NUM2307 Mental Health and Well being in Clinical Practice [2022 ed.]

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NUM1207 Module 1.1 Mental Health and Mental Illness Learning outcomes ● ● ● ● ● ● ●

Understand the nature of mental health and wellness and the factors that influence them. Become aware of the prevalence of mental disorders and the impact they have on the individual, communities and society. Define; mental health and identify factors that promote a person's wellbeing. Have a beginning understanding of the incidence and prevalence of mental health problems. Explain the impact of social determinants on mental health and social and emotional wellbeing. f Identify the ‘cost’ of mental health on services, funding and in terms of disability (DALY’s). Describe the negative influence of misconceptions and discrimination (stigma and stereotyping) experienced by people with a mental health problem. Have an awareness of how nurses, midwives and others can positively influence mental health outcomes for service users, carers and communities.

Mental health and wellness ●

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Mental health is a psychological state where a person functions at a suitable level of emotional and behavioral stability and comprises the person's ability to enjoy life and balance life events and energies to achieve psychological equilibrium. WHO defines mental health as a “state of subjective wellbeing in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively, fruitfully and is able to make a contribution to their community”.

Factors that promote a person's wellbeing ● ● ● ● ● ● ● ●

Being healthy Having strong personal relationships Feeling safe Having an adequate living standard Having a sense of achievement and purpose Perceived security Feeling connected to the community Feeling secure in the future

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Mental health issues are problems of living rather than a consequence of a mysterious disease. Can impact on an person's ability to function, but are unlikely to meet criteria for diagnosis

Healthy mental health looks like ● ● ● ● ● ● ● ● ●

Sense/state of wellbeing, Form positive relationships Use one's abilities to reach their potential Enables people to fully enjoy & appreciate other people, day to day life & their environment Deal with life's’ challenges Can cope with the ‘normal’ stressors of life Work productively & fruitfully Make a contribution to their community Flexible & adaptive

Social determinants of mental health ● ● ●

WHO the social determinants of health are the conditions in which people are born, grow, work, live and age, and the wider set of forces and symptoms shaping the conditions of daily life. Health determinants include anything that contributes to the health of the population, including the effects of behaviours or risk to health. Understanding the determinants of health leads to greater mental health promotion, prevention and early intervention

The determinants of health Number of these areas certain groups are socially or economically disadvantaged or may experience health outcomes lower than population norms ● ● ● ● ●

housing & food activity, employment (income), education peace, social connectedness, justice, and equity stable & sustainable environments & resources

People experiencing mental challenges Terminology Consumer ●

more active role, having rights, responsibility & a more equitable relationship with the health care provider.

Patient ● ●

biomedical model, illness, passive role, recipient of care – not inclusive of care, disparity between the person, psychological & physical (interconnectedness of each area). People who have ‘experience of mental health challenges’, the person ‘living with mental illness’, is the best person able to describe their lived experience.

Incidence and prevalence of mental health problems Statistics Australian National Survey of Mental Health (2007) last survey by ABS ● ● ● ● ● ● ● ● ● ● ●

1 in 5 had a mental health problem within the preceding 12 months. Anxiety disorders (14%) the most common experienced = most frequently reported being PTSD (6%). Mood disorders were reported by 6% = depression the most common (4%). Substance use disorders (5%), harmful use of alcohol (reported by 35%). The comorbidity of both mental health & physical disorders, 11.7% of respondents had both a mental disorder and physical condition. People with comorbid conditions are more vulnerable to alcohol and other drug relapses and subsequently relapse of MH problems. Women 22% Men 18% Younger people were more likely to have a mental disorder than older people, 26% of people aged 16-24 had a disorder compared to 6% of people aged 75-85. 54% of those who have been homeless had a health problem (3x the rate than for non-homeless people).

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Unemployed (29%). Incarcerated (41%). Psychotic disorders (preceding 12 months) 4-5 people per 1000 population with schizophrenia (47%) majority males (56.3%). Australian Indigenous people have a higher rate of psychological distress and children and adults – higher hospitalisation than that for other Australians in all age groups (except 0-4) & above 65 years (AIHW, 2011).

The cost of mental health problems Australian context ● ● ● ● ● ●

The cost of mental ill-health in Australia each year was around $4,000 per person, or $60 billion in total (2016). Australian Institute of Health & Welfare (2019) 4.2 million people received mental health-related prescriptions in 2017-18. National recurrent expenditure on mental health-related services was estimated to be around $9.1 billion in 2016–17. $5.7 billion was spent on state/territory mental health services in 2016–17; ○ $2.6b on public hospital services; $2.1b on community services. $536 million was spent on specialized mental health services in private hospitals in 2016–17. Mental ill-health and suicide is, conservatively, in the order of $43 to $51 billion per year. ○ Additional to this is an approximately $130 billion cost associated with diminished health and reduced life expectancy for those living with mental ill-health.

Disability and mental health Disability in mental health refers to an individual's impairment in one or more important areas of functioning ● ● ● ● ●

Disability adjusted life years (or DALY’s) are a measure of the burden of ill health obtained by calculating potential life lost by virtue of being in a state of disability or poor health. 2020 - depression - one of the greatest health problems worldwide, second only to heart disease, with major impact on health services, productivity and economic growth (WHO, 2012). The impact of chronic disability (of mental illness) on an individual's life can be measured in days out of their normal / usual role. Mental health problems 3rd among Australian causes of DALYs (13%) of the total – after cancer (19%) & cardiovascular disease (16%) AIHW (2011). Mental health problems are predicted to rank first in 2030 (WHO, 2008).

Productivity commission MH draft report Mental health and wellbeing of Australia’s population, the prevention and early detection of mental illness, and treatment for those who have a diagnosed condition.

Inquiry ●

early help for people, improving experiences with MH care and beyond the health system, participation of people, education/work, reforming funding & commissioning services/supports.

Misconceptions about mental health problems Stigma is more than just a negative connotation, it invokes rejection, stereotyping and discrimination. It often involves inaccurate and hurtful representations of people who have mental illness.

Perpetuation of stigma ●

Community perceptions & attitudes

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Misinterpreted/misrepresented by the media

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Preconceived ideas by person diagnosed (fear of rejection, alienation)

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Dual vulnerability –Mental health stigma & racial stigma

Minimising stigma ●

Awareness

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Education self & others

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Language that is positive

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Facilitating social inclusivity practice and behave in an unbiased manner and to minimise stigma – not perpetuate

In summary ● ● ● ● ●

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Nurses and midwives have a responsibility to ensure that they are well informed regarding current statistics, trends, models and philosophies relating to all areas of mental health. Examine your own beliefs, values and perceptions in regard to mental health so as to practice and behave in an unbiased manner and to minimise stigma – not perpetuate it. Social determinants of health have a significant influence on the mental health and wellbeing of individuals and communities. The degree of disability associated with mental disorders influences a person's ability to function in all aspects of life. An appreciation of the prevalence of mental health problems and disorders assists nurses and midwives to understand the impact of mental disorders on the health outcomes of individuals, families, the health care system and the demand for and on community services. Mental health issues are not confined to patients in the hospital, there are many people in the community and in the workforce who struggle to cope with their day-to-day lives and this impacts on them.

NUM1207 1.2 Nursing in Mental Health – Then & Now Learning outcomes ● ● ● ● ● ●

Describe factors behind the changes of asylums to modern day contemporary care. Identify historical practices of early treatment for mental illness. Describe the history of asylums in Australia and the emergence of mental health nursing as a distinct profession within Australia. Identify the main changes to care from the late 18th century to a more humanistic perspective in modern day holistic mental health nursing. List and describe the different ‘terminologies’ applied to describe a person who may be in the nurse/midwife’s care. Explore the role and identity of the nurse in contemporary mental health service delivery.

Historical overview of MH ●

Custodians/attendants ‘of the asylum’

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Historical terms - ‘mad’, ‘insane’ and ‘lunatic’

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Supernatural origins of disease and illness ○

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14th century, witches, exorcisms & spirit possession

Ancient mental health care ○

The asylum ■

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institution where people with a MH condition were housed.

Institutionalisation ■

places of suffering, disease, distress and depravity.

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Notoriously inhumane places to reside.

‘Lunatic asylums’ ■

16th century, not places of healing, but locked penal colonies.

History of MH in Australia ●

1890- MH nursing emerged as a distinct profession with the increased medicalisation of mental health.

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Mid-late 20th century the identification of nursing as a profession emerged as a specialisation in the field of psychiatry.

The first legislation ●

1843 - Lunacy Act.

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1887 - First evidence of education for ‘mental nurses’ (Victorian annual report – Kew asylum (Victoria).

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1958 - Modern MH nursing education commenced in the mid 20th century – Victorian Nurse Act of 1958.

People experiencing mental challenges Terminology ●

Consumer = implies a more active role, person having rights, responsibility and a more equitable relationship with the health care provider.

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Patient = biomedical model, implication of illness, passive role – recipient of care, not inclusive of care.

People who have ‘experience of mental health challenges’, the person ‘living with mental illness’ is the person best able to describe their lived experience.

Treatments throughout history Historical treatments ●

Trephination (8000BCE to 600 BCE) drilling of a small hole into the skull.

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Straight jacket (1700’s) confining garment where the patient's arms were strapped securely across their body.

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Shock treatments (1920’s -1950’s) (insulin, fever, medicine) insulin in large doses was given over a period of weeks resulting in a coma.

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Lobotomy (1935) surgical intervention that severs the pathways between frontal lobes and lower regions of the brain.

Changes to care ●

The late 18th century saw conditions begin to improve in many asylums, fresh air and interaction - more humane treatments.

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Talk therapies were developed in an effort to explore an individual's past experiences and consider the impact of these on their current MH problem.

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Mid 20th century (1950’s) psychotropic medication resulted in a revolution in both the treatment and care of people with mental health conditions.

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Psychiatry experienced changes in credibility and further interest in psychiatry as a nursing specialty.

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Late 1980’s deinstitutionalisation of people from facilities.

The role of the nurse & midwife In contemporary service delivery ●

Nurses and midwives will work with people living with mental illness - in diverse contexts and varying roles.

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Comprehensively trained nurses and midwives will increasingly carry out their work from a; ○

biomedical and interpersonal framework;

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applying the biopsychosocial approach (person holistically).

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Holistic interpersonal approach which views the relationship that develops between the nurse and consumer as the central feature of MH nursing.

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The needs of the consumer and support given is based on the identified needs of the person through collaboration and partnership.

In summary ● ●

Asylums were established in response to an increasing need to contain and segregate people with mental illness rather than treat them. Treatment & care was often barbaric, detrimental to recovery and lead to increased suffering.

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The history of mental health nursing in Australia is linked to psychiatry as a discipline. Early treatments were predominantly from a medicalised approach. Changes to mental health and education in this area has coincided with more understanding around the complexities and nature of mental disorders which has led to improved assessments, care, treatments and a recovery focused practice. As nurses and midwives of the future, practice should continue to be evidenced based, compassionate and of a holistic and person-centered nature. Working from a humanistic and holistic values base is the foundation for work in nursing & particularly mental health in modern day practice.

NUM1207 Module 1.3 Theoretical Frameworks Underpinning Mental Health Practice Learning outcomes ● ● ● ● ● ● ●

Describe and critique the biomedical psychological and sociological theories of personality and behaviour. Specific developmental issues at different stages of the life span - how they may intersect Describe the humanistic orientation to mental health and relevance to nursing/midwifery practice. Outline nursing conceptual models (including Peplau’s model) that can be utilised for nursing care within the mental health setting. Develop an understanding of mental health and illness from a theoretical perspective. Describe the relationship of psychological and sociological theories and concepts to mental health problems across the life span approach. Describe the application of (bio, psych, social, humanistic) theories to practice in nursing and midwifery care.

Introduction ●

Foundation for understanding mental health problems and psychopathology within the context of normal human development.

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Specific developmental issues at different stages of the life span - how they may intersect with mental health and in the development of disorders or in response to adverse/negative situations, events, trauma.

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Nature v nurture may lead to a ‘hiccup’ in processes and functioning from an early age.

Major viewpoints of personality development or an explanation of human behavior ? 1. Biomedical 2. Psychodynamic 3. The behavioral/social cognitive orientation

Theories of personality 1. Biomedical model: a. Result of maintaining an internal psychological equilibrium or balance. b. ‘Normal’ behaviour represents balance and abnormal behaviour represents dysfunction.

2. Psychodynamic: (Freud) a. Abnormal behaviour reflects unconscious conflicts within the person. b. Mental processes and mechanisms may be unhealthy to the person and/or ineffective and become maladaptive or result in mental or emotional dysfunction.

3. The behavioral/social cognitive orientation a. Personality is determined by prior learning. Stresses the importance of how the environment or persons social structure can shape behaviours. (Pavlov, Watson, Skinner, Bandura)

The humanistic orientation ● ●

Approach emphasises the importance of free will and self determination. Positive role of emotions such as joy, love and hope in coping with life's problems.

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People possess an innate capacity to develop and grow. Person orientated view where the personal consumer cannot be reduced into components of their parts. Sees the person in a holistic sense and the individual as unique in their humanness.

Theorists: Carl Rogers & Abraham Maslow

Relevance to nursing & midwifery practice ● ●

importance of the therapeutic relationship – education and practice. concepts such as unconditional positive regard and empathy are central to a person centred focus of practice.

NUM1207 Module 1.4 Mental Health Promotion, Prevention & Primary Health Care Learning outcomes ● ● ● ● ● ● ● ● ● ●

Outline the difference between mental illness, mental disorder and mental health problems. Describe the impact of mental illness on the individual, family, society. Define mental health promotion; and describe the relationship between prevention, promotion, early intervention and primary health care. Examine the key priorities for the action, prevention and promotion of mental health in the community. Describe the determinants of mental health and wellbeing and the biopsychosocial approach/model of mental health care. Differentiate between protective factors, risk factors and the stress-vulnerability model that may impact on a person's mental health and wellbeing. Describe the role of mental health promotion and illness prevention in the MH context. Acknowledge the importance of early intervention in preventing and minimising the onset of mental illness and /or reducing its impact (highlight ways to promote mental health). Describe the role of the nurse and midwife in the delivery of mental health care in primary health care services. Identify services accessible to people living with mental health challenges in the primary health care area.

Introduction ●

Previous focus on mental health promotion was at a population, community and individual level.

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Focus led to the development on key mental health services with a focus on: ○

mental health promotion

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illness prevention

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recovery

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primary mental health care

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Many factors can impact on mental health and wellbeing, these are out of reach of MH services specifically (employment, housing, education, social inclusion).

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Multidisciplinary and multi-level approach needed.

Mental Illness, disorder or problem? Mental Illness ●

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A person has a mental illness if the person has a condition that: ○

is characterised by a disturbance of thought, mood, volition, perception, orientation or memory and;

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significantly impairs (temporarily or permanently) the person’s judgment or behaviour. Mental disorder comprises a broad range of problems, with different symptoms.

However, they are generally characterized by some combination of abnormal thoughts, emotions, behaviour and relationships with others.

1. Exaggeration of feelings, thoughts and behaviours 2. Lose touch with what’s going on around them 3. Thoughts and feelings become disturbed

4. Unable to sort out what’s real and what’s not 5. Inability to effectively function in everyday tasks

Mental disorder A broad range of problems, with different symptoms characterized by some combination of abnormal thoughts, emotions, behaviour and relationships with others.

Mental health problem

The impact of mental illness ●

Individual, families, friends, communities & society ○

By the time the person deteriorates to the stage where mental health services such as acute inpatient care are required, the person is likely to have already experienced impaired functioning in many areas of their life.

The illness is likely to impact on: ●

Relationships (family and friend)

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Inability to get/keep a job (loss of income) or study

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Isolation, discrimination & alienation

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Self neglect, loss of self esteem, self worth

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Related physical illness

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May lead to crime

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Issues relating to substance misuse

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Homelessness

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Loss of life due to suicide

Future development of mental health services The Roadmap for National Mental Health Reform 2012-2022

Priority areas 1. Promote person-centred approaches 2. Improve the mental health and social and emotional wellbeing of all Australians 3. Prevent mental illness 4. Focus on early detection and intervention 5. Improve access to high-quality services and support 6. Improve the social and economic participation of people with mental illness

An introduction to mental health promotion MH promotion aim is to: ●

promote positive mental health by increasing psychological well being,

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building individual resilience and creating supportive environments.

MH prevention aim is to: ●

reduce symptoms and mental disorders through early identification and Intervention.

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Strategies target the determinants of health which are influenced by; bio-psycho-social, risk and protective factors.

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Primary care services are frequently first point of contact for people with mental illness.

Risk factors that can contribute to mental illness Individual ● ● ● ● ● ● ●

Cognitive patterns(constant negative thoughts, grief, feelings of guilt, poor self esteem) Chronic illness Genetic loading for illness Biochemistry Substance misuse Poor social skills and identify Insecure attachment in infancy

Family ● ● ● ● ● ●

Violence (in family & culture) Family breakdown Low parental involvement Neglect and rejection Mental disorder inpatient Harsh discipline

Life events ● ● ● ● ● ● ● ● ●

Physical/sexualabuse Divorce in parents Poverty Homelessness Stress(acute/prolonged) Diagnosis of a chronic physical condition/illness Bullying Death of a close family member Traumatic event

Community ● ● ● ● ● ●

Living in disadvantaged community Social isolation Neighbourhood Violence Discrimination Loss of social/cultural identity Lack of access to health care services,Transport

Protective factors Assist the person to maintain emotional & social wellbeing, & to cope with life.

Individual ● ● ● ● ●

Positive sense of self Good coping and problem solving skills Strong family relationships and attachment to family Self regulation and awareness Social skills (communicate or interact with others)

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Optimism (hope) Autonomy Family (stable unit & support) Safe & secure environment

Life events ● ● ●

Economic security Good physical health Support systems at times ofcrisis/stress/criticalperiods in life

Community ● ● ● ● ● ● ●

Social inclusion A sense of connectedness/belonging Access to economic resources Access to care Strong cultural identity Link to community networks/groups (and participation in those groups) Spiritual/faith/beliefs

The Stress-Vulnerability Model (Zubin 1977) Risk factors Biological ● ● ● ● ●

Family history Genetic factors Substance misuse Noncompliance meds / treatment Physical illness

Psychological ● ● ● ●

Poor social skills Poor coping skills, Communication probs. Previous learning Hx

Social ● ● ● ● ● ●

Major Life Events Family Conflict Neg Relationships Isolation Home Unemployment

Protective factors Biological ● ● ●

Compliance with meds, reduce substance use Good physical health No family Hx of mental illness

Psychological ● ● ● ●

Adaptation Resilience Coping skills Sense of self

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Early warning signs Good comm’n skills

Social ● ● ● ●

Family /social network support Employment Future goals Seek help if needed

To promote & maintain positive mental health WHO definition of health promotion states that “health is a complete state of physical, mental and social well-being and not merely the absence of disease or infirmity”. ● ● ● ● ● ● ● ● ●

Talk about or express your feelings Exercise regularly Eat healthy meals Get enough sleep Spend time with friends and loved ones Develop new skills Relax and enjoy your hobbies Set realistic goals Talk to your GP or a health professional

Promotion of mental health: in Australia The Fifth National Mental Health and Suicide Prevention Plan for 2017 -2022

8 targeted priority areas: 1. 2. 3. 4. 5. 6. 7. 8.

Integrated regional planning & service delivery of mental health services Suicide prevention Coordinated treatment for people with severe and complex mental illness Mental health and suicide prevention for Aboriginal & Torres Strait Islander peoples Improving physical health and reducing mortality Stigma reduction and discrimination Safety and quality central to mental health service delivery

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Promotion of mental health occurs within the social, economic, emotional and cognitive domains.

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Up skilling of the mental health workforce & increased intersectional collaborative approach to care is also key in supporting these goals.

The Ottawa Charter 1986 1. Building public policies that support health: a. policy makers are to be aware of and responsible for the health consequences of their decisions.

2. Creating supportive healthy living environments: a. a socio-ecological approach to health should ensure a positive benefit to health while protecting the natural and built environments.

3. Strengthening community action: a. this requires empowerment of communities, giving ownership and control of their destinies.

4. Assisting people to develop personal skills: a. this means informing and educating individuals in health to enhance life skills, permitting them control to make choices conducive to good health.

5. Reorienting health-care services: a. means sharing of responsibility for health promotionnamong individuals, community groups, health professionals and service providers.

Mental illness prevention Mental disorder prevention has at its target the reduction of symptoms and ultimately of mental disorders. It uses mental health promotion strategies as one of the means to achieve these goals (WHO 2004, p.7).

Mental disorder prevention aims at: ● ● ● ●

Reducing incidence, prevalence recurrence of mental disorders Reducing the time spent with symptoms or risks for mental illness Preventing or delaying recurrences Decreasing the impact of illness in person, family, society

Interventions and nursing & midwifery care Early intervention ● ●

early treatment to prevent development of more chronic form of the disorder. reduce the duration of disability associated with a mental health condition.

Primary intervention (before onset the onset of the illness) ● ● ●

prevent the number of new cases. minimising the incidence of disorders. whole community, at risk groups, and individuals.

Secondary intervention (during an episode of illness) ●

Reduce prevalence of disorders through early intervention and effective treatment.

Tertiary intervention (following an episode of illness) ● ● ●

burden of illness on an individuals life and overall functioning. reduce the impact of mental, illness. rehabilitation and relapse preventions strategies.

Primary health care and mental health ● ●

Focus is supporting people in their communities rather than hospitals Key provider of both mental health care and physical care for people living with mental illness ○ Secondary services include those provided through acute inpatient units and hospitals ○ Tertiary services include community and residential rehabilitation

Integrating mental health services into primary health care & the role of the nurse and midwife ○ ○ ○ ○

Mental illness frequently present with comorbid physical health problems Attention to the physical health problems that co-occur Nurses and the MDT are more accessible through generalist services and can address the complex needs of the consumer. Range of services, interventions, needs across an integrated and holistic system of care with a holistic/biopsychosocial approach.

In summary ● ●

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The role of the nurse and midwife in the early identification, intervention and referral of mental health issues in any clinical setting is paramount. Mental health promotion encompasses biopsychosocial and spiritual dimensions across the lifespan and as such; primary healthcare principles applied to nursing and midwifery practice facilitate a holistic consumer focused approach. Many services are needed to support the multifactorial issues that impact people living with mental illness and a MDT team approach is key. MH and wellness goes beyond the disease process (mental illness) and encompasses a persons life. Early identification and intervention strategies (and accurate assessments) are key to minimising the incidence and prevalence of disorders leading to chronic conditions. Health promotion and prevention strategies target the determinants of health which are influenced by risk and protective factors. Primary health care approach acknowledges that the absence of mental illness does not mean the presence of mental health and wellbeing.

NUM1207 Module 1.5 Recovery as the context for practice Learning outcomes ● ● ● ● ● ● ● ●

Describe what is meant by the term ‘recovery’ in mental health care. Identify the key differences in the way nurses conceptualise their role and their practice between the recovery and medical model paradigms. Describe the principles of recovery informed practice and the importance of hope and optimism in recovery. Explain the rationale for the shift in MH to the recovery paradigm, which values the primary role of expert knowledge that comes fro the lived experience of severe mental health distress. Describe the applicability of resilience, recovery, and reconnection to the clinical practice setting and identify the skills & attitudes that you will require in facilitating these concepts with clients in your care. Outline the concept of therapeutic optimism & the role of the nurse and midwife in supporting the consumer. Identify the key components of the model for individual resilience and link to the biopsychosocial model of MH assessment. Outline the key concepts, features & principals of recovery-orientated mental health practice and trauma informed care.

An introduction to recovery informed practice Recovery is ‘being able to create and live a meaningful and contributing life in a community of choice with or without the presence of mental health issues’ (The National Framework for Recovery-Oriented Mental Health services) ●

Recovery is about well-being & quality of life, the focus on positive engagement & activities.

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The recovery process happens outside of treatment services & is a personal & ongoing journey.

Common recovery process characteristics: 1. 2. 3. 4. 5.

Connectedness Hope Identity Meaning Empowerment

Recovery as a personal journey ●

Paramount that the person's unique personal journey drives the care, service provision and service structures they need.

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Recovery is a process to grow beyond any distress that interrupts the balance of daily life.

A consumers perspective ● ● ● ● ● ●

gaining and retaining hope understanding of ones abilities & disabilities engagement in an active life personal autonomy & empowerment social identity & connection meaning and purpose in life

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a positive sense of self

Recovery paradigm Overarching principles in recovery = hope and optimism Key features and goal include: ● ● ● ● ●

self determination personal agency (self efficacy) social inclusion and connectedness choice in a range of services Valuing the person’s imperatives rather than the clinical imperatives their active participation in society

Recovery framework Is a model for health care services to promote the health and well being and self-efficacy of mental health patients. The purpose; ●

to ensure that mental health services are being delivered in a way that supports the recovery of mental health consumers.

