Tag Archives: mental health

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.

END

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

 

Does the End Justify the Meanness?

Proposed changes to health funding in Australia’s 2014 Commonwealth Budget include direct costs (“co-payments”) to patients every time they see their GP or have pathology done, and an increase in the cost of prescribed medications. This extra revenue will be put towards medical research. Does the end justify the means meanness?

For some people with schizophrenia the only medication that keeps them well enough to stay out of hospital is clozapine. Clozapine was initially introduced in the early 1970s but was withdrawn within a few years because some people died while taking it. Although clozapine is the only effective antipsychotic for some people with schizophrenia, about 1% of those who take clozapine will develop agranulocytosis (a dangerous drop in white blood cells, especially neutrophils – the most abundant type of white blood cells). Left unrecognised and unmanaged agranulocytosis leaves people very susceptible to serious infections and, as happened back in the 1970s, can even lead to death.

Schizophrenia is a bugger of an illness. Onset of symptoms is nearly always in teenage years or early twenties. Schizophrenia is often misrepresented as split personality – that’s wrong – it infers that a person can choose or control their symptoms. The word schizophrenia has it’s roots in the Greek language, translated it means split mind – people do not choose to have a split mind. Symptoms vary between individuals, but very often people with schizophrenia will experience thought disorder (non-sequential, disorganised, confused thinking), delusions (beliefs, often unsettling and difficult to understand, that are not shared by others) and auditory hallucinations (sounds or voices that nobody else can hear, but which sound and feel very real to the individual experiencing them). If these symptoms are intense or frequent they can really make a mess of the individual’s ability to function successfully in school, university or the workplace. Consequently people with schizophrenia are over-represented amongst the unemployed and homeless.

before

Because schizophrenia is such a bugger of an illness and clozapine can be so effective at dampening-down the symptoms, in the early 1990s clozapine was made available again with some very strict protocols in place to keep the people taking it safer from serious side effects. When starting on clozapine blood tests are taken every week to check that the neutrophils/white blood cell counts don’t drop. It is built-in to the infrastucture of clozapine management – you can’t get a prescription until you’ve had a blood test and the doctor checks it against previous blood tests. If there are any problems with the blood tests the doctor will stop prescribing clozapine – no ifs, ands or buts. For about 1% of people the risk of agranulocytosis will outweigh the benefits of staying on clozapine.

For the person with schizophrenia taking clozapine this regular regime of blood tests, visiting the GP and getting a short-term prescription (there are no repeat prescriptions for clozapine) might be the difference between being in hospital and being at home, or (sometimes) being homeless and being at home. Once initial treatment is established, safe management of clozapine requires frequent blood tests, a new prescription every 4 weeks and regular visits to the GP.

The proposed budget changes include a $7 payment to see the GP, $7 fee for out-of-hospital pathology, and an additional $5 for each prescription medication. What are the benefits of making schizophrenia treatment more expensive? Are there any foreseeable problems?

after

We are being told by our government that Australia’s universal health coverage is not under threat. $7 to visit a GP costs the same as two beers says our treasurer. What a sneering, mean thing to say.

People with schizophrenia, like people with diabetes, chronic obstructive pulmonary disease (COPD) and other enduring illnesses, are already at a social and financial disadvantage. For the individual with schizophrenia whenever there is an increased intensity or frequency of delusions, auditory hallucinations and disordered thoughts they suffer terrible distress. The people who love and care for them share in this distress. Often an expensive hospital admission for a few weeks is required to bring the symptoms back under control and sort-out the social problems that a period of being out of touch with reality can cause: unpaid bills and rent may lead to loss of accommodation; neighbours, friends and family may be feeling uncomfortable having you home again; your self care and physical health may have deteriorated; your tobacco, alcohol and drug use may have increased; you may have come to the attention of the police.

Do the benefits of co-payments really outweigh the risks?

IMG_0511

Final Notes

On Monday 19th May 2014 Joe Hockey, Australia’s Treasurer, will be appearing on Q&A. I have submitted this two-part question:

For some people with schizophrenia the only medication that keeps them well enough to stay out of hospital is clozapine. 
Safe management of clozapine requires frequent blood tests, a new prescription every 4 weeks and regular visits to the GP. 
What are the benefits of making schizophrenia treatment more expensive? 
Are there any foreseeable problems?


You may have a question of your own for Mr Hockey, if so go to 
www.abc.net.au/tv/qanda

CoPayLogo2CoPayStories provides an avenue for patients and health professionals to share their perspective on the proposed GP co-payment – visit the website www.copaystories.com.au and/or follow @CoPayStories on Twitter.

For the purpose of this argument I’ve cited only one side-effect of one medication for one illness. I am aware that clozapine has more than one side-effect, and there are illnesses other than schizophrenia that require regular pathology, GP visits and prescriptions.

Thanks for visiting meta4RN: as always, you are welcome to leave feedback in the comments section below.

Paul McNamara, 17th May 2014

Short URL: http://meta4RN.com/meanness

Football, Nursing and Clinical Supervision

When I started this blog in September 2012 I made a half-joke that watching Adelaide play in the AFL can inform clinical practice (see Number 8 meta4RN.com/about).

Well, as it turns out, this is absolutely true. Please let me explain. 

