Developing Autonomous Practice in Mental Health Nursing - Essay Example

?Developing Autonomous Practice in Mental Health Nursing Table of Contents Introduction 3 Patients Background and History 3 Stress Vulnerability Model 5 Formulation- Provide Formulation and History of Physical, Psychological & Social Needs 8 Psychological Needs 10 Physical Needs 11 Social Needs 11 Identification of Aims & Goals 12 Therapeutic Nursing Intervention 13 Clinical Reviews 15 Therapeutic Efficacy 16 Conclusion 17 References 18 Introduction The essay is based on a case study of a patient, Mrs. N, suffering from paranoid schizophrenia and poly-substance abuse. In the essay, the personal and psychiatric history of the patient would be provided. Furthermore, the present psychological, sociological and physiological requirements of the patient would be observed by applying different therapeutic approaches. Therefore, the essay also intends to describe about selected therapeutic approaches, nursing interventions and medical appraisals of the patient’s health progress. The therapeutic efficiency of the present atmosphere, where healthcare is being delivered to the patient, will also be assessed with respect to the likely alternate service provision. Ultimately, a reflexive conclusion would be developed on the basis of healthcare and medical interventions delivered to the patient for curing schizophrenia and relieving substance abuse. Patients Background and History The patient is a 34 year old Black African British female. In this essay she would be referred as Mrs. N to preserve confidentiality with regard to the code of professional conduct which states it as obligatory for nurses or any other health professionals to protect privacy of patient’s medical information (American Psychological Association, 2013). The report of the patient indicates that Mrs. N was born in UK and had been taken away to West Africa in childhood, where she had completed her entire education life with satisfactory grades. After completion of university education from West Africa, Mrs. N returned to UK when she was 18 years old. In the UK, Mrs. N lived in London with her family in a seven bedroom house. At present, she has two girls and two boys who are again recoded to belong to different fathers. Mrs. N had several broken relationships. Currently, she is married and residing with the father of her last son. Mrs. N defines her family as helpful, supportive and gentle towards her. Presently, Mrs. N is unemployed and claiming income support along with disability allowance. However, previously, she had a job in a textile company, while she was residing in West Africa. Mrs. N desires to go back to Africa where she has spent her childhood life and teenage days. From the report it is very much clear that she misses her friends and wishes to go back to Africa with her family where she can feel more welcomed and can get better medical treatment with ‘Herbal Medicine’. Mrs. N’s husband had sacrificed his work in order to stay at home so that he can watch over the children and support Mrs. N with her mental illness. From the medical record of the patient, it has been observed that Mrs. N has been diagnosed with acute mental despair. She had tried to kill herself along with her youngest son affirming that someone persuades her to kill herself as well as her children. Furthermore, consumption of drugs and alcohol has made her condition worse. Her report represents devastating experiences of distress where she does not prefer to interact with any person and also lacks motivation to attend her personal sanitation. Mrs. N also agreed that there is a history of mental illness in her family. Her father and grandmother both had been diagnosed with a problem of schizophrenia, similar to her case. Mrs. N has been reported to drink alcohol at frequent instances and to smoke cannabis regularly. Before her admission as a mental patient, she was recorded to make her last attempt to kill her husband. Due to her act, she was arrested under Mental Health Act (MHA) Act of 1983 under Section 3 (Lennox, 2012). Because of challenging and threatening behaviour towards staffs and other patients, Mrs. N was transferred to Psychiatric Intensive Care Unit (PICU). As a mental patient, she requires quick tranquilisation for managing the aggression and violent behaviour (Royal College of Nursing, 2006). It has been reported that in order to celebrate Christmas with her family, Mrs. N escaped from the medical ward, but was again brought back by the police. This incident put an alert on Mrs. N on the basis of Section 136 of MHA Act of 1983 (National Institute of Mental Health, 2013). Furthermore, the report also states that Mrs. N is prescribed to take Clozapine because she was not reactive towards other form of antipsychotic medicines. With such concern, her condition of white blood cells is observed regularly for avoiding the risk of Agranulocytosis (Desai & Grossberg, 2001). She is temporarily discharged to a 24 hour supported accommodation centre because of violent behaviour on her husband and children. Stress Vulnerability Model Stress vulnerability model acts as an assessment tool and also provides structures for conducting physical health evaluations. According to this model, vulnerability to an obsession is fundamentally acquired by inherited predilection or due to the consequence of environmental aspects. Contextually, the model identifies that mental health problem can appear if a person is put under considerable level of