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This Enquiry Based Learning (EBL) essay is based on a case study of an 18-year-old man.
A fictitious name will be used in the EBL to protect the identity of the young man and henceforth the name Paul Jones will be used, as the Nursing and Midwifery Council Code of Conduct (NMC,2015) specifies that confidentiality is essential when discussing patients.
Paul was picked up by a local policeman after he was found wandering the streets. He was transferred to a psychiatric unit under Section 136 (s136) of the Mental Health Act (MHA).
The responsibility of the police will be discussed in implementing s136 and also the input and role of the multi-disciplinary team (MDT) that will be involved in evaluating Paul and implementing Section 2 of the Mental Health Act (MHA) to ascertain that Paul may be detained legally in the hospital for a period of 28 days to conduct an assessment regarding his mental health(1983 amended 2007). Secondly, the detention of Paul under Section 2 of MHA will be explored, the importance of a comprehensive assessment of Paul’s needs will also be discussed along with explaining the care and treatment that he was given during his detention.
This essay will discuss the role of the mental health nurse in the provision of care to Paul, analysing how the MDT and nurses cooperated with the patient’s family during his admission and during his discharge to the community under the care of the Early Intervention Psychosis Team (EIP). Finally, this essay will be discussing and examining the impact that having a psychotic illness is likely to have on Paul’s family, himself, peers, and education and will identify areas where a mental health nurse can help Paul and his family during this period. The conclusion will summarise the main themes analysing the most important aspects of the connection between the role of nurses in Paul’s care.
Describes the role of a police officer in the application of section 136 including who would be involved and what they would do in the assessment and application of the mental health act.
Section 136 (s136) is a part of the Mental Health Act (MHA). The MHA is a law (Mental Health Cop, 2017). s136 means that the police have the power to coney you to a place of safety or keep the person in a place of safety (Mental Health Cop, 2017). A place of safety such as a purpose-built s136 unit, police station or hospital. Police stations can never be used as a place of safety for under 18’s (Mental Health Cop, 2017). Police stations can only be used as a place of safety in specific incomparable circumstances for adults. This law cannot be used to remove an individual from their home, or someone else’s home. This law is continually used in the community like a park or streets. A police station can only be used for an adult if the detaining officer is satisfied that: (a) the behaviour of the adult presents an imminent risk of serious injury or death to that adult or to others; (b) as a result, no other place of safety in the police area in which the adult is located can reasonably be expected to detain them; and (c) the use of a police station is authorised by an officer not below the rank of inspector (Mental Health Cop, 2014). Following the incidence that Paul was found without any clear purpose or direction on the street by a local policeman and he was in a distressed situation, claimed to be hearing voices, then was arrested, placed under s136 and was informed on the reason why he was placed under this section. The police officer called the ambulance service to manage any immediate medical problems and together they decided that the mental health hospital was the most appropriate destination for Paul. He was searched by the policeman to avoid any risk of self—harming or doing harm to others. The police officer rang the hospital informing them of their situation. Once taken to the place of safety, Paul was detained for the period of not exceeding 72 hours for him to be examined and interviewed by an approved mental health professional (AMHP) and to making any necessary arrangements for his treatment and care. s44 of the MHA, 2007 amended the section to allow transfer between places of safety where appropriate (Home Office, 2008). Following the assessment by the mental health professionals, it was decided that Paul needed further treatment and was taken to a mental health hospital for further treatment either voluntary or on compulsory basis.
Makes a decision about which section of the mental health act should be applied to Paul, briefly justifying choice of section.
On his arrival to the mental health unit, Paul was taken to the admission suite, where an admission nurse who was allocated to the case welcomed Paul and introduced the team. He was offered a drink and biscuits, spoken to about why he was there and made aware that a comprehensive formal multidisciplinary health assessment will be conducted. Paul was assessed to allow the MDT to decide whether to detain him under Section 2 for 28 days assessment or under Section 3 for 6 months assessment and treatment (MHA, 2007).
Paul was reassured as he was emotionally anxious, frightened, terrified and confused as this was his first admission into a mental health unit and many patients experience their admission and stay in an acute ward very burdensome or even negative (Katsakou et al., 2011). Research conducted has shown that between 10% and 50% of patients who were voluntarily admitted in fact feel coerced to receive treatment during admission in an acute ward (Katsakou and Priebe, 2006; Kjellin et al., 2006; Schoevaerts et al, 2013). These inpatients may experience the acute psychiatric wards as a hostile environment. Also, being confronted with coercive measures applied to themselves, these patients may also witness the restraint or seclusion of other patients in the ward (Iversen, Hoyer, & Sexton, 2007). Paul’s assessment was for both his physical and mental state. The MDT decided that since it was his first psychotic episode and he had no previous mental health record. So, it was therefore decided that for his own best interest he should be detained under s2 for further assessment for 28 days. The criteria used for his Paul’s diagnosis were confirmed using the International Classification of Diseases, 10th Revision (ICD-10) World Health Organization, (WHO 1992).
