Essential mental health nursing skills
Mental health assessment [link]
Physical health assessment [link]
Care planning [link]
Psychosocial interventions with individuals [link]
Psychosocial interventions with families [link]
Working in groups [link]
Working with users and carers [link]
Engaging users and carers [link]
Developing, maintaining, and ending therapeutic alliances [link]
Empathy [link]
Interpersonal communication [link]
Counselling [link]
Medication management [link]
Safe and effective observation of patients [link]
Observations of vital signs [link]
Maintaining a safe environment [link]
Presenting reports of work with users at multidisciplinary meetings and case conferences [link]
Writing and keeping records of care [link]
Discharge planning [link]
Motivational interviewing [link]
Using rating scales [link]
Care of the survivor [link]
Crisis intervention [link]
Social inclusion [link]
Electroconvulsive Therapy (ECT) [link]
Challenging behaviour [link]
Occupational stress in the mental health workforce [link]
Working with homeless people with a mental health problem [link]
Working with women with mental health problems [link]
Working with people with a perceptual disorder [link]
Working with the client with a mood disorder [link]
Working with people with anxiety disorder [link]
Working with a person with anorexia nervosa [link]
Working with a person with bulimia nervosa [link]
Working with the person with substance misuse problems [link]
Principles of working with service users with substance misuse problems [link]
Assessing children and adolescents [link]
Interventions in child and adolescent mental health [link]
Working with the person with personality disorder (PD) [link]
Working with the person who uses forensic services [link]
Working with the person who is suicidal and self-harms [link]
Mental health assessment*
Assessment is an important stage in the nursing care of people with mental health problems. It involves collecting information and using it to decide on the need for, and the nature of, any subsequent mental health care. Assessing people's mental state involves judging their psychological health; this requires experience, a degree of intelligence, self-insight, social skills, objectivity, and the ability to deal with cognitive complexities. A mental health nursing assessment is often done during an assessment interview, but may be an ongoing dynamic process.
Reasons for doing a mental health assessment include:
• Identifying a person's needs.
• Assisting in developing and using appropriate interventions.
• Contributing to diagnostic accuracy.
• Defining a problem that needs solving.
What should be assessed?
The experience of mental illness
• The biological self – (
physical health care), should include BMI and urinalysis.• The behavioural self – how the person thinks, feels, and acts.
• The social self – how people interact with others, family history.
• The spiritual self – the person's hopes, dreams, and beliefs.
• The cultural self – beliefs and morals.
• Past history – of psychiatric disorder and physical health status.
• Current financial, social functioning, and environmental factors e.g. employment, benefits, living arrangements, social activities.
• Psychiatric diagnosis and current symptoms, past and present.
• Appearance and behaviour – physical appearance, reaction to situation.
• Mood – current mood and recent changes.
• Speech – rate, form, volume and quantity of information, content.
• Form of thought – amount and rate of thought, continuity of ideas.
• Thought content – delusions, suicidal thoughts.
• Perception – hallucinations, other perceptual disturbances.
• Cognition – level of consciousness, memory, orientation, concentration, abstract thoughts.
• Insight – understanding of condition.
• Sexual health – sexual activity, contraceptive use, substance use.
Methods of data collection during assessment
Interviews
Gathering information through questioning. The goal of the interview is to describe, diagnose, and begin the therapeutic relationship. The aims of the interview are to build trust and identify needs.
Rating scales
These are often used with interviews, as part of a mental health assessment. Some commonly used rating scales in mental health assessment are as follows:
• The Short Form-12 (SF-12) – a measure of general mental and physical health.
• The Health of the Nation Outcome Scale (HoNOS) – a measure of 12 categories of behaviour and mental state linked to mental health status.
• Brief Psychiatric Rating Scale (BPRS) – a measure of psychiatric symptoms.
• Beck Depression Inventory (BDI) – a measure of depressive symptoms.
• Side-effects Checklist (SEC) – a measure of side-effects of drugs commonly used in psychiatry.
• Suicide Assessment and Management (SAM) – a measure of suicidal intent and previous self-harming behaviour.
• Social Functioning Scale (SFS) – a measure of day-to-day functioning that can be impaired by mental health problems.
• Carers’ Assessment of Managing Index (CAMI) – a measure of stress and coping in people caring for people with mental health problems.
Using rating scales
Further reading
Andrews, G, Jenkins, R (eds.). Management of Mental Disorders, UK edn. Sydney: WHO Collaborating Centre for Mental Health and Substance Misuse, 1999.
Find This Resource
Barker, PJ. Assessment in psychiatric and mental health nursing: in search of the whole person, Nelson Thornes: Cheltenham, 1997.
Find This Resource
Norman, I, Ryrie, I. The Art and Science of Mental Health Nursing. Open University Press: Buckingham, 2004.
Find This Resource
Physical health assessment*
The assessment of a patient's physical health is important because some mental health interventions, such as drugs, may cause physical side-effects. People with mental health problems often have an increased risk of physical health problems, and they can exacerbate mental health problems. Assessing physical health provides a baseline indicator against which future changes in health can be assessed.
Types of assessment
Mini assessment
An overview of the patient's physical health, focusing on airway, breathing, circulation, appearance, level of consciousness, and vital signs. Any recent contact with other health care professionals.
Comprehensive assessment
This involves a detailed assessment of a patient's physical health, risk factors, and medical history.
What is assessed?
During a routine physical health assessment the following are looked at:
Temperature
– a Tempa-Dot™ is used. 1 minute for oral, 3 minutes for axilla, or tympanic thermometer (electronic hand held device for measuring the body temperature through the ear, usually recorded after a few seconds). It is recommended that mercury thermometers are not used as they are a potential hazard for cross infection and risk management.
Pulse
– the number of beats per minute, the rhythm (regular or irregular) and the volume (how strong it feels) is checked. The pulse can be felt in any artery that passes over the surface of a bone, e.g. radial, femoral, carotid.
Blood pressure
– is vital to ensure the patient's safety. It is measured by a sphygmomanometer and has two values: systolic when the heart contracts and diastolic when the heart relaxes. The normal range for adults is 100/60 to 150/90 depending on age. It varies with age in children.
Weight and height
– exact measures, body mass index (BMI), measurements against standards for sex and ethnic group.
Skin integrity
– check for bruises, cuts, appearance and elasticity of skin, risk of pressure ulcers, oedema.
Care planning*
Following an accurate assessment, the next stage in the care process is care planning. The needs that are identified during the assessment stage form the basis of the care plan. A care plan is a written account of how the patient's needs will be met. A well-designed care plan should involve working in partnership with the patient to agree the desired objectives and identify the actions necessary to achieve these objectives. It should provide a rationale for the agreed action, and outline criteria against which to measure progress towards the objectives.
Setting care plan objectives
It is easier to set and evaluate objectives if they are SMART – specific, measurable, achievable, realistic, and time oriented. If there are several objectives it may be necessary to prioritize them – and this should be agreed, where possible, with the patient. Each objective may be part of the achievement of a longer-term goal; it may be useful to state the long-term goal first.
An example of a SMART objective with action designed to achieve the objective, and a proposed evaluation of progress, is shown in the table below, using the fictional character of David. He has recently been unable to attend work because he is unhappy, he prefers to stay in bed most of the day, and is neglecting his personal hygiene. As a result he is very distressed.
Need | Objective | Action | Rationale | Evaluation |
|---|---|---|---|---|
David needs to get out of bed each day and have a shower. | David will be able to get out of bed each day for 5 days, and take a shower. | David will set his alarm for 9am each day. | By setting the alarm, David will be reminded of his objective to get out of bed and take a shower. | By the end of 5 days David will have got out of bed each day and taken a shower. |
Long-term goal: David will return to full-time work within 6 months.
Tips in care planning
• Work in partnership with the patient where possible.
• Use non-judgemental, user-friendly language.
• Use statements that will have meaning for the patient.
• Set measurable and achievable goals.
• Always indicate a date for evaluation/review.
• Make it clear exactly what action is required and by whom.
Assessing the quality of nursing care plans: Evaluation of Nursing Documentation Schedule (ENDS)1
The ENDS is a device for assessing the quality of nursing care plans. The ENDS has five sections pertaining to different parts of the care plan: Assessment, Planning, Problem Identification and Objective Setting, Evaluation, and Discharge Planning. The ENDS has 40 questions, the answers to which determine an overall score indicating the quality of the care plan.
Psychosocial interventions with individuals*
Psychosocial interventions (PSI) have been developed for people with serious mental illness. They are offered as part of a comprehensive care package that usually includes medication.
Definition
The term psychosocial intervention describes a number of interventions for psychosis that are based on psychological principles, but also address the individual's social context. These include evidence-based interventions such as assessment, psychological management of symptoms, and medication management.
Aim
The overall aim is to reduce the distress associated with symptoms by improving the person's ability to cope, and thereby promoting recovery.
Models
Two key models inform psychosocial interventions:
•
The stress-vulnerability model of psychosis
describes how stress impacts on psychotic symptoms.•
The cognitive behavioural model
informs the psychological management of symptoms.
Engagement and assessment
Engagement
is the process of developing a working relationship by addressing issues that the patient identifies as important.
Assessment
focuses on strengths as well as problems, and uses these to develop coping strategies and interventions.
Validated assessment tools are used to assess areas such as mental state, psychotic symptoms, social functioning, and the side-effects of medication. The identification of symptoms such as anxiety or depression will need further assessment.
Formulation
Formulation considers the relationship between symptoms and problems. For example, is anxiety the result of hearing voices or does feeling anxious lead to hearing voices?
The relationship between experiences is not always clear, and it is important not to rush the assessment stage.
Coping strategies
Nurses can use a range of interventions to help people cope with symptoms, for example, using a personal stereo or MP3 player to drown out voices is a pragmatic intervention. Coping strategy enhancement is a highly structured intervention that involves a detailed analysis of strategies currently being used, and replacing or adding other strategies in a systematic manner.
Psycho-education
This includes exploring beliefs about the nature of schizophrenia using the stress vulnerability model as a guide.
Psychosocial interventions with families*
Family interventions were developed for work with families of people with schizophrenia. A significant body of evidence supporting this work has been developed over forty years; although some services have been slow to offer family interventions.
Families play an important role in supporting and caring for people experiencing psychosis. Often they do this with little or no support from professionals.
Definitions
The term ‘family’ is used loosely, to refer to relatives, partners, carers, or people who are significant to an individual experiencing psychosis. In some cases this might include staff, such as hostel workers.
Family interventions include education, communication, and problem solving and draw on behavioural and cognitive behavioural models. They aim to reduce the risk of relapse as well as provide support to families.
Working with families
It is recommended that two members of staff work with a family. This enables the modelling of good communication. Sessions are offered in the family home, as this makes it easier for family members to attend.
Assessment
Each member of the family is assessed in relation to their understanding of the causes, symptoms and treatment of psychosis. Some families have limited understanding of these issues; and identifying their beliefs is an important part of the process.
Education and information
The findings from assessment are used to tailor specific educational sessions, so that families are not given information with which they are already familiar. Information can be provided through leaflets that the families are asked to read, and followed up by discussion.
