Issues in Acute Care: Mental Health - Essay Example

Issues in Acute Care: Mental Health Many people seek services when in a crisis. This can be described as a sudden onset or relapse of mental illnessor distress, which renders the individual and/or caregiver unable to cope with normal circumstances. This may further present a risk to themselves or others (Operational Policy, 2009). Best practice in collaboration should be based on building a trusting, open relationship between service user, caregiver and service provider. Furthermore, this should incorporate building service users' strengths and developing coping strategies which are all underpinned by the recovery approach. These approaches should all be based on knowledge of the individual service user and applying evidence-based research to enhance a positive outcome. This essay will discuss the contributions to a client's recovery of utilising a collaborative approach to assessment within an acute ward. Recovery is a very unique, personal experience which sees service users tackling and adapting to mental illness. By giving service users access to key helpers, factors (i.e. psychotherapy, medication, focus groups and peer support) aids recovery and give a sense of optimism and hope for the future. Body In clinical practice, acute care is viewed as a one-stop-shop where radical life-saving interventions are implemented in a fast-paced, ever-changing environment and where a crisis is established. In contrast to this, acute care in psychiatry is viewed as the poor relation where service users find themselves being failed by a service that itself is in a state of crisis. Furthermore, because psychiatry relies heavily on the medical model, other recognised interventions are not being offered. Psychiatric services seem on the surface to be radical or time-consuming. However, if clinical services find the time to offer the more radical interventions, why cant psychiatry Subsequently, service users find themselves in a revolving door situation, where for a short time they are in recovery, but because alternative interventions are not offered, they find life stressors activating their mental illness. So if other interventions have been developed and are proven to have positive results in relation to managing mental illness, why do service providers feel they cannot offer them to users What is New Is Really Old Collaboration and recovery seem to be the new words in mental health services with the new Mental Health (Care and Treatment) (Scotland) Act 2003 being re-written and the rights, relationship and recovery (2006) documents being recognised by parliament. However, just how radical are these new polices Looking back at psychiatric services through the last 150 years you can see how the new really has its roots in the very early framework of psychiatry; indeed, when it comes to psychiatry the statement 'everything changes and yet everything remains the same' seems very fitting. Smoyak (2007) suggests the term 'what is old is really new' in relation to modern psychiatry. Indeed, many people view concepts such as recovery and patient-centred care as modern, however they very much have their roots in the past. Smoyak (2007) highlights that care was largely based on humane, moral treatment principles, and lengths of stay were far shorter than in the 20th Century. Indeed the shift towards intensive home treatment teams in today's psychiatric services would suggest that there is a unified need for shorter or no admission to acute facilities. This in itself suggests what is old is really new and that, when asylums were at their height, they indeed recognised the very simple yet powerful focus on holistic care was at the heart of recovery. Many people can contribute to clients' care in an acute crisis, even before admission to mental health facilities, GPs have an important role to play and are usually the first people that can assess a client who may have an on going mental health problem. However, Ruane (2004) found as a caregiver that GPs sometimes do not recognise the symptoms of mental illness and that it can take up to 18 months in some cases before the problem is addressed. Unfortunately, this can come too late for clients, and this is when they find themselves being detained in acute wards, which in hindsight could have been prevented. So once a client has been admitted, it should be determined who else can contribute to recovery using a collaborative approach. Psychiatrists, nurses, psychologists, caregivers, nursing assistants, pharmacists, social workers, advocacy, cleaners, physiologists and occupational therapists all have very important roles to play in facilitating recovery. All of these services seem to go with out question and there may be a tendency to do for the client; however, the most important person in this team is the service user themselves. After all, without their want for better mental health, how can collaboration work Communication lies at the heart of this; indeed, this is the tool where trust can be built in a sometimes unstable and frightening environment. Having the skill to do this cannot just be learned in the classroom; the ability for this is the very foundation of why people whether they are staff or service users want to help others in crisis. McCann (2004) suggests that capitalising on the experiences of service users can minimise anxiety when admitting someone for the first time. Indeed, as acute admission is many service users first contact with any mental health service, it would be very fitting to have someone with real-life experience to firstly act as an advocate and, secondly, allay some of their fears in a very alien environment. This in itself would be the first wrung of building trust between all, as the actions of the institution would be suggesting that the staff are not the experts and that everyone is concerned with your recovery. The trust of the service users' carergivers also has to be embraced if a