Anna Elders BN, PGCertCAMH, PGDipCBT. Cognitive Behavioural Nurse Therapist Director/Training Facilitator The CBT Clinic Ltd

Transcription

1 Anna Elders BN, PGCertCAMH, PGDipCBT Cognitive Behavioural Nurse Therapist Director/Training Facilitator The CBT Clinic Ltd

2 Determinants of a recovery practice Reflections on current challenges for the nurse in working within our present day healthcare system and the impacts of these on our practice The Hauora project outcomes and learning Benefits for nursing in adapting a cognitive behavioural model/focus within our practice

3 Holding an accurate understanding of the service user, their journey to date and how distress may present itself today based on a trauma-informed, client lead practice Seeking to develop a genuine relationship based on mutuality (Slade, 2009) Being prepared to work alongside and therefore increase exposure to the person and their journey (Slade, 2009) Allowing the ability to learn from, be influenced, challenged and changed by the service user (Slade, 2009) Carrying an innate assumption the service user is or will be competent to manage their life and a belief that we as practitioners can bring along skills and knowledge to support this Being a mascot for hope and managing our own cognitive distortions in regards to failure, non-compliance, revolving doors and other institutionally developed schemas Intrinsic job satisfaction, our own psychological wellbeing and work hope (Oades, Walker & Fisher, 2011)

4 Expanding nursing role the demands to be more, do more, know more and provide more (expanding scopes and roles, advances in understanding and knowledge, new movements in MH) Pressure from the ever-shrinking healthcare dollar and the anxieties that this promotes as we look towards the future Recognition of movement away from our core business as nursing becomes more driven by technology, risk aversion and reporting Out of the frying pans and into the fire? The impact of moving services out of the bins and into the community continuation of custodial care with a medical focus (Mullen, 2009) The continual challenge to get nurses to recognise, value and seek out regular supervision and the impacts of this on stress and burnout (Edwards et al, 2001) Continuing struggles to be and feel valued alongside other health professions A reality that we as a profession and the wider health systems we work in are perhaps a way off from providing a trauma-informed, recovery-focused service to those who need us most

5 American study showed 21-67% of mental health workers were experiencing high levels of burnout Psychiatric nurses have appeared to show higher rates of burnout than other staff in other areas, including comparison within the mental health field (Caldwell, Gill, Fitzgerald, Sclafani, & Grandison, 2006; Pompili et al., 2006; Miller, Reesor, McCarrey & Leikin, 1995) Burnout affects quality of treatment provided and lowers moral Even considered a work-related mental health impairment (Awa et al, 2010, p 184) Burnout is considered a multifaceted phenomena including three dimensions (Maslach et al, 1993); Emotional exhaustion depleted, overextended & fatigued Depersonalisation negative and cynical attitudes towards service users and work in general Reduced personal accomplishment negative self-evaluation of ones work with service users or overall job effectiveness

6 Here we go again This person doesn t want to change I ve tried and failed to help What is the point? Systemic blaming Ever-changing priorities/pressures Reducing resources Risk averse, policy driven institutionalism Avoidance/withdrawal Blaming Attacking Punishing Defensiveness Tension Lethargy Fight/flight sx Somatic presentations Hopelessness Anger Frustration Anxiety Guilt

7 We are predominantly in a unique position to engage in a relationship with service users that spans across time and the continuum of the service user s journey of recovery We are presented with multiple opportunities to assess, support and intervene along this journey in ways that most other health care professionals are not privy to We make up a large number within the mental health care workforce We are in a unique position to walk between the two worlds of the medical model and a psychological approach, perhaps with hands on experience in one and eager interest in the other We want to utilise and see the value in talking therapies (Fisher, 2011) We are obtaining good results in our use of CBT with service users (Durham et.al.2003; Chan & Leung, 2002; Poole & Grant, 2005; Turkington et al., 2006))

8 Four day training programme for nursing staff within Counties Manukau DHB s inpatient servcie (Tiaho Mai) incorporating: Tikanga in practice Importance of occupation in recovery Introducing the Consumer perspective Various integral basic psychological theories (attachment, trauma) Self reflection and use of Cognitive Behavioural Model in this 1:1 structured, formulation-driven pieces of individual work Monthly group supervision for all trainees Research project staff survey looking at recovery beliefs and behaviours

9 Embed cognitive behavioural interventions into inpatient care Increase the amount of nurse time spent with clients Enhance clinician empathy and understanding Enhance collaborative relationship (mutuality) Transfer of recovery-focused skills and attitudes into practice Deliver an intervention adaptable for Maori other cultural groups Enhance clinician confidence and job satisfaction Provide supportive supervision for nurses Undertake informative research to contribute to nursing and MH

