Writing the book
December 12, 2010 -- Today the Post and Courier (Charleston, SC) ran a short but good article by Renee Dudley about a new mental health nursing curriculum designed by Medical University of South Carolina (MUSC) nursing dean Gail Stuart for use in war-torn Liberia. Developed with the support of the Atlanta-based Carter Center, the curriculum will be used to train practicing nurses and nursing students to diagnose and treat conditions like post-traumatic stress disorder and depression in a population struggling to recover from widespread atrocities. The piece gives readers a fairly good sense of Stuart's expertise and autonomy, noting that she "literally wrote the textbook on psychiatric nursing." However, the first online reader comment about the piece is telling. After a harsh critique of MUSC psychiatric physicians as dangerous "charlatans," the commenter actually says that it is "odd that a nurse and not a doctor developed this program" and wonders if Stuart "could or should . . . be cited for practicing medicine without a license." The commenter seems unaware that it is nurses who lead the nursing profession, so they are the ones who develop nursing curricula. More broadly, nurses are fully qualified to "diagnose and treat" serious health problems, and as the second commenter explains in response, "preventing nurses from practicing [in accord with the] full scope of [their] training by insisting that physicians are the only ones capable of providing that care is wrong, and the data proves it." We thank Renee Dudley and the Post and Courier for this helpful report on a nursing scholar's contributions to global health.
The headline of the piece is: "Nurse's influence has wide reach: Dean of nursing college takes mental health curriculum to Liberia." The piece also includes a photo of Stuart and another of Carter Center staff in Liberia. Reporter Dudley explains that Stuart's authorship of that textbook on psychiatric nursing makes it easy to understand why Liberia turned to her for help. The "professor" developed the curriculum "for diagnosing and treating anxiety, depression and post-traumatic stress disorder" in the small West African nation, which "has only one licensed psychologist for a population of 3.4 million." Stuart was reportedly first contacted about the program by the Carter Center, which was founded by former U.S. President Jimmy Carter. Thomas Bornemann, the Center's director of mental health programs, describes the years of the Liberian civil war as including "rampant" sexual assaults, "forced amputations," the "drugging of child soldiers," and other atrocities that "left the population very vulnerable." The piece continues:
Stuart, who visited Liberia in October, said years of civil unrest left the country with "pervasive and devastating" mental health problems. "So many people have faced trauma, but they don't have the skills to screen for it and treat it," she said.
The piece provides a few details about the plans for Stuart's two-month curriculum. Once the Ministry of Health and Social Welfare approves it, a first group of practicing nurses will be trained this spring to "treat masses of Liberians whose mental illnesses have gone undiagnosed," and this first group should then be able to "teach the new skills to their fellow nurses." Bornemann hopes the curriculum can be used to train 150 nurses over the next five years. The curriculum is also slated to be used in the nation's six nursing schools. The piece explains that the program "includes Liberian lexicon," and gives as an example what Liberian health professionals described as "open moles," which are "soft spots on the skull where some people think bad spirits enter." Stuart notes that the condition's symptoms resemble those of anxiety and depression, and she included it on the program "to get people to talk about it."
The article is a helpful, if short, report on an innovative nursing program that would seem to have the potential to enhance mental health in a nation that has a great need. It is fairly remarkable that the piece ran at all with no apparent physician involvement. And the reporter avoids any temptation to deflect credit away from Stuart, or to imply that she must be helping physicians or just getting things ready for them. The article might have addressed the precise nature of what the trained nurses will be doing, including the use of medications, and it might have discussed whether resource shortages are an issue. Moreover, the piece does not say what role physicians and other health workers, including traditional healers, might play. The precise nature of what the trained nurses will be doing is not explained, including the use of medications and whether resource shortages are an issue. Nor does the piece say what role physicians or other health workers, including traditional healers, might play. We assume a nation with one psychologist has few psychiatrists or social workers. Do Stuart or Bornemann anticipate significant cross-cultural issues in implementing the curriculum? In any case, it's always helpful for the media to tell readers that nurses are influential health innovators, and at a more basic level, that there are such things as nursing deans and nursing textbooks--that nursing is a real profession whose leaders are nurses.
Clearly, some people need to be told that nursing is an autonomous health profession. The first online commenter begins by suggesting that Stuart might teach her curriculum to the "psychiatric doctors at MUSC [because they] certainly don't seem to know much more now than to perform chemical lobotomies and cause people with already diminished capacity to become ever more unable to cope and thus starting a never ending cycle of dependency on these highly paid 'professional' charlatans." Certainly, some clinicians may be seen as relying too heavily on pharmaceutical treatments of mental illness. But then the commenter turns on Stuart:
And doesn't it seemed odd that a nurse and not a doctor developed this program? Could or should she be cited for practicing medicine without a license?
The answers are no, no, and no. There's nothing "odd" about a nurse developing a curriculum for diagnosing and treating mental illness, since nurses teach nursing and nurses perform those tasks constantly in the clinical setting, though historically some turf-protective physicians have pressured nurses to pretend that they were doing something else. However, physicians do not own diagnosis or treatment. The commenter seems to assume, wrongly, that any serious health care practice must be "medicine," the province of physicians; in fairness, the use of terms like "medical" to describe institutions where nursing is taught and practiced does not help.
The second comment provides a strong, articulate response to the first one:
Thank you Dr. Stuart for your service. Because of your efforts, the world will be a better place. Allowing patients complete, unrestricted access to skilled, trained registered nurses is key to improving everyone's health, both in South Carolina and Liberia. Preventing nurses from practicing [in accord with the] full scope of [their] training by insisting that physicians are the only ones capable of providing that care is wrong, and the data proves it.
We like that (no, we did not write it). Note the pointed use of the honorific "Dr.," a reference to the dean's PhD. It's not clear what data the commenter is referring to, or whether it relates to registered nurses or advanced practice nurses. It sounds like Stuart's curriculum is geared toward registered nurses, and they are well-qualified to identify and manage mental illness within their scope of practice, including treatment of the most serious and difficult conditions. The American Psychiatric Nurses Association provides basic information about what psychiatric nurses do and how their practice relates to the practices of physicians, psychologists, and social workers.
We thank Renee Dudley and the Post and Courier for this very helpful report on a nursing leader and her influential work.
See Renee Dudley's article Nurse's influence has wide reach: Dean of nursing college takes mental health curriculum to Liberia, posted December 12, 2010 on the Post and Courier website (South Carolina).