: London, January 2003. http://www.rcpsych.ac.uk/Publications/cr/cr112.htm