Tag Archives: consultation liaison

A Mental Health Nurse in the General Hospital

MHCBelow is a copy of the blog post I was invited to submit at My Health Career. The website is targeted at high school and university students considering or pursuing a career in health, guidance officers, career development professionals, and others working in or with the health care sector.

To see the post where it was first published online, and/or to have a look around at the My Health Career website, please visit www.myhealthcareer.com.au/nursing/mental-health-nurse-paul-mcnamara

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A Mental Health Nurse in the General Hospital

Paul trying not to look too much like a goob.

Paul trying not to look too much like a goob.

Paul McNamara has extensive experience providing clinical and educative mental health support in general hospital and community clinical settings. He holds hospital-based, undergraduate and post-graduate qualifications, is Credentialed by the Australian College of Mental Health Nurses (ACMHN), and has been a Fellow of the ACMHN since 2007. Paul is a very active participant in health care social media, and is enthusiastic about nurses embracing “digital citizenship”. More info via his website meta4RN.com

There is an odd little sub-speciality of mental health services called “consultation liaison psychiatry”. This waffly, jargon-ridden mouthful of syllables is usually abbreviated to “CL”. What is CL? Easy – just think of it as “general hospital mental health”.

I’m a mental health nurse on a CL team. The only ward in the hospital I don’t visit is the mental health unit (the mental health unit already has heaps of mental health nurses – they don’t need me there). It’s the rest of the hospital I serve: the surgical wards, the medical wards and the maternity unit.

General hospital patients are more at risk of experiencing mental health problems than the general public – being sick is stressful. It works the other way around too: people who experience long-term mental health difficulties are more at risk of becoming physically unwell – being under lasting emotional stress can take a toll on the body.

Nurses, doctors, social workers and other allied health practitioners will phone CL when they have concerns about the mental health of a patient. Sometimes all that is required is a bit of information and clarification about medication or follow-up services available in the community – we do that over the phone. More often, we are asked to meet with the patient and determine what, if any, mental health matters can be sorted-out while they are in hospital.

The most common mental health problems experienced in the community are anxiety and depression – it’s the same in the general hospital – a lot of the people I meet with are experiencing either or both of these conditions. There are other mental health problems like eating disorders and deliberate self harm that sometimes require input from both the medical/surgical team and the mental health team concurrently. Helping-out with planning and providing support and care of these patients is a pretty big part of my job.

Sometimes it’s not the person in the pyjamas (the patient) who needs our support – sometimes it’s the communication, the systems and the clinical staff who benefit most from CL input. This can be in the form of structured education sessions or, more typically, in the form of supporting discussion, reflection and problem-solving on how best to meet the needs of the patient within the limited resources available in the hospital. In this aspect of the job, a CL nurse will try to help the clinicians involved step-back from the busyness and pressures of the hospital ward and take “a balcony view” of what is happening. By taking ourselves out of the chaos of a busy shift and calmly looking back at things with a bit of distance, sometimes we can see how we can “do business” in hospitals a little more constructively.

We also spend a lot of time “undiagnosing” (this is a “neologism” – a made-up word – I heard recently via Sydney psychiatrist Dr Anne Wand). The people we “undiagnose” the most are those who are experiencing grief. There can be a lot of grief in general hospitals, but we try to be careful not to confuse the emotions of grief (sadness, anger, temporary despair etc) with a psychiatric disorder. Grief emotions are often really uncomfortable but they are part of what makes us who we are. We don’t want to “psychiatricise” or “psychologise” the human condition. Grief is not something to be simply fixed; grief is a part of life – a difficult part of life – that is usually successfully navigated without psychiatric input. Support from loved ones and/or social workers and/or specific counselling services can help.

So, that’s an overview of what it is to be a mental health nurse in a general hospital. It’s a varied role where we spend nearly as much time with the general hospital nurses, midwives, allied health staff and doctors as we do with the hospital patients. The role involves direct clinical care, collaborating with colleagues and providing education. For more information on the speciality please visit my website or the consultation liaison nurses special interest group section of the Australian College of Mental Health Nurses website.

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Print Version (PDF): CLnurse

Thanks to Amanda Griffiths of My Health Career for inviting me to submit this overview of consultation liaison nursing.

As always, your comments are welcome.

Paul McNamara, 2nd May 2014

 

Trying to Stay Focused

PatientFocused Some days it feels like a cruel conspiracy.

Those are the days when it feels like the time and space I have made to speak one-to-one to the patient* is in the middle of a sports arena. The patient and I walk into the middle of the empty playing surface and make our preparations for meaningful discussion, for emotional catharsis, for education, for counselling, for disclosure, for discovery, for therapy.

Then the grandstands of the arena start filling with people with loud voices. These people are not providing frontline care, so we would like to think of them as supporters. However, they all seem to think of themselves as coaches. They each have their own special area(s) of interest and shout well-meaning advice from their seats in the grandstand.

It gets very rowdy and distracting. SystemsFocused So many supporters coaches. So many systems**.

Systems are what makes airlines so safe – apparently that’s why hospitals have become so system-focused over the last couple of decades. I think it is a bit silly that public health systems try so hard to align themselves with profit-making airline systems. The cost of a regional hospital redevelopment ($454m) is about the same cost as two Boeing 787s (source), However, they serve very different purposes: the hospital is filled with critically ill people aiming to become less unwell or die with dignity. Commercial jets are filled with tourists and business people going on a planned journey. The hospital is a place of unknowns: discovery, diagnosis, treatment, trials and strong, unpredictable human emotions. A commercial jet is a trumped-up bus that travels at a scheduled time on a scheduled route between clearly defined destinations, carrying only people who are wealthy and healthy enough to travel long distances.

Hospitals and airlines have such very different clients, expectations, control and outcomes – can they really teach-each other much about systems?

Nevertheless, I understand the rationale for systems, and will make no effort to argue against them. Still, wouldn’t it be nice if there was one healthcare system? As it stands in my workplace, the emergency department has a system (EDIS) that does not speak to the ICU system (MetaVision), which does not speak to the general hospital system (ieMR), which does not speak to the mental health system (CIMHA). And that’s just within one hospital – imagine how fragmented it gets when we start thinking of the primary healthcare and rural/remote outpatient sectors.

I understand that some of these systems, some of these competing demands, are very important – but not all of them are. For example, it is not important that a clinician spend time away from their patients to transpose a bit of information that is in one hospital system into another hospital system –  this is a matter of dumb systems.

Which is why nurses and other clinicians know that sometimes the safest, most compassionate, and most ethical thing to do is to turn their back on the distractions created by dozens of disjointed systems, and make the priority to simply be with the patient.

Why? Because we are trying to stay focused – patient focused.

*Clarification re using the word “Patient”

In mental health over the last couple of decades nomenclature has changed from “patient” to “client” to “consumer” or “service user”. I understand the rationale for this – it is to move away from the passive (i.e.: “patient” as someone that the “expert” diagnoses and fixes) to participant (i.e.: “informed “consumer” of a service). In my current role I provide mental health assessment, support and education in a general hospital – the people I see are, in this context, first-and-foremost medical/surgical/obsetric hospital inpatients. It is these people’s physical health that had them admitted to an acute general hospital as “patients”, hence my use the word here.

