Acute Mental Health. Applying knowledge, skills and attitude to mental health practice. Lecturer: [REDACTED] Word count: 2730 (excl.

Transcription

1 Acute Mental Health Applying knowledge, skills and attitude to mental health practice. Lecturer: [REDACTED] Word count: 2730 (excl. abstract) Name: [REDACTED] Date: 21 April

2 ABSTRACT The acute mental health setting places the nurse within an environment where clinical practice can be dominated by legislation and the necessity to manage the tension between person-centred care while maintaining public safety. Assessing risk within politically driven mental health services can generate an imbalance of control towards people experiencing a crisis or acute mental health problem; potentially denying the person s ownership of their recovery. This focus, whether intentional or unintentional, can negatively affect how a nurse therapeutically engages with people and their families. As a result, engagement is regarded as a task instead of a means to assist recovery. The discussion of this essay is centred on the implications that limit therapeutic engagement in an acute setting, while highlighting which specific knowledge, skills and attitudes are required from mental health nurses to transform the focus of risk within a situation of crisis. As a requirement of this essay, an additional paragraph which critically reflects on my own professional developing strengths and limitations when working alongside people experiencing a mental health crisis, is provided. Crisis is a part of life and crucial for future development, which can be productive or non-productive depending on how the person develops resilience. Mental health nurses are in a privileged position to assist in positive outcomes from a crisis by applying therapeutic engagement in their working relationships with people experiencing distress. In order to do this, they require knowledge of the principles of crisis intervention and therapeutic risk-taking. This knowledge enables nurses working alongside people experiencing distress to undertake a systematic assessment of mental state and prioritise risks. An attitude of compassion is needed by nurses when undertaking crisis work so that they can work at the pace of the person in crisis and build resilience with them. Experiencing stress and emotional upset is a normal occurrence in people s lives, resulting from various biological and social changes (Hoff, 2001; Kanel, 2012; Woolley, 1990), such as the sudden death of a family member, divorce, child abuse, natural disasters, accidents or sudden reoccurrence of a mental disorder (Kanel, 2012; Roberts, 2005). An issue arises when that person cannot find the means to cope or resolve the crisis, resulting in mental instability and ineffective coping mechanisms such as withdrawal, alcohol abuse and social isolation (James & Gilliland, 2013; Wilson, 2014) that conflicts with their normal coping methods (Kanel, 2012). In mental health nursing, this may present as severe psychological 2

3 distress, or showing signs of a major mental illness (Calvert & Palmer, 2003). Crisis interventions are therefore therapeutic approaches to assist in resolution of the crisis, rediscovery of effective coping mechanisms and to assist the person in obtaining the necessary knowledge, attitude and skills to manage future biological or social changes (Calvert & Palmer, 2003; King, 1971; Roberts, 2005; Wilson, 2014). It is also noted that as crises are short-term occurrences, this means crisis interventions are concerned with short term goals that deal with the immediate problem (Hoff, 2001). Calvert and Palmer (2003) suggest that knowledge of a system of crisis intervention strategies is one of the most important aspects of crisis work. One such strategy is Roberts (1991) crisis intervention model that consists of seven principles which are: assessing lethality, establishing rapport, identifying major problems, dealing with feelings, exploring alternatives, developing an action plan and follow up (Calvert & Palmer, 2003). This is expanded further by Roberts (2005), who suggests that developing an action plan is one of the important parts of crisis intervention. This is ideally completed in collaboration with the client, who is encouraged to discover alternative coping plans. An important factor in this action plan is openly discussing the potential risks involved with their experience (Manuel & Crowe, 2014). Due to the nature of a person experiencing distress, crisis can be viewed as potential danger and risk to oneself and others (Kanel, 2012). Risk can be defined as any behaviour with a degree of uncertainty or unpredictability (Robertson & Collinson, 2006) but is also determined through what is deemed as normal behaviour by a dominant culture within a population (Crowe & Carlyle, 2003). Therefore, it could be argued that this cultural criteria is what influences the development of public legislation, such as the Mental Health Act [YEAR REDACTED]. The Mental Health Act [YEAR REDACTED] outlines that risk includes a presence of a mental disorder (continuous or intermittent nature, characterised by delusions, disorders of mood, volition, cognition or perceptions) as well as a serious risk to self, others, or a seriously diminished capacity to care for self. Therefore, if a client presented with an immediate intent to harm themselves or others due to an underlying mental disorder, interventions such as restraint or seclusion could be considered as necessary action. 3