A formal assessment for Paul was preferred to an informal assessment as the rules, guidelines and specific procedure that are established in a formal system helps in assessing the people in our care the same way. As this eliminates or reduces our own idiosyncrasies, prejudices and opinions as they can have a huge influence in our decision and introduce bias (Baker and Kerr, 2000).
According to National Institute for Health and Care Excellence, (NICE, 2011) clinical guidance 136, a mental health assessment assesses your emotional wellbeing, physical examination, family background and everyday life, to find out what the illness is, how severe it is and the most suitable treatments you need. The mental health assessment was conducted within 24 hours by AMPH, who have been commissioned by local social services to carry assessment and admission to hospital under the MHA (MIND, 2013). This is according to Rethink Mental Illness, 2017, stipulating that individuals who are detained in a psychiatric unit under s136 must be assessed within 24 hours and if this is not done, then it is unlawful to continue holding the individual in custody. The AMPH consisted of social workers, nurses, occupational therapists and psychologists.
Paul’s mental state was assessed using The Roper, Logan and Tierney, 2000 nursing model and his ability to perform Activities of Daily Living (ADLs). This model was used to assess how Paul’s ability to sustain any of the twelve activities of daily living as psychotic disorders are associated with difficulties in daily functioning ( Klapow et al, 1997). The outcome of the assessment showed that Paul had no friends at school, spent time on his own and socially isolated.
Psychosis as described in the International Classification of Diseases, 10th Revision (ICD-10) (World Health Organization, 1992), is characterised by certain symptoms, such as delusions, hallucinations and disturbed behaviour, and refers to psychotic illness. Individuals experiencing psychotic illness describe a changeable phenomenon with risks of developing acute phases of psychosis. The characteristics of an acute phase of psychotic illness are typified by increased distress and psychotic symptoms that include distortions in emotions, thinking, perceptions, sense of self and behaviour (McGorry et al, 2008, NICE, 2014; Sebergen et al. 2016). Being severely psychotic is described as adrift from one’s own body and self, from other people and from the environment (Barker 2001). It was mentioned by NICE 2004, that Psychosis affects about 1 % of the population worldwide once in a lifetime. The occurrence of new cases of psychosis is estimated to be 15–20 per 100 000 inhabitants a year (NDH, 2013). This means that in Norway in a year, 750–1000 new cases of persons suffering from psychosis were diagnosed and in the Nordic countries combined a total of 3900–5200 new cases were reported (NDH, 2013). In the UK, psychotic disorder rates are estimated at 32 per 100,000 people with significantly higher rate for BME (Black and minority ethnic groups). Yearly prevalences are estimated at 4 cases per 1000 people which have be attributed to Schizophrenia (Kirkbride et al, 2012). Most persons recover from psychosis, although are vulnerable to new phases of psychosis, and/or some persons have lifelong psychotic illness (NICE 2004). According to Garety et al, 2006, the first episode of psychosis is the first time an individual experience a combination of symptoms. These symptoms are known as psychosis. During the occurrence of a psychotic episode, a person’s perception, thoughts, mood and behaviour are significantly altered’.
In research conducted by The Centre for Addiction and Mental Health (CAMH, 2012), it was stated that the phenomenon experienced by an individual affected by psychosis could include feeling paranoid, feeling suspicious, anxious or hearing voices which are signs that were reported by Paul.
Once admitted to hospital discusses what would be Paul’s care and treatment from a Bio-Psycho-Social perspective
After his admission, a key nurse was allocated to Paul whose role was to work with him and his family whilst he was being treated. This ensured that all planning were person-centred and involved him as an active partner in his care. The focus by the MDT was to enable Paul to have a seamless transition into and out of hospital. This was in line with a research conducted by Barrett et al, (2013) who found out that patients engaged more with support as their voices were considered when discussing their care plan. The admission nurse explained to Paul and his family why he was sectioned as this led to improved communication and support between them (Fakhr-Movahedi et al 2011). Also supported more reflective practice as Identifying his family early on means they were more involved in his care and aided the MDT understand Paul and his needs (Bobier et al, 2009).