What recovery is NOT Recovery is not rehabilitation ● ●

services and technologies that are made for the person to learn to adapt to their new worlds. lived or real experience of persons as they accept and overcome the challenge of that disability (condition that limits a person's movements, senses, or activities).

Recovery is not cure ● ● ●

be in recovery and still have the experience of mental distress. MH challenges are transformative in nature and challenge peoples concepts of ‘normality’. ongoing process, so timeframes challenge the notion of ‘cure’.

Working in a recovery framework for nurses & midwives Biomedical approach (Traditional practice) ● ● ● ● ● ● ● ●

A linear process of illness and wellness Focus on treatment & medication management Spirituality & meaning are not viewed as important. Personal stories and experience not the focus of care Relapse is viewed as a failure The experience of mental illness is a negative one. The nature of mental illness is predetermined Recovery –active involvement of others Relinquishing roles & responsibilities is accepted Recovery is the end point of the process

Recovery informed practice (Person-centred approach) ● ●

Person is central Focus on meaningful relationships & leading an ‘ordinary life’

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Spirituality is important in developing meaning & understanding The experience of recovery from a mental illness is an individual & unique process Maintaining roles & responsibilities is promoted Promotes self directed care A cyclical process of trying & trying again. ○ Relapse is viewed as an opportunity for growth & learning Timeframes meaningless-ongoing process

Principles of recovery-orientated mental health practice From the National Standards for Mental Health Services

1. Uniqueness of the individual: a. Opportunities for choices and living a meaningful, satisfying, purposeful life.

2. Real choices: a. Empowers own choices on how lives are led. Build strengths,take responsibility for your own life.

3. Attitudes and rights: a. Listening, learning from, acting upon communications from individuals and carers. Human rights.

4. Dignity & respect: a. Courteous, respectful and honest in all interactions. b. Sensitivity and respect for each individual. c. Challenges stigma & discrimination.

5. Partnership and communication: a. Each individual is the expert on their own life. Work in a positive & realistic way which encourages their hopes & goals.

6. Evaluating recovery: a. Ongoing evaluation, track own progress, involve & inform quality improvement activities with MH services.

Recovery Informed Practice Guiding the nurse and midwife in recovery informed practice

How the nurse and midwife can promote; ● ● ● ● ● ●

Keep hope alive even if the person has lost sight of it. Therapeutic optimism refers to the clinicians expectation of a positive outcome for the consumer. Promote self-efficacy in the consumer’s capacity to recover from illness, set realistic goals & overcome obstacles. Self determination to maximise the person's autonomy, informed decisions and make sure they are involved in decisions concerning them. Personal agency is intrinsically motivated, fundamental in the belief to succeed, draws on strengths and a sense of overcoming adversity. What do they need? Want? Not needed or not wanted?

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Relationships are critical from a place of empathy, compassion and genuineness. Validation

Trauma informed care Imperative for nurses and midwives to be sensitive to the vulnerabilities and potential triggers that may give rise to traumatisation and be aware that this could impede recovery.

The essentials for trauma informed care are; ● ● ● ● ● ●

‘Universal precaution’ approach that assumes that all people who seek mental health care may have experienced trauma Feel safe, ensuring a calm environment trauma and abuse may have shaped difficulties in relationships and impact on therapeutic relationships, Avoid coercive interventions Maintain the dignity and individual rights of the person at all times Develop an understanding of presenting behavior and symptoms in the context of past experiences Ask questions

Understanding ‘individual’ recovery ● Understand their story ● Validation ○

everyone wants to be heard and understood,acknowledge them as a person and an individual, they are a sum of their experiences, the highs and lows and history,don’t just see the illness

● See the person

In summary ● ●

● ● ● ● ●

Recovery from mental illness is not achieved in isolation, but in partnership with health care services. Recovery, reconnection & therapeutic optimism adopted in mental health and other clinical settings should facilitate resilience & adopt a recovery-focused approach. Nurses have the capacity to positively influence outcomes for people with mental illness/disorders. Positive outcomes can be directly related to the quality of nurse skills & knowledge. Recovery models provide a therapeutic and comprehensive framework across a spectrum of mental health settings. The constructs of recovery orientated frameworks & principles have philosophical underpinnings that are consistent with global patterns of mental health care. Consider a person's experiences, vulnerabilities and potential triggers due to past experiences (and potential trauma) that may impede engagement and recovery. Be compassionate in your approach and care – see the person as a sum of their experiences.

NUM2307 Module 2.1 Mental Health Nursing as a Therapeutic Process The Provision of Holistic Care Outcomes ● ● ● ● ● ● ● ● ● ●

Describe the context of holistic nursing in contemporary nursing and midwifery care. Identify the key elements in the biopsychosocial model of care. Describe how the biopsychosocial approach can and should be applied in all clinical contexts (not just mental health). Describe the biomedical model and compare to the biopsychosocial approach. Understand the role of the nurse and midwife in the treatment and care of people with mental illness from bio-psycho-social (holistic) perspective. Discuss the benefits of a holistic approach in (all) clinical contexts/settings. Identify issues/challenges a person might present with (related to biological, psychological, social) considerations. Identify potential consequences of psychological conditions being unrecognised. Understand the concept and benefits of the multidisciplinary team, and the various collaborative approaches to care. Discuss key settings and models of care for optimal consumer outcomes.

Holistic care ● ●

The focus of nursing and midwifery and its relationship to holistic care The term holistic can be defined as “an approach to patient care in which physical, mental and social factors in the patient's condition are taken into account, rather than just the diagnosed disease”.

Basic assumptions - the person 1. always responds as a unified whole; 2. as a whole is different from, and more then the sum of their parts.

NMBA Registered nurses standards for practice standard 4: Comprehensively conducts assessments RNs accurately conduct comprehensive and systematic assessments. They analyse information and data and communicate outcomes as the basis for practice. The RN:

● 4.1 conducts assessments that are holistic as well as culturally appropriate ● 4.2 uses a range of assessment techniques to systematically collect relevant and accurate information and data to inform practice ● 4.3 works in partnership to determine factors that affect, or potentially affect, the health and well being of people and populations to determine priorities for action and/or for referral, and ● 4.4 assesses the resources available to inform planning.

The biomedical model is ● ● ● ●

predominantly used in tertiary health care settings / general hospitals. model values things than can be seen, measured and quantified, and this approach in regard Understanding mental illness provides barriers to such an approach. disease-treat-cure focus.

Biopsychosocial model of care Holistic nursing is generally defined as all nursing practice that has healing the whole person as its goal. “Mind-body-spirit-emotion-environment” (Spirit)

Biological ● ● ● ●

(physical/medical) medications genetics illness

Psychological ● ● ● ●

(mind/ psychology) thoughts, feelings emotions therapies

Social ● ● ● ● ● ● ●

(sociology) relationships family work/education

The model ensures that the client has the best opportunity to recover. considered best practice and forms the reason for the development of the multidisciplinary team. With most presentations, when you explore, there are biological, psychological and social factors that contribute to causation.

Holistic assessment and history Holistic assessment measures the persons functioning in the following domains;

● ● ● ● ● ● ●

Physical Cultural Spiritual Mental and emotional Developmental and functional Family Social/environmental

Gathers all the information about a person’s world ● Internal ○ thoughts ○ feelings ○ physical health ● Person centred ● External ○ family ○ physical world ○ social relationships Biopsychosocial model of care can identify elements critical to the person’s physical, psychological health and safety as well as therapeutic elements which aid in assessment including;

● ● ●

personal autonomy, identifying risk, enabling referral whilst detailing clear rationale for interventions (actions) to take. ○ Consumer is the centre of this model and approach.

Unrecognised psychological conditions ● ● ● ● ● ● ●

Decreased quality of life and overall well being - for the person and potentially their family/caregivers/guardians. Physical recovery may be affected. Longer inpatient stay in hospital that may lead to further physical investigations or complications. Societal/funding implication – cost implications and associated treatments – bed availability. Social isolation. Potential impacts on employment, financial burdens as a result (consider the external stressors) on mental health. Severity of mental health problems can be increased.

The context of care ● ● ● ● ●

Mental health in the general hospital People referred /or admitted to a general hospital may have psychological disorders or MH problems in addition to the physical disorders that prompted their original referral or admission. Physical focus. Make time to talk with the person about their emotional and psychological response. Reaction is unique and influenced by a variety of factors, related to their illness or injury, personal characteristics. Necessary to assess each person as an individual and wherever possible discuss with them options for further care and treatment.

Statistics ● ● ● ●

4.8% of ED presentations in public hospitals in WA were MH related (2017-2018) ABS. 2017-18, one in five (20.1%) or 4.8 million Australians had a mental or behavioural condition. 2017-18, 3.2 million Australians (13.1%) had an anxiety-related condition. ○ This was an increase from 2014-15 when 2.6 million people (or 11.2%) had such a condition. Just over one in ten people (10.4%) had depression or feelings of depression in 2017-18.

Factors to consider in assessment, care & referral on presentation ● ● ● ● ● ● ● ● ● ● ●

Suicidal ideation and suicide Poor emotional regulation (anger, outbursts, violence) Non-suicidal self injury (self-harm) Drugs and/or alcohol Sexual abuse or assault (trauma –recent/historical) Psychiatric Illness (including personality disturbances) Homelessness and/or parental abandonment Physical Illness/chronic disease (comorbid illness) Interpersonal conflict, domestic violence Sexuality Legal issues/forensics (criminal justice system)

Cause > Effect > Illness

The clinical context Clinical role of nurse and midwife to assess consumers’ mental health needs & offer therapeutic support ● Mental health hospitals inpatient unit ● Outpatient community mental health ● Child/adolescent mental health services (CAMHS)

● ● ● ● ● ● ● ● ●

Aged persons’ mental health services Forensic services Drug and Alcohol specialist services Emergency departments Acute tertiary hospital settings Emergency team responses, crisis assessment & treatment teams Specialty services for consumers (eating disorders, postpartum difficulties) General practice surgeries (primary care) Policy and/or executive

Collaborative approaches to care The multidisciplinary team can be defined “as a group of health care professionals who contribute to the planning and management of an individual's health care needs through their different areas of expertise”.

Team nurses (registered & enrolled) midwives, nurse practitioners, registered mental health nurses, medical team, psychiatrist, psychologist, social worker, occupational therapist, pharmacist.

Aim/goal ● ● ● ●

The focus being the whole person centered approach to facilitate better outcomes for the consumer. The team should therefore have a shared purpose and goal with the consumer (or patient) as the central focus of care. Important to foster trust and respect of each team member and each has a role/ part to play in assessment, care, treatment and recovery. The consumer is an integral part of the team being an active participant in their care.

Settings and models for care For optimal consumer outcomes Therapeutic milieu ● ● ● ● ● ●

Safety Organised structure Support Collaboration Validation Managing symptoms

Team work ● ● ● ●

Multidisciplinary approach Optimises options Unique & complementary skills Case management

Scope of practice ● ●

Boundaries of responsibility & accountability Negotiation of care delivery

In summary ● ● ●

Know your own values and beliefs and find a central philosophy of working with people as this can help you understand others. Usually the presentation of mental health issues has a background, don’t underestimate the power of that history. The therapeutic alliance begins the process of engagement and therapeutic rapport with clients and hence taking the time to ‘understand’ an persons’ world and the impact of such will assist in person-centered care and best practice treatment approaches.

● ● ● ● ● ●

The biopsychosocial model in mental health assessment is key in ‘holistic’ nursing care and looks at the personal world ‘as a whole’. Key concepts during the history taking will assist in gathering comprehensive information that will build on information gathered in objective assessments and hence referrals. Working from a humanistic and holistic values base is the foundation for work in nursing & particularly MH. The multidisciplinary team is the basis for person-centred holistic care – it aims to care for, manage, support, refer and assist in times of assessments, need and recovery. Ask for help ! Nurses and Midwives do not work in isolation – central and integral to the team.

NUM2307 Module 2.2 Mental Health Nursing as a Therapeutic Process Interpersonal Skills and Therapeutic Communication in the Context of Practice Outcomes ● ● ● ●

Identify the general working principles to engaging with consumers’ with mental health challenges and mental disorders. Describe therapeutic skills in the assessment process including core elements of the communication process. Identify communication(s) and documentation used to enhance optimal consumer outcomes. Identify issues that may compromise (barriers to) engagement and outline how these can effect the therapeutic relationship.

Introduction Human interaction & attachment ● ● ●

Early engagement and subsequent attachment forms the basis for a trusting, secure and healthy relationship with another person. Such commitment to the patients and consumers requires a range of interpersonal and communication skills which also include being present, the therapeutic use of self. Emotional objectivity, self awareness, critical thinking, empathy and emotional intelligence.

As a nurse or midwife we need to be able to read the signs and signals others give ● Understand both verbal and body language that is exhibited by others = importance of observation / assessment and asking.

The effective nurse/midwife Communication skills in the assessment process ● ● ● ● ●

MH nursing requires a fusion of professional knowledge, clinical and interpersonal skills and experience. Nurse as a therapeutic tool to gather information. Aims to assist the person feel at ease. Verbal & non-verbal skills. Minimise jargon, & use of medical terminology.

Building rapport Setting ●

The environment, conducting an interview/assessment

Presentation of self ●

Power imbalance, communication style

Solution based focus ●

Best practice, person centred care

Core elements of the communication process Therapeutic engagement ●

Process based on genuine interest in understanding who the person is and how they have come to be in the current situation.

How do you begin to engage with your patient/consumer? ● break the ice ● appropriate environment ● let them talk ... or give space (after a risk assessment) ● interview alone/ pairs (depending on risk) ● listen, show empathy and validate what they are saying (acknowledge their experiences) ● observation skills ● set clear boundaries All the above = start gathering valuable information to help you formulate a hypothesis on what is wrong with them and consequently formulate a plan of care in conjunction with the MDT.

The communication process General working principles to achieve positive outcomes

Principles ● ● ● ● ● ● ● ● ● ●

Empowerment Genuineness Positive validation Positive modelling Rapport building Honesty Need for flexibility Empathy versus sympathy Confidentiality vs. duty of care Environmental factors

Person ‘unwell’ may present: ● ● ● ●

Less likely to talk openly – symptom of disorder Insight maybe poor Unwilling to be there (MH Act) - involuntarily patients Harder to motivate to change - co-morbidities (substance misuse/dependence)

Barriers to engagement From consumer perspective ● ● ● ● ● ● ●

low levels of mental health literacy distrust stigma long waiting lists poor accessibility marginalised groups comorbidity with substance abuse

From nurse/midwife perspective ● ● ● ●

time constraints personal discomfort Knowledge/skills deficit Lacking empathy, clinician perpetuated stigma/labelling/judgement

RESULT ● ● ● ● ●

Impact on care Treatment not implemented Consumer may not access services again Further clinical deterioration Potential loss of life

The communication process Documentation Document findings, assessments, investigations – in a timely systematic manner to ensure; ● client safety ● forms a baseline for treatment interventions ● adherence to legal & professional standards ● promotion of continuity of care within the multidisciplinary team & optimal client outcomes

In summary ● ● ● ● ● ● ●

Develop skills to promote the therapeutic alliance that will assist in engaging, and building trust and rapport with your patients, consumers and families. Consider personal and professional values to recognise the person as more than just their diagnosis. Barriers to engagement may come from the patient or clinician – be self aware, show openness and unconditional positive regard for all. Understand the person who is unwell/challenged may not engage /be open due to the nature of their disorder – knowledge of disorders will assist in determining your approach. The result of barriers to communication and hence not building the therapeutic alliance can impact on patient care, recovery and engagement with health services in the future. Nurse/midwife as a therapeutic tool to gather information through the process of communication and creating an environment that is conducive to engagement and information gathering. Documentation is a legal responsibility !

NUM2307 Module 2.3 Mental Health Nursing as a Therapeutic Process The Therapeutic Relationship Outcomes ● ● ● ● ● ● ● ●

Describe the therapeutic relationship and its benefits for promoting person-centred care. Identify concepts and issues that are fundamental to effective and safe practice. Identify the general working principles to engage with consumers’ with mental health challenges and mental disorders. Identify issues that may compromise (barriers to) engagement. Describe caring and its challenges and ways in which to manage those challenges. Analyse how resistance, transference, countertransference, and personal values can have and adverse impact on care. Explain the importance of maintaining professional boundaries. Acknowledge the value and importance of the National Practice Standards for the Mental Health Workforce 2013, and the role they play on practice and person-centred care.

The therapeutic relationship A strong therapeutic relationship or alliance with the client enhances treatment outcomes and facilitates shared understanding of the situation, while identifying strengths and potential barriers to treatment ● Central activity of nursing and midwifery practice. ● Provides a healing connection through care, the interpersonal processes and approach that uses ‘self’ as a means of developing and sustaining the nurse-client relationship.

One-to-one relationship between nurse/midwife and the consumer 1. Mutually defined 2. Collaborative= work together & refer to others 3. Goal-orientated/directe a. physical, b. social, c. emotional, d. therapeutic goals 4. Set of sequential interactions over a period of time

Principles of engaging: goals of discussion ● ●

Make the distressed person feel safe and supported – validate their feelings. Gather enough information from the patient (& family) through the assessment process to provide appropriate interventions and care management.

Nursing & midwifery essentials Personal & professional values ● ● ● ● ● ●

Respect Working alliance Safe Environment Person-centred approach Multidisciplinary team Compassionate care

The nurse/midwife-patient relationship Concepts and issues that are fundamental to effective and safe practice

Compassion ●

underpins concepts of acceptance, a non-judgemental attitude, awareness, being present and listening.

Caring ●

context –specific practice’, interpersonal processes and sensitivity, characterised by expert nursing practice and a working environment that is conducive to caring. ○ “Caring combines both attitudes with action in the ‘nurses’ commitment to maintaining a person’s dignity & integrity. Nursing care is determined by the way the nurse is able to use knowledge & skills to appreciate the uniqueness of the consumer”

Therapeutic ‘potential’ in caring ● ● ● ● ●

Clear communication Emotional intelligence Empathy & trust Cultural sensitivity Promote consumer autonomy

Caring and the compassionate nurse and midwife Concepts and issues that are fundamental to effective and safe practice

● Hope & spirituality ○

inclusive of optimism and looking to the future, strength through belief and its relationship to health, wellbeing and recovery from illness or traumatic life events. Link to emotional healing and better adaptation to life stress.

● Therapeutic optimism ○

can make a difference and a belief that the patient or clients can recover.

● The therapeutic alliance ○

= value forming a strong, therapeutic, continued alliance has been linked to reduction in admission rates and improved QOL for patients discharged from hospital and in the enhancement of rehabilitation outcomes.

Therapeutic use of self ● ●

Engagement is a central principle to all mental health interventions. Allows for comprehensive and accurate assessment/information gathering that then informs.

Therapeutic use of self ●

personality, experience, knowledge of mental health and illness, life skills as a way of promoting, developing and sustaining the therapeutic relationship with consumers.

Purpose ●

establish a therapeutic alliance, develop dialogue in order to understand the situation, feels safe to disclose. Genuine way of conveying interest and concern.

Simple rules (skills) for engagement Skills assist in therapeutic engagement by providing a safe & consistent approach to service delivery ● ● ● ●

Treat any consumer with respect & build trust Be genuine in your interactions Remember your role & professional boundaries & standards Show empathy & unconditional acceptance

The nurse/midwife-patient relationship Concepts and issues that are fundamental to effective and safe practice

Key characteristics courtesy, kindness, honesty, compassion, respect for others, unconditional acceptance, accepting patients as people (not their diagnosis/illness or presentation).

1. Empathy a. intentional actions that are aimed at reducing the person's distress- make a conscious attempt to discuss with the person their current and past experiences and the feelings and meaning associated with their experiences.

2. Reflection a. The ability to reflect this is a process of critically reviewing experience from practice so that it may be used to inform and change future practice in a positive way.

3. Self-awareness a. The process of understanding others begins with understanding the self.

Phenomena occurring in relationships Professional boundaries invisible yet powerful lines that mark the territory of the nurse and midwife. They define a role and allow the nurse to say “this is what I do, this is the purpose of my presence here”.

Resistance ● ●

Disruption to smooth flow of feelings, memories, thoughts. Person may be struggling against change

Transference ● ●

Is concerned with transferring points of view in the form of personal attitudes between key relationships Feelings are often directed towards the nurse as well as others in the environment

Countertransference ● ●

Is the response of the nurse to the patient; these feelings can be positive or negative Potential for damage

●

Deterioration of therapeutic relationship

Caring and its challenges ● ● ● ● ●

If rapport/therapeutic relationship not built = implications in consumer outcomes. Caring for another requires ‘emotional labour’ = burnout, trauma, settings/patients. Challenges to people's health – work setting over time/relationships ‘emotionally charged’. Conflict of legislative requirements related to treatment & constraints of medical model. Stigma attached to mental illness & association of perceived view of working in MH setting.

Managing the challenges Role & responsibilities ●

Duty of care, scope of practice, professional boundaries

Confidentiality & safety ● ●

Clarify limits, explain reasons for information sharing Don’t make promises

Guidance & referral ●

Support & advice, consultation & referral to MDT

National Practice Standards for the Mental Health Workforce 2013 All care delivered by nurses (and health professionals) need to be generated from values such as respect and concern for each person and their experience

Practice essentials 1. Rights, responsibilities, safety and privacy. 2. Working with people, families & carers in recovery-focused ways. 3. Meeting diverse needs: social, cultural, linguistic, spiritual, gender diversity. 4. Working with Aboriginal, Torres Strait Islander people, families & communities 5. Access: facilitate timely access to quality evidence based assessment. 6. Individual planning: facilitate support care planning. 7. Treatment & support: informed interventions. 8. Transitions in care: exit or transition of care in a timely manner. 9. Integration & partnership: coordinated care / multidisciplinary approach. 10. Quality improvement: lived experience (families, team members). 11. Communication & information management: therapeutic relationship,documentation,evaluation. 12. Health promotion & prevention: build resilience individuals/ communities. 13. Ethical practice & professional development: scope, codes, development, education

In summary ● ● ● ● ● ● ●

The therapeutic relationship lies at the heart of nursing and midwifery, and a clear understanding of professional boundaries is crucial to the development of ongoing sustainability of such relationships. To be effective in caring for others, nurses and midwives must understand concepts andshow qualities such as compassion, caring, and – and acknowledge how these may impact or affect the person as a whole and their world. The area of practice draws on knowledge from both human and biological science. The development of therapeutic relationships is the key to effective mental health nursing. Nursing and midwifery with patients with mental illness/health issues together develop therapeutic alliances as an area for growth and recovery. It is important to develop an effective therapeutic alliance while maintaining clear and professional boundaries. The ability to think critically and develop self-awareness for the benefit of the therapeutic alliance and person centred care is central to nursing and midwifery practice.

NUM2307 Module 2.4 Mental Health Nursing as a Therapeutic Process The Nurse & Midwife’s Role in Psychopharmacological Interventions Outcomes ● ● ● ● ● ● ● ●

Describe the nurse and midwife’s role as part of the therapeutic process in the assessment, monitoring and treatment considerations of psychotropic medications. Describe what psychotropic medications are; and their targeted effects on the brain/body. Describe the action of the neurotransmitters – dopamine, serotonin & noradrenaline. Outline the major classifications of psychotropic drugs for the management & treatment of mental disorders. Identify nursing interventions & strategies in psychotropic administration. Outline & describe - metabolic syndrome and the common side effects. Outline and describe serotonin discontinuation syndrome & serotonin toxicity- inclusive of side effects & treatment. Identify ‘special populations’ in consideration of administration of psychotropic medications. Describe the clinical signs and symptoms the nurse may identify as side effects of psychotropic medications.

Medication administration as part of the therapeutic process The nurse and midwife’s role in ongoing holistic assessment and monitoring ● Comprehensive assessment, full mental health history & physical examination - prior to commencing medication ● After initial administration - close observation ● Monitor side effects & symptom management ● Dosage adjustments, additional medications ● Safety & risk assessment (drug interactions) - special populations ● Adherence/concordance & consider potential barriers ● Promote recovery ● Patient psychoeducation ● Referrals (GP) continue /discontinue maintenance dose ● Professional knowledge base & skills

Introduction: psychotropic medications Psychotropic drugs alter chemical levels/neurotransmitters in the brain which impact mood & behaviour ● Primary effects influence mental processes ● Affect(mood & emotion) & cognition (thinking) ● Brain = controls functions of eating, sleeping, temperature control, walking, talking-> imbalances in mental functioning can occur as a result of disturbances in functioning.

Understanding psychotropic medications Neurotransmitters are the brain chemicals (chemical messengers) that relay signals between nerve cells, to communicate information throughout the brain and body.