 

The Adelaide Crows, like all elite sporting teams, spend a lot of time preparing to play. For those unfamiliar with Australian Rules Football (AFL) it’s a fast, free-flowing, physical game that is played weekly during the winter months. Here’s a sample of play:

A game of AFL is played over four quarters, each lasting approximately 30 minutes (nominally each quarter is 20 minutes, but the clock stops when the ball is out of play). So, any player who stays on the ground for every moment of the game will play for two hours.

Guess how much time the player spends preparing for that two hours.

Crows warm-up at training. From left, Jarryd Lyons, Ian Callinan, Daniel Talia and Taylor Walker. Picture: Sarah Reed via Herald Sun.

Crows warm-up at training. From left, Jarryd Lyons, Ian Callinan, Daniel Talia and Taylor Walker. Picture: Sarah Reed via Herald Sun.

Think about what goes into preparation: recovery from the previous game, keeping-up and improving fitness levels, practicing individual skills, practicing team skills, discussing and developing team strategies, having coaches give feedback on what you did well and what areas could be improved, developing on-ground leadership and communication skills, nurturing confidence in yourself and your team-mates, learning about the team you’ll be playing against next week. The list goes on.

My brother, Bernie McNamara, has seen the Adelaide Crows up-close and personal over the last few years. Bern says that typically during the season a player will have about 25 contact hours each week with the club, and be expected to do about 10 hours of preparation away from the club.

So, each week, a diligent AFL player will spend  about 35 hours preparing for no more than 2 hours play.

How does that preparation:work ratio compare for clinicians?

IMG_0423

It’s not just the explicit hands-on knowledge that counts, it’s also very important that we make time for thinking-about, discussing and reflecting on our clinical roles. Clinicians, like footballers, have a desire to improve, but we may have to fight for support to do so. As noted at a recent seminar regarding clinical supervision, “in a time of austerity, high caseloads and increasing problems, the organisation is often satisfied with a ‘good enough’ (work task) rather than seeking excellence. This tends to reduce supervision to a control function rather than aspiring to best practice.” Source: Talking about supervision: conversations in Bolzano and London 

I have written about clinical supervision previously (in “Nurturing the Nurturers” meta4RN.com/nurturers), but perhaps undersold it – some have commented that it seems like a feel-good exercise for clinicians. There’s more to it than that.

Clinical supervision is a key component in providing high quality services with positive outcomes for those who use health services. Clinical supervision promotes a well trained, highly skilled and supported workforce, and adds to the development, retention and motivation of the workforce. High quality clinical supervision also contributes to meeting performance standards, meeting the expectations of consumers/carers/families and goes a long way towards developing a learning culture in a changing health care environment. Source: ClinicalSupervision

Clinical supervision guidelines are very modest compared to the preparation:work ratio of AFL footballers. Clinical supervision requires nothing like the investment of 35 hours of preparation for 2 hours of play, instead, it’s something like 1 hour of preparation for every 80 or 160 hours of work.

Are nurses, midwives and other clinicians worth the expense?

I’ve been thinking about this tweet lately:

I’m wondering whether we can tweak that sign a little – maybe something like this:

The Financial Perspective: “We can’t afford to spend money on nurses and midwives sitting around talking, thinking and reflecting.”

The Patient Safety Perspective: “We can’t afford not to.”

IMG_0449

 

As always, your feedback/comments are welcome.

Paul McNamara, 27th April 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 Workshop Links and Resources

Previously for Perinatal Mental Health Workshops I have trickled-out the links and resources we refer to during the workshop via Twitter and Facebook.  It’s a nice idea, and has worked pretty well (for more information about this experiment in social media enhanced education please see the video below and/or this link: meta4RN.com/workshop).

However, it is pretty labour-intensive to pre-schedule each individual Tweet and Facebook post every time I facilitate a Perinatal Mental Health Workshop, so to save some mucking-around I’ll list the links and resources here.

The headings in red are not mutually exclusive – some links cross boundaries. The list/links will be updated PRN:

Guiding Clinical Practice

guidelines

2014 Cairns Perinatal Mental Health Workshops (follow the link for info about the workshops and for free registration) pmh.eventbrite.com.au

Australia’s Perinatal Mental Health Clinical Practice Guidelines www.beyondblue.org.au

Promoting Perinatal Mental Health Wellness in Aboriginal and Torres Strait Islander Communities (PDF from the book Working Together: Aboriginal and Torres Strait Islander Mental Health and Wellbeing Principles and Practice; chapter 16 by Sue Ferguson-Hill) aboriginal.childhealthresearch.org.au/media/54907/chapter16.pdf

Perinatal Jargon Busting (get your head around the lingo) meta4RN.com/jargon

Using the Edinburgh Postnatal Depression Scale (tips for midwives, child health nurses, Indigenous health workers and other clinicians) meta4RN.com/epd

Edinburgh Postnatal Depression Scale  (this version is online, anonymous, free and self-scoring) justspeakup.com.au/epds

Perinatal and Infant Mental Health Libguide (a very handy for researchers and clinicians) tpch.qld.libguides.com/PIMH

pnd-dadQueensland Centre for Perinatal and Infant Mental Health (QCPIMH have some great resources) www.health.qld.gov.au/qcpimh