This included informing him about how the ward was set up and the practitioners who would be looking after him whilst he is being treated. Therapeutic relationship is described as one which is perceived by patients which include caring, and supportive non-judgmental behaviour, embedded in a safe environment during an often-traumatic period (Mottram 2009). Conversely, feelings of dehumanization and increased psychological distress are linked with negative clinician-patient relationships (Steph 2009). These relationships are short-lived or continue for extended periods. Typically, this type of relationship displays genuine interest, friendliness, empathy, warmth, and the wish to facilitate and support (Priebe and McCabe 2006; Cousin, 2012).
A biopsychosocial model of health and illness proposed by Engel (1977) was used in assessing Paul. This model was chosen as it allows the illness to be viewed because of interacting mechanisms at the organismic, tissue, cellular, interpersonal and environmental levels. According to Engel, he mentioned that the study of every disease must include the individual, his/her body and his/her surrounding environment as essential components of the total system (Engel, 1982). The biological, psychological and sociocultural predisposing factors included in the assessment looked at his genetic background nutritional status, verbal skills, morale, personality; past experiences; locus of control, social position, cultural background, religious upbringing and beliefs and level of social integration or relatedness. From the assessment, his biological history showed that his nan from his mother’s side suffered from schizophrenia and this is in line with the hereditary theory which suggests that a family history of mental illness does increase the risk of mental illness (Sellers et al, 2012).
In addition to the fact that Paul was apprehensive about his A levels exams suggest that he was vulnerable to stress-induced psychosis as mentioned by the stress vulnerability model. It deduces that stressful events of life may act on an underlying genetic predisposition to trigger the formation of delusions and hallucinations (Zubin and Spring, 1977; Nuechterlein and Dawson, 1984). This tool is used for identifying, treating and preventing the reoccurrence of mental health.
Identifies the mental health nurse’s role in Paul’s care whilst on the ward.
Nurses play a vital role for people with physical and mental illnesses. The foremost duty for mental health nurses in acute psychiatric wards is to meet the individual’s emergent needs for safety and security and his/her physical and mental needs while he/she experiences psychotic illness (Cleary, 2004; Bowers et al. 2005). The interpersonal interaction between Paul and the nurse is considered as a cornerstone of mental health care which is described by (Cleary et al 2012). The role nurses play include being an ethical decision-maker, clinical advocate, case manager, comforter and counsellor. Good communication is important between practitioners, people using mental health services and their families, parents or carers (Raya, 2006). As a clinical advocate, the nurse provided a safe conducive environment for Paul and managed protected him from every possible adverse effect of the medication. As a comforter, the MHN provided comfort to Paul by considering him as an individual with unique feelings and needs. As a leader, the CPN helped the client to make decisions regarding his health. Nursing leadership is defined as a mutual process of interpersonal influence through which the nurse helps the patient in making decisions for establishing and achieving the goals to improve their well-being (Wong et al. 2013).
Discusses which mental health team would provide his post-discharge care and justifies decision of service provider.
Paul was seen every week during ward round where his treatment was discussed by the MDT. Paul’s parents called on him and they spoke to the nurse in charge of how settled Paul was and his presentation during their visit. They were informed about Paul’s progress in his physical and mental state, his level of participation in ward-based activities and sessions arranged by the ward occupational therapist. He was given a daily behavioural feedback which was once a day in the evening. The feedback consisted of Paul’s and staff’s view on what has been good and what was not, his understanding of his mental state, remainder of the overall goal, which is to be discharged and he could return home to his family and his education. During one of the regular scheduled meetings with the MDT and his parents, Paul mentioned that the voices were quieter and said he was happy that he is feeling better and was not feeling any side effects of the medication.
Paul was discharged 28 days later and section 2 was withdrawn which was in line with (MHA, 2007). Practitioners need to work together, across physical and professional limitations, to ensure that patients experience a good transition. Paul’s discharge from hospital was a process, not an isolated event. It involved the development and implementation of a plan to facilitate his transfer. It involved working with his family, primary care providers, community services and his social worker. This was to ensure that the whole system’s approach to admissions and discharges is positively reflected in Paul’s experiences (Bennewith et al 2014).
Following his s117 discharge meeting, Paul was discharged to the Early Intervention Psychosis (EIP) team works with service users who are aged between 14 and 35 years who are experiencing their first episode of psychosis. The EIP team comprises of a range of disciplines including psychology, social work, nursing, support workers and psychiatry which was in line with (NICE 2014). Paul was allocated a care coordinator who will take lead of his care, provide family and social support, signposting and supporting with employment and meaningful activities (Edwards et al 2005). Good communication leads to better-coordinated care and a better experience for Paul and his family. Paul’s CPN met with him and his family when he was discharged and spoke to them about his psychosis, treatment, risks and management, support for his family, assessing and addressing their needs since it was his psychotic episode. A weekly meeting was arranged with Paul and his CPN to see how he was coping out of hospital. The weekly meeting was reviewed depending on Paul’s progress. Research evidence allude to that patients with support from family and guardians can accomplish better outcomes, which include fewer inpatient admissions and relapses, better engagement with services like psychosocial interventions, prescribed treatments, and improved rate of mortality (Chien et al 2013; Kuipers et al 2010). Also, the co-producing Paul’s care plan with Paul helped him feel more in control and was an active partner in his own care and recovery. Paul’s care plan contained his crisis plans, discharge and recovery plans, and Care Programme Approach documentation (CPA). This was to avoid a lack of coordination between plans as it could result in frustration and stress if persons discharged do not have as much information available to them.