Dopamine ● ● ●

Pleasure & reward centre Movements & emotional responses Influence on cognition(action/process of acquiring knowledge,experience, thought)

Serotonin ● ●

Constricting smooth muscles, transmitting impulses nerve cells,regulating cyclic body processes Contributes to wellbeing & happiness

Noradrenaline ● ● ●

Hormone & transmitter Increase blood flow muscles Provides boost of energy

Nurses and midwives role in medication management ● ●

All nurses & midwives involved in the management of people with mental disorders need to have practical, working understanding of the clinical pharmacology of psychotropic medications. The pharmacokinetics and pharmacodynamics of drugs that will ultimately therapeutic actions and adverse drug effects.

Psychotropic medications Drug interactions - what are you giving and why? ● ●

monitor treatment response as well as identify problems or side effects. importance of the interdisciplinary team.

Therapeutic communication ●

constantly assessing and monitoring the patient.

Increased risk ● ●

barriers increase risk of non adherence and deterioration in mental state Medication non-adherence is one of the most common reasons for recurrence of psychotic symptoms and readmission to hospital.

Classification of psychotropic medications For the management and treatment of mental disorders

1. Antidepressants a. major depressive disorder, some anxiety disorders, some chronic pain conditions, and to help manage some addictions.

2. Anxiolytics a. prevent anxiety and treat anxiety related to several anxiety disorders.

3. Mood stabilisers a. treat mood disorders characterised by intense and sustained mood shifts,such as bipolar disorder type I or type II and schizoaffective disorder.

4. Antipsychotics a. manage psychosis, principally in schizophrenia and bipolar disorder & are usually effective in relieving symptoms of psychosis in the short term.

5. Anticholinergics a. unwanted side effects of antipsychotic medications.

6. Psychostimulants a. often prescribed for people with ADHD/ADD.Help people focus thoughts and ignore distractions.

Special populations & psychotropic medications The nurse/midwife should consider: ● Each situation will be different –life factors, stressors, biological makeup ● So in any given situation, whilst the assessment procedure and risk assessment is ongoing – the medication administration may vary amongst different people and populations.

Pregnancy & breastfeeding ●

Placental barrier and via breast milk

Younger people ● ●

Efficacy Long term use may affect growth & development

Older people ● ● ●

Physiological changes (liver, kidney function) Polypharmacy Falls risk

Physiological considerations Metabolic side effects & physiological changes

Nursing & midwifery assessment & treatment considerations ● ● ● ● ● ●

Influence co-occurring disorders Psychiatric comorbidities Potential for drug interactions Risk of suicide, possibility of drug overdose Previous response to treatment Individual adverse effects

Clinical formulation ● ●

gathering information, background, history, risk, and data to present to the team is a core part of the medication management process.

Acceptability to Consumer = Person Centred Care

Side effects of antipsychotic medications Metabolic syndrome ● ● ● ● ●

Heart disease Lipid problems Hypertension Type 2 diabetes Dementia Non-alcoholic fatty liver disease

Intervention ●

dietary advice and lifestyle assessment and assistance must be provided (referral specialist MDT) – as part of our ongoing role.

Side effects of antidepressant medications; 1. Serotonin discontinuation syndrome ●

from abrupt cessation of antidepressant medication.

Signs & symptoms ●

flu like reaction, headache, GI distress, nausea, dizziness, altered sensation (vision/touch), worsening of mood (anxiety & depression) agitation.

2. Serotonin toxicity ●

potentially life threatening emergency resulting from excessive serotonin activity.

Signs & symptoms ●

confusion, restlessness, agitation, mania, headache, diaphoresis, increased HR & BP, tremor, nausea, diarrhoea.

Emergency interventions ● ●

cease administration of SSRis, administer anticonvulsant & benzodiazepine – reduce agitation & induce calm. If left untreated, hyperthermia, kidney failure, death.

To promote medication adherence Compliance ●

(outdated) person follows instruction with respect to medications or other treatment instructions.

Adherence ●

extent to which a person follows medical instructions.

Concordance ● ● ●

is the agreement between a consumer & clinician with respect to the plans for therapy. Working collaboratively & with flexibility Shared decision making approach – consumer at centre of care

Barriers to non adherence of medication regimens ● ● ● ● ● ● ● ●

Don’t think they are unwell, don’t need them, forget to take, not worked quickly enough Mistrust of health care system/ health professionals Lack of support Medication has or side effects Physical health implications Stigma Financial constraints – unable to purchase Intervention strategies Building a therapeutic alliance, trust

Intervention strategies ●

Building a therapeutic alliance, trust and rapport will assist in discussing medications, benefits and management - within the clinical setting.

Role of nurse & midwife encouraging medication adherence ● ● ● ● ● ● ●

Therapeutic communication - how does the person feel about medications and their illness? Discuss health behaviours - advocating and discussing with the treating team. Joint problem solving. Include family - provide information. Discuss side effects, recognise, refer, respond, & report. Education, administration of meds, decreasing dose safely. Encourage the patient to seek help.

In summary ● ● ● ● ● ● ● ●

Psychotropic drug therapy is a fundamental element of a range of treatment modalities used for the management of nearly all mental disorders. Multi modal therapies and medication treatments may be needed. New treatments in psychiatry have developed rapidly and will continue to evolve and emerge. It is important to work with the person regarding them taking the right drug and the right time to maintain wellness. Medication adherence and concordance is important in maintaining the person's mental health and wellbeing. Non-adherence is one of the most common reasons for recurrence of symptoms and readmission to MH clinical facilities'/ hospital. Psychotropic drug therapy is complex and clinicians from a single discipline can’t address all of the essential elements involved. A multidisciplinary approach to the use of drug treatment is required - referral and allied health professionals are key in collaboratively managing and administering medications in allhealth settings. Ongoing monitoring and assessment is essential – document and refer if unsure.

NUM2307 Module 3.1 Assessment in Mental Health Nursing An introduction to the assessment process in mental health Outcomes ● ● ● ● ●

Identify the essential components of a comprehensive mental health assessment. Describe the benefits of conducting a comprehensive mental health assessment. Describe the mental health assessment process (why assess?). Consider/identify and the information required to conduct a comprehensive psychiatric assessment. Describe the classification systems (diagnostic manuals) used to diagnose mental disorders.

The comprehensive mental health assessment ● ●

A mental health assessment is a method of gathering information in a structured and comprehensive manner. Successful intervention ensures: ○ treatment adherence ○ consumer satisfaction ○ allows for comprehensive and accurate assessment information to be gathered that then informs best practice interventions.

1. Therapeutic relationship 2. Setting/location & time 3. Communication & cultural issues 4. Documentation

Why assess? The gathering of data for a complete mental health assessment is part of daily practice; ● to understand the problem of the person presenting for help using a biopsychosocial approach. ● collect information (background /history/current) about the person. ● decrease anxiety/ distress. ● gain a full health picture & make a formulation/hypothesis. ● develop a treatment/care plan. ● collaboration with the multidisciplinary team.

The purpose of any assessment: ● ● ●

Engage with the person in a helpful manner to begin the therapeutic alliance. Validate that the information they have provided is accurate. Address any precipitating factors.

Approaches to assessment Consider 1. needs, 2. preferences 3. strengths

Person-centred care ● ● ● ● ● ● ● ● ● ● ● ●

Behaviour Mental & physical Environmental Financial Functional Spiritual Sexuality/sexual health Biological Cultural Educational Emotional Recreational & social

Components of the comprehensive mental health assessment ● ● ● ● ● ● ●

● ● ● ● ●

Demographic information Background information - recent & relevant past life events, personal, family Reason for presentation or referral – what is the presenting concern/problem Physical assessment – clinical obs (baseline & ongoing) Strengths and resources - protective factors Mental State Examination (MSE) (baseline & ongoing) Risk assessment ○ challenges and threats ○ risk to self and others ○ social isolation ○ few resources. Clinical risk assessment/ risk screen Social connectedness, access to resources & support Inclusion & referral MDT The person and family members or carers may contribute perspectives to the assessment Documentation

Formulation, hypothesis Classification systems to diagnosis 1. International Classification of Diseases (ICD) a. Divided into ‘blocks’ of disorders. i. E.g. F30-F39 Mood (affective) disorders

2. Diagnostic and Statistical Manual of Mental Disorders (DSM) a. Divided disorders into “externalising’ & ‘internalising’ clusters

In summary ● ● ● ●

A comprehensive mental health assessment is essential in providing holistic care and managing risks. The mental health assessment is broader in focus and incorporates different aspects of the presenting problem ○ MH problems have complex predisposing factors/causes. Familiarity and understanding of assessment tools used in mental health assessment is vital to build a comprehensive picture of the client. Family members and significant others can assist with information about the person presenting including: ○ history and development of the presenting problem, ○ previous episodes of this illness,

●

○ cultural issues/considerations. The physical assessment is another important aspect of the MH assessment that can identify/rule out any underlying biological/physical reasons for presentation

NUM1207 Module 3.2 Assessment in Mental Health Nursing Clinical formulation – physical and mental health practice Outcomes ● ● ● ● ● ● ● ● ●

Outline potential causes of physical health issues related to physiological, psychological, sociological determinants and lifestyle choices for people living with mental illness. Describe each element of the nursing process in the mental health setting. Describe the process of clinical formulation; and the role of the nurse/midwife in the gathering of information for the clinical formulation. Outline the 4 P’s of case formulation model; define each of the areas and provide examples under each of the 4 areas. Identify the importance of providing physical health assessments and related interventions for people diagnosed with mental illness. Distinguish factors that impact on the physical health of people with mental illness. Recognise the relationship between mental health and physical health and the impact on the individual, family, society. Identify the nurse and midwife’s role in the physical health screening of people with mental illness. Describe the key points the nurse and midwife would consider in general health history.

Introduction ● ● ● ●

People who are living with mental illness experience much poorer physical health outcomes compared with the general population. High levels of physical morbidity among people with mental illness. their physical health needs considered and addressed from the initial assessment right through to the discharge process. Nurses and midwives practice in a holistic manner that incorporates both the physical healthcare and mental healthcare as well = person-centred care.

The nursing process A framework for nursing practice in mental health ● Full mental health assessment ● Physical assessment ● Mental State Examination ● Risk screen ● Stress-vulnerability Model ● Biopsychosocial approach

Assessment ● ● ● ●

Assessment is the first step of the nursing process and is ongoing throughout each episode of care. Assessment is fundamental to mental health nursing and provides the platform on which nursing care is delivered. What the person is experiencing and presents with, in order to determine what they can do to help. The physical health assessment is an integral component of the assessment in mental health nursing.

Clinical formulation ● ●

●

The process of developing (with the consumer), A summary of various influences on the person's current state ○ Physical ○ Psychological ○ Problems ○ Stressors How the consumer and the nurse and/or midwife can work towards resolving those problems.

Threads of the assessment …. Assessing physical health and mental health simultaneously is essential as part of the gathering of information process.

Leading to clinical formulation ●

● ● ●

Process: ○ way that the information is gathered, part of the therapeutic relationship, gathering observation, assessment tools, instruments and informal & formal methods. Content: ○ what information is gathered, a description of the presenting problem, MSE, physical health assessment. Interpretation: ○ meaning is given to the content being gathered. Understood in conjunction with the consumer, the nurse and the treating team and informs treatment planning. Communication: ○ articulation and formulation. Gathering information and sharing the information in the way of a formula to present / share (handover, team meeting, documentation), describes a picture of the person in care.

Physical health and mental health Severe mental illness is often defined by its length of duration and the disability it produces. e.g. schizophrenia, severe forms major depression & bipolar disorder ● Physical health = (bio-psych-social) + lifestyle choices. ● Chronic conditions: diabetes, cardio/respiratory disease, cancer. ● Complications: obesity, sedentary lifestyle, iatrogenic side effects of medications. Screening for respiratory conditions: lung function - health education & promotion (physical activity).

Physical health interventions & screening Nurse & midwife’s role ● Screen: ○

metabolic health – diabetes, referral diabetes educator, cardiovascular disease.

● Management and intervention: ○

cardio-metabolic health.

● Referral: ○

specialist services.

● Lifestyle interventions: ○

smoking cessation or consider nicotine replacement.

● Nutritional support: ○

dietician, weight management, side effects of medications.

● Multidisciplinary team collaboration ○

occupational therapist.

General health history Nurse and midwife should gather ● ● ● ● ● ●

Medical history and any other health associated problems any medical comorbidities that may be impacting on their mental health at the time of presentation. Assessment should include background information of all of the physical health history that may be necessary in this person's world. Opportunity for the therapeutic relationship and a discussion around physical health issues. Rule out any other underlying physical illnesses that may be presenting as mental health signs and symptoms. Add to the clinical picture, help the team decide on interventions and care. Reinforce important health messages.

Physical health assessment Nurse and midwife’s knowledge & skills

● Routine physical observations: ○

vital signs, general & pathological investigations.

● Drug & alcohol assessments: ○

samples, screening and referral to specialist services.

● Lifestyle factors that promote wellness: ○

health education behaviors (nutrition, reduction of risk behaviours - smoking, alcohol & other drugs).

● Introduce physical health interventions. ● MDT and referral to specialist services: ○

Accurate assessment and formulation may lead to referral to specialist services.

Clinical formulation Assessment information ● ●

Subjective impression and a set of objective data. Current problems - history, background information and any precipitating factors that may have led them to admission.

Clinical formulation ●

● ● ● ● ●

The process of bringing this information together to then develop an individualised account (a formulation) of the consumer at that point in time. Includes ○ Biological, ○ Psychological ○ Social areas of assessment. Consider theoretical explanations as to help them explain the relationships between those varying aspects of the consumers history, the background information and their current presentation. Draw on the multidisciplinary team together and share information as part of a team. Discuss with consumer (interpretations / reasons) for their presentation and Collaborate between each of the multidisciplinary team members. Therapeutic relationship.

The 4 P’s of case formulation model Factors that may describe and contribute to the development of the current problems or factors that contribute to the presence or persistence of the problem that the person is presenting with.

1. Predisposing (at risk & vulnerability of developing) a. Genetic vulnerability, trauma (birth), trauma (psych), brain injury, physical illness & pain, mental illness, medications, personality, self-esteem, culture

2. Precipitating (specific event/trigger) a. Drugs/alcohol, pain trauma, grief & loss, relationships, work/finances, life events or stressors

3. Perpetuating (maintain the problem) a. Any predisposing or precipitating factors that are ongoing

4. Protective (strengths, reduce the severity) a. Good physical health, belonging, relationships (family, social), engagement with people, work, community, insight, adherence to medications, resilience & coping strategies

Documentation: progress notes, selective summary of pertinent information, MDT, referrals, may lead to diagnosis.

Diagnosis A diagnosis is the definition of a problem that can be considered once all of the available information has been gathered. ● Diagnosis in MH = criterion / grouping clusters of signs and symptoms together in individual categories. ● Primarily through the diagnostic and statistical manual of mental disorders or the DSM 5.

Nurse & midwives role ● ● ● ●

Need to be familiar with the diagnostic criteria of more common mental illnesses and the reasoning process applied to making these diagnoses. Assessment of signs and symptoms the nurse and midwife would assess/the person may be presenting with. Help gather information to present (formulation) for possible diagnosis for the medical team. Documentation.

Physical screening & health assessments Nurses & midwives are in an ideal position to:

Assess ●

Consumers physical needs to promote healthy living from a holistic perspective

Promote ●

to undertake routine screening for physical symptoms to avoid diagnostic overshadowing

Encourage ●

awareness of the signs & symptoms of physical health,& long term physical conditions for those with mental illness

In summary ● ● ● ● ● ●

Nurse & midwife’s responsibility to use tools & skills to identify potential health issues for people with mental illness. Maintaining physical health is multifaceted and is essential to well being. Refer to an interdisciplinary team and work in partnership for the betterment of the client's physical & mental health. Nurses in all settings – and increasingly the general hospital and wards will care for people with complex physical and mental health issues. The process of clinical formulation is a structured process in which the nurse & midwife will gather information about many aspects of the life of the consumer. Integrate care needs from a holistic and integrated health care response.

●

Early intervention and prevention of physical health conditions is key to improving the outcomes of people with a mental illness.

NUM2307 Module 3.3 Assessment in Mental Health Nursing The Mental State Examination (MSE) Outcomes ● ● ● ● ●

Identify the clinical features of mental illness identified in a mental status examination. Describe what a Mental State Examination (MSE) is and its purpose. Describe each of the 10 assessment components of an MSE, and what the nurse would assess in each component. Identify key nursing skills used in the MSE interview & assessment process. Define key mental health terminology/terms used to describe presenting signs and symptoms within each component of the MSE.

The Mental State Examination (MSE) The MSE is a semi-structured interview to assess another person's current neurological and psychological functioning across several dimensions at ‘that point in time’.

● Observation ● Interview The MSE interview can also be affected by a number of factors such as: ● The presence of significant others in the room ● Time of day ● The place in which the examination is performed ● The gender of the interviewer/assessor

● Documentation ● ●

An MSE forms only part of an overall mental health assessment. An MSE can occur at the first meeting –baseline- (first presentation assessment), during an admission interview, and at any time while communicating with a person.

The purpose of the MSE ● ● ● ● ● ●

Clarify the presence and extent of the person's mental health problems. Evaluate the person’s present mental state. Forms the benchmark (a baseline) for future assessments. Can evaluate any changes/fluctuations in mental state, condition and response to treatment. Identify areas for immediate intervention (consider risk). Assists in the determination of appropriate clinical pathways & interventions.

Essential nursing & midwifery skills ● ● ● ● ● ● ● ●

Engagement - attention kept on the person in the moment. Allow a greater than normal personal space. Be polite & gentle in your demeanour - but be clear and direct. Observation & non- verbal behaviour. Be honest in your responses - don’t make promises you can’t keep. Open communication – allow for explanation of the current problem. Listen carefully – focus on the content of the person's conversation (feelings & thoughts). Communication – begin open questions, then focus on specific questions.

The 10 components of the MSE 1. Appearance a. What does the person look like? (description)

2. Behaviour a. What are they doing? Description of actions

3. Mood a. How are you feeling? (subjective) Ask them

4. Affect a. Describe outwardly observable emotional responses / states.What do you see ?

5. Speech a. How the person says things (articulation), not what the person says (which is thought content)

6. Thought form a. Continuity & connection of ideas, disturbance of language

7. Thought content a. A description of what the person is talking about (suicide, delusions, disassociation)

8. Perception a. Response of the senses. Any hallucinations? You may need to ask as not outwardly observable

9. Cognition a. Level of consciousness, orientation, memory, concentration

10. Insight a. Recognise a problem & understand its nature

In summary ● ● ● ● ● ● ●

When conducting an MSE follow the policies and procedures as set out by the clinical facility. If unsure, ask. Symptoms should be monitored at every contact & changes noted. Refer/seek help if any changes in mental state from baseline/usual for that person or potential increase in risk. Documentation: objective & using correct terminology. Essential to know the 10 elements of the MSE to identify behaviours & characteristics when assessing. The MSE forms one component of the mental health assessment. Therapeutic rapport, communications skills, & observational techniques, will assist in the therapeutic goals of the MSE assessment tool.

NUM2307 Module 3.4 Assessment in Mental Health Nursing Assessing Risk Outcomes ● ● ● ● ● ● ● ● ●

Provide a definition of risk in mental health. Describe the role & responsibility of the nurse and midwife in the risk assessment process. Identify the scope of risk in mental health (the forms that risk can take). Describe the aim of the risk assessment process. List the questions asked to assess risk. Identify clinical presentations (signs and symptoms) that may increase the likelihood of risk. Outline the 3 parameters of risk and link to the biopsychosocial model of care. List the key principles for working with risk. Describe key work safety practices in the clinical setting.

What is ‘risk’ in terms of the clinical setting? ● ●

Role of any health professional assessing possible risk to the overall health and safety of a person and those around them. Decide on appropriate plan of action with / and for the person to reduce the likelihood of an adverse event occurring

Risk is defined as: ●

whether a person has the potential for self harm, either actively or passively, or is considered to pose a risk for hurting someone else.

●

Risk relates to the likelihood of an adverse event or outcome occurring in the context of 1. How likely it is the event will occur. 2. Imminence of the event to occur (how soon). 3. How severe the outcome will be if it does occur.

Risk can take many forms ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

Absconding (leaving hospital with permission) Adverse medication effects (side effects) Danger to self or others Falls Financial/unemployment (social stressors) Sexual or physical exploitation, verbal/physical abuse Homelessness, poverty, self neglect Stalking or harassment Not taking medications – risk of mental state deterioration as a result Reputation – due to public behaviours Physical / chronic conditions (life style) health impacts Reckless behaviour - driving Social isolation & risk to relationships Substance use/abuse (comorbidity) Risk to property/material possession – damage

The risk assessment The aim 1. 2. 3. 4. 5. 6.

Measure seriousness of self harm suicidal Intentions Establish ‘means’ Underlying issues causing distress Determine future/potential risk of harm Identify strengths Identify supports

The purpose ● ●

Determine a person’s intent and level of risk. Level of risk determines type of care & management (hospital V community).

The role of the nurse and midwife ● ● ● ●

assess risk to the overall health and safety of the person and those around them. reduce the likelihood of an adverse event occurring. assess the needs of the person (with a focus on their strengths). referral (MDT) and appropriate plan of action.

Determining risk due to illness ● ● ● ● ●

Psychosis/ paranoia Loss of insight, lack judgement & ability to problem solve Unpredictable in their behaviour & response (aggressive, loud, pacing) Substance use/misuse (intoxication) drugs/alcohol Non adherence with psychotropic medications /other medications

Likelihood of future aggression/dangerousness = risk Affective aggression: ●

a person reacts to a perceived threat (organic) factors or outside factors.

Predatory aggression: ●

planned, purposeful, and goal directed towards a particular target or person.

●

Physical harm that is threatened Likelihood that act of aggression may take place (past history, violent thoughts best predicts future acts Greater the frequency - higher the risk of occurring Situational factors (e.g. drugs, peers, criminal record, access to weapons)

● ●

Risk assessment questions To assess risk ask; 1. What is the risk? 2. Who is at risk? 3. What is the chance of risk occurring? 4. How immediate is the risk? 5. Over what time frame is the risk being assessed? 6. What factors increase or decrease the risk (e.g. stressors, people, situations)? 7. Are alcohol or other drugs involved? 8. What do we need to do to reduce or manage the risk? Risk assessment is vital when first meeting, on transfer of care, change in clinical condition or deterioration in mental state

3 parameters of risk Management plans must take into account the consumers changing circumstances over time, and therefore incorporate 3 parameters of risk;

1. Static factors a. historical factors, fixed, don’t change over time.

2. Dynamic factors a. change in duration & intensity, psychosocial stressors.

3. Future factors a. linked to static & dynamic factors/repeat exposure to factors.

Managing risk in the clinical setting Risk management ●

process where a plan of care is designed to address identified needs and to continue to assess & evaluate the interventions.

Organisational support in managing risk 1. Tools to assess risk 2. Policy & Procedure 3. Safe work environments 4. Documentation Risk management is not complete until a risk plan is developed, communicated & implemented.

Developing safe work practices Maintaining safety in the clinical environment ● ● ● ● ● ● ● ● ●

Consider the most appropriate place to interview / assess the patient. Ensure another staff member knows where you are. Single room with the door open. Open area removed from other patients. If in a room, sit closest to the exit. If possible, have an alarm system available. Maintain at least an arm’s length between you and the patient. Consider doing an interview in pairs (another clinician). Consider a security guard.

Health of the Nation Outcomes Scales (HoNOS) 12 scales used to rate MH service users 1. Overactive, aggressive, disruptive or agitated behaviour 2. Non-accidental self-injury 3. Problem drinking or drug-taking 4. Cognitive problems 5. Physical illness or disability problems 6. Problems associated with hallucinations & delusions 7. Problems with depressed mood 8. Other mental & behavioural problems 9. Problems with relationships 10. Problems with activities of daily living 11. Problems with living conditions 12. Problems with occupation and activities

In summary ● ● ● ● ● ● ● ● ● ● ● ●

A full risk assessment is additional to the MSE – never underestimate the necessity in doing it. Risk factors and identifying the scope of risk is paramount in assisting with the risk management plan. Many assessment tools to identify and determine (level of risk) adhere to policy, procedure, guides and tools used in each clinical facility / place of practice. Communication, engaging with the patient, asking the questions is vital in managing and caring for the person. Developing safe work practices will enable you to maintain patient privacy and confidentiality whilst also ensuring the safety of all those in the work environment. Accurate documentation & if unsure - ask

NUM1207 Module 3.5 Assessment in Mental Health Nursing Self Harm and Suicide Content warning Self-harm (non-suicidal self injury) & Suicide ● This module explores both non suicidal self injury (self harm) and suicide in detail. ● These are both important concepts and social issues for nurses and midwives to consider in their practice. The author and presenter of this module acknowledges that this may be confronting to some students. Lifeline is an Australian service that operates 24 hours a day, 7 days a week and provides a free telephone service for people in crisis. ● The telephone number is 13 11 14 in Australia If you have been affected by any of the issues brought up in this lecture – please speak to someone – seek help and/or assistance. ● ECU counselling service (08) 9370 6706

Outcomes Self-harm (non-suicidal self injury) ● ● ● ● ●

Explore the descriptions and terminology used in relation to the terms self- harm. Understand non-suicidal self injury and its aetiology and epidemiology. Describe assessment and collaborative care of consumers with non-suicidal self-injury behaviours. Describe the precipitants, factors and motivations that may contribute to self- harming behaviour. Outline the role of the nurse in the treatment and care of the person who has self-harmed.