positive recovery outcome can be reached, indeed liaison between all can reaffirm the message of hope. So, What Is Next Recent research has found that early intervention (particularly in a first episode psychosis) can help reduce the impact it has on service users' lives. Delayed treatment can be associated with an increase in complications i.e. severe behavioural disturbance, family difficulties and life threatening behaviour (Aitchison, 1999). Adolescents are particularly vulnerable to misdiagnosis as a lot of their behaviours are seen to be typical of the age group with changes in mood, depression, anxiety, cognitive changes, odd ideas about self and the world, changes in sleeping patterns and appetite. These can have the potential to be preceding a full acute episode and is seen as an great risk, but it is essentially retrospective, as not all typical behaviours proceed mental illness. Social services, educators and, surprisingly, the police have potential to be part of the collaborative team in early recognition. These particular organisations usually can have a first contact as assumptions are made that their behaviours are within the normal range of teenage behaviour or there are social problems within the family that need to be addressed. Education within these organisations has the potential to rapidly refer cases of potential mental illness to specialist opinion thus reducing the overwhelming impact of a prolonged illness and longer in-patient care. Formulations within the collaborative team can help assess whether there is a mental illness in the true sense but many other things need to be ruled out . Rapid assessment in other key specialist areas can help achieve this. Simple blood tests can rule out thyroid problems, whilst MRI scans can determine if something else is underlying the behavioural problems (i.e. tumours, head injuries and other abnormalities of the brain). Unfortunately, it can take a number of weeks for referrals to be processed and, even when there is a clear link to neurological factors, general wards seem unwilling to manage the service user on their wards, so transfer to psychiatric facilities-which is highly problematic to the service user, staff and families-and has the potential to do even more unnecessary harm. Drug and alcohol misuse can also be seen in mental illness, and there is a lot of overwhelming evidence to suggest that it can be predisposition to developing many types of mental illness. Furthermore, many addicts say that they misuse to help manage their symptoms, which can have potential harmful effects as they may already be on some form of prescribed medication which could have counter indications, thus facilitating a chicken and egg situation. Managing these behaviours can be tricky, especially when the onus is on collaboration and recovery. Many professionals view service users who misuse drug and alcohol as a waste of resources and are not willing to see the person behind the behaviours. Controversial approaches to this look at risk management or harm reduction which can help manage symptoms and behaviours in a more proactive way. Using these techniques relies on good quality education from services allowing the service users to explore reasons why they misuse, address the contra-indications that can occur and gives a sense of autonomy back to clients. This pro-active approach allows for a deeper understanding of misuse for both services and clients. Referring clients to outside agencies can help motivate a change in behaviours as it is widely accepted the support from people who have similar lived experiences is beneficial to the recovery process. Organisations such as AA and Phoenix Futures can give support, education and allow further exploration of the reasons why people misuse, whilst support groups such as the hearing voices network can educate through lived experience of better management of symptoms. According to the UK Harm Reduction Alliance, harm reduction recognises that peoples' ability to change behaviours is also influenced by the norms held in common by drug users and the attitudes and views of the wider community. Harm reduction interventions may therefore target individuals, communities and the wider society, and accepts that the use of drugs is a common and enduring feature of human experience. Given this is now widely accepted as best practice, the need for un-biased services has to be addressed in order for service users to get the best out of a collaborative approach. Medication is an important part of the recovery process; however historically there has been an over reliance on medication. Understandably, the rise of new medications has seen better achievable outcomes from illness and remarkably improved life expectancy. Dangerously, the suspicion of the wider public views on pharmacology has unwittingly seen opinion swaying the other way which has pushed the use of medication to the other extreme where it is not being used by service users. The driving force for this suspicion is that money is at the centre of pharmacology and patients care and safety is surplus to requirements. Getting the balance right is crucial to developing good collaborative partnerships, indeed many services and interestingly psychiatrist now promote interventions such as CBT in order to achieve a better quality of life for service users. Psychopharmacology is now seen by pharmaceutical companies as a way to redress this. Using flexible therapy allows for earlier identification of stressors or triggers that effect mental illness negatively and accepts the need for medication in a collaborative working partnership with service users at the centre. Before an admission, many clients have been too chaotic to attend to their basic needs. Maslow (1943) developed his hierarchy of needs and states that physiological needs (air, water, food, sleep and homeostasis) and safety needs (shelter, protection from harm, stability) have to be in place as a constant in