Perinatal and Infant Mental Health Nurse eNetwork (an email network hosted by the Australian College of Mental Health Nurses for nurses and midwives interested in perinatal and/or infant mental health) lists.acmhn.org/wws/info/perinatal-infant-mh

ACMHN Perinatal Mental Health Online CPD Program (a 3 module continuing professional development program which is open to Australian College of Mental Health Nurses members [free] and non-member nurses and midwives [$33 including GST]) www.acmhn.org/perinatal-elearning

Nurturing the Nurturers (info about guided reflective practice/clinical supervision as a self-care mechanism for health professionals) meta4RN.com/nurturers

For the Parent(s)

PANDA

Cairns Perinatal Mental Health Support Options google.com/?q=perinatal+cairns

Stay Connected, Stay Strong: Before and After Baby (cool DVD featuring Aboriginal and Torres Strait Islander parents). Borrow: lib.cairnslibrary.com.au Buy: www.health.qld.gov.au/qcpimh YouTube: http://youtu.be/CLsjgw8pvOA

Behind the Mask: The Hidden Struggle of Parenthood (DVD preview) http://youtu.be/FjqOqJLkyFs

PANDA – Post and Antenatal Depression Association (for info and phone support) www.panda.org.au

How is Dad Going? (for fathers affected by perinatal anxiety/depression)  www.howisdadgoing.org.au

Pregnancy, Birth & Baby (24 hour info and support) www.pregnancybirthbaby.org.au

beyondblue (lots of resources, including booklets regarding emotional health in pregnancy and early parenthood, some multilingual booklets) www.beyondblue.org.au

Black Dog Institute (info and resources re perinatal depression for women and men; presented in a different style to beyond blue’s info) www.blackdoginstitute.org.au

Doc Ready (for those not sure how to start a conversation about mental health with your midwife, nurse or doctor? maybe building a checklist will help) docready.org

MindHealthConnect (good place to find trusted mental health programs, fact sheets, and to access urgent support via the red “Need Help Now?” button on each page) www.mindhealthconnect.org.au

pnd-mum-torres

Puerperal Psychosis

Information on Puerperal Psychosis (2010) by Dr Anne Sven Williams and Sue Ellershaw (be alert, not alarmed: a self-downloading DOC; the target audience for this is women/families affected by puerperal psychosis,  but many of us clinicians have also found it a useful adjunct to our formal education) www.wch.sa.gov.au

Puerperal Psychosis: A Carer’s Survival Guide (PDF by Craig Allatt: Craig’s partner experienced puerperal psychosis) www.wch.sa.gov.au

Keeping Baby In Mind

Print

A Monster Ate My Mum (a children’s book looking at postnatal depression through a child’s eyes) amonsteratemymum.wordpress.com

Still Face Experiment (Edward Tronick’s demonstration of how infants respond to changes in interaction from primary caregivers is often cited in infant mental health education) youtu.be/apzXGEbZht0

Baby Cues Video Guide (trying to work-out what newborns are trying to communicate can be tricky; these video guides might help) raisingchildren.net.au

Circle of Security (re attachment theory and affective neuroscience) circleofsecurity.net

Raising Children Network (an Australian resource for parenting, covers newborns to teens) raisingchildren.net.au

wellbeing

That’s all I have on my list for now. Please add your suggestions for valuable links and resources to share at my Perinatal mental Health Workshops in the comments section below.

Paul McNamara, 7th February 2014

Cyclone: Alert, Not Alarmed

Dear Mum and Dad (and anyone else who is interested),

outlookIn a couple of days you may see on the news that a cyclone has spun-up out in the Coral Sea. At the time of writing the cyclone is predicted but not named. The forecast map (see bottom of the page) suggests that Townsville is more likely to cop it than us.

I think it’s a good idea to put you as fully in the picture as I can. We kind of like the way cyclones get named: it seems to give them each a distinct personality. We’ve had a few cross the coast nearby since we moved to Cairns.

katrinaCyclone Katrina mucked around for a couple of weeks, but never got organised enough to cross the coast as a big blow. Katrina did not cause any deaths in Australia, but a man in Vanuatu lost his life in her rough seas, and hundreds of homes in the Solomon Islands were damaged or destroyed. We were OK in Australia.

800px-New_Orleans_ElevationsCyclone Katrina was much more benign than Hurricane Katrina. The other difference is that although Cairns is not a long way above the high tide mark, at least parts of it are not below the high tide mark as New Orleans is. That’s why so many people died because of Hurricane Katrina: it was not the wind, it was the water. That’s true of most cyclone deaths: flooding and drowning is where most danger lies.