Communication
Good communication can help to reduce stress, and improve problem solving. Ground rules are set regarding communication within sessions, such as members speaking directly to each other, rather than talking about each other, and taking it in turns to speak. Family members are encouraged to praise and support each other, with the aim of building a more supportive emotional climate.
Working in groups*
The therapeutic work of mental health nurses is often done in groups. Groups have advantages in that they are often time and cost-effective, and can provide multiple sources of feedback. This chapter outlines how nurses can work effectively in groups.
Factors that influence the successful running of groups
Trust
– people are more likely to participate in a group if they trust the group process and feel safe in sharing information with others in the group.
Stages in forming and running a group
Selecting members
Agreeing ground rules, a group contract and terms of reference e.g. goals, time, length, and frequency of meetings, location, start and end dates, addition of new members, attendance, confidentiality, member interaction outside the group, role of group facilitator and participants, and where necessary, fees and expenses.
Facilitating the group
Skills in facilitating groups include: ensuring adherence to ground rules, encouraging and enabling member's participation, fostering an atmosphere of open discussion, setting boundaries, confronting people who may be assuming self-serving roles or acting in a manner that is harmful to the group.
Factors that could inhibit the success of a group
• Absenteeism
• Incapacitating anxiety
• Failure to end as agreed
• Lack of containment of difficult issues
• Hostility
• Failure to facilitate hope
• Dependence
• Group members forming into small cliques
• Group members projecting ideas and behaviours onto others
• Focusing on issues external to the group
• Rivalry
• Substance use
• Self-harming behaviours
• Regression i.e. adult members behaving in a child-like manner.
The effectiveness of groups
There is evidence from well-designed studies that group therapy leads to successful outcomes for people living with mental health problems including depression, anorexia nervosa, schizophrenia, alcohol dependency, and suicidal adolescents.
Further reading
Kneisl, CR, Wilson, HS, Trigoboff, E. Contemporary Psychiatric Mental Health Nursing. Pearson Prentice Hall: New Jersey, 2004: pp. 683–97.
Find This Resource
Roth, A, Fonagy, P. What Works for Whom? A critical review of psychotherapy research, 2nd edn. The Guildford Press: New York, 2004.
Find This Resource
Working with users and carers*
The involvement of service users and carers in mental health nursing is an increasingly important – and audited – measure of quality.
Why involve service users and their carers?
The reasons for involving service users and carers are well understood, and include:
•
The moral imperative
– as citizens and ‘owners’ of the NHS, service users and carers are entitled to have a voice in all aspects of their health care.•
Quality improvement
– involvement of service users and carers in education (and research) can lead to deeper clinical insight, resulting in changed attitudes and an improvement in delivered care.•
The political impetus
– there is a policy drive towards the inclusion of these ‘experts through experience’ in many aspects of health and social care.
Best practice
Best practice in service user and carer involvement is:
• Cooperative – working in partnership as equals.
• Comprehensive – across all components of education.
• Effective – ensuring meaningful change.
• Ongoing – across the lifespan of the programme.
• Inclusive – representative of all stakeholders.
• Reflexive – critically considering its own ongoing work.
Best practice also includes health care professionals valuing the experience of service users, and recruiting service users into education and training.
The nature of user and carer involvement
In practice, involvement may range from consultation, through collaboration, to service user and carer control.
Consultation
Service users and carers are consulted with no sharing of power in decision-making, although their views may influence the outcome.
Collaboration
An active partnership of service users and carers in the educational process and decision-making.
User and carer control
Service users and carers have overall control, although there is a valid place for professional involvement.
Cooperation and continued input are more likely to occur if service users feel that their contribution is valued; implementation of an involvement strategy is more likely to be successful if it is actively driven and supported by management.
Practical considerations
Remuneration
Payment for time and expertise (with reimbursement for all expenses) is considered best practice. However, the practicalities may be difficult, not least because payment may impact adversely on benefit payments. A useful starting point is A Fair Day's Pay by The Mental Health Foundation (www.mentalhealth.org.uk).
Clarity
It may be helpful for active user and carer contributors to have an explicit ‘job description’ to clarify their responsibilities and commitments.
Further reading
James, L, Morris, N. Good Practice Guide: Involving Service Users and Carers in Local Implementation Teams (LITs). NWMDHC: Manchester, 2001: Foreword.
Find This Resource
Simpson, EL, House, AO, Barkham, M. A Guide to Involving Users, Ex-Users and Carers in Mental Health Service Planning, Delivery or Research: A Health Technology Approach, Academic Unit of Psychiatry and Behavioural Services, University of Leeds: Leeds, 2002.
Find This Resource
Engaging users and carers*
Mental health nurses should be working in partnership with users and carers in the delivery of mental health nursing. The relationship between users, carers and practitioners is fluid; it could be one of collaboration with users and carers, consultation with users and carers or a user-led approach.
Getting users and carers involved
Tokenism
Tokenism should be guarded against – it is not cost effective and it impacts negatively on individuals and their constituencies. The extent to which any initiative is felt to be tokenistic should be under continual review.
Representation and diversity
The ‘representativeness’ of service users and carers is often questioned. While absolute representativeness is not achievable (even with respect to lecturers or researchers), working solutions can be found. An important principle is accessing a diverse local set of service users and their carers.
The ‘professionalized’ user
There is risk that certain groups or individuals will be ‘overused’. A useful approach is for new people to be consistently and regularly approached and recruited.
Approaching users and carers
Attention should be paid to local need and the structure of individual service provision. A useful example is ‘Ask the Experts’, from the Community Care Needs Assessment Project (CCNAP – see Further reading). Care needs to be taken to include groups who have previously been marginalized, e.g. by ethnicity.
Engaging users and carers
•
Introductions
– check the person's name, introduce yourself, state what your role is, the aim of the interaction and the time allotted.•
Use non-verbal skills
– such as suitable posture, eye contact, facial expression, tone of voice.•
Listen actively
– avoid interruption, pay attention, be non-judgemental, do not give direct advice, clarify anything that is unclear, provide enough time, do not undermine the person's problem.•
Use verbal skills
– paraphrase, that is, repeat back to the person what they have said, reflect on the feelings that may underpin any verbal statement, be empathic and convey your understanding of the impact of what the person is saying.•
Protect confidential information
– however, be mindful that you will need to breach confidentiality if it is in the person's or in the public's interest to do so, on the grounds that there may be harm to the person or others. The NMC Code of Professional Conduct ( chapter 1) provides guidance on this issue. For child protection issues check the Department of Health Guidelines on www.dh.gov.uk
Core attitudes and values for work with users and carers
• Communicate respect
• Communicate empathy
• Communicate genuineness
Developing, maintaining, and ending therapeutic alliances*
Mental health nursing is based on forming therapeutic relationships between nurses and service users.
Core attitudes and values in working with users and carers2
• Communicate respect
• Communicate empathy (
Empathy)• Communicate genuineness.
Developing a therapeutic alliance2
• Check the person's name and how they like to be addressed
• Introduce yourself
• State your role
• State the aim of the interaction
• State the time allotted
• Agree ground rules for acceptable and unacceptable behaviours (see below).
Setting clinical boundaries2
•
Behaviour
– do not give presents, make sexual contact or communicate in a sexual manner, or reveal highly personal information about yourself.•
Language
– profanities or swearwords should be avoided by both the service user and the nurse.•
Touch
– avoid any touching beyond a handshake.•
Space
– the health care setting is usually the most appropriate place to meet. If you work with the person in another setting, be mindful of safety issues, and the need to respect the fact that you are a guest.
Maintaining the therapeutic alliance2
•
Use non-verbal skills
– such as a suitable posture, eye contact, facial expression, or tone of voice.•
Listen actively
– pay attention, do not interrupt, be non-judgemental, do not give direct advice, clarify anything that is not clear, provide enough time, do not undermine the person's problem.•
Use verbal skills
– paraphrase i.e. repeat back to the person what they have said, reflect on the feelings that may underpin any verbal statement, be empathic and convey your understanding of the impact of what the person is saying.•
Protect confidential information
– but be mindful that you will need to breach confidentiality if it is in the person's or the public's interest to do so, if there may be harm to the person or others. The NMC Code of Professional Conduct ( Chapter 1 on the Mental Health Act) provides guidance on this issue. For child protection issues check the Department of Health Guidelines on www.dh.gov.uk.
Ending the therapeutic alliance
• Prepare the person for the end of the alliance.
• End the alliance in a manner that does not leave unresolved tensions or problems.
• End when the goals agreed at the beginning have been achieved.
• Leave the person feeling optimistic and hopeful.
Empathy*
Empathy is a therapeutic response that shows a service user that you understand what they are going through, without needing to go through it yourself.
Empathy involves
• Understanding a person's perception of their experiences.
• Accepting how the person sees him or herself.
• Understanding and validating the person's experience.
• Examining the meaning of what the person says and the feelings he or she is conveying.
• Communicating your understanding verbally so that person can confirm or alter your perceptions.
• Communicating your sensitivity of the person's experience.
The purpose of empathy3
• It demonstrates care and understanding.
• If you form inaccurate impressions of someone, they can correct you.
• It helps to focus the discussion onto what is important.
• It enables people to share their experiences with you.
• It minimizes misunderstandings, prejudice and negative assumptions.
• It promotes therapeutic alliances.
Five levels of empathy3
•
Inaccurate reflection
– e.g. conveying sympathy, being judgemental.•
Correcting your misunderstandings
– e.g. understanding the feelings associated with the person's experience.•
Expressing understanding by communicating empathic responses
– see above.•
Enhancing the person's understanding
– enabling them to improve their own awareness and insight.•
Insight
– demonstrating a high level of insight of the meaning of the person's experiences.
Active listening and empathy4
Empathy requires the activity to actively listen.
An active listener:
• Does not interrupt.
• Pays attention.
• Is non-judgemental.
• Does not give direct advice.
• Clarifies anything that is unclear.
• Allows adequate time.
• Does not undermine the person's problem.
References
4
Myles, P, Richards, D. Clinical Skills for Primary Care Mental Health Practice. In: Primary Care Mental Health [CD-Rom 3]. Centre for Clinical and Academic Workforce Innovation, University of Lincoln: Lincoln, 2006.
Find This Resource
Interpersonal communication*
Interpersonal communication is an interaction between people in which they convey their thoughts, feelings, emotions, and behaviour.
The functions of interpersonal communication
(see www.abacon.com)
• To gain information.
• To transmit information.
• To develop your understanding of something.
• To establish your identity role.
• To convey meaning.
• To express your needs.
• To control others.
• To stimulate yourself and relieve boredom.
Forms of interpersonal communication5
Ways to improve your interpersonal communication skills
Listen actively ( Engaging users and carers)
• Convey empathy
• Use non-verbal and verbal techniques (see above)
• Practice the skills
• Solicit feedback from others.
Counselling*
Counselling is a form of therapeutic communication designed to enable people to recover from distressing mental health experiences. It should be routinely considered as an option when assessing mental health problems, but is not recommended as the main intervention for severe and complex mental health problems such as personality disorder.
There are many forms of counselling, and each one comes from a different therapeutic tradition. In this chapter we will focus on Cognitive Behavioural and Humanistic counselling.
Cognitive behaviour therapy (CBT)
How effective is CBT?
• CBT was superior to befriending, especially in the long term in people with persistent symptoms of schizophrenia, which are resistant to medication.