order for a good level of functionality. Roper, Logan and Tierneys (2000) activities of daily living model (ADLs) developed in the 70s built on this and suggest a focus on these basic needs can shift the emphasis from ill-health to health. Furthermore as many factors influence ADLs with biological and psychological having the biggest impact the need to promote the very basics has to be recognised by services in order to promote recovery. They also highlight that these interventions are usually short lived as people move from a state of dependence to interdependence. Gentle encouragement to attend to ADLs can promote recovery; indeed, as services look for some form of medical intervention these basic yet empowering factor can be forgotten in the need to treat the illness. Just having access to bathing, clean clothes, food and water in a safe environment can help give a window of stability and calmness to someone who has had a very chaotic time. These small actions can also offer an area where communication and trust can be built on and also promote a working collaborative partnership where the actions of the services give back autonomy to the client. Caregivers have a difficult task in being part of the collaborative team. With trust being the basis were relationships are built from caregivers find that the boundaries of their relationships have been stretched out of recognition. Often in a crisis admission service users find that they have been detained and it is often the caregiver that is blamed for this detention by the service user as it is easier to channel frustrations towards the closest people to you. Because of this resentment, service users often tell staff not to inform their caregivers of any assessments. Caregivers can be left feeling out of the loop and frustrated as on discharge the expectations of the services is that the carer will continue as before but with insufficient information and support it is unrealistic situation to find yourself in. The our point of view survey (2003) report that effective communication and information sharing or the lack of it are common themes in acute crisis. Patient confidentiality rules can make information sharing difficult, but caregivers feel that these rules are being used against them in an unhelpful way and that the underlying reason for these barriers is not the relationship between carer and service user but mental health professional and caregivers (Rethink 2003). Developing services for caregivers and families of people with mental illnesses (2002) recommends that professionals should be inclusive towards caregivers and should be able to recognise that they are both partners and co-experts in the collaborative team. Indeed, the discharge from hospital report (2003) highlights that carers must be involved in the planning and delivery of that will be beneficial to recovery of the service users. Services have to be respectful and inclusive of caregivers when providing assessment. If caregivers' views are being disregarded by professionals, it can affect the services and users' recovery process as apathy and suspicion may be transferred from caregiver, mental health services and client, this does nothing constructive where recovery is concerned and just feeds in to the revolving door mentality, which is clearly unhelpful for mental health stability. Faith Many service users find comfort and acceptance within their faith; indeed, a time of crisis can be interoperated as a need to change something spiritual whilst addressing their beliefs and values towards the wider communities. Faith gives an outlet to explore disturbing thoughts in a non-judgemental way. Psychiatrists acknowledge that a mentally ill patient's strong religious beliefs can provide a solid platform for therapy. This is because much therapy will begin with something the patient holds as certain. A multi-faith working party was developed as many religious elders found more and more members of their church coming to them for advice on matters surrounding mental illness. Most members found that they were under prepared to deal with and advice people on these matters. Clearly, faith is something that can give hope for the future many service users talk about their faith but find little support within acute wards to explore and continue practicing religion as some services themselves have little understanding of different faiths. There is increased evidence that health outcomes may be considerably enhanced when beliefs, values, their social context and their relationship are fully taken into account in a clinical setting (Spiritual Care and Chaplaincy in NHS Scotland NES, 2008). The NHS must uphold and provide adequate resources for multi-faith chaplaincy if full utilisation of the collaborative team can be delivered, clearly there is a link between spirituality and recovery therefore should be an integral part of delivering healthcare. Patient or Expert Mental health services historically have viewed service users as weak and unable to do anything for themselves so that patients have to be looked after continuously. Increasingly, new legislation has recognised the need for autonomy, inclusion and collaboration where recovery is concerned. Service users should be fully involved, so far as they are able to be, in all aspects of their assessment, care, treatment and support. Their past and present wishes should be taken into account. They should be provided with all the information and support necessary to enable them to participate fully. Information should be provided in a way which makes it most likely to be understood (The Mental Health Care and Treatment Scotland Act, 2003). With this now being recognised by law, the need for services to catch up and utilise services users unique and expert opinions must be utilised in order to promote recovery. In 2001, the Sainsbury Centre commissioned a major interview study of service users' perspectives on mental health services. 