Mental health nursing in a rehabilitation and recovery context

In this chapter we return to the story of Anthony and his brother David, who we originally met in Chapter 4, and Joyce, who first appears in Chapter 5. Previously we considered the role of the mental health nurse in working with people experiencing acute mental health crisis. This chapter seeks to consider how as mental health nurses we might go on to work with these people to support their rehabilitation and reintegration into the community. The chapter opens by outlining some key principles of recovery and proceeds to demonstrate how these ideas might be implemented in working with both Anthony and Joyce. “The way I was feeling my sadness was mine. When I was in hospital staff rarely took time to find out what this was like for me. Not taking the time often fuelled what I was thinking: ‘I’m not worth finding out about.’ Nigel Short (2007: 23)” This service user describes how it feels to live with mental illness continuously throughout their lives, not just while they are in hospital. Professional staff may contribute to this feeling if care planning becomes too focused upon symptoms and treatment rather than person-centred care and recovery. In this context, recovery should not be seen as a new concept; rather it can be traced back at least 200 years to one of the earliest asylums, the Tuke Retreat in Yorkshire. “For it was a critical appraisal of psychiatric practice that inspired the Tuke at York to establish a clinical philosophy and therapeutic practice based on kindness, compassion, respect and hope of recovery. Roberts and Wolfson (2004: 37).” Later, during the 1960s, The Vermont Project (an American psychiatric facility) also published research on successful rehabilitative practice that was based upon ‘faith, hope and love’ (Eldred et al. 1962: 45). However, much of the current focus upon recovery practices is based on longitudinal studies in America, services in Ohio, service users were asked to identify what was important to them. This resulted in the Emerging Best Practices document that is recommended guidance in the UK today (NIMHE 2004).

The nursing care of older people with mental health problems

In this chapter you will learn about working with older people with mental health problems. The aim is to clarify your understanding of the issues that more often affect older people, and guide your learning about the process of placing these difficulties in context, and of assessment and care planning. Of course, older people can experience the same problems as younger people, such as low mood, hearing voices, substance abuse, and worries due to the problems of life. In this chapter we will concentrate on some of the difficulties felt more often by older people – memory problems, depression related to loss and the stress of caring, and emotional distress following the difficulties of growing old in a second homeland. Nursing older people is both challenging and rewarding. The lifetime’s experience of an older service user, together with a combination of physical, social, spiritual, and emotional factors mean that individuals’ situations will be different, complex, and at times, confusing. Diagnostic labels do not always ‘fit’, which means the holistic assessment carried out by the nurse within a multidisciplinary team (MDT) is even more crucial for planning personalized and sensitive care. In this chapter you meet three service users. The first two are Albert and Vera, a married couple, who have been together through thick and thin, but are facing a serious threat to their relationship caused by Albert’s increasingly poor memory. Vera is struggling to make sense of it, and cannot understand why Albert is changing. She faces the gradual loss of the man she knows and relies upon, while Albert himself is distressed by the feeling of not knowing what is going on, and the frustration he senses in his normally kind and cheerful wife. The third service user, Mrs Bibi, is an older woman from Pakistan, who is saddened by the separation from dearly loved members of her family, and despite strong support from her family in this country, still struggles with the pressures of growing old – she has arthritis and diabetes. Mrs Bibi does not speak English, and does not really understand the health and social care system nor the advice she has been given so far. People are living longer, and consequently the elderly population is increasing (Cantley 2001).