**All the systems named in the “Systems Focused” cartoon are real, as is the claim that using each one is VERY IMPORTANT.

Tech Tip

I used an easy-to-use iPad app called Notes Plus to draw the cartoons. As you can see, my artistic skills have pretty-much plateaued since kindergarten, as has my spelling. Nevertheless, I think the cartoon might have been a little better and a lot easier to draw if I had used a stylus – that’s what I would recommend if you plan to do something similar.

End

As always, your thoughts/feedback is welcome in the comments section below.

Paul McNamara, 6th April 2014

Perinatal Mental Health: A Good News Story

diabetes, for instance

diabetes, for instance

Most health messages are such a downer, surely there are many people who will either switch-off from the message, or become unduly alarmed. Compare health marketing to commercial marketing and it’s no wonder obesity is rising. Put frankly, Coca-Cola and McDonalds have better ads: they’re full of fun and optimism:

Things Go Better With Coke!  

McDonalds – I’m Lovin’ It! 

Don’t get me wrong: depression is a bugger of a thing, and perinatal mood disorders are especially poorly timed. Looking after a pregnancy/baby is tricky enough without tossing in anxiety and/or depression.

However, at the risk of sounding all Pollyanna about it, there are some good news stories we can talk about when discussing perinatal mental health. Here’s a small list of things I’d like mentioned in every antenatal class/similar forum for parents-to-be/new parents:

IMG_0328[1] 6 in 7 new mothers and 19 in 20 new fathers will not experience perinatal depression. Are there any other gambles that give you better odds?

[2] Symptoms are usually easy to recognise. There’s even a free online anonymous self-scoring tool available: justspeakup.com.au/epds

[3] If somebody is not sure how to start a conversation about mental health with their midwife, doctor or child health nurse, there’s a handy online tool to help build a checklist of things to mention: docready.org

[4] Information and resources are easy to find. In Australia the “big five” are:

[5] Support is easy to find too:

[6] There are a range of treatment options: it’s not a matter of  “one size fits all”.

[7] If required, there are some medications that can be used in pregnancy and/or breastfeeding.

[8] Recovery rates for postnatal depression are very good.

[9] Some places have access to specialist perinatal mental health clinicians.

[10] Mental health clinicians are not interested in stealing the baby. In fact, mental health clinicians seem quite pleased with themselves when they get to see parents and infants connecting and communicating with each other.

[11] If attachment between parent and baby does not happen as easily as expected (this happens a fair bit with anxiety and/or depression), there are video guides to help, for example: Baby Cues Also, in some towns and cities (especially those with a perinatal and infant mental health nurse), there are clinical staff who can help with this communication/attachment/bonding stuff too.

What’s This About Exactly?

During the week a couple of new mums declined referral to see a nurse (me) from the consultation liaison psychiatry service because they had preconceptions about how negative the experience would be. It’s not absolutely necessary for every parent to see a mental health specialist, of course, but I think we (that’s “we the health professionals”) should start fishing-around for ways to better describe the good news stories about perinatal mental health.

diabetes, that is

diabetes, that is

If Coca-Cola and McDonalds can convey a sense of fun and optimism out of the products they sell, surely we can convey a sense of fun and optimism out of the services we provide. We have something that’s much better than the offerings of either Coca-Cola or McDonalds, so let’s reorientate the language and recalibrate expectations by using positive language.

Maybe when perinatal and infant mental health (PIMH) services in Queensland are re-established, we can re-launch with an upbeat attitude and slogan:

 PIMH for a healthy head-start!

End

What are your ideas for upbeat slogans and messages? Please add them in the comments section below.

Paul McNamara, 25th January 2014

Nursing’s Peculiar Privilege

Dear Reader: please don’t read this blog post if you are offended by strong swear words or find talk of suicide a trigger for unsettling/risky thoughts. Kind Regards, Paul.

Who is Going Behind the Curtains?

Working over Christmas and New Year made me especially cognisant of one of the peculiar privileges that we nurses have: we spend a lot of one-to-one time with the person who is medically/surgically recovering after a suicide attempt. My current role is Consultation Liaison Mental Health Nurse – a role that provides mental health assessment, support and education in a general hospital (more info about the role here). When the person is admitted to the general hospital after a non-fatal suicide attempt we are asked to be involved in planning and providing their care.

There are few things more privileged and more important than spending time with the person who is alive after deciding not to be. I do worry that this role is sometimes delegated to the least qualified (and lowest paid) member of frontline clinical care: the Assistant In Nursing (AIN) when there is “nursing special” in place (i.e.: when there are concerns that the person may abscond and/or harm themselves again).

Naturally, being an AIN does not mean you are incapable of sensitive, compassionate, safe care. I just think that “going behind the curtains” to assist in holding and containing the often very strong emotions of the person who has survived suicide is incredibly important. I don’t feel comfortable that someone without mental health qualifications or clinical supervision is tasked with sitting at the bedside for hours at a time. It may not be good for the either the person/patient or the AIN.

Suicide rates per year. Chart courtesy of www.mindframe-media.info

Suicide rates per year. Chart courtesy of http://www.mindframe-media.info

Parallel Processes

In clinical supervision we often explore the parallel processes and how they apply to our clinical work. When working in perinatal mental health I aimed for the therapeutic relationship to be a template for the parent-child relationship: kind and nurturing, responsive and interactive, empowering, educative and enjoyable. The idea being that, at some level, the qualities/values that inform the therapeutic relationship can then have a knock-on effect for the relationship the parent has with their baby. Not many perinatal mental health clinicians have an abrupt, cold, clinical style of interacting with their clients: they tend to be warm, gentle communicators.

When nursing the person who has survived suicide we need to think about parallel processes again. Julie Sharrock (a rock star of consultation liaison nursing) first introduced me to the phrase “holding and containing” as a part of the therapeutic relationship. Traditionally the notion of holding and containing has been attributed as a function of the inpatient setting/building: a place to keep people safe. Julie introduced it to me as a way to keep people safe, by reframing it as a concept for interpersonal therapy. That is, we nurses can assist and model the act of holding and containing difficult emotions.

For the person who has unexpectedly found themselves alive and in hospital after intending to end life, we may need to hold and contain the person physically for a short time, but (to my way of thinking) it is even more important to support the person to hold and contain their thoughts and feelings.

Thoughts are slippery, and prone to be dropped.

Feelings are brittle, and prone to cracking.

Holding and containing such difficult-to-secure, fragile things is fraught: the clinician needs their thoughts and emotions held and contained too. Its a parallel process: as I’ve discussed previously we need to nurture the nurturers.

Suicide rates per age group (2010). Chart courtesy of www.mindframe-media.info

Suicide rates per age group (2010). Chart courtesy of http://www.mindframe-media.info

Profound Moments

Some of the most profound moments of my working life have occurred while supporting the person who has survived suicide.

The incredibly dark humour: “I’m such a fucking loser I can’t even kill myself properly!” said the very nice man. He was not laughing out loud, but smiling at the grim absurdity of his situation. He was alive, but physically worse-off than when he decided to die: now fractured, urinating through a tube, receiving fluids and antibiotics via an IV line. More wounds. More pain. Yet, despite the extra physical insults, he was pleased that he had survived.