CairnsHospital

Cairns Hospital, 165-171 Esplanade

Luckily we do not own a house on the beach front (there’s also the small matter of not having a lazy couple of million dollars lying around). Storm surges that coincide with cyclones can be a bit of a worry, but at least our place is not in a red zone like the local hospital. Feel free to check our address using storm tide surge address search/evacuation maps here or (just in case the council’s website goes offline) here.

justinThere was heaps of flooding after Cyclone Justin: I remember water lying around for days. Justin is responsible for lost lives In Papua New Guinea and a boat at sea. Closer to home an Innisfail boy was electrocuted by power lines bought down by the cyclone, and a lady was caught in a landslide near Townsville. All that rain and the buffeting wind was bad for crops and trees (some of which fell on to homes).

larryAfter Cyclone Larry we did not have power for five days. It’s amazing how often we still automatically reached for the light switch when entering a room. The reflex of a life time of luxury, I guess. Did you know that about 25% of the world’s population does not have electricity? Info about that here. Going a few days without electricity is a nuisance, but we know it will always come back on. We are better-off than many.

steveCyclone Steve made things a bit soggy for a few days too. The Barron Falls were pumping – if we get another cyclone crossing the coast be sure to checkout the webcam here for a view of the falls in full flood – spectacular! All the tourist operators trot out this cliché at this time of year: “You can’t have rainforest without rain!” It is the wet tropics, after all.

yasiCyclone Yasi looked like it was going to give Cairns a shake-up: so much so they even evacuated the hospitals - the biggest hospital evacuation in Australia’s history. Cairns was lucky that Yasi took a slight turn south before crossing the coast: Tully, Cardwell and Mission Beach really copped a belting though. Yasi was a big, powerful cyclone, but did not directly kill anyone. There was one indirect death: a young man suffocated after bringing a generator inside.

header_logoWe are used to preparing for cyclone season. Every year the Cairns City Council issues information about preparing for cyclones – it’s just part of the annual ritual. we have done it 19 times now.

We have enough food to last a few days. We have containers to store water in, if required. We have batteries for the radio, so we can stay informed about what’s going on if the power goes out. We live high above sea level. We take cyclones seriously. We are prepared.

imagesHowever, we don’t take the hyped-up TV coverage seriously. If the TV shows start shipping their main in-studio people up to Cairns for live crosses please switch of the telly. These shows need to create drama and suspense to make the story compelling, but the truth of it that it’s just weather. Weather that we’re used to. Weather that will be nuisance to many and maybe even dangerous to a few. However, the reality is that it will be more dangerous to drive to the airport to pick you up when you next visit than it is to live in a city with strict building regulations. Houses can still sustain major damage of course, but they don’t blow away anymore. Those images of houses completely blown away by Cyclone Tracy are a thing of the past: Tracy changed building codes right across the Australian tropics.

forecastPlease don’t be worried. Please don’t get seduced by the inevitable media hype. I’ll call/text when I can, and give live updates on Twitter using the @WePublicHealth handle if a cyclone comes close to Cairns this week, otherwise i will use my usual @meta4RN handle. The purpose of Tweeting will to be to provide a non-alarmist account of what’s going-on. The mainstream media are not very good at this, so (to borrow a term from Melissa Sweet ) it is up to citizen journalists to do so.

Well, citizen journalists and the Bureau of Meteorology, that is: www.bom.gov.au

Speak soon.

love, Paul

27th 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 Twitter Workshop in Tweets

Monday at the Australian College of Mental Health Nurses (ACMHN) 39th International Mental Health Nursing Conference, we conducted a workshop on Engaging with Social Media. There were three workshop facilitators: Clare Butterfield from Canberra, Communications & Publications Officer (see @ACMHN on Twitter), Paul McNamara (me), Clinical Nurse Consultant from Cairns (see @meta4RN on Twitter) and, our special guest co-facilitator Emily Mignacca (see @emilymignacca on Twitter) graduating student nurse who commences as a RN specialising in mental health early in 2014.

Rather than use a PowerPoint or other traditional presentation method, I wrote the core content of the workshop as a series of Tweets. In real time as the hands-on part of the workshop was in action, we sent the Tweets out from the @ACMHN Twitter account. The Twitter feed on this page twubs.com/ACMHN2013 was projected onto a screen so workshop participants could see the @ACMHN tweets, their own tweets using the conference hashtag and, perhaps most importantly, the comments and interaction from other Twitter users who used #ACMHN2013. It was a successful strategy – I’ll certainly use it again for future workshops on using Twitter.

You are welcome to use all or part of A Twitter Workshop in Tweets below provided you abide by the Creative Commons Licence below. This licence lets others distribute, remix and build upon the work, but only if it is for non-commercial purposes, they credit the original creator and source – Paul McNamara (2013) A Twitter Workshop in Tweets http://meta4RN/tweets – and they license their derivative works under the same terms. You are also welcome to contact me to facilitate/co-facilitate your health care social media workshop.  My email is meta4RN [at symbol] gmail.com

1. Pre-workshop info/publicity

Engaging with Social Media – Clare Butterfield and Paul McNamara Monday 21st October 2013 12:30-2:30pm

Social media allows Collaboration and Partnerships in Mental Health Nursing to transcend time and place: time through collaborative, asynchronous communication; place by being connected to the world’s online clinical communities. This hands-on workshop aims to act as a launching-pad for those who want to turbo-charge the conference theme.

The workshop will be in two parts: The first, briefest part, will introduce four examples of professional use of social media, using Twitter as the primary example. This part of the workshop intends to show participants the value of engaging with social media.

The emphasis will be the second part of the workshop. This will be a hands-on session that will assist participants gain confidence in using Twitter. This part of the workshop intends to equip participants with skills in engaging with social media in a professional capacity. Wifi will be available. Participants are asked to bring:

  • a mobile internet device (eg: smartphone, tablet or laptop computer);
  • knowledge (ie: the relevant passwords) on how to download apps onto your mobile device;
  • for those who already have an established Twitter account, the knowledge (ie: the relevant passwords) on how to access it;
  • a spirit of curiosity and fun!