On becoming a qualifi ed mental health nurse

In this chapter we will consider the knowledge, skills, and attitudes expected of you as a newly qualified mental health nurse, before discussing how to apply for a job and develop your career. To help you consider this we have tried to include contributions from people who have a range of backgrounds and perspectives, who all contribute to mental health services, including a student about to qualify, a modern matron, a clinical manager, a director of nursing, a professor, and service users. To set the scene, our first personal contribution is from Julie Cresswell, a third year student nurse at the Birmingham City University and the Royal College of Nursing’s Student Nurse of the Year 2007. We asked Julie a series of questions that we hoped would help you in preparing to become a qualified nurse; these are her answers and thoughts about the future of mental health nursing and her career. In preparation for qualifying, I am now reflecting upon the experience, knowledge base, and skills that I have developed during my training, along with the transferable skills that I already had before I embarked upon this career. As mental health nursing students, we will all have followed a similar academic course equipping us with a certain level of theory and practical skills. However, what makes us individual is how we intend to use what we have learned throughout our lives and the philosophy that underpins our work. I began this course with the belief that psychiatric nursing was grounded in science. I now feel that while science can hypothesize about the causes of mental illness, understanding and accepting a client’s life experience is central to supporting them in times of mental distress. As I progress through my career, my approach may develop or change direction but for the moment, I feel that it will be vital to be able to communicate my own perspective to future employers. Developing your own approach to mental health nursing, along with an audit of what you can offer an employer in terms of practical skills, knowledge, and experience, establishes your own ‘unique selling point’ in a competitive jobs market.

Mental health nursing in the community

In this chapter you are introduced to two fictional characters, Paul and Molly, who need help with very different problems and who are intended to represent the wide range of emotional difficulties encountered by people referred to community mental health teams. Paul is a young man of Afro- Caribbean descent who has become isolated and withdrawn over a period of time. Paul’s family are concerned and upset about his deterioration and he has been referred to community mental health services by his family doctor. Molly is a young woman who has been leading quite a stressful life; although successful in material terms, she has been experiencing anxiety and panic. This chapter demonstrates how practising community mental health nurses (CMHNs) might work with Paul and Molly in the process of assessing, planning, implementing, and evaluating the care planned alongside emerging mental health issues. The first person we meet in this chapter is Paul, a young man who is referred to the community mental health team following concerns raised by his family about his changed behaviour. As well as being concerned for Paul’s welfare, this section also prompts us to consider how we might work alongside his family, in this case, his mother Charmaine and his sister Caroline Paul is 21 years old. He lives with his parents, Joshua and Charmaine, and his 18-year-old sister, Caroline. Both Paul’s parents came to the UK in 1971 from Barbados and they try to go back ‘home’ once a year to stay in touch with their extended family. They have lived in a three-bedroom house in Birmingham for the past 15 years. Joshua is 55 years old, a tool setter at an engineering factory, and Charmaine works part-time as a care assistant at a local nursing home. Caroline is currently doing A-levels and hopes to go to university. Joshua and Charmaine regularly attend at a Christian church, and are very proud of both their children, but would like them to be a little more respectful and attend the church more regularly.

On becoming a student mental health nurse

This chapter is all about helping you to understand what mental health nursing is. To this end, we will consider what you must know and do when you first meet people with mental health problems. We will introduce a personal account from a mental health service user early in the chapter in order to help you begin to understand what working with people with mental health problems is like and what service users want from mental health nurses. In an effort to help you become familiar with what mental health nursing is, we will explore the following issues: what is a profession; what is nursing; what beliefs and values inform nursing; why is it important for mental health nurses to be self-aware; and what do mental health nurses need to know? In the final part of this chapter we explore the nature of boundaries in professional relationships and the implications of this for practice as a mental health nurse. Before you read any further we would encourage you to recognize that mental health service users are, quite rightly, the real experts in their care and needs. It is vitally important that you listen and really attend to what they are saying to you. We have asked a service user, Deborah Living, to represent for you some of the important issues that she would like mental health nurses to be aware of, and Deborah is going to tell you part of her own life story. I consider myself to be a survivor…not just a survivor of mental health difficulties but also a survivor of mental health services. I feel I am a survivor because I have reclaimed my life after more than ten years of mental health diagnoses and treatments: diagnoses from clinical depression to cyclothymia (described as a ‘milder’ form of manic depression); antidepressants and mood stabilisers from prozac to lithium; and interventions from counselling to psychiatry, through ECT to being an inpatient. It took me over a decade and a 12-month stay in a residential therapeutic community to stop the ‘revolving door’ approach within the mental health service, whereby I would gain short-term stability only to relapse yet again.