The worry: “Is my brain OK? I feel really agitated and confused.” asked the lady who had been in intensive care for a few days. Her brain was OK in the long-term, the distress she was experiencing was mostly short-term stuff:  delirium is really common amongst ICU patients. Hypoxic patients aren’t so lucky: they sometimes never recover the former function of their brain.

“You are the biggest fucking cunt that has ever existed in the whole world!”, said the man after being told he was unable to leave hospital. I was filling-in paperwork that would mean he was an involuntary patient as per the Mental Health Act. I didn’t think I was being particularly nasty. The mental health act is handy because there are times when I need to say, “It seems to me that you don’t have the capacity to keep yourself safe at the moment. So,  I’ll take some of the responsibility of keeping you safe for now. Naturally, we will hand the job back to you when you come good.” Using that framework, filling-in the paperwork for the mental health act is sometimes the most nurturing thing I can do. That’s why i was genuinely surprised, not offended, when he said, “You are the biggest fucking cunt that has ever existed in the whole world!” I asked, “Really? Worse than Hitler?” He laughed and said, “Yeah, Definitely.” I laughed too. Take that Hitler.

The person who had two high perceived lethality, but fortunately non-fatal, attempts to take his life in the fortnight before we met reworded Shakespeare’s famous opening line to Hamlet. Instead of saying, “To be, or not to be, that is the question”, he said, “After what I have experienced in hospital, I now think that it is better to have a difficult life rather than no life at all.” I was so pleased to hear him think that way, and at the same time felt so sad for those people who do not have the opportunity to reconsider: those people that bypass the hospital wards and go straight to the morgue.

These are profound moments in the lives of people.

Nurses, myself included, have the peculiar privilege of being with the people who are experiencing the most important days of their life: the first few days of life that they planned not to have.

Let’s not take that peculiar privilege of nursing lightly.

In Closing

Talking and thinking about suicide can be distressing. Australians can access support via:

 Lifeline – 13 11 14

Suicide Call Back Service – 1300 659 467

MindHealthConnect www.mindhealthconnect.org.au

phone_hotline-40Outside of Australia and not sure where to get support? Google usually displays a red telephone icon and your country’s suicide support phone number when searching for a suicide-related topic.

As always, comments and feedback on the blog post is welcome. Suicide can be a sensitive topic to comment on, and this blog is the public arena; so, before wording your comment, please check-out this: Mindframe guide

Paul McNamara, 19th January 2014

A Picture is Worth a Thousand Words

Car vs Bike Wounds: even an illustration that completely lacks artistic merit can convey a lot of information more effectively than a page full of text.

Gingerbread Person Pic “Car vs Bike Wounds”. Even an illustration that completely lacks artistic merit can convey a lot of information more effectively than a page full of text.

This week at work we have been discussing the roll-out of the ieMR (integrated electronic Medical Record). At present it is not integrated with the existing mental health system (CIMHA: Consumer Integrated Mental Health Application), the existing emergency department system (EDIS: Emergency Department Information System) or the existing intensive care unit system (CIS: Clinical Information System). Let’s not be too distracted by that though – apparently there is an integration team beavering away in a back room somewhere: they’re teaching these hospital systems to talk to each other. Once that’s sorted-out the ieMR will be the best thing since bung fritz.

A hospital file diagram such as this can assist in conveying an understanding of the patient's experience.

A hospital file diagram such as this can assist in conveying an understanding of the patient’s experience.

A different thought crossed my mind though – will the ieMR make the bad art of gingerbread women/men, genograms and other diagrams obsolete?

I hope not – even my hastily drawn-on-an-envelope examples used on Twitter during the week and in this post convey meaning quickly and easily (hopefully). Don’t get me wrong – I’m all for typing words into a digital archive (in fact, I’m doing it right now!), but there are times where it is clearer to communicate with an illustration. I hope this is not lost as we transition to an electronic medical record.

The patient is the expert. The clinician asks them about their family and draws a genogram to organise information. Sometimes genograms explain a lot.

The patient is the expert. The clinician asks them about their family and draws a genogram to organise information. Sometimes genograms explain a lot.

Does your hospital/health agency have an electronic record that easily allows illustrations still? If so (or not) I would be grateful to hear from you in the comments section below.

Paul McNamara, 21st September 2013

Emotional Aftershocks

Warning: today I will take the risk of being ridiculed for over-sharing and being melodramatic (it’s a grand tradition amongst bloggers).

8683188_lgCrap Day at Work

Recently at work I spent a bit of time wondering whether I, one of my nursing colleagues, or one of the hospital patients or visitors was going to sustain a life-threatening brain injury at the hands of a man brandishing a fire extinguisher as if it were a weapon. Fire extinguishers are generally thought of as potentially life-saving devices. However, when a fire extinguisher is being held at shoulder height by a tall, fit, powerful young man on a violent rampage in a medical ward they don’t look like life-savers.

Fire extinguishers weigh 9kg and are made of steel. The fire extinguisher this man was holding looked a lot like a skull-cracking device to me. It was the most frightening workplace incident I have experienced.

I have been a nurse for 25 years. Like many nurses I have been struck while at work (39% of nurses have experienced physical violence according to this recent Australian survey, 36% worldwide says this quantitative review). I am lucky: I have only been hit by frail people with delirium or dementia, so have never been hurt – just surprised and amused. To illustrate: once, an elderly lady forgot I was the nurse making her bed, and suddenly started punching me (with the strength of a wet kitten) saying, “Stop it Malcolm! Don’t take my money from under the mattress and go to the pub again! You’re such a bastard Malcolm!” It was pretty funny – always wondered whether Malcolm was a memory from her past or a distortion of the present (probably a bit of both).

Zero Tolerance is Unrealistic and Unfair

I am not a fan of being abused or hit, but think that the “Zero Tolerance” campaigns that have popped-up in health services in Australia over the last 5-10 years are unrealistic and unfair.

This shouty "ZERO TOLERANCE NO EXCUSE FOR ABUSE" poster hangs in the main corridor of a medical ward, adjacent to the nurses station.

This shouty “ZERO TOLERANCE NO EXCUSE FOR ABUSE” poster hangs in the main corridor of a medical ward, adjacent to the nurses station.

Unrealistic because it is inevitable that health services, hospitals especially, will have a large percentage of patients who have cognitive and perceptual deficits due to the very medical condition that has them bought them to the health facility in the first place. More than half of older persons admitted to hospital will experience delirium, and about 9% of the over-65s (a significant component of health service users) have dementia. Often these people will not have the cognitive capacity to discriminate between friend and foe, and will, at times, lash out to defend themselves against a perceived threat. We can look out for the warning signs and be proactive in protecting ourselves, but we can not expect to transfer responsibility for our safety onto someone who does not have the cognitive capacity to even keep themselves safe.

In the health system it is very common to be spending time with people who are having the most traumatic, frightening and disempowering day(s) of their life. It would be lovely for staff if everyone experiencing acute emotional distress expressed their emotions in a clear, calm and composed manner, but is it realistic?