70% of respondents wanted a non-medical approach when in crisis. Dace (2001) is a service user with over 20 years experience in the mental health system and views it as a revolving door where it is expected that she will be back in crisis before long. Importantly, what she and other service users want in order to be well is access to mutual self help networks with a valuable alternative to traditional methods (i.e. developing human relationships and friendships). These simple approaches could be harnessed in acute crisis with the onus on staff tapping in to the very basic human need of belonging and being a part of something that is beneficial to society; after all, everyone wants to feel helpful towards others, so utilising service users expert knowledge on mental illness could be used in a far more productive way. Gender Sensitive Issues Sensitivity towards gender can provide its own set of complications, particular sensitivity is needed towards women within acute wards as women have different needs and may present mental illness differently to men. When women are ill, they can be at risk from domestic abuse and exploitation and can feel powerless to speak up or are unwilling to admit that they are at risk which can seriously impact their mental health. Children are often left very vulnerable to risk at times of crisis, so services have to be able to communicate concerns in a sensitive non-judgemental way. Continual missed opportunities can and do have a profound effect on recovery with the role of females as the main caregiver having to be acknowledged in order to support these difficulties. Social services, police, teachers and particularly women's aid have to be accepted as part of the collaborative team in order to protect from further harm. Too many women who are service users and who have suffered from abuse have reported that things in their lives were going wrong for sometime and services either failed to ask the right questions, ignored the possibility of abuse or just did not liaise between agencies, thus, failing to join the dots. Historically, if police were called to domestic abuse incidents, they described it as being an domestic situation between couples and did not want or were unwilling to pursue the matter further. Recent years have seen massive changes in these attitudes and the police have the power to remove the abuser, will liaise with women's aid in order to secure a place of safety, report to social services, and attend MDT meetings in order to protect the most vulnerable in society. A major part of recovery in this sensitive, yet serious, is good education for agencies and proper opens communication. Women often found in the past that they were second class citizens and society was full of inequalities, which for the most part have long been left in the past; unfortunately, these inequalities still raise their heads from time to time and this can be reflected from staff. Of course the one thing all services need to bear in mind is that until the service user is in recovery and feels strong enough and supported to make a change services have to be patient after all without the decision coming from them solely true collaboration and autonomy can not be achieved. Care and Support in the Community On discharge, service users can find themselves facing a new set of problems. Social housing, benefits, employment, legal support and further education needs to be addressed and in place in order to promote recovery. Social workers and welfare officers can liaise on behalf of service users, and advice on benefit entitlement and help with the daunting task of paperwork. Having secure housing and financial stability can help in promoting a feeling of safety and security for service users. All outside agencies have to recognise the unique differences and challenges services face and adapt their services appropriately in order keep service users well. Collaboration between all statutory and private agencies can facilitate this and ongoing communication with the service user achieves a sense of autonomy. Social inclusion has been a term that is part of our vocabulary for sometime and recent campaigns highlight the need for inclusion, help to de-stigmatise issues surrounding mental illness, facilitate open discussion within communities and highlight that one in four people suffer from some form of mental illness. Alienation can have a negative impact on mental health and service users like everyone need to feel that they belong and can have the potential to contribute to their communities. CPNs can offer a supportive link between statutory and private agencies and can also offer psychological based interventions in the safety of service users' homes. Psychological interventions can also offer an exploration of ideas and problems that could normally put stress on service users. CPNs can also help service user to reconnect with loved ones and establish new relationships within their communities. The use of groups out with hospital setting can help achieve less admittance to acute facilities and open door clubs can give access to further education that helps maintain a sense of hope for the future. The sooner the person can begin to participate meaningfully in their own care, the sooner they will begin to gain meaningful supportive care and the sooner the person will be able to relax their dependence on formal mental health services (Barker, 2005). Conclusion In conclusion, many services need to be involved in order to promote recovery within acute settings. Nurses are usually at the forefront of liaison where multi agencies are involved or have a formal interest in service users' care. Many agencies do let the clients they work for down by seeing them as a job to be done and not the person they are. This then leads onto further stigmatisation, hopelessness and institutionalisation which undermine good practice and buys into the revolving door mentality. 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