Details what Paul’s ongoing treatment is likely to be from the service identified.
Paul was prescribed Risperidone 2mgs a day and Psychological therapy like Cognitive Behavioural Therapy (CBT). CBT was recommended as a treatment for Paul as growing evidence in the UK suggests that CBT is effective in the treatment and prevention of psychosis
(Wykes et al., 2008; NICE, 2009; 2013; 2014). It helps individuals develop other ways of rational and behaving with the aim to reduce psychological distress (Hutton and Taylor, 2013).
He was told by the nurse the right route, right dose, side effects and right time he would be taking his medication. This was to reduce medication errors and harm during admiration of medication and improving communication with patients to enable them take or adhere to their medications (Phillips et al, 2001).
According to The British National Formulary (BNF, 2017), Risperidone is an atypical antipsychotic drug which is used to treat mental health disorders like schizophrenia. It is both well-tolerated and effective in patients with chronic schizophrenia (Chouinard et al. 1993; Farah, 2005; Marder and Meibach 1994; Peuskens 1995). According to Kaas et al, 2003, Antipsychotic drugs, particularly atypical antipsychotics such as Risperidone and Olanzapine works by the symptoms of psychosis. There is reduction of serotonin levels in the brain are short-lived by occupying the dopamine receptors and then rapidly dissociating to allow normal dopamine transmission.
Whilst antipsychotic medication is important, they have related to unpleasant side effects which might be common, uncommon and rare depending on the individual. They include tiredness, increase in weight, vomiting, insomnia, agranulocytosis, embolism and thrombosis and sudden death, jaundice, sleep apnoea (NICE,2017). On the account of this, Psychological treatments like CBT may be used alongside or in place of biological treatment (Bland & Foster, 2012).
Discusses the impact that having a psychotic illness is likely to have on Paul and his family and identifies areas where a mental health nurse can help Paul and his family
Many individuals diagnosed with psychotic conditions live with or remain in contact with their close relatives such as their children, siblings, partners and parents (Weisman, 2005) and the social and emotional implications of families and patients with psychosis are stressful and strenuous, which results in impairment of occupational and social functioning (Okpokoro et al, 2014). As in this instance, this episode of Paul developing psychosis leaves his family members bewildered and frightened, working through high levels of distress often amongst family members (Baker et al 2001). Paul’s parents said they felt they had failed to help their son soon enough and wondered what key signs and symptoms indicative of the illness they missed before he was found by the police (Tharra et al, 2003 Castilla et al, 1998). Some studies on burden have shown that family members of psychiatric patients are highly burdened by the task; this burden is both objective (socio-demographic characteristics, changes in daily routines, family and social relations, work, leisure and physical health) and subjective (result of health problems and result of subjective discomfort) (Stam et al, 2001; Lauber et al 2003; Gutierrez-Maldonado et al, 2005). The more burden these relatives experience the worse their quality of life would be (Webb et al, 1998; Ötsmann 2000).
Paul’s parents were signposted to psychoeducation, stress reduction and structed problems solving family interventions. They were encouraged to join their local carer support group to discuss more about their experiences during Paul’s psychotic episode which would gradually improve their self-esteem and general wellbeing. These interventions consisted of both psychotherapeutic strategies and family intervention therapies for working with people who suffer from psychosis (Mueser et al,2013). The CPN spoke to Paul’s inclusion manager in his school and it was decided that an educational psychologist maybe required to ascertain if an individual educational plan would be required. Peer support groups was suggested to Paul as research conducted by Friis et al, 2000, mentioned persons who often experience mental and social limitations as a result of their conditions might lead to social and emotional isolation. Furthermore, due to stigma and nature of their experiences such as hallucinations and delusions they might find it difficult discussing on how they feel with people who have not come across similar experiences ( Martinsen et al, 1999).
The development of community and neighbourhood policing creates an opportunity for the police to take a more active role in identifying people at risk of more serious offending who may benefit from mental health care and other services. Police officers need more and better training in mental health issues. Mental Health First Aid is a potentially useful approach to training that would fit the role of the police in dealing with mental health-related crises.
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