Mental Health Nursing In One Of Most Remote Communities In The World

Mental Health Nurse, Ian, describes what it’s like to work as a Nurse on St Helena Island, outlining the need to develop therapeutic relationships, both within the community and externally.

Hi my name is Ian Rummery. I am a Registered Mental Health Nurse. I work on the island of St Helena which is a British Overseas Territory.

St Helena is one of the most remote communities in the world, a small island about 10 miles long and 6 wide. It is in the South Atlantic almost halfway between Africa and South America and has a population of just over 4000.

Becoming A Nurse, Reluctantly

I originally trained in Australia graduating as a mental health nurse in 1991. I admit I had never really considered being a nurse until I saw the advert for Nurse training.

This was back in the day of hospital based training when you were paid and it was the fact that I was going to be paid that really got my attention and motivated me to apply.

After graduating, and for a number of reasons, I wasn't that thrilled about embarking on a career as a Nurse but having got the ticket I figured I might as well use it and it had to better than being unemployed.

My First Visit To St Helena

So after a succession of jobs in Australia I moved to the UK. In 1994 I went travelling and visited St Helena. For some reason I had always wanted to go there and in those days the island was even more remote as it did not have an airport.

It was a fourteen day voyage on the islands ship the Royal Mail Ship St Helena from the UK to the island. I met Belinda, now my wife, on the ship. Belinda was from St Helena and was visiting her family as she was in between jobs in London.

So returning to England after my travels I moved to London. But there was something about St Helena that had gotten under my skin. I was determined to go back there and live but I needed to convince Belinda to come with me.

It took almost ten years but we moved back in 2003.

Developing My Nursing Skills

During that time in England I worked all sorts of nursing jobs. I worked in the NHS and the private sector. Agency and bank. I had several full time posts and covered everything from general psychiatry, day hospitals, nursing homes, substance misuse and learning disability.

I hope that in all these jobs I worked hard and was a competent Nurse. But there was something missing. I did not feel that I was achieving much. It felt more like I was processing people than caring for them.

Like I was on the assembly line moving patients from A to B but never really being with them on the patient journey. Somewhere along the way I had developed a sense that I should be making a difference, whatever that means, but I just seemed to be a part of a system, the proverbial cog in the machine.

Returning To St Helena

Having finally convinced Belinda we moved to St Helena in 2003 At the time I was on the only qualified mental health professional on the island. I wasn't sure what to expect but I learned early on that you had to be resourceful and resilient.

The comfort of being a cog in the machine is that if you encounter problems you can try and find someone else in the system to help. Not so on St Helena, in terms of mental health I was it.

That is not to say that I felt unsupported as people rallied around and my St Helenian colleagues were and are fantastic. But back then with only the most basic of a dial up internet connection, research, accessing a second opinion or having a clinical discussion was difficult.

But with perseverance it was possible.

Seeking External Advice

There were times when I would search out contact details for Psychiatrists and Psychologists and ask for advice. My opening line in the email was always 'I am a Mental Health Nurse on the remote island of St Helena and I have a patient who is ..... And I would go on to describe their symptoms.

I remember once feeling completely overwhelmed trying to support a person who was in the darkest depths of depression. I had just read a book by an American psychologist on what is called refractory depression, that is depression that does not respond to the normal anti depressant medication.

The Doctor and I looked at combinations of anti depressants but still did not feel completely comfortable with what we were planning. So I sent this Psychologist an email.

A few days later my phone rings and this Psychologist calls me from America to talk through the case. The psychologist, an international expert in this field, took the time to discuss with me our plan and gave us the confidence to implement this plan.

And the person recovered.

Expanding The Mental Health Services On St Helena

Over the years mental health services on St Helena have expanded and I now lead the mental health team which when fully staffed consists of myself and two other Mental Health Nurses, a Psychologist and a Support Worker.

The qualified staff are on contracts and usually spend two to three years on island. We are busy, there is always one of us on call and in addition to mental health care we provide general and mental health care to detainees in custody and the inmates in prison.

My Personal Reflections Of Working On St Helena

In a community of 4000 people you may not know everyone but you know most people or their family. So people are not a number, they are part of the same community that you live in.

One day you can be in the clinic counselling a person who is struggling and then the next day you are at a meeting where you are interacting with that person in their professional capacity.

From the start of my training I was never comfortable with the notion that when one worked therapeutically with a patient that you should keep it impersonal on your part.

That it was ok to delve into the life of another person but never reveal anything of yourself. Of course there must be some boundaries but it always struck me as fundamentally dishonest and unequal to expect someone to share their most intimate details with you while you remain impartial.

Community Nursing And Therapeutic Relationships

Well on St Helena, or indeed other remote communities, good luck with staying detached. When new staff arrive they are amazed at how quickly the community knows who they are and where they come from.

It can be disconcerting at first but it comes with living a remote community and you have to adjust. I also believe that this close personal connection is fundamental to the strength of our service is fundamental to the strength of our service.

It is this blurring of boundaries, that I work therapeutically with people but I am also a member of this tight knit community that I find so rewarding and at times challenging.

It is only since I arrived on St Helena that I believe I was able to develop very strong and meaningful therapeutic relationships. That my relationships with the people I support to recover from mental health problems are multi faceted, complex but ultimately I believe that it is the therapeutic relationship that is the foundation on which recovery is built.

Anyone who wants to contact me on St Helena will know where I live or will be able to find my phone number. Sometimes people will call me at home, occasionally when in distress a person will knock on my door.

I cannot refuse to talk to someone or turn them away. I may agree to see them at the office at a later time or date but in a crisis I need to support that person at the time they are asking for help regardless of how they ask.

Non-Nursing Duties

Often we will support people in what could be considered non-nursing duties. This might include helping them with their shopping, advocating for them if they have to go to the benefits office or just giving them a lift so that they can visit relatives.

While this may seem outside of our scope of practice I maintain that these are essential activities as they add to the persons quality of life.  Even more importantly they build trust and a sense of security.

So if there is a crisis we are more likely to be accepted by the person as someone they can relate too. I remember an incident in the early hours of the morning where a person with a severe and enduring illness was relapsing and became paranoid.

They locked themselves in the house. The police were in attendance but I was able to convince the person to let me into the house and take them to hospital.

I believe that despite their paranoia we had a strong enough relationship that the person trusted me to help them and I was able to avoid the person being sectioned as they agreed to stay in hospital.

I Found What I Was Missing

And this is what I was missing all throughout my nursing career prior to coming to St Helena. The opportunity to be involved in a person's journey, through the highs and lows, setbacks and achievements.

Not everyone recovers in the sense that they are able to be overcome their mental health challenges, not everyone wants my support, but being part of this community means that I can be there for people when they ask for help.

Sometimes it is about being available when the person is ready. There are a number of people who have dropped in and out over the years in crisis only to one day sit down and disclose what has happened to them, often it is abuse or trauma they have suffered many years before.

To be present when a person finally says 'I need help' is humbling because I know how difficult it is for them to ask.

The Moral Of The Story

I could not imagine that when I started out as a nurse that I would end up living and working in one of the most remote communities on the planet.

All I know is that at the beginning of my nursing career there were times when I wanted to quit nursing altogether but I kept trying different jobs until I eventually found the one that just made sense.

And this is I suppose is the moral of this story. I get that working in a remote community might not be your idea of the dream nursing job. But don't ever give up looking for your dream job in nursing.

In a strange way all those different nursing posts I had before going to St Helena prepared me for working on the island. As I had experience in different fields of nursing I was well placed to take on the challenges of remote area nursing where you need to know a bit of everything.

And if you don't know you keep looking until you find an answer