• CBT plus standard care was better than standard care alone in reducing relapse rates in people living with schizophrenia.
• CBT significantly benefits physical functioning in adult outpatients with chronic fatigue syndrome (CFS) when compared with relaxation or medical management.
• CBT is beneficial for anxiety disorders, phobias, OCD, chronic pain, PTSD, depression, and chronic fatigue.
Humanistic therapy (HT)
What is HT?
Humanistic therapy derives from humanistic psychology, the so-called ‘third force’ in psychology (after psychoanalysis and behaviourism).
HT is based on a set of four basic principles:
• The experiencing person is of primary interest.
• Human choice, creativity, and self-actualization are the preferred topics 2° of investigation.
• Meaningfulness must precede objectivity in the selection of research problems.
• Ultimate value is placed on the dignity of the person.
There are different forms of humanistic therapy, but most emphasize the person's natural tendency towards growth and self-actualization. Psychological disorders arise from blocks to the person's attempts to reach their potential. These blocks may be imposed by others who want us to lead lives directed by them. The goal of humanistic therapy is to enable the person to arrive at their own solutions to problems.
It is believed that the main qualities of the humanistic or client-centered therapist are warmth, empathy, and genuineness. The term ‘unconditional positive regard’ has been used to reflect the therapist's stance.
The process of HT
Assessment | Treatment | Evaluation |
|---|---|---|
|
|
|
Indications for HT
Like CBT, HT has been applied to a range of health problems. HT is probably best suited to those who are ready and willing to engage in therapy, who are interested in their inner experience, and who have good social skills and a high need for intimacy.
How effective is HT?
• HT was better than no treatment or waiting list controls, the average client would move from the 50th to the 90th percentile when compared with a pre-therapy sample.
• HT produced more favourable outcomes in clients with relationship problems, anxiety or depression; it produced less favourable outcomes in clients with chronic or more severe problems, like schizophrenia.
Further reading
Department of Health. Treatment choice in psychological therapies and counselling. DoH: London, 2001.
Find This Resource
Jones, C, Cormac, I, Mota, J, Campbell, C. Cognitive behaviour therapy for schizophrenia (Cochrane Review). In: The Cochrane Library, issue 2. Update Software: Oxford, 2000.
Find This Resource
Medication management*
Medication for mental health problems should be part of a package of care. Helping clients to manage their prescribed medication is essential to ensure that the maximum benefits of treatments are realized. There is compelling evidence that psychiatric medications are effective in reducing the distress associated with symptoms; but taking medication for a sustained period is difficult for service users. About half of all users will stop taking medication in the first year, resulting in a poorer outcome.
A variety of factors influence whether or not medication is taken regularly. The process of managing medication should be a collaboration between the client and the professional, aiming to remove barriers to adherence and maximize the positive effects of treatment. A process of assessment and intervention should follow.
Assessment
Psychopathology
– irrespective of the type of psychiatric medication prescribed, an assessment should be carried out to provide a baseline measurement of symptoms. This assessment should be repeated at relevant intervals to provide a quantitative measure of change and to measure the durability of improvements.
Side-effects of medication
– all medications cause side-effects and if these are distressing, the client will find taking it very difficult. An assessment of side-effects is required to identify those that require intervention. Repeated measurement identifies any improvements.
Client's views of treatment
– a client's ideas about medication will influence how they will engage in treatment. An assessment of ambivalence can indicate the need for intervention (see below).
Useful assessments include
• Liverpool University Neuroleptic Rating Scale – LUNSERS
• Satisfaction With Antipsychotic Medication Scale – SWAM
Interventions
Side-effects
– distressing side-effects should be reduced or eliminated. The appropriateness of the prescription should be evaluated in line with prescribing guidelines. Dose rescheduling to reduce the impact of side-effects can be beneficial, as can practical advice such as early exercise and healthy eating to reduce the likelihood of weight gain.
Exploring views about treatment
– everybody has some ambivalence about whether or not to take medication, and this uncertainty is apparent in people who take psychiatric medication. The good things and the not so good things about taking medication can be explored with the client. The good things and the not so good things about stopping medication should also be explored. This approach helps the client to examine their personal beliefs, and it can help to reinforce the belief that the benefits of taking medication outweigh the costs.
Further reading
Gray, R, Bressington, D. Pharmacological interventions and ECT. In: I Norman, I Ryrie (eds.) The Art and Science of Mental Health Nursing: A Textbook of Principles and Practice. Open University Press: Buckingham, 2004: pp. 306–28.
Find This Resource
Nose, M, Barbui, C, Gray, R, Tansella, M. Meta-analysis of clinical interventions for reducing treatment non-adherence in psychosis. British Journal of Psychiatry 183: 197–206, 2003.
Find This Resource
Safe and effective observation of patients*
The observation of patients at risk is a key component of psychiatric inpatient nursing care. It is a commonly used nursing intervention for patients ‘at risk’, and involves the allocation of one nurse (or sometimes two) to one patient for a prescribed length of time, in order to provide intensive nursing care.
Definition
According to the SNMAC practice guidance: Safe and Supportive Observation of Patients at Risk6, observation is defined as:
‘regarding the patient attentively while minimizing the extent to which they feel that they are under surveillance’ (p. 12)
Purpose of observation
The main purpose of observation is to keep people safe when they are acutely mentally ill and disturbed. This is especially important for patients who are assessed to be at risk of harming themselves or others, or at risk of being harmed or exploited by others.
Observation is typically used for patients who are:
• Suicidal or actively interested in harming themselves
• Aggressive and who pose a danger to staff or other patients
• Vulnerable
• Prone to abscond
• Sexually disinhibited.
Terminology of observation
There is no universal term to describe observation. The procedure is known by several different terms, for example: special, close, maximum, continuous or constant observation, attention or supervision; suicide watch or precaution; 15 minute or intermittent checks; specialling; one-to-one nursing; nursing observation; and formal observation.
Conducting observation
Observation is generally carried out according to different prescribed levels, which vary in intensity according to the degree of perceived risk. Patients assessed to be at greatest risk of harming themselves or others are nursed on the highest level of observation, with patients never being left alone, and the nurse often within ‘arms reach’ of the patient. The challenge for nurses who conduct observation is to maintain the safety of ‘high risk’ patients, whilst maintaining their dignity, privacy, and autonomy.
The decision-making process
Decisions about observation should be made jointly, by the multi-disciplinary team. Decisions should be based upon an assessment of risk, using an evidence-based risk assessment tool, consideration of the patient's history and an interview with the patient and their carer or advocate (as requested by the patient).
Involving the patients and carers in observation
Every effort should be made to involve patients and their carers/friends in the decision-making process, making certain that the procedure of observation and the reasons for its implementation are clearly explained, and ensuring that the observation is conducted in a way that is both supportive and therapeutic.
Observations of vital signs*
Patient observations are an important part of nursing care. They allow the patient's progress to be monitored, and they also ensure prompt detection of adverse events or delayed recovery. Patient observations, or vital signs, traditionally consist of blood pressure, temperature, pulse rate, and respiratory rate. These signs may be observed, measured, and monitored to assess an individual's level of physical functioning. Normal vital signs change with age, sex, weight, and exercise tolerance.
Temperature
Temperature can be measured in many locations on the body. The mouth, ear, axilla, or rectum are the most commonly used places. Temperature can also be measured on the forehead.
Most people think of a ‘normal’ body temperature as an oral temperature of 37°C. This is an average of a range of normal body temperatures. A person's actual temperature may be 0.6°C above or below 37°C. Normal body temperature changes by as much as 0.6°C throughout the day, depending on activity levels. A rectal or ear (tympanic membrane) temperature reading is 0.3 to 0.6°C higher than an oral temperature reading. A temperature taken in the armpit is 0.3 to 0.6°C lower than an oral temperature reading.
Body temperature is checked to:
• Detect fever (above 37.8°C oral, 38.3°C ear or rectal).
• Detect abnormally low body temperature (hypothermia) in people who have been exposed to cold, shock, alcohol or drug misuse, or infection in frail or elderly people.
• Detect abnormally high body temperature (hyperthermia) in people who have been exposed to heat, causing severe dehydration leading to confusion and delirium.
• Help monitor the effectiveness of a fever-reducing medication.
Respiration
Normal respiration is 15–20 breaths per minute on average. Respiration will vary according to activity level, emotional state, and the use of illicit substances.
Pulse
A normal pulse is 60–80 beats per minute (bpm) at rest. The normal pulse for an adult male is about 72bmp. For an adult female it is 76–80bpm, and 50–65bpm for an elderly person.
Blood pressure
Blood pressure is determined by the amount of blood your heart pumps around your body and the amount of resistance to this blood flow in your arteries. Blood pressure normally varies during the day. It is continually changing, depending on activity, temperature, diet, emotional state, posture, physical state, and medication use.
Blood pressure readings
Blood pressure readings are usually given as two numbers: for example, 110 over 70 (written as 110/70). The first number is the systolic blood pressure reading; this represents the maximum pressure exerted when the heart contracts. The second number is the diastolic blood pressure reading. This represents the pressure in the arteries when the heart is at rest. The ‘average’ blood pressure increases from 120/70 to 150/90 with age.
Procedure for taking blood pressure
• The patient should be seated, have rested for 5 minutes and have their arm supported at heart level.
• An appropriate cuff size should be used, and the bladder should nearly (at least 80%) or completely encircle the arm.
• Patients should not have smoked or ingested caffeine within 30 minutes of measurements being taken.
• Measurements should be taken with a mercury sphygmomanometer, a recently calibrated aneroid manometer, or a calibrated electronic device.
• Both systolic and diastolic blood pressure should be recorded.
• Korotkoff's phase V (disappearance of sound) should be used for the diastolic reading.
Maintaining a safe environment*
People using mental health services should feel:
Essence of care benchmarks for best practice in maintaining safety
Factor | Benchmark for best practice |
|---|---|
Orientation to the health environment | All users are fully orientated |
Assessment of risk to self | All users have a comprehensive, ongoing assessment of risk to self with involvement of client and significant others |
Assessment of risk to others | All users have a comprehensive, ongoing assessment of risk to others with involvement of client and significant others |
Balancing observation and privacy in a safe environment | Users are cared for in an environment that balances safe observation and privacy |
Meeting clients’ safety needs | Users are regularly and actively involved in identifying care that meets their safety needs |
A positive culture to learn from complaints and adverse incidents | There is a no-blame culture which allows a vigorous investigation of complaints and adverse incidents and near misses and ensures that lessons are learnt and acted upon |
The role of the mental health nurse
The mental health nurse helps to maintain a safe environment for the user by:
• Orientating the user to the environment.
• Working with the user to assess any risk to self and others.
• Identifying safety risks and taking immediate action to remove those risks.
• Setting SMART (Specific, Measurable, Achievable, Realistic, and Time-oriented) care plan objectives to maintain and promote the safety and well-being of users.
• Carrying out agreed interventions to ensure the safety of users and others at all times.
• Reviewing the care plan at agreed intervals to ensure that objectives are being met.
• Modifying the care plan where required, to ensure that objectives are maintaining the user's safety and well being.
• Keeping accurate written records of care provided, to maintain the user's safety and well-being.
