Graduate Diploma in Mental Health Nursing

1. Graduate Diploma in Mental Health Nursing Overview of Course & Role of Preceptors Barry Tolchard Course Coordinator/Senior Lecturer

2. Course Outline • Semester 1 • Primary Health Care 6units • Mental Health Nursing Practice 1 12units • Semester 2 • Mental Health Nursing Practice 2 6units • Evidence-Based Mental Health Nursing 6units • Independent Study/Option Topic 6units

3. ASSESS PLAN IMPLEMENT EVALUATE Primary Health Care Mental Health Nursing Practice 1 Client-Focussed Assessment Mental Status Examination Risk Assessment Mausdley/Psychosocial Assessment Cultural Awareness Problems & Goals Validated Measures Therapeutic Interventions Medication Management Portfolio Client Feedback Sheets Student Outcomes of Learning Problem-Based Learning Anxiety/Psychosis/Depression/Co-Morbidity/Personality Disorders Reflective Practice/Clinical Supervision/Preceptor Feedback Clinical Assignments Referral Letter Duty of Care and Legal Responsibilities Medications and their Use-Therapeutic or Not? Ethical Considerations and Other Legal Issues Reflective Practice Mental Health Assessment or Mental Health Nursing Assessment? Client-Focussed Assessment Clinical Case Management Mental Health Nursing Practice 2 Client-Focussed Assessment Therapeutic Workshops Portfolio Client Feedback Sheets Student Outcomes of Learning Problem-Based Learning Elderly/Homelessness/Adolescence/Population Health Reflective Practice/Clinical Supervision/Preceptor Feedback Clinical Assignments Leadership Family Therapy Group Therapy Advanced Therapeutic Intervention Indigenous Issues Evidence Based mental Health Nursing Independent Study/Option AOD/CBT/Forensic/Child & Adolescence

4. Client-Focussed Assessment

5. The Assessment

6. Jason Grantley—5W’s • Jason states that his main fear is that the Italian boys from school are following him and he reports hearing a man and a woman talking, even when he is alone. They give a commentary of his actions, sometimes telling him that he is bad and today he admits they told him to take his life. • Thishappens in a number of situations such as going to the shops, watching TV and in busy public places. • The problemoccurs at any time of day, but mainly happens in the evenings. • Jason experiences this problem mostly when he is alone or with strangers. Having his family around also makes the problem worse. • He fears he may be killed by the Italian boys.

7. F.I.N.D

8. Jason Grantley—FIND • Jason has had many similar episodes over the last 12 months. • Overall, he has experienced varying degrees of concern/anxiety ranging from 4-8 out of 8. • The concerns/anxiety occur at least once per day and last for up to 2 hours or until he is able to distract himself in some way. • The number of voices is 2—always the same man and woman.

9. Functional Analysis • The functional analysis aims at describing a typical situation where the client has the experience. • The aim is to determine the possible triggers, what the person does in response to those triggers and how that response affects them afterwards.

10. Typical situation

11. Functional Analysis

12. Other Questions/Prompts • When did these experiences first begin? • Is the client doing anything specifically to cope with the distress? • is the coping helpful/unhelpful • are they using modifiers • What impact is this having on work, family, friends etc? • Does the client do anything to excess or not do things to deal with the experience?

14. Formulation • Simply summarises the experience that the client has described. • The nurse may also suggest a possible diagnosis if this is felt necessary including all 5 axis on the DSM IV. • A prognosis and future management plan is given.

15. DSM-IV • Axis I • Clinical Syndromes • Axis II • Personality disorders • Axis III • Physical disorders and Conditions • Axis IV • Severity of Psychosocial Stressors • Axis V • Highest level of adaptive functioning in the past year (GAF score)

16. Jason Grantley—Formulation • Jason Grantley, a 17-year-old unemployed young adult, lives at home with his parents and sister. He presents with a 1 year history of psychotic features with increased avoidance leading to social isolation and drug use.

17. Jason Grantley-DSM-IV • Axis I • Schizophrenia • Axis II • none • Axis III • none • Axis IV • Extremely isolated from family and friends. Unemployed. • Axis IV • 21

18. GAF

19. Jason Grantley—Management Plan • Jason presents with psychotic symptoms that may result from an early onset Schizophrenia. He is suitable for treatment using a two-plus-one approach of Cognitive-Behaviour Therapy with medication management and will lead in planning his own programme of treatment involving coping strategy enhancement with assertive case management. It is anticipated he will be in treatment for 6-8 months and his overall prognosis is unclear.

20. Mental Status Examination

21. Risk Assessment (Suicide) • whether the client is thinking about suicide • whether they have a plan • whether they have a history of suicide attempts • their levels of alcohol and drug use; • the number and quality of their social supports • their reasons for hope

22. Maudsley or Psychosocial Assessment • Medical • Living circumstances • Forensic • Family • Childhood/Development • Employment • Sexual history

23. Measurement Problems & Goals Validated Measures

24. Case Specific Measures • Problem and Goal methodology • identifies the persons own problem using their own words and expressions and is written clearly and precisely by them • measurement is made using scale • goals are devised to reflect the problem • they are observable, achievable and measurable and directly related to the problem • they are also rated using a similar scale