To reinforce the learning acquired in the workshop, follow-up “skill checks” will be scheduled during conference breaks on Tuesday and Wednesday. Please come along – the workshop facilitators expect it to be a dynamic, fun, enlightening masterclass in engaging with social media.

Emily Mignacca was invited to join in co-facilitating the workshop just a couple of weeks before the workshop. Although Emily missed-out on being named in the pre-conference publicity, her participation on the day was vital. Emily worked hard and did a good job supporting people who were more than twice her age pick-up some of the skills and enthusiasm she has in using social media professionally. You could do worse than follow @emilymignacca on Twitter.

twitter

Below is a list of my pre-composed, pre-ordered tweets for the workshop. There were minor adjustments, inclusions and exclusion made as we went along, but mostly we just sent them out verbatim.

2. #ACMHN2013 Twitter Workshop in Tweets

Creative Commons License
A Twitter Workshop in Tweets by Paul McNamara is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 3.0 Unported License.
Based on a work at http://meta4RN/tweets.

Before

Please RT to show Twitter’s potential/reach to participants in today’s #ACMHN2013 Engaging with Social Media Workshop

Starting soon: #ACMHN2013 Engaging with Social Media Workshop. Info: http://acmhnconferences.acmhn.org/speakers/ (near bottom: scroll down) #HCSMANZ

No PowerPoint slides at the Engaging with Social Media Workshop. We’re Tweeting the content using this hashtag #ACMHN2013

Warning: HEAPS of #ACMHN2013 Social Media Workshop tweets next 2 hours
To join: http://twubs.com/ACMHN2013
To mute: http://roniweiss.com/2011/05/03/muting-hashtags/

Start

#ACMHN2013 Facilitator 1 of 3: Clare Butterfield @ACMHN Communications and Publications Officer with – Face of ACMHN’s Twitter

#ACMHN2013 Facilitator 2 of 3: Emily Mignacca @emilymignacca GenY/Millennial, Almost-Mental Health Nurse – Future of @ACMHN

#ACMHN2013 Facilitator 3 of 3: Paul McNamara @meta4RN clinical nurse consultant + educator – Fellow of @ACMHN

First-up, a hard-sell on some professional uses of Twitter. For those playing-along at home see http://meta4RN.com/poster #ACMHN2013

What is Twitter’s potential/reach? Here’s a demonstration we prepared earlier https://twitter.com/meta4rn/status/392021423943716866 #ACMHN2013

Here are the results: http://www.symplur.com/healthcare-hashtags/acmhn2013/analytics/?hashtag=acmhn2013&fdate=10%2F17%2F2013&shour=9&smin=0&tdate=10%2F21%2F2013&thour=9&tmin=0&ssec=00&tsec=00&img=1 #ACMHN2013

Enough chin-wagging. Let’s start doing! Go to https://twitter.com/signup to start an account #ACMHN2013

Make a choice now: is this an official, personal or professional twitter account? Mental health nurses know about boundaries, right? #ACMHN2013

Need clarification on official, personal + professional? This Qld Gov site is clear + succinct: http://www.qld.gov.au/web/social-media/policy-guidelines/guidelines/official-use.html#ACMHN2013

On your professional twitter account you’re not representing an organisation, but are primarily talking about work-related stuff #ACMHN2013

Choose a short name (aka “handle”) eg: instead of @BartholomewBonython maybe @BartB #ACMHN2013

Bad news for people without exotic names: @JohnSmith @JSmith + @SmithJ are all taken ;-/ #ACMHN2013

Short names and concise tweets are good. Twitter = Brevity Central #ACMHN2013

Struggling deciding on a name? Get creative! Example: a nerdy mental health nurse might be @MHnerse #ACMHN2013

Or… a graduating student nurse might be @SN2RN #ACMHN2013

Don’t use your workplace name/initials unless you’re 100% sure you’re representing your employer rather than your professional self #ACMHN2013

That’s why I’m @meta4RN rather than @QueenslandHealthRN – there’s a BIG difference in implications/expectations #ACMHN2013

Think about how you’ll describe yourself in your Twitter bio. Do you need to name your employer? It might be easier if you don’t. #ACMHN2013

Twitter bios accommodate a bit of personality along with a description of you/your interests #ACMHN2013

Re bio: maybe better not to say “lost virginity to a rockstar”, but “enthusiastically supporting musicians” would be OK :-) #ACMHN2013

Professional doesn’t have to be boring #ACMHN2013

Still nervous re the name/bio thing? You’ll get away with being anonymous, but why? On the run? Witness protection program? #ACMHN2013

And a pic. You’ll need a pic. Eggs repel followers. #truefact #ACMHN2013

Your pic doesn’t have to be a photo. There are avatars available online PRN. eg: http://www.twittergallery.com/?p=1985 #ACMHN2013

DON’T BE AN EGG! #ACMHN2013

Right. When you’re ready, announce your arrival to the Twitterverse. No pressure: channel Neil Armstrong. #ACMHN2013

Oh, and use the conference hashtag so we can see your tweet on the #ACMHN2013 screen

Next up you’ll want to start following some people, otherwise your Twitter feed will be bare, and you will get sad, lonely and bored :-( #ACMHN2013

Who to follow? We can start with each other – a learn as we go thing #ACMHN2013

Twitter is not like Facebook. It is perfectly acceptable, not at all stalker-ish, to follow a complete stranger. #ACMHN2013

#ACMHN2013 Also, if you want to see who else is active in health care social media in Aus/NZ sus-out this hashtag: #HCSMANZ

#ACMHN2013 @nurse_w_glasses is a rockstar amongst social-media-mental-health-nurses: well worth following.