Further reading
Department of Health. Essence of Care: patient-focused benchmarking for health care practitioners. DoH: London, 2001.
Find This Resource
Department of Health. Safety First: five-year report of the national confidential inquiry into suicide and homicide by people with mental illness. DoH: London, 2001.
Find This Resource
Presenting reports of work with users at multidisciplinary meetings and case conferences*
Mental health nurses are often called upon to present reports of their work with users in multidisciplinary meetings such as ward rounds and case conferences.
Common features of all reports
• They present facts based on evidence.
• Information provided can be checked and verified.
• Information should be presented in a useful manner.
• They are usually targeted at those with a specific interest in the topic.
Preparing and writing reports
• Gather the information that is required in a systematic manner.
• Use information from as many sources as is needed for a comprehensive and accurate report.
• Work in partnership with users and their significant others in compiling a report.
• Be factual and precise.
• Avoid abbreviations that will not be readily understood by others.
• Avoid jargon and gobbledygook.
• Avoid irrelevant speculation.
• Avoid offensive subjective statements.
• Write in way that can be easily understood.
• Use evidence and/or examples to support statements or judgements.
• Use examples to clarify or illustrate the information.
• Consider the purpose of the report.
• Consider your audience.
Presenting the report
• Be assertive.
• Speak clearly, calmly, and slowly.
• Avoid over-elaboration.
• Stick to your proposed task.
• Invite questions and comments.
• Be respectful of others.
• Stick to the time agreed.
• Make clear recommendations.
• Summarize main points at end.
• End with a clear take-home-message.
Writing and keeping records of care*
Nurses have a professional responsibility to keep accurate records of the care they provide. The NMC acknowledge that record keeping is fundamental to nursing and provides guidelines for nurses on records and record keeping.
The importance of record keeping
• Helps to protect users’ safety, health, and well-being.
• Promotes effective communication between different agencies involved in the care of users.
• Provides a written account of the care and treatment provided.
• Reflects the professional standing of nursing.
• Often the sign of a capable and safe nurse.
• May be used in legal proceedings and complaints.
• Needed for audit and risk management purposes.
• May be used for teaching and research purposes.
The content and style of records (NMC, 2002)
• Be factual, consistent, and precise.
• Write as soon as possible after an event has occurred.
• Write clearly and in such a manner that the text cannot be erased.
• Write the date, time, and sign all entries.
• Alterations should be dated, timed, and signed in a way that the original entry can still be read.
• Do not use abbreviations, jargon, meaningless phrases.
• Do not use irrelevant speculation.
• Do not use offensive subjective statements.
• Write entries, where possible with the involvement of users and their significant others.
• Write in way that can be understood by any reader.
• Write entries consecutively.
• Identify problems that have arisen and any action to rectify them.
• Provide clear evidence of the assessment, care planned, actions taken, information shared, and evaluation.
Access to, and storage of, records
Records held on users must be stored safely and securely and unauthorized persons will not normally be allowed access to these records. The Access to Health Records Act (1990) defines the rights of access of users to records held on them. The Data Protection Act (DPA) 1984 provides guidance on the safe and secure storage of information held about patients. Mental Health Nurses should not breach the DPA when holding records of users.
Discharge planning*
Discharge planning is an essential component of mental health care, and one in which nurses play an active role. The Care Programme Approach (CPA) is the basis of caring for people with mental health problems; and planning for their discharge from hospital is central to its success. Effective discharge planning is especially important for users discharged on enhanced CPA.
The role of the mental health nurse
• Build discharge planning into care plans at the earliest opportunity.
• Contribute to CPA meetings that prepare the user for discharge.
• Work in partnership with the user and significant others in planning for discharge.
• Take a graded approach to discharge planning, e.g. accompanied visits to home and other facilities that the user will participate in after discharge.
• Liaise with other members of the care team and other agencies to ensure accurate and adequate exchange of information.
• Ensure the user has an adequate supply of medication post-discharge.
• Keep accurate written or electronic records of care provided.
• Ensure that users and significant others have details of who to contact in the event of problems after discharge.
The mental health nurse as care coordinator
• Oversee care planning and resource allocation.
• Keep in close contact with the user and significant others.
• Advise other members of the care team about changes in a user's circumstances that may warrant review.
• Update the user's care plan and crisis plan.
Motivational interviewing*
Motivational interviewing (MI) is a counselling method that is used in a range of health and social care settings and is designed to change health behaviour. MI is essentially client-centred, but it has a directive momentum, with the client presenting their own arguments for changing their behaviour. It is based on a collaborative alliance between the therapist and the client.7 MI owes much to the work of Carl Rogers.8
Indications
MI is widely used in the treatment of problematic substance use, including smoking cessation; in treatment for lifestyle-related health problems, such as heart disease; and within the criminal justice system.
What does the therapist or counsellor do?
The focus of MI is not on the therapist's arguments for change, but rather on the client's own agenda. The client's own motivation for changing their behaviour is developed and worked on. By avoiding arguments, expressing empathy, supporting self-efficacy, and ‘rolling with resistance,’ an atmosphere of trust and acceptance is developed, where concerns about the behaviour can be explored.
It is important that the client is aware of the consequences of continuing the problematic behaviour. The therapist seeks to enable the client to highlight the discrepancy between what they want to achieve, and their current behaviour, highlighting how changing their behaviour will help them to achieve important goals.
The belief that change is possible is an important factor, and the instillation of hope is crucial.
Skills and techniques for MI
• Skilful reflective listening.
• Use of open ended and explanatory questions.
• Reflecting back information to the client as a statement, not a question.
Phases of motivational interviewing
•
Eliciting phase
– the therapist elicits self-motivating statements from the client.•
Information phase
– the therapist actively seeks information from the client and may introduce a decision matrix.•
Negotiation phase
– the therapist must value all decisions the client makes in this phase.
Eliciting self-motivational statements
A central part of the technique is listening for and reinforcing increases of positive expression in five key self-motivational areas:
• Self-esteem
• Concern about the behaviour
• Competence in other areas of the clients’ life
• Knowledge of the problem and strategies to deal with it
• Desire for change.
Using rating scales*
A rating scale is a device for measuring a person's reported state of mind or reported behaviour, performance, attitudes, intentions, abilities, personality, beliefs, cognitive functioning or style, preferences, and coping style. The term ‘rating scale’ is often used synonymously with test, inventory, questionnaire or measure.
The use of rating scales by mental health nurses
Rating scales can be useful in the following ways:
• They provide an assessment of users as a baseline, against which to measure the success of nursing interventions.
• They measure the behaviour of others.
• They report on aspects of people's state of mind or behaviour.
• During research as a tool to assess behaviour.
• During appraisal – as an assessment of performance.
Examples of rating scales used in mental health care
Rating scales are often used with interviews as part of a mental health assessment. Some commonly used rating scales in mental health are as follows:
• The Short Form-12 (SF-12) – a measure of general mental and physical health.
• The Health of the Nation Outcome Scale (HoNOS) – a measure of 12 categories of behaviour and mental state linked to mental health status.
• Brief Psychiatric Rating Scale (BPRS) – a measure of psychiatric symptoms.
• Edinburgh Post Natal Depression Scale (EPNDS) – a measure of depressive symptoms associated with childbirth.
• Beck Depression Inventory (BDI) – a measure of depressive symptoms.
• Side-Effects Checklist (SEC) – a measure of side-effects of drugs commonly used in psychiatry.
• Suicide Assessment and Management (SAM) – a measure of suicidal intent and previous self-harming behaviour.
• Social Functioning Scale (SFS) – A measure of day-to-day functioning that can be impaired by mental health problems.
• Carers’ Assessment of Managing Index (CAMI) – A measure of stress and coping in people caring for people with mental health problems.
• Nurses’ Observation Scale for In-patient Evaluation (NOSIE) – a measure of users’ state of mind and behaviour in an in-patient mental health setting.
• Nurses’ Evaluation Rating Scale (NERS) – A measure of users’ behaviour in an inpatient setting that might indicate level of dependency.
Care of the survivor*
Mental health services for survivors of violence should be part of a package of care that is founded on the needs of the individual survivor, rather than on a set of predetermined procedures. This is true whether the violence is intentional (e.g. partner abuse) or unintentional (e.g. a road traffic crash). The approach to care should be structured and contained within clear boundaries to provide psychological safety. There are many models on which care of survivors can be based; this chapter aims to provide a framework for practice.
Assessment
Assessment must be based on ‘working with’ rather than ‘doing to’ the survivor. The aim is always to avoid disempowering the client, and a non-judgemental attitude is essential from the outset. Respect for, and empathy with the client and the client's experiences are also key issues in avoiding disempowerment. Using an open and listening approach and avoiding an interrogative attitude will help the client to describe their personal experience.
Boundaries
Physical boundaries assist in containing the feelings and emotions of the client. For example;
• Timings – keep to previously agreed start and finish times.
• Location – this should be private, uninterrupted and comfortable, with the same room being used for later sessions.
Psychological boundaries are also important. For example;
• Keep all discussion with the client in the client-practitioner relationship.
• Keep discussion within the professional relationship focused on the event in question.
Personal boundaries should also be considered. For example;
• A client who has been assaulted may be very sensitive to an invasion of their personal space.
Outcome
The desired outcome is the long-term health of the client. It is therefore imperative that they are not re-victimized by whatever model of care is used. The practitioner must be aware of the possibility of the client being re-victimized by other processes such as cross examination in a court of law, or when asked by several different professionals to retell their story. A practitioner may be working with a client who is already re-victimized by the very processes that enabled them to survive. For example, in major incident management the focus may be on providing a standardized approach that could leave survivors unsupported in the first crucial hours after an event.
It is necessary to be gentle, and to allow space for the client to disclose in their own style and at their own pace.
Crisis intervention*
Many people with severe mental health problems, such as schizophrenia or bipolar affective disorder, enjoy long periods of relative well-being punctuated by episodes of acute illness. Acute episodes, or crises, can be triggered by a variety of factors, including environmental stressors.
Whilst people experience crises in individual ways, many will feel themselves overwhelmed and no longer able to cope. They may feel hopeless, have distressing thoughts or perceptual disturbances, and be unable to engage in everyday activities. People in crisis may also have thoughts of harming themselves or others, and be at risk of acting on these thoughts.
Interventions and services
Traditionally, mental health crises have been seen as problems to be managed within the hospital environment, often through the use of physical interventions including medication. However, alternatives to psychiatric hospital care have existed for many years. For example, in the UK, the Arbours Association has over three decades’ experience in running a crisis centre for people in acute distress.9 The development of user-led crisis services has also been supported by a leading charity, the Mental Health Foundation.10
In recent years, mainstream alternatives to hospital care have started to emerge, following the principle of providing services in the least restrictive environment. In the UK, new multidisciplinary crisis intervention and home treatment teams have appeared.11 These aim to provide intensive, round-the-clock services, including therapeutic psychosocial interventions, rapid prescription and administration of medication, risk assessment and management, and help with practical activities. A systematic review of the effectiveness of services of this type found that:12
Home care crisis treatment, coupled with an ongoing home care package, is a viable and acceptable way of treating people with serious mental illnesses. If this approach is to be widely implemented, it would seem that more evaluative studies are needed.
