Tag Archives: consultation liaison

Diagnostic Overshadowing

Source: I had a black dog, his name was depression https://youtu.be/XiCrniLQGYc

I work in a general hospital doing mental health clinical work and education. The two roles overlap. A lot.

A significant part of the job is undiagnosing mental illness. It’s not unusual for us to be asked to see somebody who is emotionally overwhelmed or dysregulated. Sometimes this is in the context of mental health problems, often it’s in the context of significant stress. We don’t want to psychiatricise the human condition. Of course you cry when you’re sad. Of course you’re anxious when, like Courtney Barnett in ‘Avant Gardener‘, you’re not that good at breathing in. Of course you’e frustrated when you’re in pain and/or don’t understand what’s going on.

It’s important to validate understandable and proportionate emotions.

It’s equally important to make sure that somebody who has experienced mental health problems previously doesn’t have every presentation to the hospital/outpatient clinic seen through that lens. That’s called “diagnostic overshadowing”. It’s a real problem.

Diagnostic overshadowing is where physical symptoms are overlooked, dismissed or downplayed as a psychiatric/psychosomatic symptom. It must be one of the most dangerous things that happens in hospitals. The President of the Royal Australian & New Zealand College of Psychiatrists, Professor Malcolm Hopwood, said in May 2016, “I sometimes think that the worse thing a person can do for their physical health is to be diagnosed with a mental health disorder.”

It often comes as a shock to people when they find out that those diagnosed with mental illness die between 10 and 25 years younger than the general public. The next shock comes when discovering suicide accounts for only about 14% of premature death. [source: ‘Please believe me, my life depends on it’: Physical health concerns of people diagnosed with mental illness]

It’s a big deal. About 60% of people who experience mental health problems experience chronic physical health problems too. Poor mental health is a major risk factor for poor physical health, and vice versa. [Source: Australia’s mental and physical health tracker 2018]

Diagnostic overshadowing happens outside of hospitals too. In this example, understandable and proportionate human emotions were misinterpreted as psychopathology. The cascade of events that followed makes for a sobering read:

Questions for Reflection

Assuming that you – the person reading this blog post – is a nurse, midwife or other health professional, I have some questions I’d like you to reflect on.

Have I ever witnessed a person’s mental health history influence how their presenting complaint was investigated or treated?

How does my workplace prevent mental health stigmatising and diagnostic overshadowing?

What can I do to support good holistic patient care, without falling into the trap of diagnostic overshadowing?

References

Happell, B. & Ewart, S. (2016). ‘Please believe me, my life depends on it’: Physical health concerns of people diagnosed with mental illness [online]. Australian Nursing and Midwifery Journal, 23(11), 47.

Harris, B. Duggan, M. Batterham, P. Bartlem, K. Clinton-McHarg, T. Dunbar, J. Fehily, C. Lawrence, D. Morgan, M. Rosenbaum, S. (2018). Australia’s mental health and physical health tracker: Background paper. Australian Health Policy Collaboration issues paper no. 2018-02, Melbourne, AHPC.

Lakeman, R. & Emeleus, M. (2014). Un-diagnosing mental illness in the process of helping. Psychotherapy in Australia, 21(1), 38-45.

Patfield, M. (2011). Undiagnosis: An Important New Role for Psychiatry. Australasian Psychiatry, 19(2), 107–109.

Seriously mentally ill ‘die younger’. (2016, May 10). SBS News. Retrieved from https://www.sbs.com.au/news/seriously-mentally-ill-die-younger

End

Sincere thanks to Bec (aka @notesforreview on Twitter) for giving permission to share her tweets re mental health stigma and diagnostic overshadowing. Her first-hand account is a powerful cautionary tale.

Paul McNamara, 1st October 2018

Short URL meta4RN.com/shadow

BridgeBuilders

BridgeBuilders is about encouraging more collaboration + less silos in health care.

There’s a cool Canadian band called Arcade Fire. One of the things that makes them cool is their eclectic and varied instrumentation.

Track two is standard guitar-driven rock. Track five features mandolin, recorder and banjo. The song that follows features piano accordion, trombone and hurdy-gurdy.