The “zero tolerance” concept is unfair because it is not reciprocated. We (that’s “we” as in “we the health system”) require patients and their loved-ones to be incredibly tolerant of us. Think waiting lists, physical discomfort, unplanned delays, unclear communication, unmet expectations, cancelled procedures, lack of privacy, lack of dignity, lack of control, lack of compassion, lack of progress… the list could go on. Can you find me a health facility where no patient has ever experienced these things? Our health system relies on people being tolerant – this “zero tolerance” malarkey doesn’t allow for a bit of crap.

Care and Crap

"Nursing ring theory: Care goes in. Crap goes out." courtesy of http://www.impactednurse.com/?p=5755 [thank you Ian]

“Nursing ring theory: Care goes in. Crap goes out.” courtesy of http://www.impactednurse.com/?p=5755 [thank you Ian]

Instead of zero tolerance, it is more realistic to expect that patients will occasionally need to vent their emotions. Not just the pleasant emotions like love, joy, gratitude and kindness, but also the less comfortable human emotions like grief, anger, sadness, worry, despair, frustration, fear, pain and hate. For these emotions swear words are adjectives, a raised voice is empowering, tears are cathartic.

In “Nursing Ring Theory” (more info here: impactednurse.com) when someone is in a ring that is smaller than the ring you are in you offer support, compassion, care and skilful expertise. When someone is in a ring that is larger than yours you are allowed to ventilate your emotions with them. It is pure client centred care: everyone sends care going towards the direction of the patient and accepts that there will be crap coming out at times.

This acknowledgement of crap coming out is not an offer to hold out nurses and other health care workers as targets for abuse. That’s not OK. However, let’s shelf the zero tolerance crap: of course we’re tolerant of people ventilating their emotions. All we ask is that nobody is put at risk and those closest to direct patient care also have an avenue to safely ventilate their crap.

In ring theory care goes towards the patient and crap moves away from the patient. Proximity to the centre of the ring will be a fair predictor of the intensity of both care and crap.

Fire Extinguisher Guy* 

Fire extinguisher guy is admitted to a medical ward for investigation of possible neurological disorder, but it might be something mental health related. So the Consultation Liaison CNC (me) spent a lot of time talking to fire extinguisher guy before the violent outburst, and again afterwards.

Fire extinguisher guy works hard, is creative, can be warm and funny at times; sadness, anger and tears bubble-up during our conversation then settle quickly. Talking to someone is both distressing and helpful, says fire extinguisher guy. He wants to get these strong, bouncing-all-over-the-place emotions under better control. Fire extinguisher guy’s experience of terrible abuse in childhood and his recent over-the-top cannabis and alcohol use wouldn’t be helping his labile hypomanic symptoms.

Fire extinguisher guy isn’t an unlikable person – he has a job, a car, a girlfriend, workmates, footy mates, other friends and a family. Fire extinguisher guy and the people who love him are all normal people. Fire extinguisher guy is one of the 20% of Australians who will experience problems with their mental health this year.

I am really grateful that fire extinguisher guy made the choice to direct his violence at property and not people. He had the capacity to make a very bad decision to hurt somebody; he chose not to. The only person physically harmed during this violent outburst was fire extinguisher guy himself: cuts from punching glass, bruises from punching and kicking windows, doors and walls of the medical ward.

I can’t figure out how long fire extinguisher guy’s violent outburst lasted. Replaying the scene in my mind I guess it was less than 2 minutes, but it’s like time measured in dog years… even though everything happened very quickly it somehow felt like slow motion too.

The fire extinguisher had been hurled into a storeroom doorway (THUD! CRACK!), the outburst was tentatively over, and fire extinguisher guy’s mum and i were lightly holding him and talking to him quietly when security arrived. Fire extinguisher guy allowed us to lead to him to an empty room and was cooperative with all of our suggestions and interventions. He apologised first to me, then to each of the other clinicians who provided care in those first couple of hours after the event. His apologies were heartfelt. He let the nurses, the doctor and the cleaner go about their business uninterrupted: his wounds were dressed, he accepted oral medications to dampen the intensity of his emotions, the blood and broken glass were cleaned-up, the other patients and visitors were reassured, detailed file entries were made, incident reports were filled-in, and negotiations between various members of the hospital’s multidisciplinary team were underway. The request for transfer off the medical ward could not be accommodated, but the insistence on two security guards overnight for staff and patient safety was.

Those of us up-close-and-personal to the incident took a couple of moments to exchange thoughts, but we tried not to get too bogged down in feelings at the time – it’s the beginning of the shift and fire extinguisher guy is just one of many patients on this busy medical ward.

Hole punched in the wall? No problem! One of the nurses covered the hole with this poster. Nurses are good at irony.

Hole punched in the wall? No problem! One of the nurses covered the hole with this poster. Nurses are good at irony.

There is a hole in the wall that fire extinguisher guy created by punching it. One of the senior nurses on the medical ward covers the hole in with an anti-violence poster. We all laugh at the delicious irony and get on with our jobs.

As with the poster covering the hole, we crudely paper-over the cracks… it’s not fixing a problem, just covering it over… that’s good enough for now.

Emotional Aftershocks

In the days that follow I find myself a bit preoccupied at times thinking about the event. Get teary every now and then when I think of what could have happened: those skull-cracking thoughts are the worst bit… acquired brain injury anyone?

Skull-cracking thoughts are from my fear and imagination not from what actually happened.

That’s a good reminder. Keep saying that.

I’m OK: no flashbacks, no vivid dreams, no avoidance, no hyperarousal. I was back at work the next day (left a few hours early because I stayed back a few hours with fire extinguisher guy the night before). I’m seeing patients in the same medical and surgical wards, spending time with my very supportive colleagues.

I’m OK: I’m resisting the urge to quietly whisper to every fire extinguisher in the hospital, “Stay where you are my little red friend. Stay gently hooked on the wall. Do not allow yourself to be raised higher than my head. Please don’t go violently leaping about medical wards – people don’t like that THUD! CRACK! sound you make. Stay exactly where you are my little red friend.”

I’m OK: I’ve told the story a few times now – it’s losing its potency. The funny bit about the poster is good – every story needs a punchline (you’re welcome). The scary bit about the fire extinguisher is getting less vivid – it feels more like a story from the past now. It’s turning into a half-joke about fire extinguishers staying on walls exactly where they belong.

I’m OK: the only thing I’ve noticed is a bit of kummerspeck (great word, eh?). Kummerspeck is a German word that literally translates as “grief-bacon” – it refers to the weight gained through emotional over-eating. I’ve had to let my belt out a notch, and my favourite shirt feels too tight. Still going to the gym, so it must be the eating, Better keep an eye on that.

Yeah yeah yeah. If you’re so OK why are you blogging about it?

Part of the motivation is catharsis. Very self-indulgent, I know.

More importantly, senior clinicians should offer information and support that will empower and protect junior clinicians. Just a few days after the most frightening workplace incident I have experienced these two tweets popped-up on Twitter:

I do not know either of these people IRL (In Real Life), but I do feel a tremendous responsibility towards Emily, Dani and any other nearly-nurse who is as enthusiastic and passionate as these two. But what to say to Emily and Dani? How do we nurture them safely into our profession and keep their enthusiasm intact?

Nursing – mental health nursing especially – needs people like Emily and Dani.

Sharing a battle story is not enough.