Good practice with people known to be vulnerable to crises includes the identification of early warning signs, and the construction of crisis management plans. These plans set out the actions to be taken in the event of acute episodes of ill-health. Both should be negotiated between practitioners, service users, and their carers.
Social inclusion*
People with mental health problems are among the most excluded in society. They have the lowest rate of employment of any disabled group; many have few friends and spend much of their time alone.
Social inclusion tackles this isolation and exclusion through the development of opportunities to engage in valued roles, relationships, and facilities, and support to access these opportunities.
Mental health nurses have a critical role in helping people move away from their identity as a stigmatized patient towards the role of recovering worker, student, parent, or friend, who can understand and manage their own mental health problems.
How mental health professionals can help promote social inclusion
Maintaining what people already have
People's roles and relationships are often lost through contact with mental health services. These need to be assessed from the start, so that friends, work, or college places are not lost, and a return to activities can be a planned and supported part of recovery.
Exploring new opportunities
Local listings, media outlets, and the Internet are all helpful in generating ideas about activities and facilities that might appeal to individuals, but it is also important to visit any facilities together with friends or family and find out what the expectations are before joining.
Helping individuals to access opportunities
It is helpful to plan and set targets if an individual is to meet their goals. Skills training might help develop confidence in particular situations. Adjustment of medication and ongoing support should be available at the level that is required.
Opportunities are more likely to be successful if the person is clear about what is expected, has an identified mentor or buddy, and has access to a mental health worker by phone. Time off for appointments, and appropriate adjustments to the physical environment to optimize the ability of the person to function should be negotiated from the start.
Increasing the capacity of communities
Target one particular organization and promote the inclusion of a person rather than an ‘illness’. Explain the person's problems in everyday (not diagnostic) language, allow them to talk about their worries, and provide a contact point for advice. The person is usually their own best advocate – so involve them as much as possible.
Further reading
Department of Health. Mental Health and Social Exclusion. Social Exclusion Unit, Office of the deputy Prime Minister: London, 2004.
Find This Resource
Repper, J, Perkins, R. Social Inclusion and Recovery: a model for mental health practice. Bailliere Tindall: London, 2004.
Find This Resource
Electroconvulsive Therapy (ECT)*
ECT is a procedure that involves a brief application of an electric current to the brain, through the scalp, inducing a seizure. It is typically used to treat a person who is experiencing severe depression or acute mania.
ECT remains the most controversial treatment for psychiatric illness, although it has been used since the 1940s and 1950s. Many of the risks and side-effects have been related to the misuse of equipment, incorrect administration and improperly trained staff. There is also a misconception that ECT is used as a ‘quick fix’ instead of long-term therapy or hospitalization. Unfavourable news reports and media coverage have added to the controversy surrounding this treatment. ECT is generally safe and among the most effective treatments available for intractable depression.
How ECT is done
The procedure is performed by an anaesthetist, a psychiatrist, and a qualified ECT nurse.
Before
General anaesthesia is used for this procedure, so the patient will be advised to not eat or drink before ECT. Patients will also be given a muscle relaxant, so that there will be no movement of the body during the procedure.
During
Electrodes are placed on the patient's scalp and a finely controlled electric current is applied, which causes a brief seizure in the brain. Because the muscles are relaxed, the seizure will usually be limited to slight movement of the hands and feet. Patients are carefully monitored during ECT treatment. When they wake up, minutes later, they do not remember the treatment or events surrounding the treatment, and may be confused.
After
Side-effects may be caused by the anaesthesia or by the ECT itself, or by both. Immediate side effects that may occur within the first few hours after a treatment include:
• Headaches
• Muscle aches or muscle soreness
• Nausea
• Confusion
• Hypotension, low blood pressure
• Tachycardia – a heart rate that is faster than normal, may accompany a bounding pulse.
• Allergic reaction to the anaesthesia
• Loss of memory for some events that occurred around the time of the treatment is common. This memory loss improves, but some patients have persisting gaps in memory for that time period. These will need to be monitored by the nurse.
Challenging behaviour*
Challenging behaviour is a term used to describe behavioural distress. It is most often used by those caring for people with learning disabilities, or children and adolescents, but it is also used by those caring for people with mental health problems.
Definitions
Challenging behaviour is defined as:
‘behaviour of such intensity, frequency or duration that the physical safety of the person or others is likely to be placed in serious jeo-pardy, or behaviour which is likely to seriously limit or deny access to, and use of, ordinary community facilities’ (Emerson et al., 1987).
The Mental Health Foundation have expanded on this to include behaviour that is likely to
‘impair an individual's personal development and family life and which represents a challenge to services, to families, and to the individual themselves, however caused.’13
Within mental health services, challenging behaviour is manifested by the following:
• Aggression
• Self injury
• Disruption and/or destruction of the environment
• Stereotyped or idiosyncratic behaviour.
Examples of these behaviours in people with mental health problems range from intimidating others, self harming behaviours such as cutting, and regressed behaviours such as refusing to self-care. Mental health professionals may label such behaviours as ‘attention-seeking’; this is often an indication of staff frustration and possible power struggles.
Management of challenging behaviour
Managing challenging behaviour requires an understanding of the underlying motivation. This motivation can be divided into two broad categories; an inability to communicate frustration or a need in a more acceptable manner, or as a means of controlling their environment. Any strategy designed to manage challenging behaviour must consider that it may be reinforced by the response of others. Strategies for managing challenging behaviour involve setting limits non-punitively. Before setting these limits:
• Carers should state their expectations of the client in a positive, rather than a negative way.
• Explore the reasons for, and meaning of, the behaviour with the client, and consider alternatives.
• Inform the client which behaviours are, and are not, acceptable, and explain the consequences for behaving unacceptably.
Once these issues have been clarified with the client, the consequences of unacceptable behaviour must occur. Firm, but not hostile, enforcement of limits is essential. Success requires that every member of the care team is consistent in their understanding of, and response to, the limits set. The care team does not assume responsibility for the client's behaviour, whether positive or negative. The client retains the right to choose how he or she behaves, as long as the consequences are clear.
Reference
13 Mental Health Foundation. MHF: www.mentalhealth.org.uk. Updates Vol 3 Issue 19, June, 2002.
Occupational stress in the mental health workforce*
Stress can be defined as
‘a condition in which there is a marked perceived discrepancy between the demands on an individual and the individual's ability to respond, the consequences of which may be detrimental to future conditions essential for bio-psycho-social equilibrium and general well-being.’14
In the UK, an estimated half a million employees believe they are experiencing stress, anxiety and/or depression as a direct result of work.15 Evans et al. in a national survey of stress levels amongst 237 mental health social workers, found substantial levels of stress and burnout, amounting to approximately double the levels reported for psychiatrists.16
Factors leading to this included feeling undervalued at work, excessive work demands, little control over decision-making, and an overall concern about the low status of the mental health social workers compared to other professional groups. Edwards et al. examined studies on burnout and stress for all members of the mental health multidisciplinary team, and 11 studies specifically on Community Mental Health Nurses. The evidence suggested that members of community mental health teams are experiencing increasing levels of stress and burnout.17
The major stress factors for community mental health nurses are:
• Job based stressors: increases in workload and administration, time management problems, inappropriate referrals, and violent and suicidal clients.
• Role based stressors: role conflict, responsibility and role change, lack of time for personal study.
• Stressors relating to organizational structure and climate such as NHS and legislative reforms.
• Stressors relating to relationships with others such as inadequate supervision and dysfunctional community mental health teams.
There is a growing body of evidence to suggest that mental health workers experience considerable stress in the course of carrying out their work. This stress and burnout not only affect the level of performance and the success of their interventions, but also job satisfaction and ultimately their own health.18 Structural costs in terms of absenteeism, loss of productivity, and use of health service resources are inevitable consequences.
References
14
Rabin, S, Feldman, D, Kaplan, Z. Stress and Intervention Strategies in Mental Health Professionals. British Journal of Medical Psychology 72: 159–69, 1999.
Find This Resource15
Mental Health Foundation. The Fundamental Facts. MHF: London, 1999.
Find This Resource16
Evans, S, Huxley, P, Gately, C, et al. Mental Health, Burnout and Job Satisfaction Among Mental Health Social workers in England and Wales. British Journal of Psychiatry 188: 75–80, 2006.
Find This Resource17
Edwards, D, Burnard, P, Coyle, D, et al. Stress and burnout in community mental health nursing: a review of the literature. Journal of Psychiatric and Mental Health Nursing 7: 7–14, 2000.
Find This Resource18
Carson, J, Cooper, C, Fagin, L, et al. Coping Skills in Mental Health Nursing: Do they make a Difference? International Journal of Social Psychiatry 42(2): 102–11, 1996.
Find This Resource
Working with homeless people with a mental health problem*
Mental illness in homeless people may present in the form of schizophrenia, depression and other affective disorders, psychoses (including drug-induced psychosis), anxiety states, or personality disorder. Mental illness is the entry into homelessness for some people. Approximately 20 per cent of homeless people with mental ill-health are also diagnosed with substance dependence. Less than one third of homeless people with mental illness actually receive treatment.
Homelessness and extreme poverty are distant realities for many of us. Our brief encounters with homeless people reinforce prejudices and perceptions that influence our practice as health care professionals. Without prejudices we are better health care providers; it is therefore essential to understand both the circumstances that lead to homelessness, and the consequences of living on the street or in shelters.
Causes of homelessness
These can include:
• Lack of affordable housing or poverty.
• Substance misuse and lack of appropriate services.
• Mental illness.
• Domestic violence, abuse in the home.
• Relationship breakdown (partners and children).
• Prison release.
• Changes or cuts in public services.
Consequences of homelessness
These can include:
• Coronary heart disease – a major cause of death in the homeless (up to three times higher that the general population) due to smoking and substance abuse, nutritional inadequacies, and under-treated co-morbidities.
• Suicide – a higher than average possibility among the homeless.
• Respiratory complaints – very common in the inner-city population e.g. asthma or chronic lung disease due to the high prevalence of smoking. Compromised pulmonary status, coupled with the risks of homelessness, increases the probability of infection.
• HIV and AIDS – may result in job loss, with subsequent difficulty establishing eligibility for disability benefits, and the social stigma of the disease.
• Gastrointestinal conditions – those of concern include liver disease, and peptic ulcers due to the high rate of smoking.
• Family planning, pregnancy, and child-care issues – particularly for homeless women.
• Dermatological disorders – skin diseases such as psoriasis, eczema, and dermatitis can be neglected until they become disabling.
• Deterioration of existing mental health problems – and the development of other mental health problems.
Homelessness can be regarded as a continuum with rooflessness at one end and secure accommodation at the other. In between are degrees of fragile and insecure arrangements, such as a friend's floor or a night shelter; which leave people vulnerable to psychological stressors.
Working with the homeless requires:
• Accurate diagnosis – they may have complex presentations and histories.
• Recognition of co-morbidity.
• Awareness of social exclusion and contributing factors – not having an address means they are unable to register with a doctor.
• Active case management at an inter-agency level.
• Assertive community treatment programmes integrating mental health and social care.
• Street outreach programmes.
• Accurate risk assessment and risk management.