Arcade Fire’s frontman was asked about how decisions about instrumentation were made. He replied that it wasn’t about individual musicianship or ego. Decisions about who played what instrument were made by what made the song sound best. He said that the band members were all in service to the song.

Replace the musicians with clinicians, instruments with our varied skill sets, and the song with the patient.

We’re all in service to the patient.

When we get it right the GP, the mental health nurse, the emergency doctors and nurses, and the allied health clinicians aren’t individuals trying to be solo rock stars.

When we get it right we’re playing together as a band. That’s the way to make the health service sing.

Source

Reblogged from bridgebuilders.vision

End Notes

  1. Shout-out to Edwin Kruys (@EdwinKruys on Twitter) for inviting my post to BridgeBuilder (@Bridg3Builders on Twitter).
  2. If you haven’t done so already, visit bridgebuilders.vision and have a look around, and read the BridgeBuilders story. Healthcare needs all the bridge builders it can get! 
  3. I didn’t really mean to duplicate the post here, but when I clicked on the “reblog” button it created an uneditable and undoable link with only half the text. It made no sense, so I deleted it. This link-back is to correct my failed experiment with reblogging, but still spread the word re BridgeBuilders as far and as wide as I can.
  4. How good are Arcade Fire?

Paul McNamara, 3rd July 2018

 

 

 

2018 ACMHN Consultation Liaison / Perinatal Infant Mental Health Conference on Twitter

The 16th ACMHN Consultation Liaison Special Interest Group annual conference, held in conjunction with the 7th ACMHN Perinatal Infant Mental Health Special Interest Group annual conference, was held at the Royal Brisbane and Womens Hospital from Wednesday 6 June to Friday 8 June 2018. The theme of the conference was “The Art of Applying the Science: Consultation Liaison and Perinatal & Infant Mental Health Nurses in Action”. As is typical of healthcare conferences, a conference hashtag was announced; #ACMHN was used on Twitter by six of the fifty-ish conference participants.

One of the observations made by Martin Salzmann-Erikson in his paper Mental health nurses’ use of Twitter for professional purposes during conference participation using #ACMHN2016 was that conference participants who do not engage with Twitter may feel that they’re excluded from a “privileged backchannel” of communication. On one hand this is complete nonsense. No conference participants are excluded from Twitter. Those who do not use Twitter/the conference hashtag are just exercising a choice. On the other hand, they may not be using Twitter and/or a conference hashtag simply because they have not been exposed to a reason to do so. It is with the latter in mind that the Tweets using the #ACMHN hashtag over the course of the conference are collated below.

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#ACMHN Tweeps

If you’ve scanned through the content above you’ll see that two Tweeps (ie: people who use Twitter) generated the vast majority of the #ACMHN Tweets. It’s not obvious from a quick glance, but many of the #ACMHN Tweets were retweeted (ie: shared). Seventeen Tweeps used/retweeted the #ACMHN hashtag 167 times over the course of the conference [data source], they are:
Cynthia Delgado @Cyn4CLMH*
Kim Foster @FostKim*
#HELLOMYNAMEISBJ @FewingsBj*
Anabel de la Riva @AnabeldelaRiva*
Chris Egginton @ChrisEgginton*
NWMH Graduate Nurses @NWMHgrads*
Peta Marks @petamarks*
Sharene Duncan @brisequine*
Chelesee @Chelesee1*
Veriti @Veritihealth*
A/Prof Rhonda Wilson @RhondaWilsonMHN*
Australian College of Mental Health Nurses @ACMHN*
Melissa Sweet @croakeyblog*
#HelloMyNameIs Kenny (RN) @kennygibsonnhs*
International Network of Nurse Leaders @inNurseLeaders*
Dr. Anja K. Peters @thesismum*
Paul McNamara [me] @meta4RN*
Key
* #ACMHN conference delegates [n = 6]
* Australian #ACMHN retweeters [n = 7]
* International #ACMHN retweeters [n = 4]

Many thanks to all who shared conference info with the #ACMHN hashtag. Thanks also to those who commented on/interacted with Tweets using the hashtag, but did not use the hashtag themselves (these Tweeps are not listed above).

