Monthly Archives: February 2009

Time to Care

A 2008 study by the King’s Fund, “Seeing the person in the patient” has concluded that nurses are failing to communicate compassion, respect, and emotional support when providing nursing care.  The authors of this study point out that patients are generally satisfied with the standards of medical and nursing intervention, but often feel on the receiving end of depersonalised and dehumanised care.

The recent NHS review & the subsequent department of health documents including “High Quality Care for All: NHS Next Stage Review” appear to emphasise the position of nurses being at the fore-front of improving the quality of patient care.  However, at the same time significance is equally afforded to the need for nurse to strive to achieve targets and outcome measures in other areas of their clinical practice that may impinge on their time and ability to provide holistic patient-centred care.

Maben & Griffiths (2008:5) suggest that “nurses have lost their way while navigating the complexity of the increasingly technical environment that is contemporary health care.”   Undoubtedly, technological advances, organisational, and educational changes have influenced the position and role of nurses in the provision of healthcare. 

Yet, within this fast-paced technological world has there been a shift in the central primacy of care and caring within the ideology and values of nursing practice? 

The nature of caring appears synonymous within the core qualities, skills, and competencies of nursing practice.  Effective communication, listening, conveying empathy, integrity, and positive regard are some of the interpersonal attributes at the heart of caring relationships. 

However, it has been suggested that “the bureaucratisation of health has contributed to the hospital setting and care becoming a soulless, anonymous, wasteful, and inefficient medical factory performing medicine as medicine demands it, not as the patient needs it”.  (Porter 2002 cited in Goodrich & Cornwell 2008: 1).

Is it always possible for nurses and their allied healthcare colleagues to provide the highest level of individualised care that meets the multi-factorial needs and wants of the individual and their family?  Furthermore, what are the central drivers influencing receivers (patients) and providers (nurses) experience of care?  Finally, as professionals with a vested interest, how can we engender the values of compassionate and personalised care in today’s student nurses that form the fulcrum of their future practice?  Remember, they are the workforce of tomorrow.

The efficacy of neuroleptics. Why a change in injection technique might settle a score between biological and social psychiatry.

Mental health nurses have been involved in the administration of depot neuroleptics ever since the first depots were designed in the 1960s. They are given by a deep intramuscular injection into the gluteal muscle every fortnight or so and are particularly useful for people with schizophrenia who we believe are not to be trusted with remembering to take their medication by themselves.

 

There appears to be a shift at the moment in the UK in the way depots are administered, away from an injection in the gluteus maximus (the dorsogluteal method, using the upper outer quadrant method to correctly site the injection), to the injection being given in the gluteus medius (the ventrogluteal or hip site, midway between the top of the hip bone and the crest of the pelvis). The old method is relatively more dangerous (the sciatic nerve is nearby, there is a large blood supply to this muscle), and we now also know that the chances of actually injecting the muscle using this method are quite poor, because there is a large amount of subcutaneous tissue around this muscle. One study has shown that as many as 19 out of 20 people might be being injected into fat rather than muscle. On the other hand, the ventrogluteal method is safer because there are no major nerves are arteries nearby, and we can inject into the muscle with greater confidence as there is less subcutaneous tissue around the gluteus medius. In short, we’ve not actually being treating people with the correct dose of neuroleptic for years, but now we can because we’re going to use a site that is more effective.

 

So this change in technique might lend weight, one way or another to the debate about whether neuroleptics actually work. The commonly held belief about neuroleptics is that they help regulate dopamine and other neurotransmitters in the brain, an overexcitation of dopamine being responsible for the so called positive symptoms of schizophrenia, such as the hearing of voices or having unusual thoughts. Some people take the view though that there is poor evidence to support this theory. A purely biological explanation for schizophrenia is unsatisfactory. Schizophrenia is a complex ‘illness’ which can be explained just as well in psychological or sociological terms than by the medical model. In fact, some say, there is no such thing as schizophrenia, and it’s not very helpful to be labelled so. Some service users will say that neuroleptics have never helped their voices go away, and some do not actually want this to happen anyway!

 

If you believe that neuroleptics help reduce the symptoms of schizophrenia, but now know that people on depots have not been receiving anywhere near the correct dose, what has been keeping people well for so long? Have people been well? Have we been actually defining wellness based on how willing the recipients of depots have been to drop their trousers every fortnight?

 

If you don’t believe that neuroleptics work, knowing that they’ve not been given correctly anyway adds a little bit of weight to your argument. But now that people are going to receive the correctly prescribed dose, we should be able to tell once and for all whether they work.

 

Although this is clearly an oversimplified way of looking at just one element of a well documented debate, think about this – how would you feel if you found out that the injection you were receiving (often unwillingly) for many years, wasn’t actually being given properly?

Service losers?