Working with women with mental health problems*
Introduction
Women are more likely than men to suffer from depression, eating disorders, and anxiety. Women often attribute their mental ill health to multiple demands (from family and work), overload (no time to rest) and isolation or lack of confidence. Women tend to focus not on personal culpability, but on the impact of the social situation (work and family, culture, religion, social class, marital status) in which they find themselves.
Women expect services that:
• Ensure safety.
• Promote empowerment and choice.
• Emphasize the underlying causes and context of women's distress.
• Value women's strengths, abilities, and potential for recovery.
Suggestions for gender sensitive practice
• Involve women in decisions about their treatment and recovery.
• Enable women to choose the sex of workers providing physical and mental health care.
• Provide women-only spaces within the physical environment of the service.
• Address issues of importance to women at various stages of their lives, e.g. menstruation, parenting, menopause, physical health, side-effects of medication (especially weight gain), sexual abuse, domestic violence, body image and sexuality.
• Provide practical help with housing and financial issues, education and employment, and flexibility around child care arrangements.
• Create opportunities for women to share with and learn from others who have had similar experiences.
• Provide women-only therapy groups, especially for issues such as domestic violence or sexual abuse.
• Advocate for women who are not able to voice their needs or stand up for themselves, e.g. in consultations where several different professionals are present.
• Collate and disseminate information about locally available resources and contacts for women.
• Acknowledge women's internal and external resources, such as personal coping strategies, strengths and social networks.
• Attempt to understand a woman's distress in the context of her life as a whole. For example, an unresolved history of physical, sexual, or emotional abuse may be impacting on their current mental health.
• Acknowledge that behaviours such as self-harm, disordered eating, or substance misuse may have meaning for the women concerned, and they may need help to understand and explore this.
Other considerations
• Planning pregnancy.
• The impact of pregnancy on medication concordance and mental well being.
• Post partum care for those with a known mental health problem.
• Child protection procedures.
• Care of the vulnerable adult.
Working with people with a perceptual disorder*
A perceptual disorder is when a person's psychological experiences cause them severe distress or severe disability. These experiences are either additional to normal (positive symptoms, e.g. hallucinations) or detracting from normal experience (negative symptoms e.g. social withdrawal).
Relationship building
Basic principles of honesty and respect are the cornerstones of any work. Within this, the clinician must be honest in terms of what they can and cannot offer. They must appreciate that the user's experiences may seem bizarre or irrational to them, but that they are real to the user, who must always be treated with consideration.
Assessment
The aim of an assessment is to gain a shared understanding of both positive and negative symptoms. It is essential that this is carried out and recorded as a baseline for future progress to be measured against.
Intervention
Assessment should give the lead to intervention. Users may receive different combinations of the following, depending on the problem that causes them most distress, or is the most debilitating:
1. Psychiatric medication
Psychiatric medication is used to balance neurotransmitters thought to influence the user's experience e.g. perception. Users should be made aware of side-effects associated with any medication, and encouraged to monitor these for themselves.
2. Problem and symptom focused psychosocial interventions (PSI)
With PSI the user is offered a menu of interventions to distract their mind away from their symptoms (distraction) or to explore their symptoms and experiment with changing and controlling them (focusing).
Working with the client with a mood disorder*
The term ‘mood disorder’ usually means depression and bipolar disorder. Biological, psychological, and social stressors increase a person's vulnerability to a mood disorder. Stressors are not always identified but include:
• Physical problems such as chronic pain or illness.
• Mood altering drugs and alcohol.
• Loss (e.g. role, health, youth).
• Unhappy life experiences leading to low self-esteem and poor coping.
• Acute personal crisis.
• Ongoing difficulties (e.g. relationships, school, work, money).
Extreme or very rapid changes in mood with a deteriorating quality of life, or presenting a risk to self or others, may require intervention.
Key points for intervention
The same range of treatments should be offered to adults of all ages. Ongoing monitoring is always required.
Nursing role
General
• Be knowledgeable and competent in your role.
• Continually assess mood and risk.
• Establish a therapeutic alliance, with the client as an equal partner.
• Whenever possible, involve family and friends.
• Maintain professional boundaries.
• Provide accurate information in a clear and sensitive way.
Psychological factors
Risk of reduction in motivation, self-esteem, and confidence.
• Encourage self-management – through a better understanding of the impact of triggers, their prevention, and treatment.
• Anxiety management.
• Positive reinforcement.
Social factors
Risk of social isolation.
• Collaborate on structured goal setting to encourage social activity.
Biological factors
Risk of self neglect.
• Health education – provide accurate information and encourage and support improvements in:
• Sleep
• Exercise
• Diet
• Fluid intake
• Rest.
• Medication concordance – liaise with prescribers and provide accurate information about medication, including unwanted effects. Discourage other mood-altering substances.
• Encourage a low stimulus environment – this is especially important for clients with elevated mood. Take care with levels of lighting, noise, and activity.
Risk associated with working with the person with a mood disorder
Increased impulsive and high risk behaviour including self-harm and suicide attempts. Ongoing monitoring is necessary.
• Reduce access to potentially harmful substances and situations
• Devise a collaborative risk management plan including:
• Close monitoring
• Assessment of available resources
• Risk reduction strategies
• Communication with carers
• Crisis plan.
Further reading
Newell, R, Gournay, K (eds.). Mental Health Nursing-evidence based approach. Churchill Livingstone: London, 2003.
Find This Resource
National Institute for Clinical Excellence. Clinical Guideline 23; Depression, Management of depression in primary and secondary care. NICE: London, December 2004. www.nice.org.uk
Working with people with anxiety disorder*
Fear is one of the universal basic emotions that is not learned and occurs across cultures. The fear/anxiety response is a basic survival response that helps an organism deal with threat or danger. Fear has been described as a ‘usually unpleasant response to realistic danger’, whereas anxiety is ‘similar to fear but without the objective source of danger’. Anxiety symptoms and disorders are prevalent and co-exist within a range of mental health disorders.
Anxiety symptoms
Assessment and treatment questionnaires
• Problem assessment
• Mental state examination
• Full history assessment
• The fear questionnaire
• The Beck anxiety and depression inventory.
Main interventions
The two main interventions for anxiety disorders are exposure and cognitive behaviour therapy. There is a limited evidence base for the effectiveness of relaxation therapies in relieving anxiety.
Exposure
Exposure can be defined as ‘facing something that causes fear and has been avoided.’ ‘In-vivo’ exposure refers to exposure in real life, where the client is actually in the presence of the feared stimulus or situation. ‘Imaginal’ exposure is where the client is asked to produce an image or mental description of their most feared situation.
When planning an exposure programme, careful assessment will reveal the range of internal and external stimuli that will reliably elicit an anxiety response. It is important that the client understands what is involved and the reasons for treatment.
Cognitive behaviour therapy (CBT)
The initial assessment and focus of CBT is on the person's automatic thoughts that reflect their ongoing appraisal of events in their lives. This is aided by the use of an assessment diary – where the person monitors emotional changes thus allowing identification of the negative thoughts that preceded them. Clark has identified the active ingredients of cognitive therapy for anxiety disorders as: education, verbal discussion techniques, imagery modification, attentional manipulation, exposure to feared stimuli, manipulation of safety behaviours and other behavioural experiments.19
Reference
19
Clark, DA. Anxiety disorders: why they persist and how to treat them. Behaviour Research and Therapy 37: S5–S27, 1999.
Find This Resource
Further reading
Hawton, K, Salkovkis, P, Kirk, J et al. (eds.). Cognitive Behaviour Therapy for Psychiatric Problems: A Practical Guide. Oxford University Press: Oxford, 1989.
Find This Resource
Marks, IM. Fears, Phobias and Rituals: panic, anxiety and their disorders. Oxford University Press: Oxford, 1987.
Find This Resource
Working with a person with anorexia nervosa*
There are five categories of eating disorder, identified by the Diagnostic and Statistical Manual of Mental Disorders (DSM IV). This chapter focuses on anorexia nervosa.
Diagnostic criteria
The diagnostic criteria for anorexia nervosa are:
• Body weight of at least 15 below normal for age, height, and body frame.
• Self-induced weight loss.
• Perception of being too fat.
• Body image disturbance (eg feeling fat when emaciated).
• Absence of three consecutive menstrual cycles.
• Denial of seriousness of low body weight.
Epidemiology
The overall prevalence in the general population is probably less than 1%. Females account for between 70 and 95% of all cases, and males 5–15%. Clinical samples show the ‘typical’ presentation is a 15–25 year old female, of upper socioeconomic status. Community samples show a more equitable distribution across different socio-economic groups.
Assessment
An assessment interview establishes the needs of the person, and agrees a therapeutic contract, if required. A brief assessment might involve determining how the client views the issue, assessing for any specific or general psychopathology, social circumstances/functioning, and physical health status. Psychometric measures used in the assessment process include: The Eating Attitudes Test (EAT), Body Shape Questionnaire (BSQ), and Setting Conditions for Anorexia Nervosa Scale (SCANS).
NICE Guidelines (clinical guideline 9) on the treatment and management of anorexia nervosa
Recommendations from NICE include:
• Assessment and management should occur in primary care.
• Helpful psychological interventions are: Cognitive Analytic Therapy, CBT, and Interpersonal Psychotherapy.
• Physical management should include managing weight gain, nutritional re-stabilization, and managing risk.
Mental health nursing care of people with anorexia nervosa
• Assess readiness to change. (
Motivational interviewing.)• Exploration of the person's view.
• Probe for signs and symptoms that cause concern to the person and their significant others.
• Identify the pros and cons for the person of anorexia nervosa.
• Provide an alternative for unhealthy behaviours.
Recognizing the onset of anorexia nervosa
The following may indicate the onset of a potential eating disorder:
• Sudden changes in eating behaviour or pattern.
• Over-involved interest in body shape and image.
• Excessive dieting behaviour, especially when weight is normal.
• Marked changes in mood, loss of menarche or failure to establish menarche.
• Severe weight loss.
• Emaciated appearance.
Possible triggers for anorexia nervosa
• Taunts about body shape and weight.
• Acne and taunts about this.
• Family conflict.
• Educational or work pressures to succeed.
• Other illnesses e.g. thyroid problems.
• Growing up in a ‘dieting culture’.
• Relationship difficulties.
• Reactions to loss.
Prognosis
About 54% of people with anorexia nervosa recover. The illness has a mortality rate of 10–15%. Most of these die of physical complications, and around 33% commit suicide. Predictors of an unfavourable outcome are purging, physical symptoms, advanced age at presentation, and high social status.
Further reading
National Institute of Clinical Excellence. Core interventions in the treatment and management of anorexia nervosa, bulimia nervosa and related eating disorders, Clinical Guideline 9. NICE: London, 2004.
Find This Resource
Treasure, J, Carolan, A, Todd, G. The Person with an Eating Disorder. In: I Norman, I Ryrie (eds.) The Art and Science of Mental Health Nursing: A Textbook of Principles and Practice. Open University Press: Buckingham, 2004: pp. 457–80.
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Working with a person with bulimia nervosa*
The Diagnostic and Statistical Manual of Mental Disorders (DSM IV) published by the American Psychiatric Association, identifies five categories of eating disorders. These are anorexia nervosa, bulimia nervosa, pica rumination disorder of infancy, feeding disorder of infancy or early childhood, and unspecified eating disorder. This chapter focuses on bulimia nervosa.