Final Notes

  1. Each of my Tweets that announced a workshop or presentation were pre-scheduled using Hootsuite (ie: I wasn’t as busy Tweeting during the conference as it seems).
  2. Collating Tweets on a web page is irritatingly time-consuming. It used to be much quicker and easier (missing you Storify!). The upside of collating Tweets on a web page is that they serve as a record/brief notes of the conference, so if I need to come back to anything it’s all in one easy-to-find place.  Hopefully others will find it of interest too.
  3. Just in case you skipped-over it: watching the vid attached to Tweet 92 is definitely worth it – a highlight of the conference!
  4. Previous visitors to meta4RN.com may be experiencing a sense of déjà vu. To rid yourself of spooky feels, visit this same-same-but-different companion piece:
    #ACMHN Looking back at the 2013 Consultation Liaison / Perinatal Infant Conference through a Social Media Lens meta4RN.com/noosa 

End

That’s it. Thanks for visiting. As always your thoughts and feedback are welcomed in the comments section below.

Paul McNamara, 10th June 2018

Short URL: meta4RN.com/Brisneyland

PS:

https://platform.twitter.com/widgets.js

@WePublicHeath

For the week Monday 27th January to Sunday 2nd February 2014 I was able to use the @WePublicHealth Twitter handle, thanks to the generosity of Melissa Sweet (aka @croakeyblog).


Here’s what happened:

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Explanation

These Tweets were initially compiled using a social media aggregation tool called Storify
storify.com/meta4RN/wepublichealth

Unfortunately, Storify is shutting-down on 16 May 2018 and all content will be deleted.

I’m using my blog as a place to mimic/save the Storify pages I created and value.

End

 

A big shout-out to Melissa Sweet. I am very grateful to Melissa for inviting a mental health nurse to have a stint on @WePublicHealth.

Melissa is a rockstar of public health and health social media in Australia. If you’re not familiar with her work read-up about Melissa here, and “croakey“, the social journalism project of which she is the lead editor, here. More info re @WePublicHealth, the rotated curation Twitter account that Melissa coordinates, here.

As always, please use the comments section below for any feedback/questions.

Paul McNamara, 2nd April 2018

Short URL: meta4RN.com/WePublicHealth

A Conversation about Documentation in Consultation Liaison

De-identified info from the ACMHN Consultation Liaison Nurse Network www.acmhn.org/home-clsig

PPT slide from the report given at the Australian College of Mental Health Nurses Consultation Liaison Special Interest Group Annual General Meeting on 5th June 2008.

Question from regional Queensland 06/02/18

My team serves two digital masters: CIMHA (the mental health only file/application) and ieMR (the electronic general hospital file/application).

Our flesh + blood masters have now suggested that we should stop documenting in ieMR.

I think that’s dangerous.

However, I  want to see if there’s any CL service(s) that does NOT document in the hospital file.

If so, how does it work? Do you spend a lot of time in coroner’s court?

Response from Melbourne 06/02/18

I can’t imagine not documenting in hospital/clinical file – what part of consultation are they missing?

Sorry – this is a redundant reply to your question but can’t not respond.

Response from Melbourne 06/02/18

I agree it is dangerous and wrong. If we don’t write in the hospital file, how do our referees know what we advise, how else do we educate them? The nurses would often tell me that they loved reading my notes as it helped them make sense of what was going on. Definitely fight it. Do the other consult teams to the hospital have a separate file? I doubt it.

Response from regional Northern Territory 06/02/18

The other justification is documenting a diagnosis for clinical coding, which may or may not be relevant to activity based funding depending on where you are working.

The issue we have found in the NT with printing notes from an electronic system and placing them in the paper file, is the mental health notes often go missing, are filed incorrectly or do not even make it to medical records after discharge, meaning our input, suggestions and recommendations don’t make it into discharge summaries or correspondence for future presentations. Hence why we also handwrite in the file.

Response from Perth 06/02/18

I agree with you – I think it is dangerous to say the least.

We currently primarily document in the general hospital file (as these patients are admitted under general medical teams) as the teams who refer to us are asking for advice, suggestions or assistance with these patients.  We do not admit these patients to MH and have no beds.  If we assess that the patient requires a MH admission only then do we refer and  complete the required MH documents (which would go with the patient to MH).  We are however, required to enter our patient contacts in to the statewide MH database in order to generate statistics for our service.