Additional skills for complex cases in mental health nursing

In this chapter we will focus on some service users and mental health nursing skills that are more specialized than many students may experience. However, in introducing these concepts it is hoped that the chapter will help to prepare students and encourage exposure to such areas. You will meet four different service users from four different areas of mental health: child and adolescent mental health (Sarah, who has the additional complexities of an eating disorder, p. 224), substance misuse issues (Charlie, p. 231), forensic involvement and personality disorder issues (Tracy, p. 237), and post-traumatic stress in a person seeking political asylum (Feodor, p. 246). It is important to state at the outset that using the term ‘areas’ of mental health may lead students to believe that these are specialisms within the field of mental health nursing. The reality is the opposite. These issues and concerns are common for many service users that mental health nurses encounter in practice. While you may find that during your education you receive little formal teaching or experience in these areas, you will find some knowledge of these issues appropriate when, after-qualification, you are working with service users who are experiencing related problems. It is important to understand the context from which many of these issues may emerge. There is recognition of the structured inequalities in Britain’s health and social system, including for example substance misuse, ageism, unemployment, homelessness, poverty, sexism, and racism. For a variety of reasons, mental health service users may find themselves in situations of social disadvantage and economic hardship. The social effects of mental health problems can lead to individuals being effectively disabled, often with greater challenges than the mental health problem itself. The National Service Framework for mental health (NSF) (Department of Health 1999) encourages all mental health professionals to promote social inclusion. But how do we promote social inclusion of individuals who are ultimately excluded from services, potentially because of our lack of skills in these ‘specialist areas’?

The nursing care of an adult in crisis with mental health problems

In this chapter we will look at the issues arising from an acute crisis in two people’s lives. Two differing crises with separate needs and outcomes but similarities in risk assessment and planning of care will be discussed. First you will meet Joyce, a mature family woman who has a history of mental health crises. You will also meet Andrew, a young man who is very troubled by his current circumstances, which have led to a significant mental health crisis. Dictionary.com defines crisis in many ways, and there are two useful definitions here: • A stage in a sequence of events at which the trend for all future events, especially for better or for worse, is determined; turning point • The point in the course of a serious disease at which a decisive change occurs, leading either to recovery or death So we will examine the nature of a crisis, what must be done about it, and what we need to do in the future to either prevent recurrence or minimize its impact. We will pay special attention to the risks included in both definitions to ensure our outcomes are for better not worse and lead to recovery not death. In mental health nursing there is, historically, difficulty in accepting death, whereas in all other branches of nursing it is accepted that a percentage of clients will die. For example in oncology, surgery, and neonatal care it is accepted that death may occur, but in our branch of nursing it causes angst, blame, and fear. In light of this we will discuss risk assessment and planning in some depth. Joyce is a 57-year-old woman, now divorced, with three children who are all now grown up and leading their own careers. The eldest is a highly respected solicitor. Joyce has a long history of bipolar affective disorder. She has, when in low mood, attempted suicide on several occasions. Some have been very serious attempts, one requiring the administration of acetycysteine (Parvalex) to redress her symptoms. For the last 18 months she has been living in Cedar Lodge, a rehab and recovery unit, following her most recent relapse. Her progress appeared to be successful until about six or seven weeks ago. She had formed a relationship with a younger man, Mark, whom many of the staff distrusted. Recently she had exhibited changes in behaviour.

Community mental health nursing care of a person with complex needs

In this chapter we will consider the care of a person living in the community with complex needs. In the past, the majority of people who suffered from severe and enduring mental health problems would almost certainly have spent their lives living in institutionalized care. Today, the majority of people with such problems live in the community, and the issue of how well (or not) they are supported is a critical one for those working as part of a community mental health team. In this chapter we introduce ‘Anthony’, a service user who has a long history of mental health problems. Anthony lives alone, and apart from his brother David, he has little contact with other people. Anthony has been referred to mental health services following a long period in which he has been having a depot injection from the nurse at his GP’s surgery. He has a complex range of problems including harassment from local youths, possible physical ill health, and housing problems, as well as a deterioration in his mental health state. In the UK, the move from hospital-based care towards a more community-oriented model is a relatively recent one. Many of the care practices and attitudes you may encounter today have their roots in an institutionalized model. From the 1840s onwards a system of ‘lunatic asylums’ was developed, the intention being that these should provide a humane and morally disciplined environment for those identified as needing care for mental health problems. They were oft en linked to county asylums and workhouses and became associated in the public view with both poverty and ‘madness’. For ordinary people at this time of great industrial and social change, working conditions were harsh and the asylum policy was intended to provide a degree of social control (Rogers and Pilgrim 2001). A popular ditty of the time illustrates some of the prevailing attitudes:… Outside the lunatic asylum, I was there and I was breaking stones, When up popped a lunatic and said to me ‘Good morning Mr Jones, How much a week do you get for doing that?’ ‘Sixteen shillings’ I cried, ‘That’s not enough to keep a wife and six kids, Step inside you silly fella, step inside’. (Anon)…