While we’re looking at who to follow, sus out the #WeNurses + #OzNurses hashtags – anyone/anything of interest? #ACMHN2013

If so, you may want to follow that person and/or retweet (ie: share) their tweet. #ACMHN2013

RT = ReTweet
MT = Modified Tweet
HT = HatTip/HeardThrough
More about Twitterisms here http://meta4RN.com/FF #ACMHN2013

Now, about hashtags… don’t be intimidated. You can use Twitter happily with never using one in your whole life #ACMHN2013 BUT…

Hashtags pull disparate conversations and people together. Like at this mental health nursing conference, for instance #ACMHN2013

Eg: even if you had the most incisive political tweet ever created, QandA viewers wouldn’t know about it without the #QandA hashtag #ACMHN2013

The hashtag thing can be fiddly at first. For the #ACMHN2013 conference this site makes it REALLY easy: http://twubs.com/ACMHN2013

Create your own hashtags, BUT learn from the Susan Boyle album launch hashtag: #susanalbumparty can be read 2 ways :-) #ACMHN2013

So, what to Tweet about? Anything that you think is relevant to people who may share all or some of your interests #ACMHN2013

Remember: the conventions of professional communication are long-established: letters, email etc. Why change it on Twitter? #ACMHN2013

Now, let’s pause and have a look at the @acn_tweet / RCNA (2011) Social Media Guidelines for Nurses http://www.rcna.org.au/WCM/Images/RCNA_website/Files%20for%20upload%20and%20link/rcna_social_media_guidelines_for_nurses.pdf #ACMHN2013

While we’re at it, let’s have a look at the @NurMidBoardAust guidelines too http://www.nursingmidwiferyboard.gov.au/documents/default.aspx?record=WD10%2F3224&dbid=AP&chksum=qhog9%2FUCgKdssFmA0XnBlA%3D%3D #ACMHN2013

Any surprises or comments about the social media guidelines? #ACMHN2013

#ACMHN2013 The guidelines are pretty common-sense stuff. Maybe this flowchart is all we need

SoMeFlowchart

On a mobile device? Install an app, eg: Twitter https://about.twitter.com/download #ACMHN2013

On a mobile device? Install an app, eg: HootSuite https://hootsuite.com/features/mobile-apps #ACMHN2013

On a mobile device? Install an app, eg: Tapbot http://tapbots.com/software/tweetbot/ #ACMHN2013

Probably the easiest way to learn Twitter is to follow people who have already learned Twitter. Stick with it – it’ll click in. #ACMHN2013

Do unto others. #TwitterTips #ACMHN2013

#TwitterTips #ACMHN2013 Be careful mixing personal and professional. Boundaries are important.

#TwitterTips #ACMHN2013 You already know about confidentiality; if you’re doing confidentiality wrong online it will definitely get spotted.

#TwitterTips #ACMHN2013 Naturally, you would NEVER give individual or detailed clinical advice on Twitter.

#TwitterTips #ACMHN2013 Generalised info is fine, eg: Getting great feedback from consumers about the @mindhealthc site http://www.mindhealthconnect.org.au

#TwitterTips #ACMHN2013 Try not to act like a dickhead. Also, don’t use words like “dickhead” – it’s unprofessional. #TwitterTips #ACMHN2013

#TwitterTips #ACMHN2013 Apologise if you do/say something stupid. BTW sorry for saying “dickhead” before.

#TwitterTips #ACMHN2013 Twitter spam is especially good at playing on the insecurities of newbies, so be vigilant + don’t click dodgy links.

#TwitterTips #ACMHN2013 Spam example 1:
This person is saying horrible things about you www.dodgylink.com DON’T CLICK!

#TwitterTips #ACMHN2013 Spam example 2:
This photo of you! LOL www.dodgylink.com DON’T CLICK!

#TwitterTips #ACMHN2013 Mostly you won’t Tweet from/about your workplace… you’ll have your work to do.

#TwitterTips #ACMHN2013 There may be an occasional exception to the workplace rule, eg: Gammin Hospital Christmas decorations are fabulous!

#TwitterTips #ACMHN2013 Would your patients or boss be offended by that photo? Yes = Delete. No = Tweet.

Finish

#TwitterTips #ACMHN2013 RT @charleneli: Twitter is not a technology. It’s a conversation. And it’s happening with or without you.

#TwitterTips #ACMHN2013 No need to worry about forgetting today’s workshop, it’s all here: http://meta4RN/tweets

#TwitterTips #ACMHN2013 Connect. Be generous. Have fun.

Creative Commons License
A Twitter Workshop in Tweets by Paul McNamara is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 3.0 Unported License.
Based on a work at http://meta4RN/tweets.