Response from regional New South Wales 06/02/18

I am lucky as we do not use the local MH electronic documentation system. Our patient files are still paper based. I would be concerned about the medicolegal aspects of not having your notes available to the general hospital staff.

Response from Adelaide 06/02/18

We use both systems (MH Community AND hospital EPAS).

Hospital is where we work; therefore MH record gets ‘cut and pastes’ for ongoing CMHT requirements (if at all)

Response from Brisbane 06/02/18

Given our clients/customers are the treating medical/surgical team it’s imperative we write all our notes within the clinical chart. At this hospital all clinical notes are uploaded into iEMR once the patient is discharged; this means our notes can be accessible by anyone with access to this system. As yet we don’t directly input notes into iEMR but I think over the years this will change.

Because our notes are also useful to MHS we either write directly into CIMHA, print off the note and put it in the clinical chart or print off the note we’ve written in the clinical chart and then upload this into CIMHA.

If a patient is clearly delirious with no mental health history we don’t usually upload anything into CIMHA, we just write in the clinical chart.

It’s helpful for the referring teams to be able to ALL aspects of a patient’s care during in-patient stays, including MH input as when the patient is next admitted it gives them a more holistic view of the patient and encourages them to think more about how their MH problems may impact on their admission.

Response from Brisbane 06/02/18

I write in the hospital chart Progress Notes and then scan and upload to CIMHA the electronic MH record.  The reason I do this is because CIMHA printouts get filed under correspondence and not chronologically in the Progress Notes of the patient chart.  I often have the debate with MH clinicians who see a patient in ED or a general ward on the weekend, come back and write an excellent entry on CIMHA but the receiving medical team has absolutely no idea that the patient has been seen, what the outcome was nor any plan for ongoing review.

My concerns are:

how are any risk issues handed over to the medical areas? If an adverse event like a suicide/attempt happened would the coroner think notes on a database not accessible from the current treatment are or team or the current record be seen as satisfactory?

the medical team who owns the patients care within the care structure and has asked for the MH input gets no report, feedback nor result from their request,

how do any recommendation get carried over?

I would also ask how MH would feel if cardiology came to review someone in the MH unit and returned to cardiology, noted their review on a bespoke cardiac notation system and not the record within MH and left it at that, if that would be seen as satisfactory practice and care.

I suspect the scope to debate this would be well achieved through the accreditation standards, documentation and/or handover, would this pass the accreditors?

Response from regional New South Wales 07/02/18

I agree with the observation made regarding fact that the treating team caring for the person must be aware of all essential clinical details and interactions that all clinical services are providing to the person.

For services that maintain separate mental health and medical records it is essential that the clinicians responsible for that episode of care (i.e. the inpatient staff) have ready access to the clinical record in the location they would be presumed to be consulting. I would strongly suggest this means mental health consultation notes should be entered into the ward medical record and a copy be provided to add to the mental health record.

I have been aware of MH clinicians and managers occasionally expressing anxiety about non-specialist health staff accessing mental health documentation for fear that clinicians will inappropriately access and use such information. All health employees in Australia are bound by a code of conduct which strictly prohibits the inappropriate access to and use of privileged information from a clinical record – the consequences of breaching this element of the code of conduct can be quite serious. One of the benefits we have in our health service in NSW is that the majority of our services are now recording in common electronic files (EMR), meaning the issue of which file to record a clinical intervention in is not an issue, and any time a clinician accesses those records a digital finger print is left on the file. This means any time a clinician accesses a file without just cause there is evidence that a breach of confidentiality has occurred.

Response from regional New South Wales 07/02/18

It is interesting this discussion has arisen now as it has been the hot potato topic of our area and specifically my role in recent months.

Prior to the review I had been documenting in the clinical file AND our electronic community record CHIME, double dipping if you please, and very time consuming.

It is now the case that I write in the clinical notes, but I will also in addition complete a form based comprehensive mental health assessment for those patients who are being referred to the MHS. That form is scanned and emailed to an email address specifically set up for each CMHT, it is then added to the electronic file, the original assessment form remains with the patients hospital file as correspondence.

