The second component in capacity to engage with wicked problems was, as one participant put it “being okay to sit with the darker stuff” (P14). Being okay to sit
with the darker stuff exacerbated the experience of untenable burden because
participants with this capacity often attracted young people experiencing wicked
problems: “if you have an openness about you for mental health and you don’t fear
120
engage with this group, increasing numbers of young people seeking support for
wicked problems translated into an increase in persistent intensity and exacerbated
participant’s experiences of untenable burden.
Participants in this study recognised that being okay to sit with the darker stuff was a choice: “some [school nurses] don’t necessarily want to see kids the way I want to see kids and have that involvement [with them]” (P6). Other participants perceived that being okay to sit with the darker stuff was an essential part of the school nurse role:
For a nurse to be able to work in a secondary school, that’s a really important part of employing someone to do that job… you need to come to the role with a certain level of comfort and willingness to work in that area. Maybe not to be an expert, but to actually want to work in that area, to see that as an important part of your role. (P3)
Participants reflected that colleagues who were not okay to sit with the darker stuff might not experience the same level of disclosure about wicked problems or the same level of untenable burden as a result: “a few [school nurses] don’t seem
approachable [about difficult issues]. Are they actually going to get [young] people presenting to them with something personal, [when] they don’t understand [it]
themselves?” (P6). The terms comfortable and uncomfortable came up several times: “some [school nurses] are really willing to deal with students and their mental health issues. They feel reasonably comfortable, at least talking [to the young person] … other [school nurses] feel very uncomfortable” (P25); “the nurse previous to me… she steered clear of mental health altogether. My understanding… is that she was very uncomfortable with it herself” (P3).
Not unexpectedly, previous experience contributed to being okay to sit with the
darker stuff because it increased the level of comfort participants had in eliciting
information about difficult issues:
Having been [professionally exposed to] sexual assault, incest, death in car accidents, poisonings and suicide… has opened me up to be much more able to go deeper. [Being able to ask] those questions around self-harm and
blended family issues that maybe some other people don’t feel so comfortable about. (P14)
In addition to being able to elicit sensitive information, participants who were okay
to sit with the darker stuff were confident that they could manage emotionally
demanding situations. They recognised non-verbal signals of emotional distress and were able to invite disclosure of emotional problems, even as they acknowledged that it exacerbated their experience of untenable burden:
[The] mum’s body language just said it all. So I took her into my room, made her a cup of tea, sat down and said ‘okay, what’s going on?’ and she just sat and cried for about 20 minutes… Her daughter doesn’t feel any better after counselling. [She says it’s a] ‘waste of time’. Her daughter’s so, so negative. The counsellor has recommended that they go back to the [doctor], because the counsellor thinks that she might need to be medicated. This girl is only a Year 9 girl, and mum is so [against] the girl being medicated. So that was hard. (P20)
Confidence managing emotionally demanding situations also translated into agile clinical responses. As one participant put it: “you’ve got to think on your feet” (P11). Many participants only referred to this agility in passing. One participant described supporting a distressed adolescent girl to disclose to her mother that she’d recently been sexually assaulted. Almost as an addendum the participant added:
[After the meeting] mum disclosed that she had been [sexually] assaulted when she was a similar age. She’d had a baby… [which] she’d been forced to... give up for adoption. The mum broke down. I wasn’t envisaging any of this happening… A lot of the issues at home between the daughter and the mum was that the mum was very depressed about these things that had happened to her when she was younger, and she felt that she couldn’t talk about it to anybody…. [I was] then able to get help for the mum as well. (P8)
122
One participant acknowledged that it was difficult to train for all eventualities and described an agile response in the midst of a crisis:
No training can prepare you for [some things] …. I said to [the suicidal student I was physically restraining with the school psychologist], “you know how I had to run after you?” and he said “yes.” I said “you know I’ve had kids, right?” and he said “yes.” I said “you know that ladies that’ve had children shouldn’t really run [referring to pelvic floor dysfunction]?” [I said] “I’m busting, busting [to go to] the toilet, so you’ve got two seconds mate. You can either walk with us into Student Services and I’ll go and do a wee on the toilet, or I’m going to go right here in my pants to keep holding on to you. Your time starts now. One...” I hadn’t even [counted] to two and he [said] “let’s go!” … The school psychologist said to me afterwards “that was brilliant, how did you know to do that?” and I said “I didn’t. That was just – I’d exhausted every avenue.” (P21)