Suicide ● ● ● ● ● ●

Explore the descriptions and terminology used in relation to the terms suicide. Describe the continuum of suicidal behaviour. Describe the aetiology and epidemiology of suicide. Identify predictors in at-risk individuals as well as understanding protective factors. Describe the precipitants, factors and motivations that may contribute to suicidal behaviour. Outline the elements of how to assess the risk of suicide, exploring the nurse/midwifes strategies to initiate conversation with consumers about suicide assessment.

Introduction ● ● ● ● ●

Suicidal and self-harming and behaviours are major issues for the community, government, health professionals & services. Combination of individual, interpersonal, community & societal factors contribute to the risk of suicide. Risk factors are the characteristics that are associated with suicide. Family and friends of people – risk of being profoundly affected - emotionally, socially, economically. Identifying people at risk allows the nurse to engage the person in effective treatments, support the presence of protective factors and provide person-centred care.

Deliberate self harm (self-injury) The term ‘self-harm’ is a generic phrase that is used to describe a wide range of self injurious behaviours

Behaviours ● ● ● ●

self-laceration self battering taking overdoses deliberate recklessness

1. Intentional 2. Direct injury of body tissue 3. Without suicidal intent ● ●

Although people who self harm do not necessarily have suicidal intent, there is the very real possibility that self harming behaviours could lead to death. People who self harm are generally trying to express their emotional pain.

Care for the person who is at risk ● ● ● ● ● ● ● ●

Treat any urgent complications, minimise future risk, severity,disability. Initial risk assessment as part of the biopsychosocial model & comprehensive mental health assessment. Safe environment maintains safety in the least restrictive manner . Specialist MH team on plan,precautions, further assessments,treatment interventions. Immediate management plan in consultation with consumers/others. Suicide protocols (observing,monitoring, restricting). Develop recovery plan – follow up Documentation

Causes of self-harming behaviour Complex mix of biopsychosocial aspects ● Manage life events/resilience ● Adverse life events ● Support of family & friends ● Mental & physical ill health ● Cultural family background ● Social geographical isolation ● Geneticmakeup ● Socio-economic disadvantage

Suicide (death by suicide) Myths ● ● ● ● ● ●

A suicide threat is just a bid for attention & should notbe taken seriously. People who talk about suicide won’t do it. Once a person has made up their mind, nothing can change it. Talking about it increases the risk of someone doing it. Once suicidal, always suicidal. Suicidal people rarely seek help.

●

Suicide is defined as “the voluntary and intentional act ofending ones life; the act of a person intentionally causing their own death”. ○ Hungerford, et al. (2018); Muir-Cochrane, Barkway, & Nizette, (2018) Suicide is a fatal, self inflicted action with an explicit or inferred intent to die.

●

● ●

Suicide is a complex phenomenon with no single explanation. It is a complicated process. Suicidal behaviour: a spectrum of activities related to thoughts and behaviours that include suicidal thinking, suicide attempts and completed suicide

Continuum of suicidal behaviour ● Suicidal ideation: ○

self reported thoughts of engaging in suicide related behaviour.Describes thoughts, ideas, plans a person has about causing their own death.

● Suicide threat: ○

threat more than suicidal intent & marked behaviour changes.

● Suicide act (attempt): ○

a potentially self injurious behaviour – evidence the person probably intended to end their life.

● Suicide attempt: ○

potentially self-injurious behaviour with a non-fatal outcome.

● Suicide: ○

death from injury – where there is evidence that a self-inflicted act led to the person’s death.

● Suicidality: ○

encompasses suicidal thoughts, ideation, plans, suicide attempts and completed suicide.

Risk factors for suicide ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

Previous suicide attempt (s) background factor. History of self-harm, mental illness or family history suicide. Separated, divorced or widowed. Social isolation or lack of support/supervision. Male, (age) younger than 25 or older than 85 years of age. Unemployment (length of time). History of prison incarceration. History of substance misuse (alcohol or drugs);alcohol dependency. Expressing hopelessness, helplessness, despair, excessive guilt, high level of distress. Poor physical health (medical illness/chronic medical illness). High incidence in rural areas. Being of Australian Indigenous heritage. Discharge from a psych inpatient unit within 14 days. Recent significant life events/ stressors (legal & financial, interpersonal problems). Dynamic factors (available means, suicidal thinking, feelings of hopelessness, harmful use of substance, por social support, impulsivity, active symptoms of mental illness).

Warning signs of suicide Nurse and midwifery assessment should consider changes in

TALK ● ● ● ● ●

Experiencing unbearable pain Being a burden to others Killing themselves Having no reason to live Feeling trapped

BEHAVIOUR ● ● ● ●

Acting recklessly Sleeping too much or to little Aggression Looking for ways to end their life (online searches)

● ● ●

Increase use of alcohol/drugs Withdrawing from activities Giving away prized possessions

MOOD ● ● ● ● ● ●

Depression Loss of interest Rage Humiliation Anxiety Irritability

Assessment of risk ● ●

Suicide risk assessment is a process by which nurse/midwife's estimate a person’s short, medium, & long term risk for suicide; is an attempt to predict the likelihood of suicide. Nurse and midwifes suicide risk assessment requires: ○ Address any major issues (precipitating, predisposing, perpetuating). ○ Interventions (actions) to ensure safety. ○ Health promotion (protective factors and strengths/supports) in place.

Factors relating to suicide and self harm Predisposing causes

Precipitating influences

Perpetuating factors

Social

Family Hx of self harm or suicide, abuse as a child, homelessness, physical illness

Bereavement, divorce, significant financial problems, assault victim

Bullied, unresolved (housing, financial, employment), available lethal means

Psychological

Family Hx of mental illness, poor emotional regulation, poor impulse control, low self esteem

Mental illness (depression, psychosis), substance misuse

Intoxication, negative thinking, not taken seriously

Interpersonal

Conflicts, bad relationships, poor problem solving

Stressful situations, relationship breakdown

Unresolved conflict, difficulty communicating feelings

Assessing suicidality Suggestions for initial questions you may ask: ● How bad are things for you? ● Are you worried about yourself? ● Do you ever think of harming yourself when you are down? Next questions, proceed gentle but directly: ● Have you ever thought of taking your own life? ● Have you ever been so sad that you wanted to end it all, maybe by dying? ● How long have you been feeling that way? ● How are you thinking of hurting / harming yourself?

Consideration of care ● ● ● ● ● ●

Consideration of care Uncompleted suicide attempts may often be considered a cry for help or call for attention and should never betaken lightly. Ensuring the safety of the patient, as well as anyone around the patient is of utmost importance. Screening for depression. Treatment of symptoms – medications(antidepressants). Monitoring the effects of medications – increasing ‘energy’ may result going through with ending of their life. Therapies may be beneficial – referral to specialist services.

Discharge planning ● ● ● ●

Leave the hospital when they are physically well enough. When risk of suicide is at a level that can be managed in the community. Assessed by MH professionals prior to D/C. Referred to community MH specialist for follow-up .

In summary ● ● ● ● ● ●

To develop professional confidence and skills in this area, the nurse and midwife should be aware of why people engage in self harming and suicidal behaviour. A full risk assessment is additional to the MSE – never underestimate the necessity in doing it. Communication, engaging with the patient, asking the questions is vital in managing and caring for the person. Each mental health service will have their own variation on how to assess and record suicide risk. Ensure that you always question thoroughly and do not jump to solutions before you know all of the areas of risk. Documentation is a legal requirement in all aspects of patient care, and assessment.

NUM1207 Module 3.6 Assessment in Mental Health Nursing Challenging behaviour, risk and response Outcomes ● ● ● ● ● ●

Explore the nature of challenging behaviours. Outline the most common causes & triggers of disturbed behaviour. Discuss the concept of aggression, and factors that lead to clients aggression, including the influence of the environment. Identify skills and techniques to minimise escalating behaviours & aggression. Discuss the role of nurses in the prevention & management of aggression in clinical settings. Describe a range of management strategies & approaches to deal with challenging behaviour.

What is it that challenges us? ● ● ●

Behaviour identified through interaction with others Problematic in the environment Challenging behaviour implies a threat, which evokes a defensive response

1. Difficult 2. Conflict 3. Disruptive 4. Inappropriate 5. Bizarre 6. Anti-social The nurse and midwife can can avoid, retaliate, challenge or address & defuse

Challenging behaviours can include: ● ● ● ● ● ● ●

The mental illness itself (withdrawn, aggressive, & hard to reach/engage) Behavioural/ psychological symptoms (demanding, manipulating). Aggression & violence and/or violent outbursts… may also be related to illness (pain, fear). Related to intoxication by alcohol or withdrawal from drugs. Self-harming behaviours. Behavioural/ psychological symptoms. Refusal/non adherence to treatment or medication regimens.

Causes and triggers of challenging behaviour The experience of illness ●

Need to seek help → Vulnerability & powerlessness → Unfamiliar environment, Needing assistance, Marginalised group, Loss of self-determination

Organic cause ●

Delirium & dementia Head injury

Triggers ●

Demands on consumer

● ● ● ● ●

Negative attitude by health Pressured into taking meds Power imbalance Generally feeling unwell Long waiting times

Communication Learned experience, Altered perception, behaviours Physical reaction behaviour → External stimuli → Cognitive/Physiological process → Emotional response → Context of situation → Impulse to act

De-escalation skills Interventions to manage ● Remain calm, unhurried, warm & friendly ● Be supportive, respectful, courteous, & avoid defensiveness ● Maintain safety of self & others ● Focus only on essential tasks ● Do not touch the aggressor ● Provide adequate personal space ● Actively listen – acknowledge their anger ● Diminish environmental stimuli ● Be aware of your own feelings (avoid counter-transference) ● Place limits on behaviour & provide consequences ● Observe for escalation of aggression

Managing & responding Nurses and midwife’s role Helpful behaviours ● ● ● ● ● ● ● ● ● ● ● ● ● ●

Clear management plan Regular review of goals Maintain an attitude of hope Set limits/ boundaries Be honest & open Respond to person/ not diagnosis Set realistic goals with the person Written care plan in times of crisis Clear management plan Regular review of goals Maintain an attitude of hope Set limits/ boundaries Be honest & open Respond to person/ not diagnosis

Behaviours to avoid ● ● ● ● ● ● ● ●

Wanting to rescue the person/being their friend Being ’super nurse’ the only one who an help Defensiveness/ verbal retaliation Taking things personally Avoiding the person Over controlling behaviours Sarcasm/ cynical Judgemental

Interventions to manage: seclusion & restraint Restraint: Manual ●

physically holding the patient to prevent or restrict movement’.

Physical

Rapid tranquilisation ● ● ●

medications administered to sedate the client quickly who is exhibiting challenging behaviour.

Documentation – consent from family. Safety is paramount at the end of the day.

In summary ● ● ● ● ●

People exhibit challenging behaviours in a health context for many reasons – and not necessarily the outcomes of a mental health problem/ illness. Triggers can be situational – need to consider all aspects (injury, pain, illness, fear, frustration) When assessing challenging behaviours, it's important to know why the behaviour was presented as a problem at that time. Risk assessment is essential & considerations based on this will influence teams response and management. Consider personal (own) responses to patients behaviour – reflective practice and ‘nurse triggers’ – to ensure

NUM2307 Module 4.1 The Legal and Ethical Context of Mental Health Care Law and Nursing Practice in Mental Health Care https://www.mhc.wa.gov.au/media/1437/consumer-handbook-to-the-mental-health-act-2014-version-2-1.pdf

Outcomes ● ● ● ● ● ●

Identify the key legal and professional principles/ standards guiding the provision of mental health care. Outline the concept of duty of care. Identify nursing interventions in mental health care under a Mental Health Act. Outline the use & application of mental health legislation & recognise how these apply to your practice. Understand the principles of mental health legislation (voluntary/involuntary clients). Explain the importance of patient’s rights in health / mental health care and the principles of ‘least restrictive’ environment (seclusion/ restraint). Recognise the key areas in mental health practice requiring legal analysis.

Law in the health context Professional standards ● Duty of care ○ ○ ○ ○ ○ ○ ○ ○ ○

Legal duty – obligations (acts/ omissions - harm), standard of reasonable care. In nursing & midwifery (health care) Actions are reasonable Act in the person's best interest Actions undertaken with informed consent Not act or fail to act in a way that could cause harm Always act within your scope of practice and do not do something that you cannot do safely.

● Standard of care ○

Codes of conduct, ethics, standards

● Negligence ○

Consent V assault/ battery/false imprisonment – failure to act

● Professional boundaries ○ ○

Ethics & law Unprofessional/ misconduct – trust & privilege

● Confidentiality ○

Legal responsibility –privacy

Introduction to mental health law Mental health legislation Designed to protect consumers from inappropriate treatment and the direct provision of mental health care & the services in which it is provided. ● Treatment ● Care ● Rehabilitation

Principles of Mental Health Acts ●

Autonomy

● ●

Freedom Self-determination

●

Provision of least restrictive environment

●

Rights of people with mental illness

●

Confidentiality, voluntary treatment where possible, no treatment to be given without informed consent, least restrictive care, live & work in the community

●

Protect individual people & the community as a whole

Human rights - and your patient under the law ● ● ● ● ● ● ● ● ● ● ●

Explanation & information as to why the referral was made Personal records (harm V good) consider insight Not to be ill-treated Personal possessions (consider harm) Send and receive mail Receive and make telephone calls Visitors (can be reviewed or revoked) Vote Consent and refusal of certain treatments (insight/capacity) Appeal (Access MH Advocacy Service) Second opinion

Admission to mental health services Patients might come to the service; ● ● ● ●

Referred by a GP or AMHP. A Community Treatment Order has been revoked and they have to return to the hospital. A court order has been given for the patient to be assessed. Transported by Police.

Role of police and ambulance A police officer may apprehend a person if the officer suspects, on reasonable grounds, that the person: ● Has a mental illness and needs to be apprehended to: ○ protect the health or safety of the person or any other person; or ○ prevent serious damage to property.

Voluntary & involuntary admission ● ● ● ● ● ●

A voluntary patient is someone who came into the care facility on their own volition. ○ They chose to go there because they were feeling they were not coping well or they needed help. An involuntary patient is someone who has been admitted not necessarily against their will, but meets the criteria of admission/detention. An involuntary patient is a person who has been placed on an involuntary treatment order. An involuntary treatment order means either an inpatient treatment order or a community treatment order (CTO). An involuntary inpatient can be detained in hospital and provided with treatment for mental illness without the need for consent. An involuntary community patient can be provided with treatment for mental illness without the need for consent, while they are living in the community (usually at home, but sometimes in another place such as a hostel).

When can a person be made an involuntary patient? Only a psychiatrist can make you an involuntary patient. ● An inpatient treatment order can only be made where the psychiatrist who examines you concludes that: ○ You have a mental illness requiring treatment; and ○ Because of your mental illness, there is significant risk to your health or safety, or the safety of another person, or there is a significant risk of serious harm to yourself or another person; and ■ You are not well enough to make a decision about your treatment; and ■ Treatment in the community would not be sufficient; and ■ There is no option that will be less restrictive to your freedom of choice and movement. ● A community treatment order (CTO) can only be made where the psychiatrist who examines you concludes that: ○ You have a mental illness requiring treatment; and ○ Because of your mental illness, there is significant risk to your health or safety, or the safety of another person, or there is a significant risk of serious harm to yourself or another person, or there is a significant risk of you suffering serious mental or physical deterioration; and ■ You are not well enough to make a decision about your treatment; and ■ Treatment can be provided in the community; and ■ There is no option that will be less restrictive to your freedom of choice and movement.

Nursing interventions of mental health practice ● ● ● ● ●

Patients, carers and families often have concerns about involuntary treatment Treatment in line with evidence based practice Thorough mental health assessment Consider environment -is there a less restrictive intervention Documentation

Included or prescribed in the MH legislation ● ● ● ● ● ● ● ● ●

Mental health assessments Involuntary mental health treatment orders Restriction orders Electroconvulsive therapy Referrals from courts/ prisons The provision of official visitors Private mental health facilities Rights of clients/ carers/ families/ guardians Seclusion & restraint guidelines

The least restrictive environment 1. Seclusion a. confinement of a person alone, room/area who is unable to leave.

2. Physical restraint a. application of a bodily force to the person’s body to restrict movement.

3. Criterion a. provide treatment, prevent physical injury, prevent serious damage to property.

4. Compulsory community treatment a. Community treatment order (CTO) advantages to increase engagement of consumers with services, reduce relapse and promote recovery. i. less restrictive form of involuntary order; ii. the same criteria for involuntary care;

iii. iv.

managed in the community; can also be used to prevent a person’s physical and mental health from deteriorating.

In summary ● ● ● ● ●

Mental health legislation is in place to protect individuals and communities. Nurses need to be aware of their roles & responsibilities. Relationship between the law/criminal justice system and balancing ethics and compassionate care – can be challenging. Scope of practice – professional guidelines. Adopt least restrictive – person centred approach is key goal to treatment/interventions & recovery principles.

NUM2307 Module 4.2 The Legal and Ethical Context of Mental Health Care Ethics and Ethical Issues in the Mental Health Setting

Outcomes ● ● ● ● ● ● ●

Identify the key ethical principles and theories guiding the provision of mental health care. Identify terms used in ethics and mental health settings. Discuss the concepts of consent, capacity, incapacity, & competence. Describe how the nurse would assess a person's capacity/incapacity to consent to interventions/treatment/ care. Describe the challenges for nurses when making ethical decisions in mental health care. Apply ethical reasoning to decision making in mental health practice. Recognise the key areas in mental health practice requiring ethical analysis.

Introduction to ethics in nursing & midwifery ● ● ●

Equity & Equality Respect & dignity Sanctity & quality of life = Patients views - cultures - aspirations - expectations - behaviours

●

Reflection and consideration needs to be given to the personal values that nurses and midwives hold in relation to mental health and illness and all patients in the clinical setting/workplace. All ethical principles must be upheld and the International codes of ethics are now in effect for Australian nurses and midwives. The International Council of Nurses (ICN) Code of ethics for nurses and the International Confederation of Midwives (ICM) Code of ethics for midwives took effect as the guiding documents for ethical decision-making for nurses and midwives in Australia on 1 March 2018.

● ●

Ethical principles To assist in decision making – ethical dilemmas Ethical theories - ethical dilemmas

● Beneficence ○ ‘do good’ ● Autonomy ○ Freedom and self -determination ● Nonmaleficence ○ Do no harm & remove harm ● Veracity ○ Truth Telling ● Justice ○ Respect, fairness & rights for all ● Fidelity ○ Faithfulness & commitment

Ethical theories - ethical dilemmas To assist in decision making – ethical dilemmas ● Life experiences ● Personal values ● Systems ● Cultural perspectives

● Deontology ○

Choices are right/wrong (Moral absolutes)

● Utilitarianism ○

The end justifies the means

Ethical decision making Decision based on personal moral, ethical & legal positions that needs to be made between two or more often unfavourable alternatives, in any given circumstance.

● ● ● ● ●

Professional judgement Ethical principles Legal requirements Decision making framework Self reflection

‘Terms’ in ethics & mental health settings ● Concepts ○

Application to nursing & midwifery

● Privacy ○

Information is safeguarded and kept private from general public-records/notes.

● Confidentiality ○

Information about patient kept secret unless shared for the purposes of giving care.

● Informed consent ○

Providing info about: ■ nature of persons illness, ■ therapeutic procedures, ■ care & treatment,

■ ■ ■ ■ i. ii. iii. iv. v. vi.

risks, benefits, outcomes, treatment options. Provided with all the information to make an informed decision. Decision is expressed voluntarily (not coerced / influenced). Consent to or refuse treatment, demonstrates understanding of their situation. Understands the nature of their condition, risk, benefits, alternatives to treatment. Competent to know significance & consequences of decision. Displays logical coherent process of reasoning –condition.

● Capacity ○

Understanding, decisions based on ability to process information, benefits & risks.

● Competence ○

Speak, understand, communicate, tasks, duties, expected level in community.

● Paternalism ○

Decisions made deemed in ‘best interest’ of patients.

Assessing capacity and competence Principles of capacity and competence

Defining competence: Principle 1 Has capacity unless demonstrated otherwise +

Principle 2 Proportional to seriousness of decision +

Principle 3 Specific to particular decision & time frame

Determining if the patient can give informed / valid consent. Incapacity: Inability for a person to look after their health, safety, welfare, or to manage affairs, due to cognitive deficit that impairs decision making abilities.

Reasons for incapacity maybe permanent - temporary – partial)

Signs and symptoms (presentations) ● ● ● ● ● ● ● ● ● ●

neurological disease mental illness (e.g. psychosis, delusions, delirium), sedation, fatigue, drugs/alcohol, intellectual disability, panic & fear, emotional shock, medications, pain

In summary ● ● ● ●

Important for nurses to be aware of their roles & responsibilities when balancing patient rights (autonomy) with treatments and interventions. Capacity & competence (the nurses assessment vital) in ensuring consent for interventions, treatment and care (consider: safety/necessity). Challenge (ethics/law) to treat people with mental illness with the least restriction on their autonomy while ensuring they receive the best care that encourages recovery. Ethical values – traits including empathy, compassion, sensitivity to others – forms elements of therapeutic relationship.

NUM1207 Module 4.3 The Legal and Ethical Context of Mental Health Care The Law in the Local Context: The Mental Health Act (2014) W.A.

Outcomes ● ● ● ● ● ● ● ● ●

Demonstrate an understanding & purpose of the Mental Health Act 2014 (MHA 14 W.A.), and its application to clinical practice. Identify the key objectives under the MHA 14 W.A. Identify the key forms for assessment, detainment, transport and referral under the Mental Health Act 2014 W.A. Identify the legislative framework(s) pertaining to people in MH care. Describe the assessment and referral process under the Act. Recognise the rights of families, carers and guardians under the MH Act. Outline the nurse/midwife’s role in promoting & upholding the rights of consumers in mental health practice. Describe the provisions made for children under the MH Act. Understand the roles of: Chief Psychiatrist, Mental Health Tribunal, Mental Health Law Centre, Mental Health Advocacy Service.

An introduction to the Mental Health Act (2014) W.A. ● ●

The overall aim of the MHA 2014: is to protect the public & provide care for people with mental illness in the least restrictive manner possible. The Mental Health Act 2014 W.A. (MHA14 W.A.) is informed by: ○ United Nations’ Principles for the Protection of Persons with a Mental Illness; for the Improvement of Mental Health Care (1991); ○ National Mental Health Statement of Rights and Responsibilities (1991)

Mental Health Act ● ● ●

Sharing of responsibility across community; care & protection of people with mental illness Balance between civil rights & need for treatment Enhanced partnerships (patient & services)

The Mental Health Act Principles 1. 2. 3. 4.

Protection of patients rights Least restrictive environment (treatment) Mental illness alone not sufficient for compulsory admission Balance of rights & responsibility for best outcome

Objectives 1. Best care & treatment with least restriction 2. Prevention of harm to self & community 3. Minimise adverse effects on family life

The Charter of Mental Health Care Principles ● ●

Patient centred care The recovery approach

●

Involvement of carers

Expectations for patients who receive care & treatment at mental health services 1. Principle 1: Attitude towards people experiencing mental illness 2. Principle 2: Human rights 3. Principle 3: Person-centred approach 4. Principle 4: Delivery of treatment, care and support 5. Principle 5: Choice and self-determination 6. Principle 6: Diversity 7. Principle 7: People of Aboriginal or Torres Strait Islander descent 8. Principle 8: Co-occurring needs 9. Principle 9: Factors influencing mental health and wellbeing 10. Principle 10: Privacy and confidentiality 11. Principle 11: Responsibilities and dependants 12. Principle 12: Provision of information about mental illness and treatment 13. Principle 13: Provision of information about rights 14. Principle 14: Involvement of other people 15. Principle 15: Accountability and improvement

Referral and assessment process 1. 2. 3. 4.

Assessed by a Medical Doctor or Authorised Mental Health Practitioner. Practitioner considers if the person meets criteria for involuntary treatment. If yes (reasonably suspects) referral to a psychiatrist for examination. Maybe detained/transport order.

Mental illness disturbance of thought, mood, volition, perception, orientation or memory that significantly impairs (temporarily or permanently) judgement or behaviour.