Diagnostic criteria
The diagnostic criteria for bulimia nervosa are:
• Episodes of compulsive binge eating.
• Lack of control over eating binges.
• Use of extreme methods for controlling weight e.g. self-induced vomiting, laxative abuse, diuretic abuse, restrictive dieting, or vigorous exercise.
• At least two binge eating episodes per week for at least three months.
• Obsessive concern with body shape, body weight, and body size.
• The behaviour does not occur exclusively during episodes of anorexia nervosa.
Epidemiology
Estimates of the overall prevalence of bulimia nervosa suggest 1.3% for females and 0.1% for males. Some college studies report rates of between 12.5% and 18.6%.
Assessment
An assessment interview is necessary to establish the needs of the client and agree a therapeutic contract, if required. A brief assessment might involve determining how the client views the issue, assessing for any specific or general psychopathology, social circumstances, social functioning and physical health status. Psychometric measures used in the assessment process include The Eating Attitudes Test (EAT) and the Body Shape Questionnaire (BSQ).
NICE Guidelines on the management and treatment of bulimia nervosa
Recommendations from NICE include:
• Helpful psychological interventions are: CBT, self-help, or Interpersonal Psychotherapy as an alternative to CBT.
• Helpful pharmacological interventions are: antidepressants such as SSRIs.
• Management of physical aspects should include: assessment of fluid and electrolyte balance; plus an oral supplement if there are imbalanced fluids and electrolytes.
Mental health nursing care of person with bulimia nervosa
• Assess readiness to change (
Motivational interviewing).• Exploration of the person's illness perception.
• Probe for signs and symptoms that cause concern to the person and significant others.
• Identify the pros and cons of bulimia nervosa.
• Provide an alternative for unhealthy behaviours.
Recognizing the onset of bulimia nervosa
The following may indicate the onset of a potential eating disorder:
• Sudden changes in eating behaviour or pattern.
• Over-involved interest in body shape and image.
• Excessive dieting behaviour especially when weight is normal.
• Marked changes in mood, loss of menarche or failure to establish menarche.
• Severe weight loss.
• Emaciated appearance.
• Excessive teeth brushing and prolonged visits to the toilet after every meal.
Many people with bulimia experience the decay of dental enamel caused by hydrochloric acid passing through the mouth during episodes of vomiting. Frequent dental visits are often necessary.
Factors which may trigger bulimia nervosa
• Taunts about body shape and weight.
• Taunts about appearance, e.g. acne.
• Family, educational, or work pressures to succeed.
• Other problems, e.g.
• growing up in a ‘dieting culture’.
• relationship difficulties.
• reactions to loss.
Prognosis
The prognosis for bulimia nervosa is good on the whole. Predictors of an unfavourable outcome are significant loss of self-esteem or severe personality disorder.
Further reading
National Institute of Clinical Excellence. Core interventions in the treatment and management of anorexia nervosa, bulimia nervosa and related eating disorders, Clinical Guideline 9. NICE: London, 2004.
Find This Resource
Treasure, J, Carolan, A, Todd, G. The Person with an Eating Disorder. In: I Norman, I Ryrie (eds.) The Art and Science of Mental Health Nursing: A Textbook of Principles and Practice. Open University Press: Buckingham, 2004: pp. 457–80.
Find This Resource
Working with the person with substance misuse problems*
Substance misuse is a major public health problem and is associated with a number of common mental health problems. Persistent or recurrent problems with substance misuse are defined as either:
• Harmful use – substance use which causes actual damage to physical or mental health for at least one month, or repeatedly; or
• Dependence syndrome – a group of behavioural, physiological, and cognitive symptoms characterized by: compulsion to use, impaired control of intake, withdrawal states, tolerance, and continued use, despite a subjective awareness of adverse consequences.20
The use of lay terms in clinical settings (such as drug addict, alcoholic, or drug abuse) can further stigmatize people with substance misuse problems, encourages non-disclosure and should therefore be avoided.
The assessment process
A comprehensive assessment of substance misuse history, current problems, and physical and psychiatric co-morbidity are essential in planning effective care and support for service users, and should include the following basic elements:
• A full physical examination.
• Assessment of current substance use – use during the past month.
• Primary or other drug use – volume and frequency, route of administration, any prescribed drugs?
• A urine screen – to confirm history, especially where substitute prescribing is being considered.
• Past substance use history – including age of first use (and substances used), pattern, and progression of use.
• Social and personal circumstances – relationships, social and support network, children, housing status, employment, use of leisure time, interests.
• Reasons for and function of substance use.
• Subjective awareness of the problem.
• Periods of coerced or voluntary abstinence.
• Current contact with substance misuse service.
• Current and past treatment episodes – length and type of treatment (e.g. residential, rehabilitation, community detoxification). What worked? What didn't work and why?
• Assessment of risk – current or past injecting use? HIV and hepatitis status, home circumstances, safety, and use.
• Physical and mental health – acute or long-term medical issues, including any history of overdose. Current or previous mental health service contact.
• Association between use and psychiatric symptoms (e.g. exacerbation, self-medication, relapses).
• Legal and forensic issues – current or previous contact with criminal justice system, including probation, funding of substance use, outstanding charges, type of offences (acquisitive or violent).
Principles of working with service users with substance misuse problems*
Substance misuse is a common and increasing social phenomenon. It is often seen in mental health services, both as a ‘primary’ problem, and as a co-morbidity with mental illness. Substance misuse problems can include the misuse of alcohol, illicit substances e.g. prescribed medicines.
A positive therapeutic attitude in health workers is strongly associated with better clinical outcomes in people with substance misuse problems.
Approaches and interventions
Clinical interventions should be based on a comprehensive assessment of substance use history and current use ( Chapter 1, Introduction).
Interventions and service contact should match the severity of the illness or problem, and the stage of change that the person is at (see below). There are a number of interventions aimed at increasing motivation to change, and these include: increasing awareness of the need to change, increasing concern about current use, and use as a frustration of goals. Other interventions that are useful in working with substance users include: motivational interviewing and relapse prevention methods, including the use of matrices ( Motivational interviewing).
The stages of change
This is also known as the cycle of change21 and includes: pre-contemplation, contemplation, decision, active change, maintenance, and relapse.
Most users are at least ambivalent about their substance use, and this ambivalence, linked with other adverse events (such as relapses or precipitation of illness) can be used to help the service user move further in the cycle of change.
Harm reduction
Therapeutic work with service users with substance misuse problems should initially be focused on reducing substance related harms for the person, their family, friends and community. Subsequently, it should look at the reduction of actual substance use.
It is now widely recognized that the so-called ‘harm reduction’ approach to managing substance misuse problems is pragmatic, user-focused, and meets users ‘as they are’ with no hard and fast rules. It acknowledges the social context of much substance misuse.
Harm reduction approaches should be seen on a continuum with abstinence at one end, and ‘safer’ use at the other. It may use a plethora of clinical tools including substitute prescribing, needle and syringe exchange programmes (where appropriate), drug education, and user involvement.
Reference
21
Prochaska, JO, Di-Clemente, CC. Towards a comprehensive model of change. In: WR Miller, N Heather (eds.) Treating Addictive Behaviours: process of change. Plenum Press: New York, 1982.
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Assessing children and adolescents*
Growing up takes time – perhaps as much as 20 to 25 years. Even then, many people consider they still have some way to go. Within this time span, difficulties will be encountered, problems will arise and conflicts will develop.
Mental health nurses may be asked to assess a child or adolescent who is having difficulty dealing with life's problems, but who will find resolutions eventually, without formal or professional interventions.
The Common Assessment Framework (DfSS 2004) offers an integrated approach to assessment and intervention. Local services should develop best collaborative practices for children and their families.
Child-centred focus
As they prepare to undertake an assessment, it is important for the professional to remind themselves that the child or adolescent they see is a unique individual, with his or her own individual capacities, strengths, and resilience. An assessment should seek to elicit these aspects as much as any risk factors, difficulty and/or signs and symptoms of underlying disturbance.
Issues to consider in the assessment process
Concerns
• Who has the concerns – the child, parent, teacher, or health professional?
• What are they concerned about – behaviour, relationships, school work?
• How does it manifest in the child or adolescent – the degree to which it interferes with day-to-day life?
Context
Assessment is undertaken with the following factors in mind:
• The child's developmental stage.
• The child's social and cultural context.
• Life events experienced by the child.
Global Assessment
Assessment is a systematic process of eliciting information about a child or adolescent that allows the professional to decide on an effective and appropriate level of intervention.
A holistic assessment framework (see Fig. 2.1) allows the professional to work systematically with the child and the family.
Factors specific to the child or adolescent
Who to involve in the assessment
You will need to discuss this with the child or adolescent, their parent(s) and siblings. With agreement, you may want to talk to staff from any agency or service involved. Decide who you will need information from and check that the child/adolescent/family are clear about this.
Factors that impact on the child or adolescent's experiences and relationships
Environmental | Family |
|
|
Social | Cultural |
|
|
Assessment focus
Have you sufficient information to understand the child or adolescent's current position and to identify their needs? Can this information help clarify the factors that have triggered concern
•
Antecedents
– what was happening prior to the behaviour?•
Precipitants
– what triggered the behaviour?•
Perpetuators
– what maintains the behaviour?•
Prognosis
– what are the chances of recovery?
Interventions in child and adolescent mental health*
Core principles
It is important that:
• Children and young people with mental health problems are cared for in a safe and trusting environment.
• Care is family-centred.
• Interventions are developmentally appropriate.
Core knowledge
The mental health nurse must/should have the following skills:
• Child protection policies and procedures.
• Child development.
• Mental-ill health presenting in childhood and adolescence.
• Risk and resilience factors:
•
Risk factors for a child:
genetics, low IQ, development delay, communication difficulties, physical illness, academic failure, low self-esteem.•
Resilience factors for a child:
self esteem, autonomy, sociability.•
Risk factors for a family:
parental conflict, family breakdown, inconsistent discipline, rejection, abuse, failing to meet development needs, parental psychiatric illness, parental criminality, death, or loss.•
Resilience factors for a family:
family compassion, warmth, no discord, good support.
• Interventions (see below).
• Family systems theories.
Core skills
The mental health nurse must/should have the following skills:
• Listening and attending.
• Communication and social skills.
• Observations of social interaction, play, mood, behaviour, sleep and diet.
• Formulating a care plan.
• Managing care (see below).
Care planning
When planning or managing care, the mental health nurse should:
• Remember that families are often involved with other services – consider these when planning care.
• Work in partnership with the child and family.
• Consider risk – be clear about how to keep children safe.
• What does the child and the family want to achieve? What are their goals and objectives?
• Negotiate child-centred interventions that are sensitive to difference, ethnicity and culture.
• Use equipment – drawing paper, painting equipment, human figures, animal figures, and toys to help you in your planning.
Interventions
These are all interventions that may help children and adolescents:
• Counselling.
• Behavioural interventions – based on social learning theories, these help children and families to change their behaviour.
• Cognitive behavioural interventions – helps children understand how their thoughts and feelings affect their behaviour.
• Motivational interviewing – a communication technique to promote decision making and behaviour change.
• Solution-focused therapy – helps children work towards their own goals.