Referring to a patient as “fire extinguisher guy” is not a good example to set (more about that later – look for the red asterisk*).

As a senior nurse I should be supportive and encouraging to Dani, Emily and other enthusiastic nearly-nurses, and also be providing safety-tips and useful hints. I have two:

One: Make Like a Boy Scout

Be prepared.

Be prepared for some fantastic days at work where you’ll glide home feeling like you’re doing the most important and rewarding work that any one human can do. Those will be the days where you will use your knowledge-base, your skill-set and (most importantly) yourself to make a profoundly positive difference in somebody’s life. That person might never forget you.

Not every nurse gets exposed to violence or abuse, but you’ll see it up-close-and-personal through your patient’s eyes sometimes. Nurses do emotional labour: be prepared for the emotional aftershocks that come with the job. Find out about stress reactions and how to be pro-active in protecting yourself. I have an old, kind-of-dicky resource to share with you here, but you might find something better.

Two. Nurture the Nurturer

I’ve written about this before: meta4RN.com/nurturers

I am so angry that my nurse and midwife colleagues don’t have ready access to clinical supervision as a tool to reflect on practice and keep themselves (and their patients) safe. People say it would be too expensive to provide clinical supervision to every nurse who wants it, but there is huge cost already being paid. This cost (in terms of relationship stress, sleep disturbance, emotional trauma, anxiety, depression, substance use and kummerspeck) is being borne by individual nurses and the people who love them. Clinical supervision allows another way – through guided reflective practice many of these costs can be prevented.

I don’t see why looking after a nurse’s practice and emotional self through regular confidential support with a trusted colleague would be any less important than looking after a nurse’s back. Australian health facilities all have tools, time and training devoted to safe lifting, it is time to provide tools, time and training devoted to safe thinking.

Clinical supervision is available to mental health nurses, but not nurses in general hospital wards. In his epic novel Catch-22, Joseph Heller wrote:

People knew a lot more about dying inside the hospital, and made a much neater, more orderly job of it. They couldn’t dominate Death inside the hospital, but they certainly made her behave. They had taught her manners. They couldn’t keep death out, but while she was in she had to act like a lady. People gave up the ghost with delicacy and taste inside the hospital.

It is the nurses that make death and illness more neat, orderly and ladylike.

It is the nurses who paper-over the holes punched in the walls.

It is the nurses who stay on the ward to make sure that care keeps going in.

The nurses should be provided with an avenue to let crap out.

Guided reflective practice (aka clinical supervision) should be available for all nurses and midwives.

Closing Remarks

I would like to leave the story there because I have waffled-on for a long time already. However, it is necessary to address two tricky subjects raised in this blog post: [1] mental health and violence, and [2] my use of “fire extinguisher guy” when referring to a hospital patient.

Mental Health and Violence

Let’s get the facts straight:

  • the overwhelming majority of people who experience mental health problems are not violent: never have been and never will be
  • most violence is not perpetrated by people with a mental health problem
  • people who experience mental health problems are more likely to be victims of violence than perpetrators

I started specialist education in mental health nursing in 1993 and have spent most (not all) of my career working in clinical mental health nurse positions since then. I have never been physically assaulted by a person experiencing mental health problems. Never. However, earlier in the week there was a newspaper article reporting that “half of the nurses working on hospital psychiatric wards are themselves suffering from mental illnesses such as post-traumatic stress disorder, depression and anxiety.” I know that I have been more fortunate than some of my colleagues.

There are lots of myths and misunderstandings about mental health and violence. Please scroll to the bottom of the post for evidence-based resources and references.

Explanatory Note re the use of “Fire Extinguisher Guy”*

Using the term “Fire Extinguisher Guy” protects confidentiality and is, obviously, an irreverent, playful way to refer to a person. I don’t think this is wise for somebody creating a professional social media portfolio – somebody might think I’m being disrespectful.

Yet, here i am doing it anyway. Why?

Irreverence, humour and playfulness can be useful defence mechanisms: used correctly they can trivialise the other/traumatic events and empower the self. During the event I did what I could (very little) to assist this man to regain control and to keep himself and others safe from physical harm. It would not be useful to dwell on how powerless and vulnerable we all were at that time. I spent many hours talking to the man both before and after the event and treated him with kindness, respect and dignity.

Care goes in. Crap goes out.

This blog post is some crap coming out.

End

As always, your comments and feedback are welcome (scroll down).

Paul McNamara, 11th August 2013

.

References and Resources re Mental Health and Violence

SANE Australia have a very readable resource, downloadable fact sheet and MP3 file here

Queensland MIND Essentials includes a resource for nurses and midwives caring for a person who is aggressive or violent here

The references below are via Australia’s Mindframe National Media Initiative:

New South Wales Health. (2003). Tracking tragedy: A systemic look at suicides and homicides amongst mental health inpatients. First report of the NSW Mental Health Sentinel Events Review Committee.

Walsh, E., Buchanan, A., & Fahy, T. (2002). Violence and schizophrenia: Examining the evidence. British Journal of Psychiatry, 180, 490-495.

Noffsinger, S. G., & Resnick, P. J. (1999). Violence and mental illness. Current Opinion in Psychiatry, 12, 683-687.

Brennan, P. A., Mednick, S. A., & Hodgins, S. (2000). Major mental disorders and criminal violence in a Danish birth cohort. Archives of General Psychiatry, 57, 494-500.

#ACMHN Looking back at the 2013 Consultation Liaison / Perinatal Infant Conference through a Social Media Lens

Context

The 2013 ACMHN Consultation Liaison / Perinatal & Infant Mental Health Nurses Annual Conference was held on June 6th and 7th, in Noosa – on Queensland’s Sunshine Coast. It is a boutique conference: these two subspecialties account for a tiny fraction of the total mental health nursing workforce. Given the size of these subspecialties, the conference organisers were pleased with the attendance of about 70 nurses, who gathered together from New Zealand and most states/territories in Australia. 70 is probably about par for the course.

IMG_1850The theme of the conference was “Present and Available” – an exploration of the process of presence, being with and affecting change in the variety of settings that we work. This post explores whether social media can also help mental health nurses and their conference content be present and available to others via social media, specifically: via twitter.

Quantitative Data

There were 26 twitter participants using the #ACMHN hashtag over four days (the two conference days being in the middle of this period). Interestingly, only 3 of the 26 #ACMHN participants were delegates (ie: only 12% of those tweeting about the conference were actually at the conference). Let’s look at the make-up of all #ACMHN participants:

  • 3 conference delegates (each of them Australian mental health nurses)
  • 4 Australian mental health nurses, across three states (Victoria, South Australia & Queensland)
  • 2 European mental health nurses (Germany & Netherlands)
  • 2 Australian general nurses (New South Wales & Australian Capital Territory)
  • 2 Australian nurse/midwife academics (both in Queensland)
  • 1 UK nurse academic
  • 1 Australian psychologist
  • 6 Australian health-related agencies
  • 1 Australian health service manager
  • 1 USA physician
  • 2 non-clinicians from the USA
  • 1 mental health clinician?/consumer advocate? from Scotland

It’s surprising and enthusing (to me, anyway), that a boutique conference being held in a small regional Australian city attracted such an eclectic, geographically widespread group of social media participants. The 26 #ACMHN hashtag participants sent 141 Tweets in the timeframe being examined. The three delegates generated 90 #ACMHN tweets, being 64% of the total during the examined period.