5 criteria for inpatient treatment order Reasons for making the inpatient treatment order: All requirements must be met. 1. the person has a mental illness requiring treatment; 2. because of the mental illness there is a significant risk to the health or safety of the person or to the safety of another person, or a significant risk of serious harm to the person or to another person; 3. the person does not demonstrate the capacity to make a decision about provision of treatment to himself or herself; 4. treatment in the community cannot reasonably be provided to the person; and 5. there is no alternative that would be less restrictive to the person’s freedom of choice and movement

The Authorised mental health hospital ● ●

Strict rules governing which hospitals can receive involuntary mental health patients. Only authorised hospitals (a process governed by the Office of the Chief Psychiatrist) can receive for assessment and treatment a patient under the Mental Health Act (2014) W.A.

Physical examination Any patient admitted to hospital must be offered a physical examination from a medical practitioner within 12 hours (consider physical illness/substance misuse - can mimic MH conditions)

Emergency psychiatric treatment Without consent if needed to save the person’s life, or prevent the person from causing serious physical injury to themselves or others

Common forms in the clinical setting Referral for Examination / Detention ● ● ● ● ● ● ● ● ●

Form 1A - Referral for examination by a psychiatrist Form 1A attachment - Referral for examination by a psychiatrist Form 1B - Variation of referral Form 2 - Order to detain voluntary inpatient in authorised hospital for assessment Form 3A - Detention order Form 3B - Continuation of detention Form 3C - Continuation of detention to enable a further examination by psychiatrist Form 3D - Order authorising reception and detention in an authorised hospital for further examination Form 3E - Order that a person cannot continue to be detained

Transport / Transfer orders ● ● ● ● ●

Form 4A - Transport order Form 4B - Extension of transport Order Form 4C - Transfer order Form 4D - Interstate transfer order (Currently unavailable) Form 4E - Approval of interstate transfer order (Currently unavailable)

Community Treatment Orders ● ● ● ● ● ●

Form 5A - Community treatment order Form 5B - Continuation of community treatment order Form 5C - Variation of community treatment order Form 5D - Request for practitioner to examine patient Form 5E - Notice and record of breach of CTO Form 5F - Order to attend

Inpatient Treatment Orders ● ● ● ● ● ● ● ● ● ● ●

Form 6A - Inpatient treatment order Form 6B - Inpatient treatment order in a general hospital Form 6B - attachment - Inpatient treatment order in a general hospital Form 6C - Continuation of inpatient treatment order Form 6D - Confirmation of inpatient treatment order Form 7A - Grant of leave to an involuntary inpatient Form 7B - Extension and variation of leave Form 7C - Cancellation of leave Form 7D - Apprehension and return order Form 8A - Record of search and seizure Form 8B - Record dealing with seized article

Treatments ● ●

Form 9A - Record of emergency psychiatric treatment Form 9B - Report to Chief Psychiatrist about provision of urgent non-psychiatric treatment

Restraint ● ● ● ● ●

Form 10A - Record of oral authorisation of restraint Form 10B - Written bodily restraint order Form 10C - Record of informing medical practitioner and treating psychiatrist of bodily restraint Form 10D - Record of observations made of restrained person Form 10E - Record of examination of restrained person

● ● ● ●

Form 10F - Variation of bodily restraint order Form 10G - Revocation of expiry of bodily restraint order Form 10H - Review of bodily restraint order by psychiatrist Form 10I - Record of post restraint examination

Seclusion ● ● ● ● ● ● ●

Form 11A - Record of oral authorisation of seclusion Form 11B - Written seclusion order Form 11C - Record of information medical practitioner and treating psychiatrist of seclusion order Form 11D - Record of observations made of secluded person Form 11E - Record of examination of secluded person Form 11F - Revocation or expiry of seclusion Form 11G - Record of post seclusion examination

Access to Information ● ● ● ●

Form 12A - Nomination of nominated person Form 12B - Refusal of request to access document Form 12C - Restriction on freedom of communication Form 12C - attachment - Restriction on freedom of communication

ECT ●

Form 13 - Statistics about ECT (contact OCP monitoring if required)

Carer and family rights Under the Mental Health Act (2014) W.A. ● Type of mental illness being given treatment ● Involuntary patient & grounds for admission ● Care & treatment proposed & other options ● Services available, support & accessibility ● Rights patient/carer, review of treatment/support & discharge planning

Provisions specific to children Under the Mental Health Act (2014) W.A. Nurses, midwives and clinicians under the MH Act must act in; ● Regard to child's wishes ● Involve parents/guardians in discussions ● Safeguards & recognition of vulnerability ● Youth advocate ● Best interests of child ● Child’s health & safety paramount

Monitoring of the Mental Health Act For people under the Act

1. Office of the Chief Psychiatrist a. Responsibility for medical care/welfare of all involuntary patients. Other states - monitors standards of psychiatric care in the state.

2. Mental Health Tribunal a. Reviews of involuntary patients detained in authorised MHfacilities or (CTOs) to ensure the best treatment is being provided.

3. Mental Health Law Centre a. Aim: to promote the legal & social rights, & responsibilities of involuntary MH consumers.

4. Mental Health Advocacy Service a. Answer questions about the patient's admission. Provide Information about treatment. Advocate/ assistance to exercise their duties.

In summary ● ● ● ● ● ●

Mental Health Act 2014 W.A. is legislation that protects the rights of consumers and families living with mental illness. Guides practice, policy, procedure in the care, treatment, & support of voluntary & involuntary patients. The treatment ‘forms’ guide what is correct practice & mandated by the law - must be adhered to & followed. Safeguards & advocacy services in place to support the person, family & caregivers. The nurses role in accurate assessment, patient centred-care and best treatment/ practice options – in the least restrictive manner. The (ongoing) importance of documentation & legal responsibility.

NUM1207 Module 5.1 Anxiety & Anxiety Disorders An Introduction to Anxiety and Anxiety Disorders

Outcomes ●

● ●

Describe the distinguishing features of anxiety across the following manifestations; ○ biological, ○ psychological and ○ behavioural . Identify how ‘physiological’ anxiety differs from an anxiety disorder. Identify and describe common features of anxiety disorders. Describe the four theories of causation for the development of anxiety disorders. Describe the contributing factors to the development (potential risk factors) for development of anxiety disorders.

Overview to Anxiety & Anxiety Disorders Statistics ● ● ● ● ●

Present statistics show 14.4% of the Australian population have a diagnosed anxiety disorder. 10% of the population experience anxiety at a level that affects their daily life. Females are identified as experiencing anxiety more than males (17.9% compared with 10.8%). Anxiety is a normal human experience & affects various systems of the body. Anxiety affects individuals biologically, psychologically and socially. Identifying the difference between anxiety and an anxiety disorder is often difficult, identifying the difference is extremely important. Anxiety disorders are recognised psychiatric conditions, but anxiety can also be present, as a symptom in a range of psychiatric disorders.

Accurate diagnosis of anxiety disorder is important, as treatments vary from one anxiety disorder to another.

Anxiety disorders Theories of causation ● Biological theories ○

genetic inheritance, altered brain chemistry. Learning theories - acquired through learning by association, reinforcements through role modelling.

● Cognition theories ○

a trigger in the environment leads to the person thinking in distorted ways and this exacerbates anxious feelings and behaviours.

● Social – ecological theories ○

The environment as well as social events can play a role in creating stress, depleting coping mechanisms.

● Social media ○

is having an increased influence on mental health, specifically anxiety disorder.

Contributors to the development of anxiety disorders Potential risk factors: Biological: ●

Genetics, drugs, drug withdrawal, inadequate nutrition,

Medical: ●

chronic illness, menopause, depression, endocrine (thyroid/adrenal).

Psychological: ●

Coping strategies, traits, self – talk or thinking processes, trauma, anticipatory distress/stress. Early childhood experiences.

Social/ecological: ●

Accumulative stress - life events, life changes, bullying, social media influences.

Everybody experiences anxiety at some time, BUT anxiety disorders are an exaggeration of a normal response. ● It is long lasting ● is more severe ● It interferes with a person’s work and relationships

Physiological response to anxiety Common signs & symptoms Physiological response to anxiety Cardiovascular ● ● ● ●

Palpitations Chest pain Increased HR Flushed face

Respiratory ● ●

Hyperventilation Shortness of breath

Neurological ● ● ● ●

Dizziness Light headed Headache Tingling & numbness

Gastrointestinal ● ● ● ● ●

Choking Dry mouth Nausea Vomiting Diarrhoea

Musculoskeletal ● ● ●

Muscles aches & pains Restlessness Tremor/shaking

Psychological response to anxiety Signs, symptoms, emotional responses, thoughts ● Unrealistic or excessive fear & worry, nervousness, feeling ‘on edge’ ● Mind racing or going blank ● Decreased concentration & memory ● Indecisiveness & confusion ● Irritability, impatience, anger ● Tiredness, sleep disturbances, vivid dreams ● “A sense of doom” ● Panic attacks ● Depression

Behavioural response to anxiety ● ● ● ● ●

Avoidance of situations Distress in social situations Becoming overly attached to an object, routine or a person Phobic behaviour Increased use of alcohol of other drugs

In summary ● ● ● ● ●

Anxiety disorders are a prevalent mental health issue in Australia. Contributors to the prevalence of anxiety disorders include biological,psychological and social risk factors and it is important to understand and recognise these. The nurse & midwife should understand and recognise the common biological, psychological and behavioural signs and symptoms of anxiety =accurate assessment, care and referral. Know the difference between anxiety as a natural biological reaction and how this may reflect from a physiological (fight & flight) response. Effective assessment, will identify if the presentation is associated with a (biological /medical presentation) or a mental health concern.

NUM2307 Module 5.2 Anxiety & Anxiety Disorders Assessment and Diagnosis of Anxiety Disorders Outcomes ● ● ● ●

Identify and describe what assessment tools are required in the assessment and diagnostic process for anxiety disorders. Examine the importance of a physical assessment when assessing for anxiety disorders. Understand the importance of / and describe the risk assessment process associated with anxiety disorders. Outline the nursing assessment specific to anxiety and anxiety disorders. Describe the principles of care for effective assessment and treatment of consumers living with anxiety/anxiety disorders.

Assessing and diagnosing anxiety & anxiety disorders ● ● ● ● ● ● ● ●

Where do you go for help – GP, primary health care professional, midwife, Aboriginal and Torres Strait Islander health worker, multicultural health worker and ED with physical issues. Referral – mental health services, mental health nurse, psychologist, psychiatrist. Environment for the assessment – safe, comfortable and free from distraction or triggers. Physical assessment – baseline, eliminating underlying physical health conditions. Psychosocial history –predisposing, precipitating and perpetuating factors. Drugs and alcohol misuse – increased risk of misuse. Risk – self harm and suicide. Diagnosis – DSM-V, observations and all information gathered from assessments.

Anxiety screening & assessment tools ● ●

All anxiety screening tools are carried out prior to, or as part of a comprehensive mental health assessment and should be ongoing. Self screening tools are available on most mental health web sites – Beyond Blue, Black Dog Institute And Headspace.

Common screening tools ● ● ●

GAD – 7 DASS (Depression, Anxiety & Stress Scale), K-10 (Kessler Psychological Distress Scale) Antenatal Risk Questionnaire (used in conjunction with the Edinburgh Post Natal Depression Scale)

Physical assessment ● ● ● ● ● ●

Rule out any underlying medical condition. Assess the impact of the physical symptoms of anxiety. Identify any self harm wounds that require immediate treatment. Treat side effects and/or withdrawal from medications or substance misuse. Identify short term physical issues/conditions (headaches, dizziness, weakness, impaired sexual functioning). Assess for any possible long term effects (heart disease, respiratory, digestive, immune or sexual health issues).

Risk Assessment ● ● ●

Individuals with an anxiety disorder or anxiety related conditions are at a higher risk of suicide & engaging in self harming behaviors. Risk assessment identifies immediate risk and interventions can be initiated to avoid further harm and safeguard the patient. Carried out on first contact (GP, referral or inpatient) and continually utilized until the risk has significantly reduced or been eliminated.

Nursing and Midwifery Assessment Principles of Care 1. 2. 3. 4. ● ● ● ●

Respect Empathy Positive regard Validate

Risk management Co-existing conditions MSE Co-existing conditions

In summary ● ● ● ● ● ●

It is important to understand where individuals experiencing anxiety can go for help. There are many factors that need to be considered when assessing and diagnosing anxiety disorders. Many assessment and screening tools available, to meet the diversity of anxiety disorders, these should all be carried out as part of a comprehensive mental health assessment Physical assessment is essential to identify any underlying physical condition,comorbidities, self harm injuries and to reduce the risk of long term physical conditions. Risk assessment is essential to identify and eliminate any immediate risk and implement interventions to avoid further harm Anxiety is a treatable condition and accurate assessment and diagnosis can reduce the biopsychosocial impact on individual lives and reduce long term risks.

NUM2307 Module 5.3 Anxiety and Anxiety Disorders Generalised Anxiety Disorder & Social Anxiety Disorder Outcomes ● ● ● ● ● ● ●

Outline a beginning understanding of the epidemiology and aetiology of Generalised Anxiety Disorder (GAD). Outline the key signs and symptoms of (GAD). Outline a beginning understanding of the epidemiology and aetiology of Social Anxiety Disorder (SAD). Outline the key signs and symptoms of SAD. Consider the nurse and midwife’s role in the assessment and care of people experiencing generalised anxiety disorder and social anxiety

Generalised Anxiety Disorder (GAD) Debilitating condition, characterised by excessive or unrealistic anxiety about two or more aspects of life (e.g. work, social, relationships, finances), often accompanied by physical symptoms (shortness of breath, chest pain, palpitations, dizziness).

Prevalence ● ● ●

Accounts for 2.7% of anxiety disorder (14.4). More common is women than men (6.6% vs 3.6%). 18 – 34 years has the highest prevalence.

Aetiology/causes ● ●

Increased risk of GAD with a family history of anxiety disorder, prolonged stressful situations and/or childhood trauma. Excessive use of caffeine or tobacco – reported to increase worry associated with GAD.

Signs & symptoms & nurse/midwife considerations ● ● ● ●

Physiological – ‘fight or flight’ – adrenergic response (elevated clinical obs). Constant excessive (uncontrollable) worry, inability to focus or concentrate & sleep. Can increase risk of physical health issues if left untreated. Comorbidity – muscle tension, gastric reflux, thyroid disorders, cardiac issues.

Social Anxiety Disorder (SAD) social phobia Social Anxiety Disorder (SAD) is characterised by an excessive fear in social situations.

Prevalence ● ●

Constitutes 4.7% of all anxiety disorders (total all anxiety disorders 14.4%). More prevalent in females, more common in younger age groups.

Aetiology/causes Exact cause unknown - combination of biopsychosocial factors, negative childhood experiences, bullying, learned behaviour.

Symptoms Bio: ●

Physiological manifestations of anxiety (fight/flight response).

Psych: ●

Excessive fear/worry of social situations (avoidance). ○ Fear of being judged, teased or criticized, embarrassed. ○ Feelings of dread, & panic attacks.

Social: ● ●

Avoiding social situations - affect daily activities, education, work, relationships. Lead to isolation.

Assessment & screening of GAD & SAD Assessment & referral ● ● ● ● ●

Most will present at the GP for help with physical symptoms associated with anxiety. GP - carry out a screening test for anxiety and refer to a specialist or psychiatrist for further assessment. Specific measuring tools for social/generalised anxiety disorder will be used. Questionnaire, that measures the severity of the signs and symptoms specific to the disorders. Diagnosis is made by a psychiatrist utilising observations and assessments collected by the nurse/midwife and MDT, in conjunction with the DSM-5.

Treatment and Therapy – GAD & SAD ● ● ● ● ● ● ● ● ●

Sleep Health diet,exercise Benzodiazepines Yoga/Meditation GAD CBT Reduce alcohol,tobacco & caffeine Exposure therapy SAD Self help techniques SAD Psychodynamic therapy SAD

Prognosis & recovery Receiving help and support, with effective treatment and therapy options specific to the individual diagnosis, can reduce the effects significantly, allowing individuals affected to live a full and productive life.

Prognosis GAD ● ● ●

If left untreated prognosis can be poor - physical health problems will worsen - risk of developing secondary depression. Without treatment - high relapse rate and considered chronic fluctuating disorder. 50% of those affected will be symptoms free within approx. 6 months (treatment/therapy).

Prognosis SAD ●

If left untreated - exhausting, debilitating and symptoms can worsen.

● ● ● ● ●

SAD is a treatable condition, with accurate assessment, diagnosis, treatment therapy and support recovery is possible. Nurse & midwife should consider their role on positive recovery outcomes Education, provision of resources, support group referral. Provide a safe, secure environment, acknowledge consumers (fear/worry) related to ‘anxiety’ signs & symptoms. Therapy in conjunction with medications, consistent support (nurse/midwife/MDT & family).

In summary ● ● ● ● ●

Social and generalised anxiety disorders are the most recognised anxiety disorders, with a higher prevalence in females and can affect a wide range of age groups. Although both disorders have similar symptoms, social anxiety is concerned with excessive fear and generalised anxiety disorder with excessive worry. Combining medication, therapy and lifestyle changes, with ongoing support from health professionals will promote positive recovery outcomes for those affected to live a full and productive life. Nurses and midwives should be aware of the differences and similarities in both presentations to effectively care for and support people living with both disorders. Appropriate assessment, diagnosis and treatment/therapy is a necessity in treating patients holistically to provide the best recovery outcomes possible,for a full and productive life.

NUM2307 Module 5.4 Anxiety & Anxiety Disorders Obsessional Compulsive Disorder, Panic Disorder, Agoraphobia and Specific Phobias Outcomes ●

● ● ●

Describe the central characteristics of; ○ Obsessional Compulsive Disorder (OCD); ○ Panic disorder; ○ Agoraphobia ○ Specific phobias. Identify the contributing factors (potential risk) to the development of OCD, panic disorder, agoraphobia and specific phobias. Describe the key presenting symptoms/features/behaviours of OCD, panic disorder, agoraphobia and specific phobias. Describe the assessment(s), treatment and general nursing/midwifery principles of care for people with specific anxiety disorders.

Obsessional Compulsive Disorder ● ●

Obsessional Compulsive disorder also known as OCD is characterised by obsessions and compulsions. OCD accounts for 1.9% of all anxiety disorders.

Obsessions ●

Common obsessions are; contamination, pathological doubt, need for symmetry, routine and structure, also excessive religious focus).

Compulsions ●

Common compulsions are; excessive hand washing, cleaning, checking doors, switched and electrical appliances, lining things up or counting repeatedly, excessive praying.

Causes / or contributing factors ●

biopsychosocial and environmental factors, family history, trauma in childhood from illness or experience, family conflict (in combination with other factors), learned behavior.

Treatment ●

CBT, behavioral and e-therapies.

Nursing & Midwifery care ● ● ● ●

Support, acknowledgement, encouragement, nonjudgmental, family inclusion. Working collaboratively with the patient and the MDT for positive recovery outcomes. Psychoeducation and support as well as lifestyle changes can help. Medication management (in conjunction with the treating team) can be used but only in severe cases.

Panic Disorder ●

Panic disorder is characterised by unpredictable intense experiences, episodic anxiety surges, often described as “panic attacks”.

Stats: ● ●

2.6 % of all anxiety disorders, more common in women (5%) men (2%). Ages between 15 and 25.

Symptoms ●

clinical manifestations of anxiety (e.g. shaking, tachycardia, difficulty breathing) frequent panic attacks that exceed a specific time margin.

Factors known to increase risk: ●

family history, genetics, chronic medical conditions, negative childhood experiences, ongoing unrelenting stress.

Treatment options: ● ●

Psychological interventions (CBT), medications only have a moderate influence.

Nursing & midwifery care ● ● ● ●

Supporting patients with anxiety and panic free form judgement. Acknowledgement of their situation, encouragement to participate in treatment and therapy. Provide a safe environment. Ensure physical assessment and clinical obs (to rule out underlying medical conditions)

Agoraphobia ● ●

Agoraphobia is a cluster of phobias, where there is excessive fear of open spaces, using public transport, going outside, travelling and crowds. This is a disorder that will significantly impact a person’s life without help.

Stats ● ●

2.8% of all anxiety disorders more common in females.

Symptoms ●

Social withdrawal, panic attacks when trying to leave the house, becoming increasingly dependent on others, (including the physical manifestations of anxiety).

Factors known to increase risk ●

Genetic vulnerability, trauma in childhood, previous anxiety disorder diagnosis.

Measurement tool ●

Severity Measure for Agoraphobia (used with comprehensive mental health assessment, inclusive of physical assessment).

Treatment options ● ● ●

Psychotherapy, CBT and exposure therapy. Lifestyle changes, including meditation. Medications can help relieve symptoms.

Specific Phobias ●

A specific phobia is where someone has developed a fear that is disproportionate to the actual level of risk, which is persistent and irrational

Factors that may increase risk ●

Genetic vulnerability, family history of a specific phobia (can be learned behavior), traumatic experience.

●

Specific phobias tend to develop in early childhood, however it is possible to develop a specific phobia at any age.

Treatment ●

Specific phobias are treatable with professional help and support from families/community

In summary ● ● ● ● ● ●

Obsessive compulsive disorder (OCD), panic disorder, agoraphobia and specific phobias are less common than other anxiety disorders but can impact lives significantly. Symptoms of these disorders are similar; however the characteristics are differentand accurate assessment and diagnosis by a qualified professional is essential. Seeking professional support is the first step towards recovery and although not curable OCD, panic disorder, agoraphobia and specific phobias are treatable. Nursing and midwifery care should include the establishment of the therapeutic relationship, providing a safe and calm environment (where possible). Validation and acknowledgement of the person's behavioural/emotional responses will assist in calming and reassuring the consumer/patient. Include family/caregivers where possible and in conjunction with the person's needs/wants.

NUM2307 Module 5.5 Anxiety and Anxiety Disorders Clinical and Therapeutic Treatment Modalities Related to Anxiety and Anxiety Disorders Outcomes ● ● ● ● ● ●

Identify treatment approaches and nursing & midwifery strategies in the care and management of anxiety and anxiety disorders. Describe the primary aim for drug treatment for anxiety disorders. Identify the main side effects associated with drug treatments for anxiety disorders. Outline the main therapeutic interventions for the management, care and treatment of anxiety and anxiety disorders. Outline the importance of educating people and their families about pharmacological and non pharmacological treatments for anxiety disorders. Describe the role of the multidisciplinary team and the integration of specialty care for a ‘holistic’ approach to assessment.

Skilled nursing & midwifery care General strategies that nurses and midwives can use to help people who do not go on to develop an issue with anxiety include: ● therapeutic engagement empathetic non-judgemental ● develop personal coping strategies ● manage medications ● diversional techniques ● safe supported trust listen validate ● address lifestyle factors ● encourage relaxation techniques

Therapeutic interventions Medications ● ● ● ● ● ●

Anxiolytic (reduce intensity) Low dose antidepressant Care: monitor for side effects Interactions Risk Clinical obs

Behavioural Therapy ● ● ●

Breaking (negative) associations through guided exposure Care: conjunction with MDT Encourage relaxation mindfulness

Cognitive Behaviour Therapy ● ●

To alter their thought processes and behaviors Strategies the promote logical thinking about how they respond to situations

Develop Personal Coping Strategies & Mindfulness ●

Anxiety disorders are not stand-alone conditions with time limitations

They tend to be self perpetuating and contribute to high levels of stress that lead to co-morbid conditions. Often they get worse instead of better.

Drug treatment for anxiety disorders Anxiolytics: CNS depressants – reduce the body's response to adrenaline and noradrenaline. Slowing down & calming effect

Primarily aim ●

Relieve symptoms of acute anxiety states

Side effects ●

Drowsiness & sedation, impaired memory & concentration, low mood, poor motor coordination, moodswings, irritability.

Treatment & management ● ● ● ●

Generalised anxiety disorder (GAD) Panic disorder Post traumatic stress disorder Obsessive compulsive disorder

MDT Collaboration Because of the persistent, self perpetuating characteristics associated with anxiety and anxiety disorders, even with successful treatment and therapy, it is important to address all areas of an individual's life (biopsychosocial) = MDT to avoid recurrence of anxiety and anxiety disorders.

In summary ● ● ● ●

Effective patient centred nursing and midwifery care is about supporting, educating and empowering patients/consumers to make informed treatment and therapies choices specific to their individual diagnosis and biopsychosocial circumstances. It is important as nurses and midwives to educate patients about what they might experience, who to talk to if they are concerned, how and when to take the medication and the importance of not ceasing the medication without medical support and advice. Ongoing education for individuals and their families and/or carers about pharmacological and non pharmacological treatments and therapies is essential to maintain biological, psychological and social aspects. Collaboration of the MDT is there to ensure a range of skills, knowledge and experience are utilised to promote medication/therapy compliance with holistic support measures to provide the best possible recovery outcomes for those living with anxiety and anxiety disorders.

