Advanced Mental Health Nursing Practice

Advanced Mental Health Nursing Practice Five stages of Motivational Interviewing - 1. Precontemplation: has not considered possibility of change. May not consider the behaviour a problem 2. Contemplation: ambivalent about change, knowing reasons to change and reasons not to. Loss vs. gain considered and barriers assessed. 3. Preparation: individual is prepared to take action. May include graded exposure or sampling alternatives. 4. Action: currently engaged in attempts to change. Praise is useful during this stage. 5. Maintenance: successful in achieving changed behaviour. Relapse can occur, so relapse prevention should be implemented. Reasons for high prevalence of mental health disorders in incarcerated populations - - Hx of trauma, abuse, neglect, etc. - Social disadvantage: most leave school before year 10, working class, no experience of a stable family, etc. - Criminalisation of MI and medicalisation of criminal behaviour - Lack of services for mentally unwell people in community/hospital beds - Transinstitutionalism - Drug and alcohol dependency: may be coping mechanism or role modelled behaviour Transinstitutionalism - Process of transferring mentally ill people from long-stay psychiatric hospitals into the justice system. Often due to inadequate community support. Iatrogenic trauma and re-traumatisation - 1. Harm caused by a health professional regardless of the action or intervention's intent. E.g. periods of seclusion, nasogastric re-feeding, or the use of physical or chemical restraints. 2. When these interventions trigger an emotional response due to past experiences or negative associations, e.g. using seclusion on a patient with a profound fear of abandonment (BPD). Trauma-informed care - - Responsive to psychological and physical effects of trauma - Strengths-based and person-centred - Symptoms as adaptations to trauma rather than pathologies - Rebuilds sense of control - Takes power away from trauma - Requires emotional safety (ability to be open and vulnerable with others) Impact of childhood trauma - DINDI (Disruptions, inabilities, negative coping mechanisms, dissociation, intense paranoia/OCD) - Disrupted or delayed psychosocial development impacting on interpersonal relationships - Inability to set boundaries or respect the autonomy of others due to poor role modelling - Negative coping mechanisms begin from a young age and continue into adulthood. E.g. substance use - Dissociative disorders such as DID or BPD can emerge affecting consciousness, memory and function. Episodes can be triggered by emotional arousal later in life - Intense paranoia or obsessive-compulsive tendencies as a way to protect self or regain control Agitation and de-escalation - - Repetitive questioning/requests: instead of saying "I'm busy/we'll talk about it later", deal with the request then, or give a specific time that you will do it. E.g. "I just have to give out these medications before dinner. Can we chat at 6PM?" - Pacing/restlessness: ask the patient if they would like to sit down and have a quick one-on-one. If they don't want to talk, offer a low-stimulus environment for relaxation, or something for healthy distraction e.g. mindfulness activities - Raised voice: identify what it is that the patient needs and repeat it back to them. E.g. "I heard you mention that there wasn't a tea bag on your tray at dinner. Is that why you're upset? ...Okay, you're upset about the tea bag, I see. We don't want you to be upset, so this is what I'll do for you..." If it's not possible to give the patient what they want, offer alternatives and remain optimistic. Impact of suicide on family and carers - - Feeling at fault or responsible - Feeling of failure (paid carers) - Intense loss prolonged grief depressive disorders - Isolation to avoid grief triggers and being confronted by others - Financial strain due to funeral expenses, loss of income and therapy for grieving members of the family - Occupational impairment due to grief/inadequate support - Loss of role/identity e.g. mother/wife All of these things have the potential to cause a domino effect if there is insufficient support during the grieving process. Core steps of ACT - 1. Values: recognising what matters most to the individual and whether current behaviours help or hinder them to live in line with those values 2. Committed action: using values to shape behaviour by going out and doing the things that reinforce them. E.g. if a value is creativity, continuing to draw/paint/write etc. even when you don't feel like it 3. Defusion: creating distance between the self and thoughts/beliefs by looking at them objectively. This can be done by using activities such as "Leaves on a stream", allowing them to simply notice the thoughts as they come without focusing on or altering them. Or, "I'm having the thought that..." Goals of clinical supervision (Proctor model) - The purpose of this is to create a good relational space between the supervisor and supervisee where the focus is on creative and collaborative learning and personal growth, allowing the support and monitoring of supervisee's work for the welfare and safety of the client. 