Use of the #ACMHN by those away from the conference was almost entirely in the form of retweets – a simple process where one twitter user shares the content of another twitter user, thereby spreading information quickly and widely. Through this compounding, amplifying effect that social media activity has, during the 96 hours being examined the #ACMHN hashtag had a potential reach of over 94,000 (source). Two specific examples of this will be examined below under Twitter is an Amplifier.

Qualitative Data

The qualitative data is the content of the tweets.

I recommend that you scan through the curated (ordered, edited and quite readable) version of the transcript here: http://storify.com/meta4RN/noosa

Also available is the un-curated (asynchronous and jumbled to read, but complete) transcript here: http://qld.so/tweets 

Twitter is an Amplifier

IMG_1841IMG_1840Assuming that a key purpose of a health care conference is to share information, it would be foolish to overlook the amplifying effect of social media. This first example of a simple statement in a presentation on anorexia nervosa, shows how a message reached beyond the 70 people at the conference to a potential audience of over 20,000.

Let me show the maths on that:

579 = the number of people following the @meta4RN Twitter account. So that one Tweet could have been seen by up to 579 people/organisations. I doubt very much that it was seen by that many. Believe it or not, people have better things to do with their time than read every single one of my tweets. Nevertheless there is a very good chance that many dozens, maybe as high as a couple of hundred or so, people see any single tweet sent. That single Tweet was retweeted (ie: shared/passed-on) by five other Twitter accounts, each with their own group of followers, thus:

Let’s add those numbers up: 579 + 9712 + 8433 + 1969 + 178 + 1403 = 22,274. (source)

So, the potential (not actual) audience for that one message delivered to 70 conference delegates suddenly becomes a message that would have been seen by thousands of people. How many exactly? No idea. As long as you pick a number less than 22,274 your guess will be as good as mine.

IMG_1848IMG_1849Another example of Twitter being used as an amplifier is with this Tweet regarding the publications of one of the conference presenters. The bit at the end that reads “Ping #nswiopCS13” can be interpreted as “You people following the Advances in Clinical Supervision conference may also be interested in this”.

One of those in attendance at the Clinical Supervision conference retweeted, as did two Professors of Nursing: one with James Cook University in Cairns, the other with City University in London. So, while the numbers of people exposed to the presenter’s publications via a tweeted internet link is more limited than the previous example, they were also more targeted… nobody values peer-reviewed journal publications more than an academic. It’s good for Chris Dawber’s professional profile to have nursing academics on either side of the world to be aware of his papers and sharing them with their Twitter followers. It is also useful that Chris had his papers bought to the attention of those at/following a Clinical Supervision conference that was being held in Sydney at the same time as our conference. The link to Chris’s papers is here.

Danger Will Robinson!

This amplifying effect of Twitter comes with a cautionary note… what if I misquoted or inadvertently misrepresented what Catherine Roberts said?

Easily could have.

I don’t doubt that I’ve captured the essence of what Catherine said as I heard/understood it. However, by using quotation marks I have attributed it as a direct quote from Catherine. Now, a few days after the conference, I’m not 100% confident that I have used Catherine’s exact words.

Naturally, I’ll pass-on a genuine and contrite apology to Catherine if I have got it wrong and caused any offence or embarrassment. However, in practical terms, it’s too late – the horse has bolted. For better or worse, there are probably thousands of people who now think that’s what Catherine said.

Another point of risk: all the way through the conference I tweeted out the take-home message from sessions as I understood it (as seen by scrolling through here). What if I’ve missed the point that speaker wanted emphasised? What if I got it wrong?

Does that make social media too scary and dangerous to use professionally? Of course not.

For me, there’s three strategies that these reflections suggest:

  1. Be careful with what you Tweet if you’re attributing it to others. For example, only use quotation marks when you’re sure you have the presenter’s exact phrasing correct. Also, try to make it clear whether the take home message is the presenter’s words, or your own understanding/interpretation.
  2. Encourage more social media conference participation. As with this example from a keynote presentation at the International Council of Nurses 25th Quadrennial Congress, it’s more interesting to have multiple people using social media rather than just one. Multiple participants also makes it less likely that a single participant’s misunderstanding will be read in isolation… a safety in numbers thing.
  3. For presenters: take control of your social media presence – don’t leave it to chance. That’s what I did with my presentation at the conference (see example below).

1

2As you can see above,  rather than take the risk of being misunderstood and/or misquoted by a conference delegate tweeting, I did the tweeting myself via scheduled tweets in the lead-up and during my presentation. As I did, you can include links to websites that are relevant to your presentation. This is a good way to keep control over your message. (BTW: a summary of my presentation is online: meta4RN.com/twit)

For presenters, the alternative way to take control of your social media impact from a conference is to announce, “No Live Tweeting Please”. That’s fine – it should be the presenter’s prerogative. However, what you’re actually saying is either, “What I Have To Say Is Too Precious For People Like You To Share” (in which case, should you be talking about it at a conference?), or “I Do Not Understand or Trust Social Media” (which sounds a bit like, “I do not understand or trust traffic lights” – charmingly quaint, but oddly old-fashioned).

Finishing-Up

For those familiar with my web site, you’ll notice that this post is an obvious companion piece to three previous posts:

Looking Back at a Nursing Conference through a Social Media Lens

Looking Back at Postnatal Depression Awareness Week through a Social Media Lens

Looking Back at a Mental Health Nursing Conference through a Social Media Lens

Through examining and reflecting on this collection of data, I am gathering confidence and understanding of professional use of social media. By sharing it online, hopefully other health professionals will do likewise: more the merrier.

References/Data

That’s it. As always, your comments/feedback are welcome.

Paul McNamara, 12th June 2013

Precovery: a proactive version of recovery

Recovery

recoveryIn mental health services the term “recovery” has been all the rage for the last few years. Australia’s mental health services are encouraged to be “recovery orientated” and use the “recovery approach” or “recovery model” [same same]. In fact, Australia’s 2010 National Standards for Mental Health Services embed the recovery model in clinical practice [see here]. This is a move away from seeking to “cure” the individual. It is a move towards supporting the individual on their journey towards healing.

The recovery model emphasises hope for the person who is experiencing mental illness. Ingrained in the recovery approach is encouragement for the individual to increase their understanding of both their abilities and their disabilities, and to take-on as much autonomy as possible. The person can then use hope, insight and autonomy as a platform to engage in an active life – one with purpose and meaning – and thereby acquire and sustain a more positive sense of self.

All good stuff. What’s not to like?

Well, the recovery model assumes existing psychiatric disability and/or psychopathology, but in perinatal mental health we’re trying to head problems off at the pass. Recovery is a journey towards healing, but perinatal mental health seeks to decrease either the need for that journey or, at worst, that the journey is not too long or too complex. “There’s nothing to be gained from waiting for a pregnant woman or new mother to be in crisis before intervening, but there is much to be gained in preventing symptoms becoming severe or debilitating.“# So, if we’re doing perinatal mental health prevention and early-intervention the recovery model isn’t a great fit – we’re trying to avoid the level of acuity or chronicity that the recovery model caters for.