• Family therapy – looks at the family as an interconnected system of relationships. Skilled questioning and reflections helps families discover ways to change. Example question, ‘How do you think Eric feels when you shout at him?’
• Parent training – is based on social learning theories. It is structured, delivered on a sessional basis and helps improve parenting practices.
• Child psychotherapy – helps children and young people come to terms with complex emotional and relationship problems.
• Individual play therapy – helps children recover through communication and play.
• Creative therapies e.g. drama, art. and music – help children and young people express themselves and discover ways to change.
• Group therapy – provides support and an environment for change.
• Pharmacology – the most common medications are Ritalin (Methylphenidate) for ADHD (attention deficit hyperactivity disorder). Other drugs are used to treat psychosis and mood disorders.
• Intensive care – inpatient and day care facilities are suitable for more serious and persistent mental health problems.
• Multi-systemic therapy – wider systems are managed to ensure the young person receives a consistent package of care. Can be helpful with severe conduct disorder where education, youth justice, social services, and others are involved.
Further reading
Department of Health. National Service Framework for Children, Young people and Maternity Services. DoH: London, 2004.
Find This Resource
DfES. Every Child Matters: Change for Children. DfES: London, 2004.
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Working with the person with personality disorder (PD)*
Personality disorder is functional impairment or psychological distress resulting from inflexible and maladaptive personality traits. The person commonly presents with problems in thinking styles, emotional regulation, and impulse control, and has particular difficulties in relating to other people. These problems are long-standing and pervasive across a variety of situations.
The main types of PD are described in the two major diagnostic classification systems, the DSM-IV and ICD-10 (see table opposite). The three clusters have been derived from empirical work and are represented in terms of: A – odd eccentric behaviours; B – dramatic flamboyant and impulsive behaviour; and C – anxious and fearful behaviour.
DSM IV | ICD-10 |
|---|---|
Cluster A | |
Paranoid | Paranoid |
Schizoid | Schizoid |
Schizotypal | |
Cluster B | |
Antisocial | Dissocial |
Emotionally unstable | |
a)Impulsive type | |
Borderline | b) Borderline type |
Histrionic | Histrionic |
Narcissistic | |
Cluster C | |
Avoidant | Anxious |
Dependent | Dependent |
Obsessive compulsive | Anankastic |
It is important to understand that each different personality disorder consists of a varied collection of impairments, and therefore different presenting problems and issues. It is rare for someone to present with one personality disorder; co-morbidity is common.
People with cluster C anxiety based problems most often present in primary care settings, while those in cluster B tend to present to mental health services. Those in group B have often been associated with antisocial behaviour and deliberate self-harm, leading to problems of stigmatization and social exclusion from services.22
A minority of people with a personality disorder get the treatment they need in a forensic setting, after coming into contact with the police and the courts. This has led to many people with personality disorders being further stigmatized as representing a danger to society. Those people with antisocial PD in the forensic system tend to be the individuals who pose the greatest risk to others, whereas most people with PD are more at risk of harming themselves than other people.
Key issues in working with people with PD
Working with an individual with a personality disorder is challenging for nurses, as many of the problematic behaviours manifest in the person's interactions and relationships.
The following are important when working with people with PD:
• Supervision
• Effective team work
• Emotional support
• Knowledge and empathy for the traumatic and distressing histories that are common in this group.
Evidence-based interventions
• Cognitive behaviour therapy
• Cognitive analytic therapy
• Dialectic behaviour therapy
• Psychodynamic group therapy.
Further reading
Bateman, A, Fonagy, P. The effectiveness of partial hospitalization in the treatment of borderline personality disorder – a randomized controlled trial. American Journal of Psychiatry 156: 1563–9, 1999.
Find This Resource
Livesley, J (ed.). Handbook of personality disorders: Theory research and treatment. The Guilford Press: New York, 2001.
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Working with the person who uses forensic services*
Forensic mental health services specialize in the assessment and treatment of people with mental health problems who are undergoing legal or court proceedings, or who have offended. People with mental health problems, who have never been involved with the criminal justice system, might also be treated in forensic psychiatric services, if they cannot be safely managed elsewhere.
Mental health nurses provide forensic interventions in healthcare and penal settings, including secure hospitals, the courts, prisons, and young offenders’ institutions. The level of risk posed by an individual will dictate the level of security within which they are cared for. The range is from community services and low or medium secure hospitals to high secure hospitals with dangerous and severe personality disorder (DSPD) units. Most patients in these settings are detained under the Mental Health Act 1983.
Key skills in forensic nursing
• Psychological assessment
• Interpersonal and engagement skills
• Inter-agency working
• Risk assessment and management.
The offence for which a client is either charged or convicted is central to forensic nursing in any environment. Offences vary greatly, from the petty to the severe. The nurse's focus is working with the mental health issues that led to the offending behaviour.
Nurses need knowledge of therapeutic interventions, so they can rehabilitate clients with severe and enduring mental illnesses and personality related difficulties. They also need well developed support and supervison systems to help them process the emotional impact of this work.
CBT based psychotherapeutic approaches have been shown to be the most effective intervention for modifying some forms of difficult behaviour, as displayed by people presenting to forensic services. These treatments require time and special expertise, and are usually delivered by specialist multidisciplinary treatment teams.
People with mental health problems who have offended are often socially deprived and psychologically needy individuals who do not fit neatly into either the health or the penal system.23 As a consequence, there is an increasing focus on developing hybrid services, combining the containment skills of the penal system with the therapeutic inputs of the health service. Nurses are key players in these developments, as the specialist nature of forensic practice is now being recognized and developed.
Working with the person who is suicidal and self-harms*
People with mental health problems are at a greater risk of harming themselves than others. The rates of self-harm have continued to rise since the 1980s; and self-harming behaviour is a particular risk factor for suicide. About one quarter of all people who successfully commit suicide have attended hospital following an act of self-harm in the previous twelve months.24
Self-harming behaviour is commonly known as ‘deliberate self-harm’ or (DSH). DSH involves intentional self-poisoning or self-injury, irrespective of the apparent purpose of the act.25 The two most common types of DSH are self-poisoning, such as an overdose, or cutting.
Who is at risk?
Men are three times more likely to commit suicide than women, although self-harm is more common among females, especially young women under the age of 25. The incidence of suicide increases with age, although there has been a recent increase in suicide among young adult men under 45. Suicide and self-harm are more common in white people than in other racial or ethnic groups. Social factors such as living alone, being homeless and unemployed are additional risk factors.26
Engagement and assessment
Self-harming patients most commonly access the health service through A&E departments, although this will depend on the nature and severity of harm caused. Successfully engaging with self-harming patients is challenging for healthcare professionals, as such behaviours can be difficult to comprehend and may challenge some of our most fundamental values and beliefs.
People who self-harm have complex needs, they may have problems in their lives and feel hopeless. Any risk assessment needs to address a number of different factors and to be part of a comprehensive package of care.
Therapeutic interventions
There are a number of strategies that can be employed to reduce self-harm or its repetition. The choice of therapeutic intervention should be based on the results of a comprehensive psychosocial assessment. DSH may be related to a person's depressed mental state, for example.
Self-harming behaviour may not simply be attributed to a mental illness, but may also arise from social problems such as unemployment, debt or problems with personal relationships.
Existing research evidence suggests three useful interventions: problem solving therapy; the use of crisis cards; and dialectical behaviour therapy.
References
24
NHS Centre for Reviews and Dissemination. Deliberate Self Harm. Effective Health Care 4(6): 1–12.
Find This Resource25
Hawton, K, Catalan, J. Attempted Suicide: A Practical Guide to its Nature and Management. Oxford University Press: Oxford, 1987.
Find This Resource26
Appleby L, Five-Year report of the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness, DoH: London, 2001.
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Notes:
* Patrick Callaghan, Professor of Mental Health Nursing, University of Nottingham & Nottinghamshire Healthcare NHS Trust
* Patrick Callaghan, Professor of Mental Health Nursing, University of Nottingham & Nottinghamshire Healthcare NHS Trust
* Patrick Callaghan, Professor of Mental Health Nursing, University of Nottingham & Nottinghamshire Healthcare NHS Trust
* Madeline O'Carroll, City University, London
* Madeline O'Carroll, City University, London
* Patrick Callaghan, Professor of Mental Health Nursing, University of Nottingham & Nottinghamshire Healthcare NHS Trust
* Patrick Callaghan, Professor of Mental Health Nursing, University of Nottingham & Nottinghamshire Healthcare NHS Trust
* Patrick Callaghan, Professor of Mental Health Nursing, University of Nottingham & Nottinghamshire Healthcare NHS Trust
* Patrick Callaghan, Professor of Mental Health Nursing, University of Nottingham & Nottinghamshire Healthcare NHS Trust
* Patrick Callaghan, Professor of Mental Health Nursing, University of Nottingham & Nottinghamshire Healthcare NHS Trust
* Patrick Callaghan, Professor of Mental Health Nursing, University of Nottingham & Nottinghamshire Healthcare NHS Trust
* Patrick Callaghan, Professor of Mental Health Nursing, University of Nottingham & Nottinghamshire Healthcare NHS Trust
* Dr Richard Gray & Dan Bressington, Institute of Psychiatry, Kings College, London
* Dr Julia Jones, City University, London
* Helen Waldock, Health and Social Care Advisory Service
* Patrick Callaghan, Professor of Mental Health Nursing, University of Nottingham & Nottinghamshire Healthcare NHS Trust
* Patrick Callaghan, Professor of Mental Health Nursing, University of Nottingham & Nottinghamshire Healthcare NHS Trust
* Helen Waldock, Health and Social Care Advisory Service
* Patrick Callaghan, Professor of Mental Health Nursing, University of Nottingham & Nottinghamshire Healthcare NHS Trust
* Patrick Callaghan, Professor of Mental Health Nursing, University of Nottingham & Nottinghamshire Healthcare NHS Trust
* Patrick Callaghan, Professor of Mental Health Nursing, University of Nottingham & Nottinghamshire Healthcare NHS Trust
* Phillipa Sully & Malcolm Wandrag, City University, London
* Ben Hannigan, University of Cardiff
* Dr Julie Repper, University of Sheffield
* Helen Waldock, Health and Social Care Advisory Service
* Lynny Turner, City University, London
* Professor Peter Ryan, Middlesex University
* Helen Waldock, Health and Social Care Advisory Service
* Professor Sara Owen, University of Lincoln
* Geoff Brennan, Prospect Park Hospital, Tilehurst, Berkshire
* Professor Karina Lovell & Sarah Kendall, University of Manchester
* Professor Paul Rogers, University of Glamorgan
* Patrick Callaghan, Professor of Mental Health Nursing, University of Nottingham & Nottinghamshire Healthcare NHS Trust
* Patrick Callaghan, Professor of Mental Health Nursing, University of Nottingham & Nottinghamshire Healthcare NHS Trust
* Peter Phillips, City University, London
* Peter Phillips, City University, London
* Marya Limerick, University of Nottingham
* Jenny Cobb, City University, London
* Patrick Callaghan, Professor of Mental Health Nursing, University of Nottingham & Nottinghamshire Healthcare NHS Trust
* Patrick Callaghan, Professor of Mental Health Nursing, University of Nottingham & Nottinghamshire Healthcare NHS Trust
* Dr Julia Jones, City University, London