Response from regional Queensland 07/02/18

CLP writes notes in CIMHA and places them in the medical record in the relevant admission or community section of the medical note. This seems to flow smoothly here and has the advantage that if the consumer is discharged to a rural area the CLP notes are available to general hospital staff in the viewer. We use the CLP templates  which are in CIMHA.

The community mental health teams no longer write notes in medical records. Their notes are all recorded in CIMHA and no hard copy is placed on the medical record.

Response from Melbourne 07/02/18

We used to have two separate files but now have EMR and record directly on to the medical file under mental health (there is a function to put it “behind the glass”) so you can record more sensitive information if necessary. Someone has to “break the glass to look at it”.  We’ve had this system now for about 18 months and it has cut down our paper work enormously.

Anyone we refer within our region to the community can be accessed through their own service on EMR and we link our referral to the UR of the patient.

If they are referred to another service (outside our region) we print out and fax our assessment to them from EMR.  Everyone we see is recorded on CMI (demographics, clinician, contacts, diagnosis, advance statement etc but we don’t record assessments or impressions there.)

So just for those in Victoria, so you know, once they hit the adult system you will be able to see their registration date etc and can always make contact for more info.

Response from Sydney-based, covers many NSW Local Health Districts (LHDs) 07/02/18

This thread is particularly useful, thank you!

The clients/patients we see via telehealth, have an open encounter/MRN/electronic Medical Record (eMR) – including community/inpatient – in the referring/responsible LHD, and we need to create a new encounter/MRN/eMR in my LHD. I then extract notes from eMR, create a letter of feedback (impression and recommendations) which I email same day, with request that the MH Clinician at the other end upload the feedback into their local eMR, then to maintain privacy, delete the email and attachment from their inbox and deleted folders.

Uploaded files/feedback appear in ‘correspondence’ which as pointed out in this thread, need to be hunted for. Getting the feedback into the eMR also relies on the receiving Clinician to access their email and process it.

Many of the women we see are at high risk of relapse or first episode psychosis around the time of childbirth so Maternity Services would benefit from seeing our notes.

I have taken initial steps toward a pilot project whereby we may be able to write directly in the eMR in the other, usually rural LHD.

Response from Melbourne 07/02/18

We document in the hospital paper file in the episode of care.

Simple.

It works for us but we are getting an electronic medical record “soon”

Response from Sydney 09/02/18

Our system here is all eMR and went this way last year with MH going this way before the major hospital. So anyone can see anything from D&A, MH, general inpatient and community services. There are just a couple systems that work differently (oncology – which includes our psych oncology outpatient) and maternity.

It has made life so much easier to be able to see recent interactions and it has also stopped the need to fax assessments etc as it can be seen.

Like others, if it is an individual who is from outside our area health, we fax it and give verbal handover.

Prior to this, we only ever wrote in the medical file as they are the services that we work with. We use to fax to same AHS but no longer do this 🙂

I would be very worried for all the reasons that others have stated in relation to medico-legal issues as well.

Response from regional Queensland 09/02/18

Thanks to everyone for your generous and thoughtful responses.

I had been given the impression that there was something peculiar about my stubbornness on the matter. The reassurance and wisdom of the CL Nurse community is very much appreciated.

Attached is a deidentified version of our conversation about documentation in consultation liaison.

The title will make for a good rap refrain.

I’ve left-out names of people and hospitals/districts, and the side-conversation re timeliness (no offence meant; hopefully none taken).

I didn’t ask the question to gather data for a conference presentation, but I might use the attached for something more academic than a funky rap refrain.

If you’d rather your info be excluded please contact me directly (off-list).

The Mental Health Consultation Liaison Nurse Network started-off in 2002 as a Yahoo email list. More info: http://www.acmhn.org/index.php/home-clsig

End

Many thanks to all those who participated in the email discussion. I’m reminded of our old flyer for the email network which was headed by this catchphrase:

Consultation Liaison Nurses.
Isolated Geographically. Connected Electronically.

I’m leaving the transcript of the conversation here for three reasons:

  1. There may be others who battling the same/similar issues. This page is googleable, so may be of assistance.
  2. The conversation isn’t about nuclear missile launch codes. There’s no need to keep it secret or hidden away from the world.
  3. I, and others who are interested, will be able to find the conversations (ie: qualitative data) quickly and easily PRN.