However, we don’t want to throw the baby out with the bathwater [dud idiom for a perinatal mental health nurse to use - sorry about that]. Recovery enshrines the uniqueness of the individual, that the individual will be treated with dignity and respect, that the individual will be empowered to make real choices, and that clinicians work in partnership with the individual and ensure that communication is a two-way street. We want to keep all those values from recovery and prevent symptoms/disability from becoming severe or long-lasting.

That’s why i suggest we start making-up words (a practice often classed as psychopathology in my business: look-up the word “neologism“). Anyway, undeterred, here’s a neologism I prepared earlier: “precovery” – please, let me explain:

Prehab

In October 2012 I attended a Health Roundtable workshop in Sydney. There were some really bright people from all over Australia and New Zealand there, representing just about every speciality in health care. During a break a I got chatting to a Physiotherapist, Judy Chen, who introduced me to the word/concept of “prehabilitation” or “prehab”. Prehab is where the patient is taught and practices the skills and exercises that s/he will required for post-operative recovery before the operation.

For example, let’s pretend that you require an operation on your right knee which will leave you on crutches for a week afterwards; you must avoiding twisting movements, but to maintain a full range of movement after the healing is completed, you’ll need to bend the knee and partially weight-bear as soon as possible post-op. Wouldn’t it be better to get accustomed to using crutches and practice the movements/exercises required when you’re not experiencing post-surgical pain, and you don’t have IV drips, drains and wound dressings hampering your mobility? That’s the premise of prehab; practice the exercises and/or using a mobility aid while in comparatively good shape, so when you’re in not-such-great shape you won’t have to be learning a new skill set from scratch.

Who would've guessed that physiotherapy could inform psychotherapy?

Who would’ve guessed that physiotherapy could inform psychotherapy?

Prehab is a good idea, eh?

It’s OK for perinatal mental health nurses to shamelessly steal ideas from physios, isn’t it?

I hope so.

Precovery

PrecoveryPerinatal Mental Health Precovery would borrow the prehab idea, and encourage pregnant women and new mums to acquire supports and practice skills before symptoms of depression and anxiety arise. Precovery will be built-in to antenatal care: just part of the everyday health service routine.

So, what would precovery include? Well that’s where I’m looking for input – I’m really hoping to draw on the wisdom of others to come-up with a more complete, more rounded-out notion as to what to include in precovery.

Reflecting some good clinical practices I’ve been exposed to/heard about, here are some of the components I’d suggest for Perinatal Mental Health Precovery:

[Precovery 1] Create or Reinforce Support Networks

Antenatal and Parenting classes – for most women I’ve spoken to, the content/information in the classes is less valued that the relationships/contacts made with other parents. The notion of “teaching” and “learning” is a bit of a smokescreen for the really valuable stuff: “connection” and “attachment”.

Playgroup - as long as it’s a supportive, friendly playgroup. Some of the mums I’ve met tell me that some playgroups can feel a bit competitive, and give their sense of confidence a bit of a bruising. To quote a delightful lady I met with a few times, “You know those f#@*%^g Lorna Jane mums? The perfect ones who look great, have babies that sleep well and breastfeed like champions? The playgroup I went to was full of them. And then there was milk-soured, frumpy, messy me with mastitis and a bottle-fed baby. It was awful. I felt worse. I had to stop going.”

Targeted supports – eg: teenage mums will almost certainly feel much more comfortable, better supported, if they get to meet with other young women who are pregnant/have new babies.

[Precovery 2] Informed & Supportive Significant Others

A supportive partner can have an incredibly positive influence; traditionally that is baby’s father, but families come in all shapes and sizes now – the supportive partner isn’t always a bloke, and there’s not always one on the scene. When baby’s father is on the scene, let’s get him worded-up on how important he is to both mother and baby. The beyondblueHey Dad” booklet can get the conversation started. In same-sex relationships, maybe grab the same free booklet, and a bottle of liquid paper and a pen… or (more seriously) connect with others who share your experience – there are some good online forums available, try the Raising Children Network for instance.

If baby’s Dad isn’t around, we need to go looking for a family member(s) or close friend(s) who can step-up and share some of the good, and not so good, stuff. Single parent families are the fastest growing type of family in Australia; some resources and agencies are responding to that better than others – more info here.

[Precovery 3] Symptom Awareness/Monitoring

This will happen to some degree with the universal screening as recommended by the National Perinatal Depression Initiative, and/or via regular contact with GP/Midwife/Obstetrician/Child Health Nurse/Perinatal Mental Health Worker/other clinician.

It is also worth encouraging people who experience depression, anxiety or other mental health difficulties in the past to have a good awareness of what their early-warning signs of relapse are. Significant others can play a part in this too. The online, self-scoring version of the Edinburgh Postnatal Depression Scale could also help some people keep an eye on things. For instance, I encourage many of the women I meet with to visit this site regularly (but not too frequently): justspeakup.com.au/epds Ask the woman’s significant other(s) to use it too – perhaps make a diary date for the first of each of month. This self-awareness/self-monitoring fits nicely with the empowering aspects of recovery, so certainly belongs in precovery.

[Precovery 4] Easy Access to Appropriate Information & Support

Often the supports that help the most aren’t specialist mental health supports. In my clinical experience many Mums have found an approachable Midwife or a friendly, relaxed Child Health Nurse has done more practical stuff to decrease anxiety than weeks of “talk therapy” could ever achieve. Practical parenting supports need to be easy to find – having an online presence, such as Parentline and Tresillian, is part of being easly accessible.

Sometimes the support required will be catered for by phoning the Post & Ante Natal Depression Association (PANDA) on 1300 726 306, and/or a visit to the PANDA website

Other websites such as beyondbabyblues, Just Speak Up, Black Dog Institute and mindhealthconnect are worth visiting, as are some of the grassroots supports that have sprung-up on Facebook – pages such as Daisy Chains Postnatal Support Network and Peach Tree Perinatal Wellness, amongst others.

Hopefully there will be specialist mental health support available in most health districts. Where there isn’t a perinatal mental health service GPs and local mainstream mental health services/clinicians will need to plug that gap as best they can.

[Precovery 5] Recognition of the Uniqueness of the Individual

This will assist us to resist the temptation to imagine “one size fits all’ solutions to complex, individualised circumstances. The values and the goals of the individual will determine what, if any, support is required.

Part of this will require health services to promote realistic expectations. Health services will make sure that families have heard of Donald Winnicott’s concept of “the good-enough mother”, and that those books which prescribe baby or parent behaviour are left in the bookshops just as they should be: unsold and dusty. Let parents know what to expect: if 25% of births end-up as emergency caesarean at this hospital, make sure that’s known: “There are 16 pregnant women in this antenatal class – a bookmaker would take a bet that 4 of you will have an unplanned caesarean section. If you happen to be one of those 4, how will that match-up with your hopes and expectations? Will it mean that you’re a ‘bad mother’ or ‘a failure’?” We need to be proactive about managing idealised, unrealistic versions of the pregnancy/parenting story.