As always, your comments and feedback is welcome. Please use the comment facility below.

Paul McNamara, 23rd October 2013

Professional use of Twitter (my #ACMHN2013 conference poster)

At the Australian College of Mental Health Nurses 39th International Mental Health Nursing Conference (Perth, 22nd-24th October 2013) there are three poster presentations (no oral presentations) regarding social media:

  1. Utilising social media collaboratively to strengthen interdisciplinary understanding and networking (Zara Mills)
  2. Twitter: a contemporary nursing conversation tool (Rhonda Wilson)
  3. Turbocharging mental health nursing collaboration and partnerships: professional use of Twitter (me)

Social media is a good fit for the conference theme “Collaboration and Partnerships in Mental Health Nursing” (hence the full name of my presentation). There are many examples of nurses acting as “digital citizens“, reflecting the ever-changing practice domains and the importance of partnerships to the nursing professions. My poster presentation cites four examples of nurses embracing social media, adapting content that I have accrued on my blog and presented as the closing plenary session at the ACMHN Consultation Liaison / Perinatal Infant Mental Health Nurses Conference in June 2013.

Anyway, with no further ado, here’s a breakdown of my poster presentation for the conference with the #ACMHN2013 Twitter hashtag:

Abstract 

Working in partnership with consumers, carers and colleagues is part of mental health nursing’s heritage. Over time we have adapted this collaborative approach to the technologies available to us. For example, telephones and videoconferencing are commonly used to establish and maintain therapeutic and professional relationships by mental health nurses. Yet, for some of us, there seems to be hesitation to use one of the technologies of our time – social media – in a similarly confident manner.

This presentation will make a clear distinction between official, personal and professional use of social media. Using case studies, four specific examples of professional use of Twitter will be presented, covering these aspects of mental health nursing:

  • mental health promotion
  • sharing mental health nursing conference information and innovations
  • collaborative multi-national discussions re contemporary issues
  • enhancing education

Referring to these examples, the argument will be made that professional social media participation builds collegial relationships and enhances the profile of mental health nursing.

Those baffled or intimidated by social media are strongly encouraged to attend, as are those interested in exploring ways mental health nurses can use social media to turbocharge our collaboration and partnerships.

The abstract was submitted as an oral presentation, but accepted as a poster presentation. I used many (not all) of the ideas found in Colin Purrington’s enlightening and entertaining blog post “Designing conference posters“. The post was divided into into four parts, each part giving different examples of nurses embracing social media. Those four parts are presented separately below:

1. Health Promotion

1

#bePNDaware and Postnatal Depression Awareness Week 2012

Hashtags mark keywords or topics. This facilitates information sharing: clicking on a hashtag will lead you to other tweets with that same hashtag.

As a health promotion strategy, #bePNDaware was the designated Twitter hashtag for Postnatal Depression Awareness Week 2012. This facilitated the sharing of resources, information and support across a variety of agencies and individuals.

Data

From midnight beginning Thursday 8th November 2012 to midnight ending Sunday 25th November 2012 (Cairns time) using the #bePNDaware hashtag there were:

  • 250 Twitter participants
  • 928 tweets
  • 3 of the most prolific Twitter accounts represented mental health nursing
  • the “impressions” (potential number of views) was over 1,500,000

So what?

Australia’s National Perinatal Depression Initiative (NPDI) cites improved community awareness as one of the key performance indicators for the success of the NPDI.

As the data demonstrates, Twitter provides a vehicle for active participation in health promotion activities with a very large reach.

Social media health promotion is an example of effectively using the internet. Some nurses are “digital citizens” who use the internet to curate and share health-related information.

For further data analysis and information about this example, please visit meta4RN.com/bePNDaware

2. Sharing Conference Information

2

Case Study: The Reach of One Tweet

A key purpose of health care conferences is to share information and professional values. Can social media play a role in this?

Below is a tweet of a statement made during a presentation at a small Consultation Liaison and Perinatal Infant Mental Health Nurse conference held in June 2013. The presenter’s message went beyond the 70 people attending the conference in a small Queensland regional city, and reached many thousands of people elsewhere in Australia and internationally.

Data

579 = the number of people following the @meta4RN Twitter account in June 2013. So, that one tweet could have been seen by up to 579 people/organisations.

That single tweet was retweeted (ie: shared/passed-on) by five other Twitter accounts, each with their own group of followers, thus:

  • 9712 following @nurse_w_glasses
  • 8433 following @yayayarndiva
  • 1969 following @ClaudiaNichols
  • 1403 following @HR1529
  • 178 following @SameiHuda
  • + 579 following @meta4RN
  • = 22, 274 impressions (potential views).

This conference tweet had an audience over 300 times larger than the conference audience.