To find out more about the Australian College of Mental Health Nurses Consultation Liaison Special Interest Group and/or the email network, go to: www.acmhn.org/index.php/home-clsig

As always, your comments and feedback are welcome in the space below.

Paul McNamara, 20th February 2018

Short URL: meta4RN.com/documentation

Social Media and Digital Citizenship: A CL Nurse’s Perspective

This post is a companion piece to my keynote presentation at the 5th Annual Queensland Consultation Liaison Psychiatry Symposium “Modern Approaches in CL Psychiatry”, on 2nd November 2017,

The function of this page is to be a collection point to list references/links that will be mentioned in the presentation. The Prezi is intended as an oral presentation, so I do not intend to include a full description of the content here.

Click on the picture to see the Prezi

Bio/Intro (you know speakers write these themselves, right?)

Paul McNamara is a CL CNC in Cairns.

Paul has been dabbling in health care social media since 2010. He established an online portfolio in 2012 which includes Twitter, Facebook, Instagram, YouTube and a Blog.

In 2016 Paul was appointed to the Editorial Board of the International Journal of Mental Health Nursing specifically because of his interest in social media.

This morning’s presentation “Social Media & Digital Citizenship: A CL Nurse’s Perspective” aims to encourage the converts, enthuse the curious, and empower the cautious.

Disclaimer/Apology/Excuse

Regular visitors to meta4RN.com will recognise some familiar themes.

Let’s not call it self-plagiarism (such an ugly term), I would rather think of it as a new, funky remix of a favourite old song.

Due to this remixing of old content I’ve included lots of previous meta4RN.com blog posts on the reference list.

This, in turn, makes the reference list look stupidly self-referential. #TrumpBrag

 

Anyway, with that embarrassing disclosure out of the way, here is the list of references and links cited in the Prezi prezi.com/user/meta4RN

References + Links

Altmetric Attention Score [example] https://wiley.altmetric.com/details/23964454

Australian College of Nursing (n.d.) Social media guidelines for nurses. Retreived from http://www.rcna.org.au/WCM/…for_nurses.pdf

Australian Health Practitioner Regulation Agency. (2014, March 17). Social media policy. Retrieved from http://www.ahpra.gov.au/News/2014-02-13-revised-guidelines-code-and-policy.aspx

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My Tweets = my lecture notes. Other people’s Tweets also = my lecture notes. 🙂

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McNamara, P. (2016, October 21) Why on earth would a Mental Health Nurse bother with Twitter? (my #ACMHN2016 presentation). Retrieved from https://meta4RN.com/ACMHN2016

McNamara, P. (2016, October 15) Learn about Obesity (and Twitter) via Nurses Tweeting at a Conference. Retrieved from  https://meta4RN.com/obesity

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End 

Finally, a big thank you to the organisers of the 5th Annual Consultation Liaison Psychiatry Symposium, especially Stacey Deaville for suggesting this session, and Dr Paul Pun for pulling on all the right strings.

That’s it. As always your comments are welcome.

Paul McNamara, 19th October 2017

Short URL: meta4RN.com/CLPS

Mental State Examination: Looking, Listening and Asking

Mental State Examination: Looking, Listening and Asking
By Paul McNamara @meta4RN
RGN (RAH), RPN (SAMHS), BN (Flin.), MMHN (USQ), Cert IMH (WCHN), CMHN, FACMHN
Adapted from the original work of Jenni Bryant @JenCLNinja
RN, RPN (NPC) RGN (BDH), MRN(MH), BN(UNE), MN (Research) (UoN), FACMHN

Every Australian undergraduate nurse is introduced to mental health and undertaking mental state examinations/assessments. However, only about one in every twenty nurses will specialise in working in mental health. For the majority of nurses (ie: those not working in mental health) undertaking a mental state assessment can often become a forgotten skill. This, in turn, deskills the nurse and disadvantages the patient – it’s not holistic care if mental health isn’t considered along with the medical/surgical/maternal aspects of care. As the adage says: there is no health without mental health.