[Precovery 6] Making Real, Informed Choices

This does carry the risk that the clinician’s recommendations are not always followed [see Exhibit A: the cigarette smokers]. However, it carries the benefits of avoiding coercion and inadvertently causing harm by disempowering the individual. Advocating for real, informed choices puts the clinician on a more realistic footing too. Let’s not even entertain the fantasy that every pregnancy/birthing/parenting experience will be ideal – we’re not aiming for perfection, we’re aiming to minimise harm. Bottle feeding works better for your family than breastfeeding? No judgement, no coercion, no worries – shall we run through bottle preparation together? Dignity and respect are also straight out of the recovery model – let’s include them in precovery too.

[Precovery 7] Partnership & Communication

As with advocating for real choices, these are the qualities that will build resilience and trust. Part of precovery will be to provide the individual with opportunities to ask questions and ventilate concerns, and to be supported by the clinician to explore the solutions together.

The other bit of partnership and communication is with the new baby. Let parents know that babies are born with a brain primed for experience, and ready to socialise and learn from day one. Show something like the Getting to Know You DVD in antenatal classes so parents can ready themselves for the communication part of early infancy. New parents may not be aware of baby’s capacity to socialise, learn and explore from the get-go – it would be cruel not to let them in on the secret. That information may, in turn, strengthen the partnership and the quality of attachment between baby and her/his primary caregivers.

Ideas? Comments?

That’s my little brainstorm on what precovery should include. What have I missed? Is this idea of “precovery” as a way to frame perinatal mental health early-intervention and prevention strategies a nutty neologism or a nifty notion?

Please add your thoughts/suggestions in the comments section below.

Paul McNamara, 5th March 2013

Reference

McNamara, P. (2011) Perinatal mental health, O&G Magazine, Vol 12, No 2, Winter 2011, pp 56-7. http://www.ranzcog.edu.au/publication/oandg-magazine/editions/cat_view/38-publications/409-o-g-magazine/410-o-g-magazine-editions/538-vol-13-no-2-winter-2011.html [tragically, shamelessly, self-refrencing again: please note that the "Dr" afforded me in this paper is a typo in the magazine - I don't have a PhD]

Post Script (added 6th July 2013)

ANJKay McCauley, Senior Lecturer at the Monash University School of Nursing and Midwifery, suggested that I tidy-up this blog post so it would be suitable to publish in a journal. To be honest, I never would have thought of doing so without Kay’s prompt, and am very grateful to Kay for her encouragement and support. The waffly ramblings above were tidied-up and abbreviated to meet the ANJ word limit (I recruited Kay to help with the slash and burn as co-author).

Anyway, I just found out this morning that it has been published. Yay!

Here’s the citation, link and PDF:

McNamara, Paul and McCauley, Kay. (2013). ‘Precovery': A proactive version of recovery in perinatal mental health. Australian Nursing Journal: , Vol. 21, No. 1, Jul 2013: 38.

http://search.informit.com.au/documentSummary;dn=396717147073212;res=IELHEA

PDF: ANJ

On Being a Dementia Nurse Newbie

The #dementia hashtag has been showing-up on Twitter a fair bit lately. This is due in no small part to British Nurses hosting an online chat and gathering resources under the #WeNurses social media portal: see their chat info and transcript here.

It’s had me thinking back to my first experiences of nursing the person with dementia, of being a dementia nurse newbie.

Since those early days as a nurse I’ve come across dementia in a number of roles, most frequently when working as a Consultation Liaison (CL) Clinical Nurse Consultant (CNC). CL CNC is a role where mental health assessment, support and education is provided in the general hospital setting in partnership with the clinical staff working there. Dementia isn’t usually part of a mental health nurse’s day-to-day work, but it is a frequent trigger for referral to a CL mental health nurse. In a 2005 survey of Australian CL nurses the “Four Ds” of common CL presentations were identified: Delirium, Dementia, Depression and Deliberate self-harm (Bryant et al, 2007, p 34). These four conditions aren’t mutually exclusive, of course. In fact, somebody with dementia (even very early stage) is much more prone to developing delirium and/or depression. Additionally, there are very clear links between dementia, depression and deliberate self harm.

Anyway, back to the subject. The prevalence of the dementia hashtag on Twitter reminded me of the clinical placement where I first encountered dementia amongst the residents of a large nursing home. Being new to nursing and new to dementia I felt pretty baffled at first. Luckily there are some secret weapons to feeling baffled: they’re often found in literature, art and music.

In 1989 Elvis Costello released a song he co-wrote with Paul McCartney called Veronica. The story I’ve heard is that the song was about Elvis Costello’s Grandmother who had dementia. As we know, dementia is a progressive, irreversible brain condition that results in cognitive and physical decline with some fluctuations in alertness and lucidity. Dementia can leave many long-term memories fairly intact, but makes laying-down new memories very difficult. The song Veronica captured the fluctuations in mood and memory beautifully, and was a timely, poignant accompaniment to my clinical placement.

Veronica by Elvis Costello helped me a lot when I was a newbie to nursing the person with dementia; maybe the song will help other dementia nurse newbies too.

Veronica video [via www.youtube.com]

Veronica lyrics [via www.sing365.com]

Is it all in that pretty little head of yours?
What goes on in that place in the dark?
Well I used to know a girl and I would have
sworn that her name was Veronica
Well she used to have a carefree mind of her
own and a delicate look in her eye
These days I’m afraid she’s not even sure if her
name is Veronica

[Refrain:]
Do you suppose, that waiting hands on eyes,
Veronica has gone to hide?
And all the time she laughs at those who shout
her name and steal her clothes
Veronica
Veronica

Did the days drag by? Did the favours wane?
Did he roam down the town all the time?
Will you wake from your dream, with a wolf at
the door, reaching out for Veronica
Well it was all of sixty-five years ago
When the world was the street where she lived
And a young man sailed on a ship in the sea
With a picture of Veronica

On the “Empress of India”
And as she closed her eyes upon the world and
picked upon the bones of last week’s news
She spoke his name outloud again

[Refrain]

Veronica sits in her favourite chair and she sits
very quiet and still
And they call her a name that they never get
right and if they don’t then nobody else will
But she used to have a carefree mind of her
own, with devilish look in her eye
Saying “You can call me anything you like, but
my name is Veronica”

[Refrain]

Veronica mp3 [via iTunes]

In Closing

Nurses (#wenurses) are referred to in the lyrics: “And they call her a name that they never get right, and if they don’t then nobody else will.” It’s especially important for we, the nurses, to be fully present when dementia has made the person’s own presence tenuous, brittle.

We Nurses are fortunate to have art, literature and music to inform our empathy and build our emotional intelligence. Neither empathy or emotional intelligence are exclusive to nursing, of course, but both are core nursing qualities. I found those qualities, as they relate to nursing the person with dementia, in Elvis Costello’s song in 1989, and again by following the #wenurses and #dementia hashtags on Twitter in 2012.

Reference

Bryant, J., Forster, J., McNamara, P. & Sharrock, J. (2007) You are not alone: Results of the 2005 Australian consultation liaison nurses survey, Australian College of Mental Health Nurses. Available online here http://eprints.jcu.edu.au/2013/1/ACMHN2007.pdf or here http://www.acmhn.org/images/stories/Media/CLSIG_survey_report.pdf 

Paul McNamara, 30th November 2012