Being okay to sit with the darker stuff also meant having the emotional energy to
engage with young people who might be perceived as “difficult” or “challenging”: “I’ve been called the bitch from hell because I put things in place for somebody and they didn’t like it” (P6). One highly experienced participant recalled a student who was under significant stress and lacked the skills to appropriately articulate her needs:
[A young Aboriginal girl] had come in just as the bell had gone [for the end of] lunch time. She said she wanted some paracetamol for a headache. I said “no, you have to have your three glasses of water, come back in an hour if it’s still there” ... She stood up and told me “[expletives], you’re not listening to me” … [She] got up, smashed my door shut… I took a few deep breaths, found out where she was supposed to be, [and] of course she wasn’t there. (P21)
Reflecting on the situation, the participant acknowledged:
I hadn’t read the signs [that there was another reason for her visit]. [I could have] said “What else is going on for you at the moment? Life’s really busy
isn’t it? What’s happening? What can I do for you?” If I’d approached it that way there wouldn’t have been this outburst. (P21)
The capacity to engage with challenging young people could significantly exacerbate the experience of untenable burden, because these participants were not afraid to reflect on the darker stuff. Participants who had a capacity for being okay to sit with
the darker stuff typically described applying a social lens to the difficulties some
young people experienced regulating their emotions. Reflecting on young people who were violent at school, one participant explained:
You need to take a holistic view of it… They could have mental health conditions, they could have stresses in their lives that they’re not disclosing. Maybe [they feel] they have to conform [like] everyone else. Bottling things up builds that tension to a point where they explode. Maybe not
understanding, not [having been taught] how to be tolerant of other people… I see a lot of students who use drugs and alcohol which can be a contributor [too]. (P11)
Previous experience in mental health could also enhance understanding:
My mental health training at Graylands [Psychiatric Hospital in Perth] as part of my [Western Australian School of Nursing] training opened my eyes to a lot of mental health issues… I’ll always remember, because it obviously had a huge impact [on me], the girl who was my case study [for a nurse education activity]. [She] had been used [sexually abused] by her father.… [She] was pimped out to her father’s mates and cigarettes put out on her butt [buttocks]. No wonder she was in Graylands with a huge amount of issues related to that kind of stuff. (P14)
As with the participant quoted above, being okay to sit with the darker stuff meant recognising that some variables were not amenable to intervention: “we can't change their parents [and] we can't change their history, so it’s about finding how they are
124
going to cope with life and go from there” (P5). This often translated into being able to tolerate a certain level of clinical uncertainty:
She is still struggling, this [young person] … If she was one that turned [out] to [die by suicide], I wouldn’t be surprised. She is impetuous, and she is contemplative [of suicide] … [The parents and mental health services] all know about it but I'm not sure what more I could do to prevent that situation [or] outcome. (P18)
By contrast, a participant in the same circumstances who had not yet developed the same capacity to tolerate clinical uncertainty stated: “Gatekeeper [suicide prevention training], [is] very grey… it’s not black and white… there’s no form saying: list protective behaviours, list this, ask these questions” (P26).
Despite possessing sophisticated clinical skills, participants who were able to tolerate clinical uncertainty accepted the limits of their influence: “there’s going to be times when I’m going to stuff up [make mistakes], but you can’t always get all the
information. You can only deal with what that person gives you” (P6). Participants with a tolerance for uncertainty also accepted the scale of the problems they faced: “[Initially] I felt very overwhelmed with [the wicked problems] and so often wanted to fix the world. [I] pretty soon realised that that was not feasible” (P28). Accepting that one had done ‘all that could be done’ was a common thread: “everything had been done that we could [do]” (P16); “I've got to tell myself … I've done as much as I can do” (P23); “sometimes you just have to take that step back and say “I've done as much as I can” (P2).
These perspectives were often hard-won, requiring significant self-reflection on the part of the practitioner. Being okay to sit with the darker stuff also required
something that was often in short supply: uninterrupted clinical time.