Data: Three Nurse Conferences on Twitter

  • Consultation Liaison & Perinatal Infant ACMHN Conference
    • Noosa
    • June 2013
    • Approx 70 delegates
    • Conference Hashtag = #ACMHN
    • 125,794 Twitter Impressions
    • 141 Tweets
    • 26 Twitter Participants
  • Australian College of Mental Health Nurses 38th International Mental Health Nursing Conference
    • Darwin
    • October 2012
    • Approx 700 Delegates
    • Conference Hashtag = #ACMHN2012
    • 395,557 Twitter Impressions
    • 586 Tweets
    • 38 Twitter Participants
  • International Council of Nurses (ICN) 25th Quadrennial Congress
    • Melbourne
    • May 2013
    • Approx 4000 delegates
    • Conference Hashtag = #ICNAust2013
    • 2,201,098 Twitter Impressions
    • 3,764 Tweets
    • 288 Twitter Participants

For more information about these examples, please visit

3. Discuss Important Issues

3

Case Study: #WeNurses Twitter Chat

Planned Twitter discussions (those with a designated time and topic) are known as “chats”.

On 21st December 2012 (Cairns time) nurses from the United Kingdom and Australia came together on Twitter to discuss issues raised by the highly publicised suicide of a colleague. During this chat 33 participants used the #WeNurses hashtag. There were 360 tweets, and the impressions (aka “TweetReach”) of the chat was well in excess of one million views.

The structure of the discussion and the issues that emerged are as below:

  • Preliminary Information
    • Introductions
    • Setting the Tone
  • Theme: Communication & Confidentiality
    • Patients and Mobile Phones.
    • Social Media
    • Individualising Communication & Confidentiality
    • WiFi for Hospital Patients
  • Theme: Compassion
    • Prank Call
    • Targeted Crisis Support
    • Clinical Supervision
    • Supportive Workplaces
    • Preventative/Early-Intervention Resources
    • “The 6Cs” (Care, Compassion, Competence, Communication, Courage & Commitment)
    • Integrating Defusing Emotions into Clinical Practice
  • Finishing-Up
    • Key Learnings
    • Closing Remarks
    • Farewells

Outcome

Nurses from opposite sides of the world utilised a high-profile social media platform to engage in a conversation about the high-media-profile suicide of a nurse. Unlike much of the commentary on both social media and mainstream media, the #WeNurses discussion was conducted professionally, calmly, and with thoughtfulness and grace.

For a curated transcript of the discussion and more information about this example, please visit meta4RN.com/WeNurses

4. Enhance and Amplify Education Sessions

4

The Experiment

A perinatal mental health workshop on 8th February 2013 also served as an experiment in using Twitter to bookmark and share resources. Using HootSuite 19 scheduled tweets with the #bePNDaware hashtag were sent from the @meta4RN Twitter account before or during the workshop. Additionally, one tweet was sent during a break and one after the workshop had finished (ie: 21 tweets in total). The scheduling of tweets allowed the facilitator to be fully present during the workshop, while simultaneously making links to the resources/topics discussed in the workshop readily available to workshop participants and a broader audience.

Data

9 Twitter accounts other than @meta4RN retweeted 6 of the original tweets; one tweet re Clinical Practice Guidelines was retweeted 3 times. Between 7:00am and 7:00pm on 8th February 2013 (Cairns time) there were 30 workshop-related tweets which, through the amplifying effects of social media, had 17,784 impressions.

Outcome

The links shared on Twitter had a theoretical/potential reach of 17,784 people. This is in stark contrast to the number of participants who attended the perinatal mental health workshop face-to-face that day: 4 people.

For references, more information and a short video about this example, please visit meta4RN.com/workshop

Four Versions of the Poster

1. Portable Document Format (PDF) pdficon

meta4rn.files.wordpress.com/2013/09/twitterposter.pdf

2. Picture (JPG)

3. Prezi (online presentation) prezi.com/user/meta4RN

4. YouTube (animated online presentation) youtube.com/meta4RN

The YouTube version was made in four steps

  1. Visual content assembled and arranged using Prezi
  2. The track “Sevastopol” generously provided royalty-free by mobygratis
  3. Vision and sound captured and melded using Screenflow
  4. Completed video uploaded to YouTube

Citations (this section added on 9th November 2013)

Sometimes it is useful to be able to cite references that carry more prestige than this blog page (short IRL = meta4RN.com/poster), well have I got a deal for you! Because the poster was presented at the ACMHN conference it was accepted into the book of abstracts published by the IJMHN, this allows you to cite this content thus:

McNamara, P. (2013) Turbocharging mental health nursing collaboration and partnerships: Professional use of twitter (poster, Australian College of Mental Health Nursing 39th International Mental Health Nursing Conference – Collaboration and Partnership in Mental Health Nursing). International Journal of Mental Health Nursing, volume 22, Issue Supplement S1,  page 22.  doi: 10.1111/inm.12047 http://onlinelibrary.wiley.com/doi/10.1111/inm.2013.22.issue-s1/issuetoc

Also, snippets of this content made there way into a paper recently accepted into another nursing journal. If you can get access to the full content via your employer/university (otherwise there’s a paywall) you will find info that reflects some of this blog post. The paper is currently in press, so the citation will change from this in coming weeks/months:

Wilson, R., Ranse, J., Cashin, A. & McNamara, P. (2013) Nurses and Twitter: The good, the bad, and the reluctant. Collegian (Royal College of Nursing, Australia), 4 November 2013 (DOI: 10.1016/j.colegn.2013.09.003) http://www.collegianjournal.com/article/S1322-7696(13)00090-5/abstract

End

That’s it. Thanks for dropping by. As always, you’re welcome to leave comments/feedback below.

Paul McNamara, 1st October 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

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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.