4 The Mental Health Act [YEAR REDACTED], whilst having an underlying expectation that assessment and treatment will be in the least restrictive environment, is a means of social control (Wand, Isobel & Derrick, 2015; Wilson et al., 2016); designed to favour protection of the public (Stickley & Felton, 2006). This has resulted in services being dominated by extensive risk assessment and management (Wand, 2015), creating an environment where nurses are confined within organisational guidelines with a defensive focus (Manuel & Crowe, 2014; Robertson & Collinson, 2011). As a consequence, this can lead to consumption of valuable time and resources (Wand et al., 2015) and a loss of autonomy from the individual (Stickley & Felton, 2006). Although risk assessment and management is vital (Sands & Gerdtz, 2012), it needs to be done so in a way that facilitates recovery, by balancing the autonomy of the individual with the protection of public safety (Manuel & Crowe, 2014; Stickley & Felton, 2006). This balance is what therapeutic risk-taking (a.k.a. positive risk-taking) endeavours to uphold. The goal of therapeutic risk-taking is to determine a plan of action with the service user that recognises the potential benefits of an associated risk while outweighing the potential negative concerns of the plan (Hart, 2014; Stickley & Felton, 2006). This focuses on the positive outcomes of risk-taking instead of the avoidance of undesirable consequences (Clifford, 2011). It is a holistic concept utilising collaborative engagement with the serviceuser, carers and key workers; acknowledging that any plan will carry risk, therefore recognising that risk cannot be fully eliminated (Clifford, 2011; Hart, 2014). This will ultimately mean that any clinical decision that is made will be in the best interests of the client whilst seeking the least restrictive option of crisis intervention (Morgan, 2004 as cited in Robertson & Collinson, 2011; Clifford, 2011; Hart, 2014). Other considerations for using therapeutic risk-taking in practice include: the benefits of assessment/management/interventions at home compared to admission to hospital; assessing the level of responsibility someone can take in managing their own safety; and considering the long-term impact that restrictive measures can place on the individual, which can impact the therapeutic relationship, thus therapeutic engagement completely (Hart, 2014; Lees, Proctor & Fassett, 2014). The knowledge of the principles of crisis intervention and therapeutic risk-taking are what underpin the assessment skills that contribute to therapeutic engagement. As the nurse is ethically and clinically responsible for any intervention outcome, accurate assessment is a vital skill (McAndrew et al., 2014). One such assessment that will benefit 4

5 from applying the principles of crisis intervention in practice, is the mental state examination (MSE). The MSE is a structured interview, included in the whole-person assessment, which allows the mental health nurse to assess a client s current neurological, cognitive and behavioural functioning (Muir-Cochrane, Barkway and Nizette, 2014) which assists in defining the service users experience (Wilson et al., 2016). It covers: behaviour and appearance, speech, mood (subjective/objective), affect, thought process, thought content, perceptions, cognition and insight/judgement (of crisis/condition) (Muir-Cochrane et al., 2014). The MSE is designed to be conducted at a particular point in time and forms a benchmark for future assessments. This will provide essential data for any plan of action (Muir-Cochrane et al., 2014). In addition to the MSE, the mental health assessment will include history of the present issue, allowing an opportunity for the client to tell their story in their words, encouraging collaborative practice and therapeutic engagement (Deegan, 1996; Muir-Cochrane et al., 2014). These assessments are also what Sands, Elsom, Gerdtz and Khaw (2012) identified as a tool to pre-empt undesirable events of a crisis, as these are clinical factors immediately observable in a person (such as irritability, agitation), reducing the incidence of unnecessary restraint and trauma to a person (Sands et al., 2012). Moreover, application of the principles of crisis intervention as an assessment framework for the MSE, will avoid the overuse of assessment drawn from legislation (Wilson, et al., 2016). In addition to the MSE is the requirement for a risk assessment (Muir-Cochrane et al., 2014). Risk assessment needs to have a strength-based focus (identified through MSE) through a therapeutic working relationship, in collaboration with the service user, the goal being to determine a level of risk towards the client and others (Muir-Cochrane et al., 2014). This will assist in identifying an action plan with the service-user while pre-empting any immediate risk. Ideally in relation to the crisis intervention principles, this would be conducted initially in conjunction with the MSE (Muir-Cochrane et al., 2014). Robertson and Collinson (2011) identify that risk-taking is important in the sense of improving the quality of life to service users, therefore utilising positive risk-taking as the focus for a risk assessment will help identify the priority of risks to the service-user (Clifford, 2011); which could range from self-harm, to lack of self-hygiene, to substance abuse (Robertson & Collinson, 2011). One method of risk assessment using positive risk-taking is offered by Clifford (2011), where assessment determines the distinction between an underlying risk and contextual risk, which ultimately assesses whether the risk of an event occurring is either independent or judged relative to the specific circumstances in which the person finds 5