25. Problem statement The problem The feared consequence The antecedent The behaviour The consequence “Anxiety whenever I believe the Italian boys are out to kill me leading me to become isolated at home for fear of the this happening and thus restricting my daily life” Goal statement The behaviour The conditions The frequency The duration “To arrange to go out with one of my friends for the day to the local sports centre” Problems and Goals

26. General morbidity scales Diagnostic Schedules Specific measures for particular disorders Nurse-Rated Measures Work & Social Adjustment Scale Brief Psychiatric Rating Scale Kessler 10 HoNOS Validated Measures

27. Work & Social Adjustment Scale (WSAS) • Simple measure of disability • 5 items rated from 0 (no difficulty) to 8 (severe impairment) • Work • Social Leisure • Private Leisure • Relationships • Home Management

28. Somatic concern Anxiety Depression Suicidality Guilt Hostility Elated Mood Grandiosity Suspiciousness Hallucinations Unusual thought content Bizarre behaviour Self-neglect Disorientation Conceptual disorganisation Blunted affect Emotional withdrawal Motor retardation Tension Uncooperativeness Excitement Distractibility Motor hyperactivity Mannerisms and posturing Brief Psychiatric Rating Scale (BPRS)

29. Brief Psychiatric Rating Scale (BPRS) • 24 symptom constructs • each to be rated in a 7-point scale of severity ranging from 'not present' to 'extremely severe' • if a specific symptom is not rated, mark 'NA' (not assessed) • circle the number headed by the term that best describes the patient's present condition.

30. The Kessler Psychological Distress Scale (K10) • consists of 10 questions, which all have the same response categories • In the last four weeks, about how often? • Did you feel tired out for no good reasons? • Did you feel nervous? • Did you feel so nervous that nothing could calm you down? • Did you feel hopeless? • Did you feel restless or fidgety? • Did you feel so restless that you could not sit still? • Did you feel depressed? • Did you feel that everything was an effort? • Did you feel so sad that nothing could cheer you up? • Did you feel worthless?

31. The response categories for each of the 10-items are: All of the time Most of the time Some of the time A little of the time None of the time K10 score Level of anxiety or depressive disorder 10 to 15 Low or no risk 16 to 29 Medium risk 30 to 50 High risk The Kessler Psychological Distress Scale (K10)

32. HoNOSHealth of the Nation Outcome Scales • 1993—developed to measure the health and social functioning of people with severe mental illness • aim to provide a means of recording progress towards the Health of the Nation target ‘to improve significantly the health and social functioning of mentally ill people’

33. HoNOS versions • HoNOS: • for services for working age adultsHoNOS65+: for services for older adults • HoNOSCA: • for services for children and adolescents • HoNOS-LD: • for services for people with learning disabilities • HoNOS-MDO: • for services for mentally disordered offenders • HoNOS-ABI: • for services for people with acquired brain injury

34. 12 scales that rate mental health service users of working age. Rate various aspects of mental and social health, each on a scale of 0-4. Designed to be used by clinicians before and after interventions so that changes attributable to the interventions (outcomes) can be measured. The scales are as follows: Overactive, aggressive, disruptive or agitated behaviour Non-accidental self-injury Problem drinking or drug-taking Cognitive problems Physical illness or disability problems Problems associated with hallucinations and delusions Problems with depressed mood Other mental and behavioural problems Problems with relationships Problems with activities of daily living Problems with living conditions Problems with occupation and activities HoNOS

35. HoNOS - Rating • Each scale is rated as follows: • No problem • Minor problem requiring no action • Mild problem but definitely present • Moderately severe problem • Severe to very severe problem

40. Problem-Based Learning • PBL is the learning that results from the process of understanding and resolving a real life problem. • The problem comes first in the learning process.

41. The three components of PBL • The PBL case (the task(s) of PBL) • The small group—process of PBL • Independent learning—self directed learning

42. In Mental Health Nursing • health care problem presented stepwise aka “the PBL case” • students work in small groups • students identify important issues in the problem • students set their own learning goals

43. Between tutorials • independent study of resources • in ‘hybrid’ curriculum additional resources provided eg lectures pracs, seminars CAL, accessing ‘resource persons’ • return to discuss new information (report back) • apply new knowledge to understanding and explaining the underlying presentation • continue further problem pages…..

44. Key steps • identify important information in the ‘case’ • key information & presenting problem • generate ideas about what is happening • hypotheses • attempt to explain problem with what already know • mechanisms • decide what is not known • learning issues • study and return with new knowledge to group for discussion • report back • continue the case—progressive disclosure model • new learning issues

45. Next... • learning issues are worked on by students between tutorials • report back of learning issues at next tutorial • new knowledge is critically appraised • new knowledge is applied to case • then the case progresses page by page …..

46. Problems are multi dimensional • creates a knowledge base rich in connections • integrates important knowledge in a professional context close to actual conditions for use • encourages elaboration of prior knowledge base

47. The three components • The PBL case “task of PBL” • The small group “process of PBL” • Independent learning “self direction”

48. Small group learning: student issues • high level faculty/student interaction • question, explain, challenge, appraise • learn for understanding • examine own values and attitudes with peers • gain high level skills in communication, time management, group skills and team work • feedback skills practice & development

49. Small group learning: tutor • process of small group learning is important to effectiveness and efficiency of learning • tutor must have highly developed process skills • student will develop high level process & group management skills • tutors lose authoritative role (+ & - aspects)

50. The three components • The PBL case “task of PBL” • The small group “process of PBL” • Independent learning “self direction”