NUM2307 Module 6.1 Trauma and Stress Related Disorders An Introduction to Trauma Related Disorder Outcomes ● ● ● ● ● ● ●

Outline the reclassification of trauma and stress related disorders. Describe what is meant by trauma and stress related disorders. Describe the difference between trauma, crisis, acute crisis and stress. Describe what crises may affect people across their lives from a biopsychosocial perspective. Describe how vulnerability and resilience will impact a person's ability to manage crisis and stress. Understand how change reflects the significance of trauma as a cause of mental illness. Outline ways in which the nurse and midwife can provide information to consumers around strengthening resilience.

Overview of trauma, crisis and stress ● ●

Traumatic incidents, crisis, loss and grief can result in significant destabilisation for some people. DSM-V category changes from anxiety disorders to traumatic stress disorders.

Trauma or a traumatic event It will trigger psychological and emotional distress resulting in suffering and a disruption to the individual’s physical and emotional wellbeing.

Crisis ● ●

A dangerous situation that requires attention. Usual coping mechanisms fail to respond adequately because they are overwhelmed.

Acute state of crisis ● ● ●

Can become an emergency situation. Stress is an inevitable part of the human experience. Excessive stress can also lead to issues associated with mental health.

Early intervention is best for recovery

Loss and Grief Experiencing loss and grief are a part of human life

Loss Where something meaningful is taken away Minor to devastating

Bereavement Relates to the loss of a loved one

Grief A natural response to loss may experience range of feelings, thoughts, behaviours The nurse and midwife should assess and monitor for psychosocial impacts

Effects of grief relationship breakdown, disconnection, conflict (due to emotions), maybe vulnerable for depression (assessment & review), increase in emotional pain (self-medication) = alcohol, drugs.

Health promotion exercise, healthy diet, fresh air, friends, family.

Resilience and mental health Resilience ● ●

Is used to explain the ability to cope with life events (positive & negative) & to grow from the experience in most cases. When you have the right amount of resilience at the right time during a crisis, it can act as a catalyst to stimulate a whole cascade of other internal and external factors.

Resilience can be strengthened in consumers by; ● ● ● ●

Knowing strengths, building self esteem, knowing when to ask for help. Build and maintain healthy relationships. Manage stress and anxiety levels, making mistakes and learning from them. Problems solving skills and coping strategies.

Model for resilience Domains Spiritual, biological, psychological, social, emotional - significant role in enhancing the experience of resilience for individuals

Reconnection – key elements Support of nurse, midwife (health care), family, friends, community ● Values Needs Aspirations Future ● Independence ● Self worth ● Control

In summary ● ● ● ● ● ● ●

Trauma and stress related disorders are a separate category from anxiety disorders. If left untreated, trauma can develop and affect adult life, as such early identification by the health care team is key for the recognition of the impact of loss/grief on the person to prevent chronicity of mental health related effects. Crisis, regardless of severity, requires attention to avoid progressing to an emergency situation and an accurate risk assessment should be undertaken as part of the comprehensive assessment. Loss and grief, although a normal part of life, need to be recognised and those affected supported to avoid developing into depression. The nurse and midwife (and appropriate MDT) should have an understanding of the effect loss and grief can have from a biopsychosocial perspective. The therapeutic relationship, compassionate care and referral to specialist services for support is key for supportive person-centred holistic care. Understanding the importance of resilience, reconnection and support for ongoing recovery is an essential part of nursing and midwifery practice.

NUM2307 Module 6.2 Trauma and Stress Related Disorders Post Traumatic Stress Disorder (PTSD) Outcomes ● ● ● ● ●

●

Identify the aetiology and epidemiology of Post Traumatic Stress Disorder (PTSD). Describe the types of trauma which may be responsible for PTSD. Identify the symptoms and characteristics of PTSD. Outline the comorbidities associated with PTSD. Describe the: ○ -screening; ○ -assessment; ○ -treatment and recovery outcomes for PTSD. Describe the nurse and midwife's role in the process of assessment, screening, and recovery from people with PTSD.

Introduction ● ● ● ● ● ●

Post-traumatic stress disorder (PTSD) is a disorder that develops in some people who have experienced a shocking, fear evoking, or dangerous event. PTSD develops in about 1 in 3 people who experience severe trauma. Women are more vulnerable. Can affect anyone at any age. Up to 57% of Australians experience a traumatic event at some stage in their lives. Aboriginal peoples living in remote Western Australia - concerning high rates of PTSD at 55.2%.

Aetiology ● ● ● ●

Ity is not fully understood why some people develop the condition while others do not – known that traumatic experiences lead to PTSD. Not everyone with PTSD has been through a dangerous event. Culture - can influence the risk of PTSD. History of depression and/or anxiety are more susceptible to developing PTSD after a traumatic event.

Post Traumatic Stress Disorder (PTSD) For diagnosis: Establish that an individual has been exposed to an extreme stressor that satisfies the DSM-5 definition of trauma. 1. directly experienced the event, witnessed it, or learned about it indirectly; 2. the event must have been life-threatening; 3. involved serious injury, or threatened physical integrity; 4. it must have triggered an intense emotional response of fear, horror, or helplessness. Team would also assess for exposure to other traumatic events across the life span.

Symptoms & characteristics Symptoms and characteristics of PTSD can vary between individuals and depends on the trauma or experience which has caused the PTSD.

Re-experiencing where the individual re-lives the trauma or experience (flashbacks, nightmares).

Avoidance avoiding people and places that remind them of the event.

Emotional numbing trying not to feel anything at all can include using drugs and alcohol.

Hyperarousal constantly aware of surroundings and possible threats (hypervigilant), difficulty switching off and relaxing (Irritability, sleeping problems, concertationimpaired).

Physical symptoms headaches, dizziness,chest pains and digestive issues.

Psychological symptoms depressed mood,anxiety, self-harming/destructive behaviours.

Trauma and PTSD exposure Nurses and midwives when gathering information should consider historical/precipitating factors. Rates of PTSD are shown to be much higher after exposure to specific types of interpersonal trauma: ● Sudden death of a loved one. ● Natural disasters (e.g., bush fires, earthquakes, hurricanes). ● Terrorist attacks, ● Car or plane crashes. ● War, kidnapping. ● Assault, sexual or physical abuse. ● Childhood neglect. It is important to remember that not everyone who experiences a traumatic event will suffer from PTSD.

Comorbidities ● ●

It is estimated that up to 80% of PTSD patients have a comorbid disorder. The best results are achieved when both PTSD and the other disorder(s) are treated together.

Depression Depression is approximately three to five times more likely in people who have PTSD, and often occur simultaneously.

Anxiety A symptom of PTSD, also an increased chance of developing an anxiety disorder.

Substance use/abuse PTSD risk factor for developing substance misuse/abuse comorbidity, and substance misuse/abuse a risk factor for developing PTSD after a trauma.

Nurse and midwife need to consider ● ●

Accurate assessment (signs & symptoms) – nurse/midwife clinical formulation key to referral to appropriate services/care. Risk assessment – suicidal ideation/plan.

It is important to note that any traumatic event, especially those experienced in child hood or of an interpersonally violent nature, are at a higher risk of suicide.

Assessment & treatment Assessment ●

risk assessment, comprehensive mental health & the impact of event scale is a scale.

Medications ●

not recommended as a first line intervention (anti-anxiety / some anti depressants) = symptomatic relief.

Therapy ●

CBT, acceptance & commitment therapy, self-help treatments.

Psychoeducation ●

self awareness, resources, identifying strengths.

Trauma Informed Care ●

do no harm, work to understand what happened, not what's wrong.

Reassurance, validation and support and the initial most beneficial nursing & midwifery interventions.

Recovery focus The nurse & midwife’s role in promoting lifestyle changes, mental health & wellbeing ● Manage co-morbidities ● Address any physical complications ● Referral to specialist services (treatments, therapies, service providers, support) ● Promote lifestyle changes ● Establish a regular routine ● Focus on self care ● Limit further exposure ● Grounding techniques ● Connect to social supports ● Education ● Seek help

In summary ● ● ● ● ● ● ● ●

There are a variety of causes for PTSD and it is important for nurses and midwives' to be aware of the causes to enable them to consider interventions required for long term recovery. Therapeutic principles of compassion, understanding, kindness, validation of persons experiences is paramount in all care and interactions. PTSD symptoms vary between individuals and depend a lot on the event, a holistic biopsychosocial approach is best practice. Assessment must respond to the consumers account and care and treatment must be reflective of their needs. Individualised care plans are essential to ensure the multidisciplinary team is working to the needs of the consumer. All nursing and midwifery care needs to be in collaboration with the consumer so that their strengths are recognised and built on. Anxiety depression and/or substance abuse are common comorbidities of PTSD and screening, a comprehensive assessment and referral should occur. Inclusion and acknowledgement of the needs of family /caregivers in the process is part of the process of person centred/trauma informed care.

NUM2307 Module 6.3 Trauma and stress related disorders Acute Stress Disorder & Adjustment Disorder Outcomes ● ● ● ● ● ●

Describe the difference between Acute Stress Reaction and Acute Stress Disorder (ASD). Outline the factors that can influence stress reaction. Briefly outline the incidence and prevalence of both AD & ASD. Describe the symptoms and key characteristics of ASD and AD. Describe and outline the goals of treatment for ASD and AD. Identify the nurse and midwife's role in the assessment and care of a person experiencing ASD and AD.

Introduction to Stress Disorders Acute Stress Reaction ● ● ● ●

refers to the symptoms of the development of transient emotional, cognitive and behavioural symptoms in response to an exceptional stressor. Symptoms are considered to be within the normal range of reactions given the extreme severity of the stressor. Symptoms - hours to days after stressful stimulus. Subside within a week after the event or following removal from the threatening situation.

Introduction to Acute Stress Disorder (ASD) Acute Stress Disorder an intense, unpleasant, and dysfunctional reaction beginning shortly after an/or exposure to an overwhelming traumatic event - symptoms experienced 48-hours to one-month following the event.

Incidence ● ● ●

Between 5 – 20% of those who experience trauma will develop ASD, and more than half of those will go on to develop PTSD. Likelihood of developing acute stress disorder is greater when traumatic events are severe or recurrent. First responders and emergency services are at a high risk of developing ASD.

ASD is similar to PTSD but nurses and midwives need to be able to recognise the differences; ● Shorter duration. ● Shorter interval between trauma and symptoms. ● Three dissociative symptoms (detachment, numbing, dissociative amnesia, decreased awareness of surroundings). ● The dissociative symptoms will interfere with effective coping.

Acute Stress Disorder (ASD) Causes and risk factors associated with ASD ● ● ●

Having experienced trauma in the past. Having a mental illness before the trauma. Experiencing a trauma that is severe.

● ● ●

Experiencing physical assault. Using avoidant coping strategies (often drugs and alcohol). Being female.

Cause of trauma/event needs to be known and documented to assist with effective assessment and interventions and management. ● ●

May also experience depression, anxiety, accompanied by an overwhelming sense of hopelessness and despair. Risk assessment is essential as part of the nursing process = high risk for suicide which can be unpredictable and impulsive.

Diagnostic criteria - DSM-5 ASD Exposure to actual or threatened death, serious injury, or sexual violation in one (or more) of the below; 1. Directly experiencing the traumatic event(s). 2. Witnessing, in person, the events(s) as it occurred to others. 3. Learning that the traumatic events(s) occurred to a close family member or close friend. 4. Experiencing repeated or extreme exposure to aversive details of the traumatic event (first responders).

(9) or more signs and symptoms over five categories (DSM-5): 1. Intrusion: a. recurrent and intrusive distressing memories of the traumatic event e.g. flashbacks.

2. Negative mood: a. persistent inability to experience positive emotions.

3. Dissociation: a. altered sense of reality of surroundings or self (being in a daze, time slowing).

4. Avoidance: a. of feelings, memories, places or people associated with the trauma.

5. Arousal: a. sleep disturbance, irritable and angry outbursts , hypervigilance, inability to concentrate, startle response.

Introduction to Adjustment Disorder (AD) Adjustment Disorder stress-response syndrome – sometimes referred to as situational crisis or situational depression. ● Abnormal (maladaptive) and excessive reaction to an identifiable life stressor. ● Characterised by a limited ability to adjust or cope with a significant, negative life event(s). ● Often seen when a stressful event prompts a lengthy and extreme negative reaction.

Incidence ● ●

5 – 20% of all mental illnesses in Australia, almost 50% of inpatient facility beds in Australia. 70% of people diagnosed with AD are also diagnosed with other mental illnesses.

Causes and risk factors The following are some of the known causes and risk factors associated with AD: ● Relationship or interpersonal problems (divorce or marital problems) ● Changes in situation (retirement, having a baby, moving) ● Adverse situations (losing a job, loss of a loved one, financial issues) ● Problems in school or at work (bullying) ● Ongoing stressors (medical illness or living in a high crime area) ● Life experiences

The nurse & midwife should assess for ●

Not everyone who experiences stress will develop this condition.

●

Factors more susceptible to stressors; genetics, resilience and coping strategies.

Signs, symptoms & experiences Biological ●

Insomnia & fatigue, body pain, twitches, indigestion, nausea, hypertension, tachycardia, diaphoresis, weight loss/gain, appetite changes, drugs/alcohol use/misuse, chronic illness, terminal diagnosis.

Psychological Related to emotions, feelings, thoughts ● Anxiousness & restlessness, sadness & crying, withdrawn, hopelessness, feeling trapped, reduced self esteem, suicidal thoughts, lack of concentration, memory issues, feeling anxious, overwhelmed, loss / grief

Social Behaviours: ●

rebellious, impulsive actions,

Impacts on: ●

Relationship issues, housing, employment, financial issues, education, social groups, friends bullying

Diagnosis and assessment adjustment disorder The nurse/midwives role in diagnosis and assessment includes:

Effective communication: ●

Without this no information can be obtained for accurate assessments (including risk assessments), building effective therapeutic alliances will enhance trust.

Observing: ●

(non-verbal) – withdrawal, isolation, risk taking behaviours, anxious/restless, crying.

Assessing: ● ● ● ●

physical assessment, risk assessment, working with MDT (psychological & social assessments) including severity measures. AD is often screened for in vulnerable populations. Aboriginal and Torres Strait people (aged 12-24) are a high risk population.

Documenting: ●

progress notes, reporting changes, increasing observations if required, legal documentation (MH Act, 2014).

Supporting: ●

educating and cultural safety are also part of the nurse/midwife role in caring for those with adjustment disorder.

Diagnosis is carried out by a psychiatrist who will utilise a comprehensive mental health assessment, which will have been carried out by nursing/midwifery and MDT, and will be in line with the DSM-5 criteria for AD

Treatment ● ●

Treatment for ASD will depend on the trauma, cause and risk factors that will be individual to the person affected. The goals of treatment for stress disorders focus on resolving symptoms and improving everyday functioning – prevent onset of PTSD.

How the nurse and midwife can facilitate goals for treatment and recovery

● ● ● ● ●

Minimise immediate risk identified through assessment. Medications for symptom relief. Focus on psychoeducation providing needed support and resources. Screening and diagnosis of possible comorbid mental illnesses. Ongoing treatment includes trauma-informed care approaches, crisis intervention psychotherapies (CBT), mindfulness based approaches.

Recovery Adjustment disorder ● ● ● ●

There is no guaranteed way to prevent an adjustment disorder. AD is considered a short term mental health condition that responds well to therapy and professional support. The primary goal for AD is to relieve symptoms and to help an individual achieve a level of functioning comparable to what they demonstrated prior to the stressful event. The prognosis for adjustment disorder is very positive

Acute stress disorder ●

The prognosis for ASD is a positive one, it is a short term condition that most people recover from, even those who go on to develop PTSD can recover within several months.

In summary ● ● ●

● ●

Stress disorders are common mental health conditions seen in a variety of settings throughout health care. As a nurse or midwife, it is important to observe common symptoms which are often the product of maladaptive reactions. Nurses and midwives play an important role in supporting individuals, reducing stress, and educating on using healthy coping mechanisms to help relieve symptoms and restore function in all areas of life. Immediate intervention can make a big difference, helping someone right after a trauma can help prevent the progression of situational/stress disorders. Nurses/midwives need to be active in collaborating with the MDT for a holistic care approach focusing on the biopsychosocial elements for effective recovery outcomes. Therapy and professional support shows good recovery outcomes with most people recovering in a relatively short period.

NUM2307 Module 6.4 Trauma and Stress Related Disorders Treatment Modalities and Nursing and Midwifery Interventions

Outcomes ● ● ● ● ● ●

Describe the nursing/midwifery approach to a person who is in crisis. Identify treatment approaches and nursing & midwifery strategies in the care and management of trauma and stress related disorders. Describe the Stress-Vulnerability Model. Describe the drug treatment and therapy options for trauma and stress related disorders and their primary aim. Understand the importance of educating people and their families about pharmacological and non pharmacological treatments for ASD & AD. Understand the importance of promoting cultural safety when undertaking nursing and midwifery interventions and for ongoing care.

Skilled nursing & midwifery care Therapeutic engagement ●

sensitive communication, caring, compassion, respect, validation of feelings, being empathetic, on-judgmental, trusting.

Assessment, planning and implementation ●

risk assessment, comprehensive mental health assessment, physical assessment, severity scales, psychoeducation, provide resources.

Trauma Informed Care (TIC) approach ●

practices that promote a culture of safety, empowerment and healing.

Crisis intervention ●

the safety of the suicidal person and others in imminent harm must be preserved and maintained.

MDT ●

collaborate with MDT for holistic approach, ongoing care, treatment, therapies that promote best practice for recover

Stress Vulnerability Model (SVM) ● ●

Model for identifying and treating mental illness SVM created by Zubin in 1977 offers a framework to further investigate the nature of the relationship between trauma, stress, PTSD, ASD & adjustment disorder, by considering a number of biopsychosocial vulnerabilities to developing symptoms.

Treatment and therapy Medications ●

anti-anxiety, antidepressants can be used for associated symptoms.

Behavioural therapy ●

because trauma and stress related disorders can involve anxiety.

CBT ●

cognitive restructuring to modify or replace negative, irrational thoughts.

Cultural support ●

culture provides a certain amount of protection and helps build confidence and resilience, because it provides a sense of belonging.

In summary ● ● ● ● ●

Trauma and stress related disorders can develop from many situations. There are many approaches to care and treatment options for people with trauma and stress related disorders, including crisis interventions and trauma infirmed care. The stress vulnerability model (SVM) offers a framework to investigate the nature of the relationship between trauma and stress related disorders. Therapies are considered best practice but can be used in combination with medications to reduce symptoms associated with trauma and stress related disorders. For nurses and midwives, knowing about a person's culture is important as often there is a different belief system and /or health practices, coping strategies and protective factors.

NUM2307 Module 7.1 Mood Disorders An Introduction to Mood Disorders Outcomes ● ● ● ● ● ● ●

Identify the incidence of mood (depressive) disorders. Understand the aetiology and epidemiology of depressive disorders. Identify how mood is distinguished. Develop an understanding of the presentation associated (signs and symptoms) with depressive disorders from a biopsychosocial model. Identify factors that contribute to a person developing a mood disorder. Describe the relationship between mental illness (depression/mood disorder) with physical illness. Identify assessment tools that can assist clinicians measure the level of a person’s mood over time.

An introduction to mood disorders Mood disorders are mental health problems that are characterised by a consistent alteration in a person's mood that impacts on their thoughts, emotions and behaviours(person’s sense of emotional or affective regulation).

Mood is the pervasive, sustained emotional tone that influences behaviour, cognition and thoughts. ● Not a static state and fluctuates along a continuum.

Mood disorders distinguished by ● ● ● ●

severity persistence duration impaired functioning

Disorders of mood Incidence & prevalence ● ● ● ● ●

Significant impact on both National and International burden of disease and thought to affect approximately 300 million people worldwide. Between 3-5% of the global population experience depression (at any given time). 15% of adults had been diagnosed with depression at some time in their lives. Depression is the leading cause of disability in the western world. High proportion of females report (7% female - 9% males) previous 12 months.

Aetiology ● ● ●

No clear cause of depression identified. The disorder is considered to be a combination of genetic, environmental and neurochemical factors (multifactorial) that impact on the person and their world. Association between depression and physical illnesses.

Key information when assessing mood ● ● ●

Complex interplay between the various predisposing and precipitating factors that may be impacting on this person's present state. Biopsychosocial approach in conjunction with ‘point in time’ assessment. Clinicians make observations and ask questions that enable them to gauge the person's mood.

MSE Assessing mood Subjective: ●

person's description of how they feel.

Objective: ●

clinicians professional observations.

Nursing & midwifery assessment A thorough assessment is always first line management of any patient.

Biopsychosocial (holistic) assessment Biological ● ● ● ● ● ●

Patient & family history Full medical & physical assessment (exclude or include other disorders) Concurrent disorders Full blood picture Endocrine system/thyroid Medication review

Psychological ● ● ● ● ● ● ●

Current mental state Previous mental state Coping ability Past / recent traumas Recent loss - grief Trauma & distress Feelings and emotions

Socio-cultural ● ● ● ●

Relationships Family/cultural history/impact Current social supports Accommodation/environment

Multidisciplinary team approach ●

key to link to services, referrals, support and recovery.

Physical ill-health and mood disorders ● ● ●

Mood disorder (such as depression) increases the likelihood of developing a chronic physical illness. Mental illness will reduce a person's capacity to manage the physical illness and also their overall health outcomes. Nurse and midwife should be aware of similar symptoms (presentation) when undertaking all assessments.

Comorbidity ● ● ●

High incidence of co-occurring substance use disorders. Physical conditions - cardiovascular disease, stroke, diabetes, and respiratory disorders related to risk factors. Metabolic syndrome - side effects of psychopharmacological treatments.

Physical illness & depression Pain ●

effect on perception & tolerance of pain.

Loss & grief ●

common reaction to stressful/distressing events – impact over time.

Prescription medications ●

can lead to the development of depressive symptoms.

Alcohol ●

complicating factor (CNS depressant).

Assessment tools ● ●

DSM-5 for diagnosis of a disorder. Tools can assist clinicians to measure the level of depression over time.

Depression Anxiety Stress Scale ○ ○

measures depression, anxiety, stress or tension. strike up a conversation about depression and or anxiety experiencing a number of symptoms.

Kessler 10 ○ ○

Useful tool for identifying symptoms. 10 items relating to the psychological distress experiences - previous month.

Other screening tools ○ ○ ○ ○ ○

Beck Depression Inventory Centre for Epidemiologic Studies Depression Scale Self-Rating Depression Scale Geriatric Depression Scale Edinburgh Postnatal Depression Scale

In summary ● ● ● ● ● ●

Mood disorders are highly prevalent disorders that impact on people's lives globally. The clinical presentation & assessment of the person experiencing mood major depressive disorder is multifaceted. Nurses and midwives caring for people who are physically unwell – especially those with chronic physical conditions, must be aware of the factors (biopsychosocial) to ensure monitoring for depression is conducted. Understanding of the person's mood is a core aspect of a holistic nursing assessment. Building the therapeutic relationship and talking with the consumer/patient will assist in identifying factors affecting/impacting on them. The decline in a person's physical state when coupled with depression is significant, and recovery from depression in people with chronic physical illness is also more difficult.

NUM2307 Module 7.2 Mood Disorders Depression (Major Depressive Disorder) and Bipolar Affective Disorder Outcomes ● ● ● ● ● ● ● ●

Identify the aetiology of depression across a biopsychosocial perspective. State the distinguishing features (diagnostic criteria) of depression. Identify the incidence of presentations associated with bipolar disorder. Identify the aetiology and epidemiology of bipolar disorder across a biopsychosocial perspective. State the distinguishing features (signs and symptoms) of bipolar disorder. Differentiate between Bipolar I and Bipolar II disorder – describing the difference between mania, hypomania and depressive features. Identify the nurse and midwife's role in the screening and assessment for mood disorders. Briefly outline considerations for mood disorders related to childbirth.

Introduction to major depressive disorder Introduction to major depressive disorder ● ● ● ● ● ●

The term depression is commonly used to describe a feeling of sadness. Depression (major depressive disorder) is a mood disorder with a clearly defined set of symptoms and criteria. Depression is the leading cause of disability in the Western World, and is increasingly recognised as one of the most prevalent and pressing mental health issues in contemporary society in Australia and globally. A depressive episode is classified as a significantly lowered mood (may be mild, moderate or severe), and can be described as a unipolar depression - refers to the presence of one aspect of mood only. Differentiation needs to be made between the person experiencing distress and/or loweredmood that may be situational or difficulty in coping and the person who is depressed. Of particular concern in relation to depression is the risk factor of physical ill-health andsuicide.

Major depressive disorder Aetiology of depression Common causal factors associated with major depressive disorder Biological ● ● ● ● ● ● ●

Genetic Vulnerability, Gender, Biochemistry (Neurotransmitters), Birth Trauma, Physical Illness, Substance Use/Misuse

Psychological ●

Link to personality,

● ● ● ●

past experiences, loss, coping methods, ‘responses’ to life events.