6 themselves (Clifford, 2011). This will acknowledge that an underlying risk can be high, however in context, the likelihood of an event occurring can be low if there are support networks, for example, in place. By using an assessment such as this, the nurse is openly engaging with the service-user about the actual and potential risks, while allowing the opportunity to develop a plan of action that has collaboratively prioritised risks. Through these thorough assessments, an understanding of the person s lived experience can begin to be established (Barker & Buchanan-Barker, 2011; Warne & McAndrew, 2010), providing an opportunity for the service-user to feel listened to, respected and understood (Lees et al., 2014); all of which contributes to effective therapeutic engagement (Lees et al., 2014; McAndrew et al., 2014; Proctor, Hamer, McGarry, Wilson & Frogatt, 2014). Although mental health practice is dominated by risk assessment and management (Wand et al., 2015), through the use of crisis principles and positive risk taking, the chances of crisis assessment and interventions becoming a task instead of a means to assist recovery will be reduced (Manuel & Crowe, 2014). Being in crisis does not last forever, as finding a resolution is a part of the natural course, lasting normally between four to six weeks (Hoff, 2001; Kanel, 2012). It is for this reason various literature allude to as the underpinning reason crisis can present as a danger or opportunity (Hoff, 2001; Roberts, 2005; Wilson, 2014; Woolley, 1990). Any crisis serves as a basis for further growth (Kanel, 2012); and literature surrounding crisis interventions has shown how in the midst of a crisis, the service user is in a vulnerable position where he or she can either face the challenge of the crisis or not (Hoff, 2001; Kanel, 2012). Therefore seeking help during the midst of a crisis will significantly improve its outcome (Calvert & Palmer, 2003; Kanel, 2012) preventing future emotions that are overwhelming. If a service user does not receive adequate crisis intervention, they are at risk for further crisis events that are further dealt with undesirable mechanisms, ultimately removing the service user s resilience to deal with future stressors (Kanel, 2012). As a result, future crisis states are continually unresolved, lower levels of functioning are compounded further, opening a possibility of the development of personality disorders, suicidal ideation, increased likelihood to harm others or psychotic breakdowns (Calvert & Palmer, 2003; Kanel, 2012). It is for these reasons why crisis carries a degree of risk, which unfortunately places the service user in amidst an environment heavily focused on protecting the public. This environment has been developed through the introduction of legislation such as the Mental Health Act [YEAR REDACTED] where service users are either deemed of risk or at risk 6

7 (Wilson et al., 2016). Prior to the concept of positive risk taking, service users have generally been kept in the dark regarding to the accountability of risk management (Byrne, Happell, Welch & Moxham, 2013). The increased pressure to control risk can raise tension (due to the possibility of restrictive measures), potentially jeopardising staff safety (Wilson et al., 2016). As such, coercive behaviour can be developed from nurses, all of which threaten therapeutic engagement, therefore recovery. It has been recognised that there is a requirement to change the attitudes of mental health services in order to promote recovery (Bennetts, Cross & Bloomer, 2011; Byrne et al., 2013). The stigma that is associated with using mental health services can impede the recovery journey itself and requires significant envisaging to understand any feelings of social isolation, inadequacy and hopelessness that it ensues (Byrne et al., 2013; Yanos Roe & Lysaker, 2010). Furthermore, Byrne et al, (2013) discuss that the attitudes of mental health professionals influence the culture of mental health services and the extent to which they change in response to policy directives (p. 200). To counteract the issues of a dominant focus on risk assessment and management will require not only the knowledge of the crisis intervention principles, positive risk-taking and assessment skills, but an attitude of compassion (Cleary, Horsfall & Escott, 2015). Compassion is what underpins nursing philosophy (Straughair, 2012) and although empathy and positive-regard are elements for patient-centred care, compassion not only allows one to place themselves in another s shoes, but involves an intent to actively support and work with another facing difficulty (Cleary et al., 2015; Day, 2015). Demonstrating compassion will enhance therapeutic engagement by providing a positive experience of care to the service-user (McAndrew et al., 2014) and the service user will feel empowered to make sense of their own situation, thus building strength and resilience to face a current or future crisis (Cleary et al., 2015). I have continually identified and developed my own strengths and limitations over the past few years in relation to mental health practice. On reflection back to our first year of training, we were introduced to concepts such as empathy, compassion, trust and partnership as the foundation for establishing the important therapeutic relationship. I can recall initially thinking that these would be simple concepts I could easily incorporate into practice. However, what I subsequently discovered was that although we can obtain the knowledge of what the ideal attitudes are to facilitate a therapeutic relationship, it still requires a great degree of experience and reflection. For example, I have recognised the importance of identifying and acknowledging my own personal biases in a clinical setting in order to 7