I have just been reading some work written by people looking at issues of stigma and discrimination in mental health, some of the material made me think quite a lot about this subject. Not only did the work state the obvious – things we already know such as people with a mental health issue treated differently to others, but it also examined the role of mental health nurses and I couldn’t help but recognise some of these statements were actually true.

Much is written about stigma and discrimination in mental health, particularly regarding service users, patients clients etc. Erving Goffman, in his book Stigma: Notes on the Management of Spoiled Identity (1963), describes stigma as ‘ a special kind of relationship between attribute and stereotype. An attribute that is deeply discrediting, that reduces the bearer from a whole and usual person to a tainted, discounted one. We believe that a person with stigma is not quite human. We tend to impute a wide range of imperfections on the basis of the original one. We may perceive his defensive response to his situation as a direct expression of his defect’. Goffman goes on to point out that stigma is generated in a social situation. It is a reaction by society that spoils a person’s identity by a set of imposed norms that are brought to bear on an encounter.

There are ‘them and us’ distinctions that underpin prejudice and discrimination and pervade mental heath services. People with mental health problems are devalued and, therefore those who work with them are also devalued by association: this is termed ‘courtesy stigma’ (Goffman 1963) or ‘stigma by association’ ( Neuberg et al 1994) The image of the psychiatric nurse compared to that of busy A&E ‘angel’ or life-giving midwife is seen very differently. Psychiatric nurses receive least recognition, affirmation, acknowledgement and validation from their family and friends (Cronin-Stubbs & Brophy 1985) and the psychiatric system as a whole is downgraded to a ‘Cinderella service’.

In an attempt to preserve our status, it might be tempting for mental health nurses to dissociate themselves from the devalued patients, to amplify differences in order to reduce the perceived threat from ‘out-group’ members (Heatherton et al 2003). When out with clients/patients/service users, it is often clearly demonstrated that you have not chosen to be with this person, that you are not a friend, neighbour, relative, but are with a patient AND are just doing your job!

Does this happen?

 

 

New Mental Health Nursing Textbook published!

Just a quick post to remind everyone to have a look at  ‘Fundamentals of Mental Health Nursing’ which was published this month.

Fundamentals of Mental Health Nursing
Fundamentals of Mental Health Nursing

The book is intended to cover the pre registration mental health nursing course and was written by a team of Mental Health Nurses – many (but not all) from Birmingham City University or the local trust. The book also benefits greatly from contributions by service users and student nurses.

The book is a little different in that it is partly an on-line resource, if you go to the publishers website you can access a lot of the supporting material from the book such as videos, quizzes and additional chapter material.

The book is intended as an intoduction for people who have had no previous experience of mental health nursing. We have also tried to write it in plain English – I believe that Mental Health Nursing isn’t rocket science! (although perhaps we sometimes make out that it is?)    Anyway – for obvious reasons we are a bit biased about this so, take a look and see what you think about it , all comments welcome!

Andy

Health Promotion?

I’m getting a bit tired of the emphasis on just promoting physical health – what about mental health? Of course, five portions of fruit and vegetables are important, so is not smoking etc – of course mental health nurses have a role in this, but…

 

When I became a mental health nurse, it was because I believed that I could help people in distress. I found that I could easily talk to people and communicate on a variety of levels. I developed the ability to enter into someone’s ‘world’ to see it as they did. Indeed, as time passed I found that I had a particular skill in talking to those who were becoming physically aggressive to de-escalate the situation. I can spot side effects and help people who are experiencing these distressing consequences of the medication that we give. I can help a depressed person out of their hole and assist families to understand.

 

I have got some idea about physical needs, despite a relative lack of training in this area. I am not suggesting that I couldn’t spot the overweight person who smokes 40 a day and drinks alcohol like it is going out of fashion. Rather, what I am saying is my area is essentially concerned with facilitating people to enjoy their life. To give an example – I do not smoke,  yet I will defend the rights of smokers to do so provided that they understand the potential consequences and do not force me to inhale their smoke. We are adults capable of making a decision. Surely my job is to facilitate the making of an informed decision? The Code of Conduct clearly states that we should respect the right of a patient to decline care yet too frequently if a patient declines then ‘no insight’ is recorded in their notes. I firmly believe that the majority of nurses break the Code on this point.

 

What about Mental Health promotion? WHO have identified that depression will be the number 1 illness in Europe by 2020 but rarely do I see any health promotion on this issue. The ubiquitous health promotion posters tell me to lose weight, stop drinking, stop smoking, lower my cholesterol, go jogging etc etc but I have never seen a poster saying

 

‘Hey! Go and chill out!’

 

And I probably never will. Yes I am well aware that many physical promotion has a knock on effect on mental health but surely we should be promoting factors that are primarily aimed at mental health promotion?

 

The candle that burns twice as brightly lasts half as long. Personally, I want to enjoy my life rather than extend a miserable one.