Social ● ● ● ● ● ●

Situational & life events, unemployment, housing, financial problems, substance use/misuse

Each of these factors is interrelated and interact, adding to the possibility of the person becoming depressed. The variety of factors/points reflects the multifactorial causes of depression.

DSM 5 Diagnostic criteria ● ●

Assessed through GP, psychiatrist, or an Authorised mental health professional. Diagnosis would need to meet the DSM 5 criteria. ○ Major Depressive Disorder requires two or more major depressive episodes. ○ depressed mood and/or loss of interest or pleasure in life activities for at least 2 weeks; ○ at least five of the below symptoms; ○ cause clinically significant impairment in social, work, or other important areas of functioning almost every day.

Symptoms 1. 2. 3. 4. 5. 6. 7. 8. 9.

Depressed mood most of the day. Diminished interest or pleasure in all or most activities. Significant unintentional weight loss or gain. Insomnia or sleeping too much. Agitation or psychomotor retardation noticed by others. Fatigue or loss of energy. Feelings of worthlessness or excessive guilt. Diminished ability to think or concentrate, or indecisiveness. Recurrent thoughts of death.

The nurse and midwives role Acknowledge the links between the person’s physical and psychological well being. ● Assessing for factors, influencing, perpetuating, precipitating. ● Identifying the difference between someone who may not be coping with life’s stressors (point in time) or to the person who is depressed.

Factors involved in the development of depression may include ● ● ● ● ●

Prescribed medications, illicit or non prescription medication Alcohol (depressant effect) Pain Cognitive impairment Environmental stressors

Introduction to Bipolar Disorder Serious recurrent mental health condition characterised by periods of extreme mood elevation (mania) coupled with periods of depression mixed in over months (cycles).

Incidence ● ●

Between 1.3 and 4.4% of people develop any bipolar disorder at one point in their life. Preceding 12 months = approx. 0.6 %

●

Approximately 1.8% of males and 1.7% of females have had bipolar disorder in the previous 12 months – rates are fairly equal.

Clinical course ● ● ●

Average age of onset is around 18 years. Maybe variable depending on other factors. Comorbidity conditions are seen more prominently in populations diagnosed with BD (anxiety, phobias, ADHD, PTSD, substance use disorders). Contributors to the morbidity of people with BD ○ cancer, ○ cardiovascular disease ○ suicide.

Aetiology of bipolar disorders Causative factors associated with bipolar disorders Genetic Vulnerability ●

first degree relative

Biological Neurotransmitters ● ●

circadian rhythm(sleep cycle) menstrual cycle

Individual ● ● ● ● ●

Stress & maladaptive coping mechanisms(substance use), Head injury, childhood trauma, Neglect, parental death

Environmental ● ● ● ●

High-income countries, Relationships, prenatal environment, substance use/misuse ** significant association

Bipolar affective disorder – diagnostic features Bipolar disorder is characterised by variations or ‘swings’ (cycles) in mood, from elevation (hypomania) and (mania) at one end, and depression at the other end.

Mania: ●

prolonged, elevated (or ‘high’) mood which interferes significantly in day to day life.

Hypomania: ●

a period of milder mania – associated with sleeplessness and mood elevation (not as extreme as mania) has less impact on functioning.

These episodes (of depression or mania) must last at least one week.

Types of Bipolar disorder Bipolar I ● ● ● ●

has more severe manic episodes. *** More serious of the conditions. Mania is only seen in BD I. To be diagnosed the person must experience at least one manic episode, which is commonly followed and or preceded by hypomania and depression (criteria for major depressive disorder). Don’t have to experience a depressive/or hypomanic episode to be diagnosed with BP I.

Bipolar II ● ●

has less severe manic episodes (hypomania). Must experience both a depressive episode and hypomanic episode throughout the course of the condition (to be diagnosed).

Bipolar disorder symptoms ● ●

CYCLES from feeling depressed to feeling euphoric. Mania- rapid onset peaking in days – may present with hypomania

Mania/hypomania ● ● ● ● ● ● ●

Decreased need for sleep Pressured speech Racing thoughts or flight of ideas Distractibility Increased activity Inflated self-esteem or grandiosity Excess pleasure or risky activity

Difference: Mania/hypomania: ●

The symptoms cause marked impairment.

Present: ●

greater than or equal to 7 days.

Depressed mood ● ● ● ● ● ● ● ●

Diminished interest or pleasure Weight loss or gain Insomnia or hypersomnia Psychomotor agitation or retardation Loss of energy Feeling worthless or guilty Recurrent thoughts of death Indecisiveness

Present: ●

greater than or equal to 7 days.

Nursing & midwifery considerations For disorders of mood ● ● ● ●

Depression is twice as common in patients in the general hospital as in the rest of the population. Ongoing mental health and physical health assessment (consider overlap of both anxiety or stress). Risk assessment for a person experiencing an episode of depression and or mania is a key element of a comprehensive mental health assessment. Assessment of suicide is an essential component of the nurses midwives professional responsibility and role in ensuring the safety of the patient. 7-20% of individuals with BD will attempt to end their life. ○ Comorbidity ○ Identify protective factors ○ Show sensitivity and compassion

Prognosis ●

Highly episodic – further episodes likely after diagnosis.

● ●

Episodic nature impacts social and occupational functioning. Lifetime of chronic disordered symptoms.

Childbirth and mood disorders ●

About 13% of women may develop depression during their pregnancy. Some women up to 50% (a few men) experience postpartum ‘blues’ (after birth).

Symptoms: ● ● ● ●

anxiety, tearfulness may be episodic. Signs and symptoms pre & post natal depression are similar to general depression.

Cause: ● ● ● ● ● ●

unclear, hormonal changes, Exhaustion stress.

If symptoms persist beyond 2 weeks, medical assistance is required. Approx. 50% of women with BD experience a depressive episode during pregnancy, into post delivery period.

In summary ● ● ● ● ● ● ●

Consumers commonly present within a general hospital with mood disorders associated with a physical/chronic condition presentation. Untreated depression remains a major factor in relation to problems such as delayed hospital discharged rehabilitation and recovery, and the ongoing perpetuation of chronic depression. Multifactorial causes of mood disorders require a holistic approach. Primary healthcare settings can play a significant role in the early intervention and detection of mood disorders (primarily depression) and treatment. The assessment of risk (to self, others, suicide) is an essential component of the nurses midwives responsibility. High incidence of risk associated with mood disorders. Accurate assessment treatment and referral is imperative to ensure that early intervention occurs so chronic conditions do not perpetuate. The nurse and midwife has a pivotal role in supporting and working with consumers and families living with people living with the experience of depressive disorder in the community settings.

Module 7.3 Mood Disorders Approaches to the Care, Treatment and Management of Mood Disorders Outcomes ● ● ● ● ● ● ● ●

Outline the nursing/midwifery approaches to care of a consumer with a mood disorder. Outline and describe examples of treatment strategies available for mood disorders;pharmacological, psychological, physical treatments. Describe the purpose and aim of antidepressant medication, their aim and the disorders for which they can treat. Outline the four (4) main types of antidepressants; their target symptoms, & major side effects. Describe the purpose and aim of mood stabilisers, their aim, common side effects and the disorders for which they can treat. Identify the nursing and midwifery interventions required when caring for a person who is experiencing a disorder of mood. Outline general recovery and relapse prevention strategies for mood disorders. Describe how nurses and midwives can work with consumers and families living with the experience of a mood disorder.

Introduction to the approaches of care Nursing & midwifery support - leading to interventional strategies ● Responding to the person's needs. ● Engaging with the person & interpersonal skills. ● Safety & risk. ● Maintaining or supporting physical health. ● Psychoeducation. ● Identifying areas of treatment can assist in baseline measures. ● Comprehensive approach - consider other needs: biological, psychological, social , ● spiritual, environmental, functional needs. ● Multi-disciplinary team – referral, inclusion, consultation, support. ● Develop a management /intervention plan. ● Documentation.

Treatment strategies for mood disorders ● Best approach to treatment is early recognition and intervention. ● In conjunction with the MDT and specialist services. 1. Pharmacological – medications ○ (primarily antidepressants and mood stabilisers) 2. Psychological therapies ○ (primarily cognitive and/or behavioural strategies) 3. Physical treatments ○ (Electroconvulsive therapy)

Pharmacological treatment for mood disorders Antidepressants correct chemical imbalances (particularly serotonin & noradrenaline) - that can help relieve depressive symptoms (cause change in mood & behaviour), including suicidal thoughts and feelings.

Primary aim: ●

stabilise mood & feelings (including suicidal thoughts).

Goal: ●

ongoing stabilisation of mood & prevention of further episodes of depression.

Treatment & management for: ● ● ● ● ● ● ● ● ●

Major depressive disorder (moderate-severe depression) Some anxiety disorders (generalised anxiety disorder), panic attacks, & PTSD Depressed phase of a bipolar episode Obsessive-compulsive disorders Some chronic pain conditions Some eating disorders Help to manage some addictions

Various factors may influence the selection of an antidepressant for an individual consumer Bi polar affective disorder – a mood stabiliser medication would also be used as = combined therapy.

Antidepressant groups ● ●

The choice of treatment options for the person with depression is made by the multidisciplinary team in collaboration with the person. Standard dose 3-4 weeks – then may be increased or changed depending on individuals side effects.

There is a wide range of antidepressant medication available. Below is a description of the different classes of antidepressants used in Australia.

Selective Serotonin Reuptake Inhibitors (SSRIs) This class includes sertraline; citalopram; escitalopram; paroxetine; fluoxetine; fluvoxamine. SSRIs are: ● the most commonly prescribed antidepressants in Australia ● often a doctor's first choice for most types of depression ● generally well tolerated by most people ● generally non-sedating.

Serotonin and Noradrenaline Reuptake Inhibitors (SNRIs) This class includes venlafaxine; desvenlafaxine; duloxetine. SNRIs: ● have fewer side effects compared to the older antidepressants ● are often prescribed for severe depression ● are safer if a person overdoses.

Reversible Inhibitors of MonoAmine oxidase (RIMAs) The class includes moclobemide. RIMAs: ● have fewer side effects ● are non-sedating ● may be less effective in treating more severe forms of depression than other antidepressants ● are helpful for people who are experiencing anxiety or sleeping difficulties.

TriCyclic Antidepressants (TCAs) The class includes nortriptyline; clomipramine; dothiepin; imipramine; amitriptyline. TCAs are: ● effective, but have more harmful side effects than newer drugs (i.e. SSRIs) ● more likely to cause low blood pressure – so this should be monitored by a doctor.

Noradrenaline-Serotonin Specific Antidepressants (NaSSAs) This class includes mirtazapine. NaSSAs are: ● relatively new antidepressants ● helpful when there are problems with anxiety or sleeping ● generally low in sexual side effects, but may cause weight gain.

Noradrenaline Reuptake Inhibitors (NARIs) This class includes reboxetine. NARIs are: ● designed to act selectively on one type of brain chemical – noradrenalin ● less likely to cause sleepiness or drowsiness than some other antidepressants ● more likely to: ○ make it difficult for people to sleep ○ cause increased sweating after the initial doses ○ cause sexual difficulties after the initial doses ○ cause difficulty urinating after the initial doses ○ cause increased heart rate after the initial doses.

Monoamine Oxidase Inhibitors (MAOIs) This class includes tranylcypromine. MAOIs are prescribed only under exceptional circumstances as they require a special diet and have adverse effects.

Agomelatine ● ● ● ●

This is an atypical antidepressant that works in part by stimulating melatonin receptors. As with all medicines there are a range of side-effects, and interactions with other medicines so you should discuss it with your doctor. Side effects such as headaches and sleep disturbances are quite common. A more rare side-effect is that it can affect the function of your liver and so it requires regular follow-up liver tests (a blood test) to be arranged, and generally it is not recommended in people who already have liver problems.

Selective serotonin reuptake inhibitors (SSRIs) ● ● ●

citalopram (Celexa) escitalopram (Lexapro) paroxetine (Brisdelle, Paxil, Pexeva)

● ● ●

fluoxetine (Prozac) fluvoxamine sertraline (Zoloft)

Common side effects The more common side effects of SSRIs include: ● ● ● ●

headaches nausea trouble sleeping dizziness

● diarrhea ● weakness and fatigue ● anxiety ● stomach upset ● dry mouth ● sexual problems such as low sex drive, erectile dysfunction, or ejaculation problems 1. SSRIs are more likely than some antidepressants to cause sexual side effects. 2. They can also increase appetite, potentially leading to weight gain.

Serotonin-norepinephrine reuptake inhibitors (SNRIs) ●

desvenlafaxine (Khedezla, Pristiq)

●

duloxetine (Cymbalta)

● ●

levomilnacipran (Fetzima) milnacipran (Savella)

●

venlafaxine (Effexor XR)

Common side effects The more common side effects of SNRIs include: ● ● ● ● ● ● ● 1.

headaches ● constipation nausea ● sexual problems such as low sex drive, insomnia erectile dysfunction, or ejaculation drowsiness problems dry mouth ● weakness and fatigue dizziness ● sweating loss of appetite SNRIs can cause sexual side effects, but not as often as SSRIs. Some people who take SNRIs may also gain weight, but weight loss is more common. 2. In some cases, people taking SNRIs may notice increased blood pressure.

Tricyclic antidepressants (TCAs) ● ● ●

amitriptyline (Elavil) clomipramine (Anafranil) desipramine (Norpramin)

● ● ●

doxepin imipramine (Tofranil) nortriptyline (Pamelor)

Common side effects The more common side effects of TCAs include: ● ● ● ● ● ● ●

headaches dry mouth blurred vision digestive issues, such as stomach upset, nausea, and constipation dizziness drowsiness trouble sleeping

● ● ● ● ● ● ●

memory problems fatigue weight gain sexual problems such as low sex drive, erectile dysfunction, or ejaculation problems trouble urinating fast heart rate sweating

Monoamine oxidase inhibitors (MAOIs) ● ●

isocarboxazid (Marplan) phenelzine (Nardil)

● ●

tranylcypromine (Parnate) selegiline (Eldepryl, Emsam)

Common side effects The more common side effects of MAOIs include: ● ● ● ● ● ● ● 1. 2.

low blood pressure ● stomach pain nausea ● confusion headaches ● diarrhea drowsiness ● runny nose dizziness ● sexual problems such as low sex drive, dry mouth erectile dysfunction, or ejaculation weight gain problems MAOIs are more likely to cause low blood pressure than other antidepressants. These medications can also interact with foods containing tyramine and cause dangerously high blood pressure.

Serotonin antagonist and reuptake inhibitors (SARIs) Some SARIs include: ● nefazodone ● trazodone (Oleptro)

Common side effects The more common side effects of SARIs include: ● ●

drowsiness dry mouth

● ●

headaches dizziness

● ● ● ● 1. 2.

nausea ● diarrhea fatigue ● constipation vomiting ● low blood pressure blurred vision ● confusion Many people taking SARIs experience drowsiness or sleepiness. This makes them a potentially good option for people with insomnia, especially if they also have depression.

Atypical antidepressants Some antidepressants simply don’t fit into any of the main groups, usually because of the way they work. These are known as atypical antidepressants.

Mirtazapine (Remeron) The more common side effects of mirtazapine include: ● ● ● ●

drowsiness dry mouth increased appetite weight gain

● ● ● ●

high cholesterol constipation weakness and fatigue dizziness

● ● ●

dry mouth trouble sleeping vomiting

● ● ● ●

dizziness dry mouth constipation vomiting

Vilazodone (Viibryd) The more common side effects of vilazodone include: ● ● ●

diarrhea nausea dizziness

Vortioxetine (Trintellix) The more common side effects of vortioxetine include: ● ● ●

sexual problems, such as orgasm or ejaculation problems nausea diarrhea

Mood stabilisers Prescribed to maintain a balanced mood for people with intense or sustained mood shifts. ● Provide relief from symptoms. ● Mood stabilisers have clinical efficacy in treating depression in bipolar disorder.

Treatment and management for ● ● ●

Bipolar disorder type I & II Mania Schizoaffective disorder – with both psychotic and mood variations

Medications: Lithium: Inhibits noradrenaline release, prevents mania and cyclic depressive states. Side effects; sleepiness, dizziness, metallic taste in mouth, nausea, vomiting, skin rashes, tremor, changes in blood count (consider toxicity).

Anticonvulsants: ● ●

Sodium valproate (Epilim) Carbamazepine (Tegretol).

Antipsychotics & anxiolytics ●

often given in conjunction with anticonvulsants.

Psychological approaches to treatment Cognitive behavioural therapy (CBT) ●

focus on thoughts and behaviours (actions).

Behavioural strategies ● ●

assist the consumer to maintain a regular routine; exercise, socialisation & goal planning.

Cognitive strategies ●

assist review patterns of thinking and involves identifying beliefs and assumptions that ideas, assumptions (preconceived) are built on.

Interpersonal therapy: ● ● ●

talk through specific interpersonal issues that may have resulted due to a major life transition. Goals to reduce depression, decrease distress, build support.

Mindfulness - based cognitive therapy ● ●

mindfulness/self awareness, attention to thoughts, feelings ‘in the moment’. Meditation based integrated with cognitive therapy strategies.

Physical treatments Electro-convulsive therapy (ECT) ● ● ● ●

High success rate for severe depression. ECT application of a brief electric current to unipolar or bipolar sites on the scalp. Prior to ECT – short acting anaesthetic & muscle relaxant. Side effects may include: muscle aches, headache, confusion, and memory loss (temporary).

Transcranial magnetic stimulation (TMS) ● ● ●

Consumers who don't tolerate other forms of treatment or to enhance other treatment options. Treatments administered via coil that's placed over the scalp applying a magnetic field stimulates brain activity. Side effects (uncommon) may include, headache, facial twitching, temporary hearing problems.

Recovery and relapse prevention Early intervention in any clinical setting ● ● ● ●

Depression symptoms begin to decrease usually within 3 months of the onset of symptoms (with treatment). 40% of people diagnosed with a major depressive disorder recover within one year. Risk of recurrence decreases the longer the period between episodes of major depressive disorder. Risk of recurrence is increased – severe symptoms, or multiple episodes over years(chronic).

Relapse prevention Varied and personal experience – as is the recovery journey ● Self monitoring of symptoms (changes in mood & triggers). ● Strategies that promote health and wellbeing (lifestyle factors, sleep, diet, exercise). ● Developing coping strategies to manage stressors and triggers. ● Action plan.

Supporting the family Living with mood disorders

Nurse & midwife’s role ● ● ● ●

Acknowledge the impact that depression has on the family member(s). Support family unit – caregivers increased psychological distress, impact on their own physical and mental wellbeing. Education and awareness are vital for families – identify signs and symptoms. Strategies in place for supporting themselves and others.

In summary ● ● ● ● ● ●

Mood disorders are highly prevalent - the best approach to treatment is early recognition and intervention. Treatment options must be person- centred in order to identify priority care. Treatment is tailored to the specific needs of each consumer and can involve a combination of treatment options as part of holistic recovery-orientated practice. Relapse prevention is an important component of consumers' recovery journey. Nurses and midwives should be aware of the pharmacological, psychological and physical treatment options to be able to holistically and competently care for people experiencing disorders of mood. Essential to work within the MDT and with specialist services to facilitate care, interventions and strategies to promote wellbeing and recovery - hence minimising risk of chronic and perpetuating conditions.

NUM2307 Module 8.1 Schizophrenia and Other Psychotic Disorders An Introduction to Psychotic Disorders & the Defining Features of Psychotic Disorders Outcomes ● ● ● ●

Describe the term ‘psychosis’. Outline the three (3) predominant features of psychosis. Describe the main theories of psychotic disorders. Identify the clinical features of a psychotic disorder (how psychosis is characterised). Consider the role of the nurse/midwife in first episode psychosis.

An introduction to psychotic disorders Psychosis ●

●

abnormal condition of the mind, some loss of/or contact with reality. ○ There may be severe disturbances and/or changes in: thought, emotion & behaviour. ○ Severe disruption to a person’s life - relationships, work, study. ○ Self-care is difficult to initiate & maintain. Psychosis itself (that break or split from reality) ○ is a symptom of a psychotic disorder. ○ It may be transient.

Predominant features of psychosis Aetiology ●

unclear evidence of cause;

Delusions ●

belief or impression maintained, despite being contradicted by rational argument or reality.

Hallucinations ●

re a sensory experience that a person can see, hear, taste, smell or feel something that is not there.

Thought disorder ●

thoughts & conversation appear illogical and lacking in sequence. Content may be delusional or bizarre.

Theories of psychotic disorders Genetic: ● ● ● ●

no single genetic factor has been identified. identical and non-identical twins are more likely to develop the disorder if their twin has it. one parent with the condition less than 10%. considered inheritable over half the individuals who have the condition do not have an immediate relative affected indicating its complexity. family history of psychotic disorder.

Biological: ●

irregularities that have been noted in the brain structure and neural transmission.

Biochemical factors: ●

Destruction of neurotransmitter dopamine during foetal development resulting in dysregulation.

Environmental: ●

psycho-social stress, histories of childhood diversity (abuse, neglect trauma).

Drug/substance misuse: ● ●

trigger to set off psychosis - smoking cannabis, using amphetamines. Cannabis use has been extensively studied as an influencing factor in worsening symptoms of schizophrenia.

Psychosis is characterised by changes in Emotion and motivation ● ● ● ●

Irritability Suspiciousness Blunted, flat or inappropriate emotion Reduced energy and motivation

Thinking and perception ● ● ● ● ●

Disturbance in thoughts, beliefs, memory. Difficulties with concentration or attention. Altered sense of self, others or the world. Ideas may be odd or bizarre. Perceptual(sensory disturbances).

Behaviour ● ● ● ●

Altered sleep patterns /disturbance. Socially isolated or withdrawn (family, friends). Reduced capacity and ability to carry out ‘everyday 'activities, work or social roles. Actions may be ‘odd’, ‘bizarre’, ‘uncharacteristic, inappropriate (outside social norms).

First episode psychosis Nursing and midwifery care considerations ● ● ● ●

Traumatic and frightening experience for the patients and their families. Symptoms seen in psychosis make it a frightening illness and often the person's behaviour is quite different. Left untreated, it is likely to result in poorer long-term outcomes. Early identification & intervention may prevent long term prognosis and prevent chronic functional impairment.

In summary ● ● ● ● ● ●

The importance of the holistic assessment in determining all disorders. Psychotic disorders are characterised by: changes in emotion & motivation,thinking and perception and behaviours. Psychotic disorders are considered multifactorial (biological, genetic component, psychological factors and environmental components) The nurse and midwife’s role in a comprehensive assessment (MSE, risk,physical ) – essential. Nurses and midwives should be able to identify signs and symptoms of psychosis and key features of psychotic disorders. Engagement may be challenging – due to the nature of the presentation.

● ●

The tenants of the therapeutic relationship remain the same. Ensure a safe environment – and consider risk associated with the altered signs and symptoms.

NUM2307 Module 8.2 Schizophrenia and Other Psychotic Disorders Schizophrenia Outcomes ● ● ● ● ● ● ● ● ●

Define the term schizophrenia. Identify the prevalence and incidence of schizophrenia. Describe biological, psychological and environmental theories on the development of schizophrenia. Distinguish between the presentations of the prodromal, acute and chronic phases of schizophrenia. Identify the diagnostic criteria for schizophrenia. Describe the clinical manifestations (signs and symptoms) of schizophrenia. Outline the difference between ‘positive’ and ‘negative’ symptoms of schizophrenia. Describe co-morbidity associated with schizophrenia. Outline the ‘prognosis’ associated with the disorder. Outline the nurse and midwife’s key clinical considerations.

Introduction toSchizophrenia ● ● ● ● ● ●

Word “schizophrenia’ originates from the modern Latin term split (schizo) mind (phrenos). Schizophrenia is more related to a disintegrating personality – not a split personality. Historically – stigmatised, negative connotations Considered one of the most serious (severe) mental illnesses. The condition is considered multifactorial. It is possible for a person to experience a psychosis but not have schizophrenia.

Schizophrenia: Incidence & Prevalence ● ● ● ● ● ● ●

Approximately 1% of the population worldwide at any given time. Psychotic symptoms often diagnosed/develop late adolescence & early adulthood. Affects both genders equally - more severe and develops earlier in males. The rate and severity of psychotic symptoms often increase during the first five years of the illness. Risk suicide greatly elevated – lifetime risk at 10% (or higher) - first year after diagnosis highest risk. Around 50% of individuals with schizophrenia attempt suicide People with schizophrenia constitute around 5 to 10% of all deaths from suicide in Australia (Schizophrenia Research Institute in 2014)

DSM-5 Diagnostic criteria 1. 2. 3. 4. 5. PLUS ● ●

Delusions, Hallucinations, Disorganised speech Grossly disorganised or catatonic behaviour Negative symptoms (flat affect, lack of volition) Disturbance in level of functioning (social & occupational, self care, interpersonal relations dysfunction) Evidence of dysfunction in the previous six months.