Mental health law

This book has been written to reflect modern ideas about what constitutes good mental health nursing care, and you will see that values such as partnership working within the framework of a therapeutic relationship have been deliberately stressed. However, the role of the mental health nurse has always required some involvement in what is essentially custodial care. It is necessary for us as mental health nurses to try to balance the demands of these two seemingly paradoxical elements of the role of a mental health nurse. This chapter is intended to introduce you to some aspects of mental health law. We have partly based this upon the law as it currently applies in England and Wales but you will notice that we have also tried to include some material from an international perspective. The history of the profession of mental health nursing is inextricably bound up with the story of the rise and fall of the asylum and with institutionalized models of care. It was only following the Macmillan commission, which was set up to investigate allegations of abuse at Prestwich Hospital in 1924, that the term ‘psychiatric nurse’ (which later evolved to mental health nurse, Department of Health 1994) became a commonly used description (Coppock and Hopton 2000). Prior to this time, people working in institutions for the mentally disordered were more oft en referred to as ‘attendants’ or ‘keepers’ (Nolan 1998), and as these names imply, their roles were mostly custodial or supervisory in nature. Mental health nursing has moved away from this limited model of providing ‘care’ but is still unusual amongst other health care professions in that its members continue to be involved in compulsory detention (even though the main responsibility for this rests with the medical profession; Rogers and Pilgrim 2001). In England and Wales the 1983 Mental Health Act and its 2007 update is currently the legislation directing compulsory treatment of people with mental disorder. In common with legislation in most countries, this Mental Health Act aims to achieve a balance between the rights of the individual mental health patient to be treated and protected and the perceived need to protect others.

Fundamental skills of mental health nursing

A mental health nurse practises the skill and craft of their role in a variety of different settings to reflect the varied range of services provided in today’s mental health services. Whatever the setting or nature of the mental health problem, a set of adaptable mental health nursing skills will be required to enable the nurse to facilitate the safe and effective care of the service user. This care is expected to be individually tailored to the needs of the service user, developed (with only occasional exceptions) collaboratively with the service user, and evaluated with the service user and key partners in care. The principles of the nurse’s practice have to be underpinned and informed by the policies and guidelines that shape contemporary and future services. In the UK, nurses must respond to the essential capabilities (Department of Health 2006a) and the Chief Nursing Officer’s review of mental health nursing (Department of Health 2006b) in order to deliver a service that reflects the reform and quality improvements expected in modern mental health services. Practical skills have to be backed up by a strong knowledge base, with nurses knowing why they do what they do and being able to explain their actions whenever called upon to do so. Where possible and available, what mental health nurses do needs to be done on the basis of the most up-to-date evidence or guidance, which comes in many forms (Sainsbury Centre for Mental Health 2004, National Institute for Clinical Health and Excellence 2004a, Nursing and Midwifery Council 2008a and 2008b). As not all the scenarios that nurses encounter have a textbook answer, it is important that other complementary skills are developed to help them make decisions and deal with scenarios for which there is no clear and obvious answer available. These skills include: • Reasoning using principles and frameworks to weigh up a situation, e.g. ‘To adhere to the NMC Code of Conduct, what do I need to be aware of in this case?’ • Reflecting in or on practice (Schön 1987, Rolfe and Freshwater 2001, Johns 2004) to get a deeper understanding of situations and your own reactions and judgements, especially those values and attitudes you hold that may cause conflict with service users and significant others.