If you’re not accustomed to incorporating mental state examinations (MSE) into your everyday role, it can feel a bit intimidating. Nurses I’ve worked with sometimes feel that they’re not adequately equipped to assess someone’s mental state. Of course they are – as long as they have a bit of emotional intelligence (self-awareness, self-regulation, social skills, empathy and motivation), and break down mental state examination to the three core skills that Jenni Bryant identified in her original powerpoint presentation: looking, listening and asking (adapted, online version available via www.slideshare.net/paulmcnamara).

This online version is in response to a few people requesting to have a print-friendly version (here: MSE), and/or something they’ll always have “in their pocket”, via internet-connected smartphones. The meta4RN.com website readily acknowledges that .edu and .gov websites have more credibility. However, many of those websites are not device-agnostic, so don’t render as well as meta4RN.com does on smartphones and tablets.

It’s a good habit to document a brief MSE for all your patients, not just those with a diagnosed mental illness. Mental state can and does change over a shift, day or week – it’s important to notice and communicate changes.

A comprehensive mental state assessment will include a full history: medical history, psychiatric history, medication history and personal history (developmental, relationship, education, employment, social). As history is static, there is no need to make this part of your “everyday” regular MSE.

A MSE is a snapshot as the person as they are at the time. A well-documented MSE conveys this impression for the reader. Using non-judgemental language, direct quotes of what the person says, and finding the right descriptors/adjectives makes for good MSE documentation. No need to worry about sentence construction. Dot points are fine.

Hopefully the following info will assist.

Mental Sate Examination (Looking, Listening and Asking)

General Description (Looking)

Level of Consciousness
drowsy, alert, sleeping, fluctuating

Appearance
grooming, makeup, posture, clothing, obvious physical deformities or characteristics

Behaviour
eye contact, rapport, level of activity (do you see psychomotor agitation or psychomotor retardation? if so, describe it), body language, mannerisms, specific activities

Speech (Listening)

Flow
smooth, hesitant, interrupted, staccato
easy to interrupt/redirect?
are responses prompt or delayed?

Rate
fast (pressured), slow, or unremarkable?

Volume
soft, loud/pressured, unremarkable.

Tone
flat, monotonous, restricted range, expressive

Continuity
the capacity to maintain a normal progression from one stream of thought to the next: over-inclusive, poverty, circumstantial, perservation or blocking?

Form
assess for abnormalities of form of speech, not form of thought eg stammer/stutter, dysarthia, expressive or receptive aphasia.

Clarity

Accent

Affect (Looking)

An objective assessment of facial and bodily expression of mood state.
Is affect appropriate to content? (congruent)
Assess the range, appropriateness, intensity and quality of affect
Rapid shift from one emotive response to another? (lability)

Some Useful Adjectives:

sad, tearful, angry, irritable, elated, euphoric, frightened, despondent, animated, expansive, cooperative, ingratiating, distressed, discouraged, anxious, hostile, guarded, anxious, calm, ambivalent, dysphoric, euthymic, suspicious, fatuous, bewildered, perplexed

Mood (Asking)

A subjective assessment of mood state:
How has your mood been lately?
How do you feel within yourself?
What has given you happiness, joy or enjoyment recently?
Are you a good person?
Have you been feeling guilty or sad?
If 10 is as good as you ever feel and 0 is as low as you go, where on the scale have you been over the last couple of weeks?

Neurovegetative signs and symptoms:
Sleep
Appetite
Irritability
Tearfulness
Energy
Motivation
Libido
Withdrawal

Thoughts (Asking & Listening)

Form
coherent? rational? sequential/linear?
amount – poverty, flight of ideas, vague
continuity of ideas – incoherent, blocking, circumstantial, tangential, irrelevant
disturbance in meaning or use of language – neologisms, word salad

Content
delusions, obsessions, compulsions, suicidal ideation, phobias, paranoia, preoccupations?
Do you feel safe here/at home?
Are you able to project your thoughts onto others?
Are other people able to insert ideas/thoughts into your head?