Symptoms of schizophrenia Symptoms divided into 2 groups (positive & negative symptoms)

Positive symptoms ●

Symptoms in addition to the normal experience and behaviour of that person.

Hallucinations

False sensory perceptions

Delusions

Fixed false belief - can’t be dissuaded despite contradictory: persecutory or paranoid, grandiose, somatic, ideas of reference, religious

Thought disorder

Disorganized thinking, underlying disturbance to conscious thought

Disorganised behaviour

Agitation, grossly disorganised or abnormal motor behaviour (including catatonia)

●

Antipsychotic medications control psychotic symptoms such as hallucinations, delusions, or mania symptoms and help regulate the functioning of brain circuits that control thinking, mood and perception.

Negative symptoms ●

Take away from or suggest a deficit (absence/lack) in relation to common, ordinary or usual experiences and behaviours.

Blunted emotions

Restricted emotional responses

Cognitive deficits

Difficulties in communication, concentration

Apathy/Avolition

Difficulty with straightforward tasks Slow & unmotivated, withdrawal & dysfunction (maybe ADLs)

Comorbidity Physical health ● ● ● ●

Higher rates of smoking & substance misuse are most common. Lower life expectancy – high risk of cancer. High rates of cardiovascular disease (lifestyle risk factors), diabetes (metabolic syndrome) – medication related. Metabolic syndrome - weight gain, hypertension, elevated BGL,triglycerides.

Psychological health ●

Anxiety disorders diagnosed more frequently, obsessive compulsive disorder and panic disorder.

Social health ● ● ●

Functioning issues, living in poverty. Lack of access to healthcare. Mental health literacy.

Clinical course of schizophrenia 1. Prodrome phase (may last for a period of years) ●

Early emerging stage of schizophrenia, early warning signs, subtle behavioural changes & diminishing functioning.

Assessment ○

strange beliefs, suspicious thoughts, social withdrawal, dysfunction social, psych, work function.

2. Active phase ● ● ●

Characterised specifically by psychosis. Most likely to require hospitalization in their acute phase – early intervention key at this stage.

Assessment ○

delusions, hallucinations, thought disorder.

3. Residual phase ● ● ●

Resembles the prodromal phase where the individual may withdraw; they may have a flat or blunted affect, odd/bizarre behaviours. Not classified as psychotic at this stage. Negative symptoms

Assessment ○

hypervigilance, suspicious.

Clinical observations The nurse & midwife’s role Comprehensive and holistic risk assessment

Predicting violence ●

History, drugs/other substances, due to symptoms (command hallucinations, paranoia, suspiciousness, poor insight, involuntary).

Risk ● ● ● ●

suicide (1.8%), prodromal stage (increase to 5.6%) self-injury alcohol/drug use features of depression

Self-care deficit ●

sleep patterns, diet, ADL’s

Nurse and midwife to provide general support in addressing the self care deficit and encourage intervention when necessary.

Prognosis ● ● ●

● ●

The earlier the age the individual is diagnosed with schizophrenia the more likely this is to be associated with poor outcomes. Consider risk (present/absent), protective and support systems in regard to onset and getting care. Favourable ○ negative family history for schizophrenia ○ pre-morbid personality intact ○ good social structures and networks in place ○ no other comorbidities ○ stats favour more positive outcomes for females No cure - therapy and the potential for recovery about 20% of people diagnosed with schizophrenia do experience long term remission without any further relapse. Adherence to treatment regimens including medications and support beneficial (identify signs/symptoms).

In summary ● ● ● ●

Schizophrenia is multifactorial caused by biological, genetic and environmental circumstances. Schizophrenia is considered a severe mental health condition and can have a significant impact on a consumer's life. The experiences may include confusing, frightening and challenging symptoms which can have a significant impact on the person's world. The nurse and midwife needs to ensure accurate assessment and referral for the person with schizophrenia.

● ● ● ●

The therapeutic relationship, engagement and building report may be more challenging with the person experiencing distressing (psychotic) symptoms. The nurse and midwife should be familiar with the key presenting signs and symptoms and how best to manage your approach with the person with schizophrenia. The multidisciplinary team is skilled to holistically manage the person through the acute and recovery phases. Ensure a comprehensive assessment including a physical and risk assessment – in considering the disorders significant comorbidities and risk factors.

NUM2307 Module 8.3 Schizophrenia and Other Psychotic Disorders Other Psychotic Disorders Outcomes ●

● ●

Have a beginning understanding of the difference between the following psychotic disorders; ○ *Schizoaffective disorder; ○ *Schizophreniform disorder; ○ *Brief psychotic disorder; including - puerperal psychosis, substance induced psychotic disorder, depression (major depressive disorder) with psychotic features. Identify key presenting features of each disorder. Have a beginning understanding of the similarities and differences of ‘other psychotic disorders’ with a diagnosis of schizophrenia.

Disorders of the schizophrenia spectrum The difference between all of the psychotic disorder diagnoses is ● the severity of the conditions ● duration = the length of time they have the condition ● the symptoms they exhibit.

Other psychotic disorders Schizoaffective disorder ● ● ●

Experiences a period of disordered mood (mania or depression), while simultaneously experiencing symptoms of schizophrenia (delusions or hallucinations). Complex condition resulting in significant distress for the person. Presence of other serious mental conditions can make diagnosis challenging.

Prevalence Diagnosis is about a 3rd as often as schizophrenia affecting about 0.3% of the population.

Schizophreniform disorder Differs only from the diagnosis of schizophrenia in that the duration of symptoms is; ● present for longer than one month, but less than 6 months ● functioning not negatively affected.

Brief psychotic disorder ● ● ●

Experiencing a psychotic episode that endures for at least one (1) day but less than one month, with eventual return to premorbid functioning. Acute state - followed by complete recovery. Brief psychotic disorder may be the first experience of reality distortion, characterised by experiences of delusions, hallucinations, disorganised speech and/or behaviour (positive symptoms).

Substance-induced psychotic disorder (drug induced psychosis) ● ●

Causes symptoms seen in schizophrenia (hallucinations, delusions, paranoia, thought disorder), and that is triggered by misuse of drugs or alcohol. Most cases the psychosis is short-term, long-term drug use – may cause psychosis that lasts for months/years.

Depression with psychotic features ●

Clinical depression mixed with psychosis.

● ● ●

Approx. 20 % of people with major depression also have symptoms of psychosis. Signs and symptoms of those of depression and psychosis. Risk assessment - high risk suicide - prompt treatment required, safety protocols.

Puerperal psychosis ● ● ●

Period immediately following childbirth - episode within 4 weeks of childbirth and for many, psychotic symptoms will appear 3 days postpartum. Affecting approx. 1 in every 1000 women who have given birth. Signs mimic delirium, other clinical features include: insomnia, anorexia, agitation, restlessness, mania type symptoms, paranoia, psychosis.

Risk assessment serious consequences of the condition not being addressed; ● infanticide (up to 4%), ● maternal suicide, ● ongoing psychotic illness.

Midwifery & nursing care ● ●

Prompt hospitalisation, where safe - admission of infant, risk and safety protocols, specialised mother and baby mental health units, follow up care. Compassion, support of ‘family unit’.

In summary ● ● ● ● ● ● ●

First episode psychosis and brief psychotic disorders may be triggered by numerous events and causes are multifactorial. Nurses and midwives need to be familiar with signs and symptoms of psychotic disorders in order to formulate plans and refer to services / MDT for assessments - accurate diagnosis and care. Nurses and midwives need to also be aware of how to best help family members, as the sudden onset of first episode psychosis can be distressing to both the person and family. Referral for support (person & family) following a brief psychotic episode is important – to consider any future diagnosis, being aware of signs and symptoms (emerging), or minimising recurrence of episodic psychosis. Experiencing symptoms of a brief psychotic disorder can lead to confusion and feeling misunderstood by the person experiencing the symptoms, the nurse & midwife should continue to build the therapeutic relationship – show care, compassion, understanding and support. Ongoing risk assessment associated with brief psychotic disorders is an essential component of the nurse and midwife’s role – and duty of care to ensure the safety of the patient (& infant - puerperal psychosis) in their care. Psychotic episodes, and experiences that come with them, can impact on work, study, relationships and biopsychosocial stressors - consider these also in the approach to care.

NUM2307 Module 8.4 Schizophrenia and Other Psychotic Disorders Interventions, Treatment and Psychopharmacology related to psychotic disorders

Outcomes ● ● ● ● ● ●

Identify the major pharmacological strategies in the treatment of psychotic disorders. Identify what ‘symptoms’ antipsychotic medications target. Outline & describe major adverse side effects of antipsychotic medications. Define extra pyramidal side effects (EPSE) and describe examples. Describe the purpose and aim of antipsychotic medications; identify the difference between atypical & typical medications; & the treatment goals of antipsychotics. Identify non-pharmacological strategies in the treatment of schizophrenia. Outline the role of the nurse and midwife in the care of people with schizophrenia and psychosis.

Managing psychosis & psychotic disorders The role of the nurse & midwife ● Key engagement principles – trust & rapport, validate ● Assessment – implement safety precautions, findings, documentation ● Determine nature of psychosis (hallucination, delusion) ● Risk and safety ● Manage the environment ● Distraction/diversion techniques ● Medications –acute stress psychosis, agitation, anxiety ● Physical assessment & ongoing physical care with the multidisciplinary team refer if necessary ● Treat co-morbidities

Antipsychotics: Drug treatment for psychosis Antipsychotics Reduce or eliminate ‘positive’ signs & symptoms of schizophrenia - delusions, hallucinations, paranoia, abnormal mood & thought disorder

Aim ● ●

Reduce the positive symptoms of schizophrenia Reduce the likelihood of further episodes of psychosis ○ ○ ○

Typical – first generation developed 1950’s treat psychosis Atypical - second generation approved for use 1990’s Extra Pyramidal Side Effects -> anticholinergics

Treatment goals ● ● ● ●

Relapse prevention Maintenance therapy Reduced relapse rate Manage symptoms – not cure

Extra pyramidal side effects (EPSE) ● ●

Are unpleasant motor (movement) side effects as a result of dopaminergic pathways in the brain. Due to antipsychotics

EPSE may include

Signs & symptoms

Dystonias (dystonia)

Muscle spasms, oculogyric crisis torticollis

Akathisia

Restlessness, compulsion to move

Tardive dyskinesia

Abnormal involuntary movements

Neuroleptic Malignant Syndrome

Severe parkinson like symptoms and hyperthermiamedical emergency

Parkinsonism

Tremor/ rigidity, hyper-salivation

Anticholinergics Anticholinergics: class of drugs that block the action of the neurotransmitter acetylcholine (at the muscarinic receptor site) in the brain. ● May make original symptoms return ● Also used to manage Parkinson’s disease

Aim Treatment specially to reduce the distressing & unwanted side effects of antipsychotic medication.

Side effects Tachycardia, nausea, vomiting, dry mouth, constipation, dizziness delirium, hallucinations

Non-pharmacological interventions ● ● ● ●

Music theory – established as an effective adjunct to traditional methods. Cognitive behavioural therapy (CBT) mixed effectiveness. Often recommended in the treatment. Some evidence to suggest mildly effective to treat symptoms.

Recovery & relapse prevention ● ● ●

Personal journey for each individual. Live independently with the absence or presence of symptoms. 10-20% (estimate according to research) consumers will recover (to their pre morbid state).

Relapse ●

Non adherence to pharmacological treatment - repeat hospitalisation, impaired quality of life, dysfunction. Relapse – strain on family/relationships, health care system.

In summary ● ● ● ● ● ●

Early diagnosis and early intervention (pharmacological/adjunct) can assist in managing and treating the illness. Consequences of delayed treatment – slower & less complete recovery – poorer long term outcome of functioning. The nurse & midwife in their MH assessment – must assess risk – due to increasedrisk of suicide associated with commencement of medications. Antipsychotic medications are effective in treating the positive signs/psychosis –undesirable side effects result in non-adherence to treatment in some consumers and poorer health outcomes. Nurse and midwife should observe for side effects, and implement interventions tomange. Referral to treating team or dosage adjustment may be necessary. Assess comorbidities – alcohol / other drugs.

●

Communication is essential – assist the client in the working relationship which builds trust and facilitates care, treatment and adherence to treatment/medication regimens.

NUM2307 Module 9.1 Personality Disorders An Introduction to Personality Disorders Outcomes ● ● ● ● ●

Describe characteristics of a ‘healthy personality’. Identify the contributing factors to the development of personality disorder. Outline the aetiology of personality disorders. Identify the prevalence and incidence of personality disorders. Describe what constitutes a personality disorder.

An introduction to personality disorders Personality Patterns of thinking, feeling or behaving that are persistent across time & situations.

Explanatory model of personality as a regulation of biopsychosocial factors in the service of good-quality survival of the individual within particular constraints of their habitat and environment

An explanatory model of ‘healthy personality’ 1. 2. 3. 4. 5. 6.

Individual levels of arousal, impulsivity & emotion Self-directedness & self-soothing – response to challenges of stress & change Reality testing Integrated sense of self over time (character development, self awareness) Social cooperativeness Attachment

Epidemiology of Personality disorders ● ● ● ● ● ●

Worldwide it is estimated that Personality disorders account for 6.1% of mental illness. Women are more affected by personality disorders,but this depends on the personality disorder type(cluster C has a higher prevalence of males). Diagnosis is usually between late adolescence and early adulthood. It is estimated that individuals with a history ofsuicide attempts have a personality disorder. 40% of individuals with mental health conditions are stated to have coexisting personality disorder. Personality disorders decrease in prevalence with age. The most prevalent personality disorder is Borderline Personality Disorder (BPD), with an estimated 3.5% of those aged 24-25 having BPD.

Aetiology of personality disorders Contributing factors and context for the development of personality disorders ● Adverse family environments: poor attachment and vulnerable temperament. ● Childhood maltreatment: abuse (sexual, emotional - neglect). ● Maladaptive family functioning: behavioural control, emotional involvement & communication (attributable to the whole family system). ○ Impaired parental bonding ○ Trauma experiences ○ Genetic factors

Personality disorders Personality disorder ●

abnormal, extreme, inflexible, pervasive variations from the normal range of one or more personality attributes. ● An enduring ‘pattern’ inner experience & behaviour that deviates from the norm of the individual's culture. The pattern is seen in 2 or more of the following: 1. cognition (thinking) 2. affect (feeling) 3. interpersonal functioning 4. behaviour 5. impulse control ● A result of either a situational reaction or a disruption in personality development.

Personality disorder 5 traits Trait

Features

Presentation

1

Negative affective

Anger, anxiety, irritability, vulnerability, depression

2

Dissocial

Manipulation, poor empathy, self-entitlement

3

Disinhibition

Impulsivity, risk taking, distractibility, recklessness

4

Anankastic

Perfectionism, stubbornness, rules & obligations

5

Detachment

Social withdrawal/indifference

Normal

>

(non-disordered) Wellness mild

> > moderate

Significant trouble & disability (disordered) Illness severe

ICD-11 Diagnosis The diagnosis of PD will require a pervasive disturbance in; ● experiences & thoughts about self, others, the world – manifested in maladaptive patterns of cognition, emotional experience, emotional ● expression & behaviour. maladaptive patterns – inflexible, associated significant problems in ● psychosocial functioning (relationships/situations). ● across range personal & social situations. ● disturbance is relatively stable over time and is long in duration. First manifestations in childhood – clearly evident in adolescence.

DSM-5 Diagnosis Personality disorders are classified based on the principal personality features.

Cluster A ●

Odd, eccentric, withdrawn ○ Paranoid ○ schizoid ○ schizotypal

Cluster B ●

Dramatic emotional, Erratic ○ Narcissistic ○ Antisocial ○ Histrionic ○ Borderline

Cluster C ●

Anxious, fearful ○ Avoidant ○ Obsessive compulsive PD

Summary ● ● ● ● ● ●

With ‘healthy’ attachments people can develop a healthy personality. Number of contributing factors known to increase the risk of developing a personality disorder. The complex nature of personality disorders makes diagnosing difficult and therefore the specific prevalence and incidence of personality disorder can only be estimated. Personality disorders’ can cause suffering to the person as well as those around them. Comorbidity, suicide attempts and risk is a factor which needs to be consideredfor those living with personality disorders. Assessment of both risk and mental state is an essential component of the nurse midwife’s role.

NUM2307 Module 9 .2 Personality Disorders Borderline Personality Disorder Outcomes ● ● ● ● ●

Describe the central characteristics of borderline personality disorder. Identify the aetiology (causative/contributing) factors to the development of borderline personality disorder. List the signs and symptoms (diagnostic features as per the DSM-5) of borderline personality disorder. Outline the importance of risk assessment in both short and long term care of patients with borderline personality disorder. Describe the role of the nurse and midwife in the care of people living with borderline personality disorder.

An introduction to the disorder Borderline Personality Disorder (BPD) is a serious mental Illness that effects an estimated 1-4% of the population. ● BPD affects a person's ability to function even at the most basic level. ● BPD is often marginalised and misunderstood, with much stigma negatively impacting those affected. ● People with BPD tend are seen in variety of settings and most present with a range of comorbidities, rarely BPD alone. ● The causes of BPD are complex and often uncertain. ● The core feature of BPD is an impaired ability to regulate emotions. ● Those with BPD tend to self manage through maladaptive coping mechanisms – self injury, risky behaviours and often substance abuse. ● High risk associated with BPD - accurate assessment is essential. There is no definitive cure at present for BPD, but recovery is possible with accurate assessment, diagnosis, treatment and management

Aetiology of Borderline Personality Disorder Contributing factors and context for the development of personality disorders

Genetics ●

inherited genes increase vulnerability

Biochemical ●

chemical variations have been linked to BPD

Childhood experiences ●

abuse (sexual, physical, emotional), neglect Impaired parental bonding: lack of attachment or early separation

Nurse & midwife to consider ● ●

exacerbation of BPD - most likely have experienced a trigger prior to the event. knowledge of predisposing, perpetuating, precipitating factors to fully understand the current and historical influences = help with diagnosis, treatment and long-term management of BPD.

●

Identifying the trigger should be a priority as part of a risk assessment to reduce further harm and/or remove immediate risks.

Criteria for diagnosis –DSM 5 ●

Will have a pervasive pattern of instability of interpersonal relationships, self-image and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts.

5 or more of the following criteria; 1. Frantic efforts to avoid abandonment or being alone. 2. A pattern of unstable and intense interpersonal relationships characterised by alternating between extremes of idealisation and devaluation. 3. Identity disturbance: markedly & persistently. 4. Impulsivity: spending on items they don’t need, promiscuity, substance abuse, reckless driving, binge eating. 5. Recurrent suicidal behaviour: gestures, or threats, or self-mutilating behaviour. 6. Chronic feelings of emptiness: seen in periods of depression and withdrawal. 7. Irrational emotional outbursts: inappropriate anger, crying, screaming, laughing. 8. Paranoia – often stress related, people talking about them, hypervigilant, constantly looking around them.

The nurse & midwife’s role ● ● ●

A holistic approach is best practice, maintaining patient centered care, in a collaborative manner. symptoms are complex and often individual to those affected, due to the complexities of variables important to know what to look for, especially if the individual has undiagnosed BPD.

The nurse/midwife should assess for; Symptoms include • Intense mood swings (depression, anxiety, anger) • Self harm, threats of self harm, suicidal intentions • Feeling out of touch with reality, paranoia • Inability to settle

Behaviours • Fear of being alone, neglected, misunderstood • Lack of flexibility – rigid thinking • Inappropriate behavior/intrusive, risk taking, impulsive behavior

Nursing/midwifery management and care ●

By identifying immediate and long-term risks, interventions can be implemented to reduce harm and promote patient safety

Nurse & midwife role ●

assessment is imperative and must be ongoing

Interventions ● ● ● ● ●

Mental health assessment Risk assessment (BRA, suicide risk assessment) Observations may be increased to 1:1 line of sight, 15:50/30/60 Drug & alcohol assessment Nutrition related concerns – restrictive eating/ binging, purging patterns and laxative abuse, must also be considered (referral-dietician)

Considerations ● ●

Therapeutic alliance (compassion, kindness, validation) - key principles of engagement, communication Set boundaries & limit setting – maintained by the team

● ● ● ●

Encouragement & positive reinforcement – engage with others Therapeutic optimism MDT input & support = referrals, resources, education Family/friend/carer input

In summary ● ● ● ● ● ● ●

Risk and risk assessment are an important aspect related to those living with BPD - risk assessment is imperative and must be ongoing. Management strategies should include all principles of nursing and midwifery care, but also firm boundaries and consistency of care throughout the nursing/midwifery and MDT. The symptoms of BPD are complex and for this reason, diagnoses can be difficult. Carrying out a collaborative assessment, information gathered will assist in accurate diagnosis using the DSM-V. Diagnosis can take longer than some other mental health diagnosis, due to the complex nature of the disorder. BPD is the most recognised personality disorder, it is complex and the behaviours are unpredictable. Maintain therapeutic relationships, ensuring boundaries are maintained by nurse/midwife and the team. Long term care and support for those affected can recover.

NUM2307 Module 9.3 Personality Disorders Assessment, interventions and treatment practices for personality disorders Outcomes ● ● ● ● ● ●

Describe the risk assessments and risk indications associated with personality disorders. Outline the general principles of nursing & midwifery care for people with personality disorders. Outline and describe the key treatment strategies for personality disorders. Understand the importance of implementing interventions based on assessment outcomes (including risk). Describe common treatment practices & therapies for personality disorders & issues relating to personality disorder. In consideration of long-term management of personality disorders, outline nursing/midwifery/MDT interventions to promote recovery.

Assessment of personality disorders ● ●

When someone presents to hospital, they are experiencing a sense of struggling with life relationships, housing, general stress of life and these factors are referred to as “situational crisis”. Gathering this information gives the team a holistic view.

Assessments include: Risk Assessment ●

this need to be a priority and includes self harm and suicide risk assessment, as well as aggression and violence.

Physical Health Assessment ●

wounds, infection, underlying physical conditions, dehydration,malnutrition, drug/alcohol withdrawal.

MSE ●

as part of the comprehensive mental health assessment to consider current mental state and establish a baseline.

Drugs and Alcohol Assessment ●

Screening tools and standardised assessment measures are used throughout hospitals and community practice to assess clients who may be at risk of drug or alcohol use.

Crisis Assessment ●

considers the level of risk and options for management.

Severity Assessment Scales

Interventions for personality disorders Nursing, midwifery & MDT care ● ● ●

Risk assessment – assess the level of risk (high, medium, low). Increase observations – 1:1 for a (high risk) or regular 60/60 (low risk). Therapeutic relationship – open communication, non-judgmental, approachable.

● ● ● ● ● ● ● ●

Physical assessment – wound care, comorbidities, medication side effects. Safe Environment – relaxed, near nursing station, low stimuli, triggers, isolation. Maintain safety measures – duress, work in pairs, remove harm, security. Medications – side effects, increased falls risk, toxicity. Therapy/counselling – referrals for treatment (short and long term). Mental Health Act -2014 – absconding, no other option. Family & patient involvement – support, informed choices, empowerment. Multi disciplinary team input – education, long term goals.

Treatment of personality disorders ● ● ● ●

Always actively involve the client/patient in any decision making Complex disorders and as such treatment and therapy needs to be specific to each situation and individual Actively involve the consumer/patient in any decision making Hospitalisation is not recommended -offers 24-hour attention

Medication interventions Antidepressants ●

help regulate mood

Antipsychotics ●

reduce paranoia and psychotic features

Mood stabilizers ●

reduce impulsivity and mood swings

Anti-anxiety ●

reduce emotional distress

These medications, in combination, can help to reduce the range of effects associated with personality disorders –reduce anxiety/distress, modulate mood, manage emotions and reduce hyperarousal.

Therapy for personality disorders There are also many group therapies and support groups which can be a benefit to those who have experienced trauma and domestic violence.

Psychodynamic Therapy ●

Goal: to enhance the client's self awareness and understand what happened to them in the past, how it affects their present behavior.

Cognitive BehavioralTherapy (CBT) ●

Works by changing people's attitudes and their behaviour by focusing on the thoughts, images, beliefs and attitudes that are held.

Dialectical Behavior Therapy ●

Uses mindfulness and acceptance to change thoughts and behaviors.

Acceptance and Commitment Therapy ●

Therapy works on 6 principles,towards a main goal - often confronting painful thoughts and experiences.

Summary ●

Assessment is required to identify and address the immediate risk and stress a person is experiencing as well as long term factors for positive recovery.

● ● ● ● ●

Self harming, suicidal thoughts and intention need to be addressed; risk assessment identifies the severity of risk and aids in implementing interventions. Although medications are used in the treatment of personality disorders,psychological therapies are regarded as the most effective option. Encouraging the client to make choices on their treatment and therapy, is important, part of their recovery is understanding the consequences of their choices. It is important to work with individuals in an open, nonjudgmental manner,conveying hope and optimism Self care and reflecting are an important part of nursing practice to enable us to continue to provide care to our patients at the optimum level