10 The following quantitative results however showed significant p values: In comparison to the no training group, participants who had received training in a talking therapy (CBI or other) reported: a higher level of belief that clients can recover spending more informal time with clients spending less time administering/dispensing medication a lower rating of importance of administration tasks as a nursing activity higher levels of confidence in utilising talking therapy skills Qualitative results showed that participants who had attended the CBI training were more likely to make comments regarding beliefs that: talking therapy tasks make the most difference to client recovery learning further talking therapy skills would make the most difference in their ability to help clients recover

11 Here is another opportunity to support this person to recover What do I need to learn in order to support them? What can I do to help Systemic cohesion Reducing pressure, SU prioritied Freeing up/rechannelling of resources Individualism, freedom, growth Making meaning Fostering engagement Empowering action Empathic approach Collaborative guidance Mental clarity Equilibrium Physical containment Hopefulness Compassion Care

12 Increasing a sense autonomy empowerment pride and professional self esteem Passion for what we do and compassion for whom we do it with Reducing Burnout and compassion fatigue Service user blaming Punitive, traumatising behaviours including seclusion and restraint Enhancing Outcomes for service users Outcomes for ourselves and our profession into the future

13 How would the mental health of a country be affected if all mental health nurses were able to receive training, supervision and offer talking therapies as part of their routine practice? How would this affect health outcomes and the lived experience of individual service users? How might this impact on the wider socio-economic climate of a country like New Zealand? How could this impact on the nursing profession and its own journey into the future?

14 Caldwell, B., Gill, K., Fitzgerald, E., Sclafani, M., & Grandison, P. (2006). The association of ward atmosphere with burnout and attitudes of treatment team members in a state psychiatric hospital. American Journal of Psychiatric Rehabilitation, 9, Chan, S. W. & Leung, J. K. (2002). Cognitive behavioural therapy for clients with schizophrenia: Implications for mental health nursing practice. Journal of Clinical Nursing, 11(2), Durham, R., Guthrie, M., Morton, V., Reid, D., Treliving, L., Fowler, D., & MacDonal, R. (2003). Tayside- Fife clinical trial of cognitive-behavioural therapy for 299 medication-resistant psychotic symptoms. British Journal of Psychiatry, 182, Miller, L., Reesor, K., McCarrey, M., & Leikin, L. (1995). Nursing Burnout. Employee Assistance Quarterly, 10(4), Elders, A. & Stewart, M. (2009) Hauora Cognitive Behavioural Interventions Project; Staff Survey Impact of training on recovery behaviours and attitudes. Executive Summary. Unpublished. Fisher, J.E.M (2011) The therapeutic role of the mental health nurse: implications for the practice of psychological therapies. Southern Cross University Thesis. Maguire, N., Grellier, B. & Clayton, K. (?) The impact of CBT training and supervision on burnout, confidence and negative beliefs in a staff group working with homeless people.

15 Maslach, C. (1993). Burnout: A multidimensional perspective. In W.B. Schaufeli, C. Maslach, & T. Marek (Eds.), Professional burnout: recent developments in theory and research (pp.19-32). Washington, DC: Taylor & Francis. Mullen, A. (2009). Mental health nurses establishing psychosocial interventions within acute inpatient settings. International Journal of Mental Health Nursing, 18, Oades, L., Walker, R. & Fisher, N. (2011) Staff wellbeing predicting positive attitudes towards mental health recovery. The International Journal of Person Centred Medicine. 2011, 1 (3) Poole, J. & Grant, A. (2005). Stepping out of the box: Broadening the dialogue around the organizational implementation of cognitive behavioural psychotherapy. Journal of Psychiatric and Mental Health Nursing, 12(4), Pompili, M., Rinaldi, G., Lester, D., Girardi, P., Ruberto, A., & Tatarelli, R. (2006). Hopelessness and suicide risk emerge in psychiatric nurses suffering from burnout and using specific defense mechanisms. Archives of Psychiatric Nursing, 20 (3), Slade, M. (2009) 100 ways to support recovery; A guide for mental health professionals. Rethink recovery series: volume Turkington, D., Kingdon, D., Rathod, S., Hammond, K., Pelton, J. & Mehta, R. (2006, July). Outcomes of an effectiveness trial of cognitive-behavioural intervention by mental health nurses in schizophrenia. British Journal of Psychiatry, 189,