8 effectively practice empathy and compassion. Through this reflective practice I have established that although I may feel like I am generally a non-judgemental person, I will always continue to make judgements in my practice and this is OK, as long as I acknowledge this and don t let it impede on my practice. Currently, my limitations working with mental distress are my assessment skills, as the comprehensive mental assessment and interview skills appear to be a refined art. Although I am continually developing traits such as empathy, compassion, trust and partnership well, my experience is limited in applying these to assessments such as MSE and risk assessments. Furthermore, I have had limited exposure working with a person who is experiencing immediate mental distress or crisis and as such, would not carry the confidence needed to interact effectively with a service-user. However, possessing knowledge of the MSE and frameworks such as crisis intervention principles and therapeutic risk-taking, will provide a helpful base-line in which experience can be further developed; and confidence will follow thereafter. There are many contradictions and complexities in mental health nursing which require a need for specific knowledge, skills and attitude from the mental health nurse in order to therapeutically engage. In crisis, this requires knowledge of crisis intervention principles and therapeutic risk-taking, assessment skills and an attitude of compassion. In mental health, a service user who is experiencing a crisis will be in a vulnerable state that can involve many risks, but also open an opportunity for change and growth. Although each crisis will naturally resolve itself, a positive outcome is dependent on the effective use of crisis interventions. Furthermore, in a society dominated by risk assessment and management focused to protect the public, is the risk for the person experiencing the crisis to lose autonomy and their contribution towards their recovery; this can be balanced by the nurse applying therapeutic risk-taking. As a result, the nurse can assess the service user in a manner that will promote recovery. Underpinning this knowledge and skill is the requirement for the nurse to show compassion, which will open up further dialogue for therapeutic engagement and a means to rediscover strengths and build resilience to cope with future crises. 8

9 References: Barker, P., & Buchanan-Barker, P. (2011). Myth of mental health nursing and the challenge of recovery. International Journal of Mental Health Nursing, 20(5), doi: /j Bennetts, W., Cross, W. & Bloomer, M. (2011). Understanding consumer participation in mental health: Issues of power and change. International Journal of Mental Health Nursing, 20, doi: /j x Borg, M., & Kristiansen, K. (2004). Recovery-oriented professionals: Helping relationships in mental health services. Journal of Mental Health, 13(5), doi: / Byrne, L., Happell, T., Welch, T., & Moxham. (2013). Things you can t learn from books : teaching recovery from a lived experience perspective. International Journal of Mental Health Nursing, 22(3), doi: /j Calvert, P., & Palmer, C. (2003). Application of the cognitive therapy model to initial crisis assessment. International Journal of Mental Health Nursing, 12, Retrieved from: [WEBSITE REDACTED] Cleary, M., Horsfall, J., & Escott, P. (2015). Compassion and mental health nursing. Issues in Mental Health Nursing, 36(7), doi: / Clifford, P. (2011). Evidence and principles for positive risk management. In R. Whittington & C. Logan (Eds.), Self-harm and violence: towards best practice in managing risk in mental health services (pp ). doi: / ch11. Crowe, M., & Carlyle, D. (2003). Deconstructing risk assessment and management in mental health nursing. Issues and Innovations in Nursing Practice, 43(1), doi: /j Day, H. (2015). The meaning of compassion. British Journal of Nursing, 24(6), doi: /bjon Deegan, P. (1996). Recovery as a journey of the heart. Psychiatric Rehabilitation Journal 19(3), 91. Retrieved from: [WEBSITE REDACTED] Forchuk, C. (2002). People with enduring mental health problems described the importance of communication, continuity of care, and stigma. Evidence-Based Nursing, 5(3), doi: /ebn Hart, C. (2014). A Pocket Guide to Risk Assessment and Management in Mental Health. NY: Routledge. Hoff, L.A. (2001). People in crisis: Clinical and Public Health Perspectives, (5 th ed.). San Francisco, CA: Jossey-Bass. 9

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