1. Normative: concerned with maintaining and monitoring the effectiveness of tasks with a focus on accountability. E.g. using the Gibbs Reflective Cycle and analysing outcomes/critiquing practice to improve future outcomes. Using problem-solving skills and moral sensitivity. 2. Formative: actions that develop the supervisee's skill set, knowledge or understanding. Requires humility on both ends and an analysis of strengths and weaknesses. E.g. one-on-one teaching or revision of a clinical skill, or discussing an evidence-based journal article. 3. Restorative: offers the supervisee a chance to "recharge" to prevent burnout, and respects personal agency and needs. E.g. Validating feelings of overwork/stress and encouraging help-seeking for tasks that are very physically or emotionally laborious. Mental Health Nurse Practitioner - - Advanced practice level RNs whose purpose is to meet the needs of those who are underserved - Began in sexual health, wound care, mental health liaison and military - Was seen as physician replacement in Canada with poor legislation (60s-70s, ceased in 80s) - Huge success in socially disadvantaged and rural groups - Effective in health promotion and illness prevention - Recognises clinical expertise of RNs committed to professional development Mental Health Nurse Practitioner challenges - - Provokes medical backlash as it "disrupts" hierarchy - Potential for role confusion, thus NPs must establish themselves as "equal but different" - Competing demands: clinical work, admin, research, teaching and meetings - Difficulty managing extended privileges (assessment, diagnosis and treatment) particularly when working independently - Poor understanding and support of the role Development of MH services in Australia - - Began in early 1800s - First came Tarban Creek Lunatic Asylum now called Gladesville Hospital - All states opened an asylum - Lunacy Act developed standards of care for mental health consumers - Mid 1800s saw this become established widespread employing male attendants (warders) - Early-mid 1900s saw the Nursing Federation increase nursing positions and mental health as a speciality - In the 1950s came the first psychotropic medications which were associated with effects such as sedation - Deinstitutionalisation (1950s) - Burdekin report (1993) raised public awareness of human rights violations in MH population - HREOC (Human Rights and Equal Opportunity Commission) established, still in use Deinstitutionalisation - - Dismantling of MH institutions upon noticing their limited efficacy. Inadequate funding left large numbers of people without follow up care and homeless, or incarcerated (transinstitutionalisation) 5 Strategies of the MH Plan - 1. 1992: Mainstreaming of MH services, introduction of priority areas e.g. MH workforce, consumer rights, standards and legislation 2. 1998: Awareness and stigma reduction (depression and anxiety), partnerships and prevention 3. : Widening spectrum of MH services to more districts, health promotion, modernisation of facilities 4: : Population health framework (SDH and vulnerability due to demographic, early intervention) 5: 2017: Measurable improvements across 7 priority areas (e.g. suicide prevention, Aboriginal and Torres Strait Islander People's health, stigma, safety and quality in MH care) 5th NMHP (2017) and RN's role - - New priority areas (e.g. suicide prevention, Aboriginal and Torres Strait Islander People's health, stigma, safety and quality in MH care) - Language reorientation (compliance - adherence) - Strengths-based rather than deficits - Values - Lived experience - Rehab - recovery (living well) - RN to aid consumer to engage in the activities or tasks through which most people's needs are met, and to use EBP models e.g. the recovery model, trauma-informed care Assessing physical and mental health care - - Cardio-metabolic monitoring on all pts taking anti-psychotics or mood stabilisers: BMI, waist circ. 94 European men, 80 all women, HDL, LDL, BGL (fasting and random), TG, BP - Nutritional assessment: give Guide for Healthy Eating - Sleep assessment: give Sleep Right factsheet, use Pittsburgh Sleep Quality Index - Physical activity assessment: give guidelines, International Physical Activity Questionnaire (IPAC) - Substance use: Fagerstrom Nicotine Dependence test If metabolic syndrome present, it must be documented and interventions implemented.