Perception (Looking, Listening & Asking)

Hallucinations = false sensory perception that occurs in the absence of a stimulus.
Can affect any of the senses:
Auditory
Visual
Olfactory
Tactile
Gustatory
Have you been experiencing any unusual sensations that you can’t easily explain?
Do you any special powers?
Sometimes when people are really stressed they hear voices/noises, but there’s nobody there. Has that ever happened to you?
You seem distracted by something I can’t see. Can you help me understand what you’re experiencing?

Ideas/delusions of reference
Do you have any unusual experiences when watching TV, or listening to music?
Do you ever feel that the TV has special messages just for you?

Illusion = misinterpretation of sensory stimulus
eg: responding to a pyjama top on a chair as if it were a cat; being startled by something out the corner of their eye.

Cognition (Asking & Listening)

Orientation
time, place, person, situation
Memory
Concentration
Attention
Clock Drawing Test [brief frontal lobe assessment]
please draw a large circle, then insert numbers to make it look like a clock.
now draw in the hands to show ten past eleven

MMSE: Mini Mental State Examination
– screening [ie: not diagnostic] tool for cognitive impairment – best for mild to moderate
– does not differentiate between delirium and dementia
– used to detect impairment, to follow course of illness, to monitor treatment response
– affected by education, intelligence, age, literacy, culture and inter-rater reliability

MMSE alternatives include:

MoCA: Montreal Cognitive Assessment
ACE-R: Addenbrooke’s Cognitive Examination
RUDAS: Rowland Universal Dementia Assessment Scale
KICA: Kimberley Indigenous Cognitive Assessment

Insight & Judgement (Asking & Listening)
Insight = to see one’s self as others do
Judgement = capacity to make reasoned decisions

Does the person recognise symptoms (eg: confusion, hallucinations) as symptoms?
Is the person aware that they are ill and understand the effects and implications?
Is the person seeking assistance/information or rejecting help?
Good, partial or poor? As evidenced by…

Risk (Asking & Listening)

Estimation of risk will be influenced by the person’s history (ie: previous experiences, behaviours and exposures) – the static factors.

Risk is best explored after rapport has been established, and the person knows that you are a safe, non-judgemental person. If somebody discloses intent/plans of harming themselves or others, thank them for trusting you, and let them know that it is too important a matter for just the two of you to handle alone. You’ll arrange for support.

The suggested questions below are for dynamic, “here and now”, factors only

Risk to Self
Do you still have “the fighting spirit”?
Do you ever think, “what’s the point in going on?”
What’s keeping you going?, what makes life worth living?
Have you thought you would be better off dead? How strong are these thoughts?
Have you thought of suicide?
Have you made a plan? [if “yes”, does the person have access to means?]
When would you do this?
What can I do to help you to stay safe?

Risk to Others
You seem pretty angry.
Are you able to express that anger safely?
Do you feel like acting on that anger?
Do you feel like hurting someone?
Are you safe to be around at the moment?
Am I safe with you? What about the other staff and patients here?
What can I do to help you to stay safe?

Alcohol, Tobacco & Other Drugs (Asking & Listening) 

Most substance abuse is contextual
Give “permission” for honest answers

“Sounds like you’ve had a lot of stress lately. How have you been coping?”
“You’ve got a lot of stuff going on at the moment… are you drinking or smoking more than usual?”
“In FNQ plenty of people use the bottle shop or a bit of choof or speed to try to manage stress. How about you?”

Quantity. Frequency. Recency. Route.

Substances:

  • Alcohol
  • Tobacco
  • Cannabis (choof, gunja, yarndi, weed, dope)
  • Amphetamines (speed, goey)
  • Methamphetamines (ice, crystal meth)
  • MDMA = methylenedioxymethamphetamine (ecstasy)
  • Opioids (codeine, morphine, methadone, heroin)
  • Benzodiazepines (benzos: diazepam, oxazepam, nitrazepam/moggies, temazepam/normies, alprazolam/xannies)
  • Hallucinogens (LSD, magic mushrooms)

End

That’s it. Hopefully you’ll find it as a handy memory-prompt/word-finder/confidence booster when providing holistic patient care.

There is a printer-friendly version here:
pdficon

There is a slideshow version here:
MSE

The short URL for this page is: meta4RN.com/MSE

As always, your feedback is welcomed in the comments section below.

Paul McNamara, 22nd July 2016