stress. Nevertheless, the level of stress which leads to mental health problem can vary from person to person. For instance, an individual who is highly vulnerable to stress is more likely to face mental health problems even in an environment deciphering low amount of stress and vice-versa. Hence, it can be stated that the limit of an individual towards dealing with stress depends on various aspects such as personal history and inheritances among others. This particular aspect confirms that identification of the source of stress for an individual is vital in order to mitigate the mental health problem suffered by the patient (Mental Illness Fellowship of Australia, 2008). Correspondingly, ranges of biological aspects, personal aspects and environmental aspect can influence a patient’s vulnerability to mental health problems. Accumulatively, these aspects are termed as risk factors. Applying the model, it can be thus stated that mental health can only appear from intersection of high stress and high vulnerability towards mental illness (Mental Illness Fellowship of Australia, 2008). Hence, the risk factors identified for Mrs N for increasing vulnerability towards mental illness are: Biological aspects The major biological aspect which acted as causing factors for the mental illness of Mrs. N can be identified as her family history. From the medical record it has been observed that there is a history of mental illness in her family. The past records depict that her father and grandmother both had been affected with a problem of schizophrenia. Personal Characteristics The personal characteristics which played a vital role in causing mental health problem for Mrs. N can be identified as her weak social skills, weak stress handling abilities and communication problems. As per her records, it can be observed that Mrs. N had isolated herself and did not communicate properly with the family members, which generated risks for mental illness in terms of depression. Environmental Aspects Several environmental aspects also generated risks for Mrs. N towards mental illness. For instance, substance abuse, work related problems and stressful relationships were a few of the causes which influenced mental illness in the case of Mrs. N. Stating precisely, Mrs. N was observed to be infested with substance abuse such as consumption of alcohol and drugs regularly. Besides, being unemployed also generated a degree of financial stress on Mrs. N leading to her mental illness. Apart from these environmental factors, she has gone through numerous broken relationships, which made her more vulnerable towards mental illness. As per the stress vulnerability model, there are other aspects which can help a person to prevent mental illness. These factors are termed as protective factors. The major protective aspects which can help Mrs. N to recover from mental illness can be noted as a stronger physical health, effective stress dealing abilities, enhanced communication skills, satisfactory social supports and regular medication for a certain period of time. The following figure will show the stress vulnerability model for Mrs. N: Formulation- Provide Formulation and History of Physical, Psychological & Social Needs From the report, it has been observed that Mrs. N’s capability to fulfil the regular needs has been deteriorating. She has been experiencing suicidal tendency and an inclination towards self-injury. Due to this reason she was prescribed to take Clozapine at the time of medical appointment. It is believed that she has not been compliant with her medication. This aspect along with consumption of alcohol and drug is making her condition worse. She reports having worries about her childhood days and income. Hence, as a mental health worker, it is the duty of nurses to help her in order to prevent any kind of fatalities and needless medical admission. In order to provide support to a medical patient, it is necessary to understand the physical, psychological and social needs of the patient. In this regard, there are several theoretical approaches, described below, which can help to recognise the patient’s physical, psychological and social requirements. Psychodynamic Approach: Psychodynamic approach concentrates on the way through which the patient shapes his/her internal world. This approach tends to evaluate early childhood experiences, problems of self-confidence, intimacy, relationships and painful memories of the patient to diagnose his/her actual needs. This type of treatment inspects complications of interactive relationship with the psychotherapist. In psychodynamic approach, the association with psychotherapist is quite essential as it acts as a medium for recognising the patient’s relationships (Stricker & Gold, 2004). The psychodynamic approach again can be classified into two sub approaches which are ‘classical psychoanalysis’ and ‘analytical therapy’. Classical psychoanalysis focuses on unconscious aspects in the development of psychosis. This approach concentrates on performing through the conversion, where patients perceive their therapist as reawakening of important figures from childhood and explanation of thoughts. On the other hand, analytical therapy splits the unconscious mind into personal unconscious and collective unconscious units. Analytical therapy thereby comprises evaluation of transferences, active imaginings and dream examinations (Jones, 2010). Humanistic Existential Approach: The humanistic existential approach is based on identifying the opinion of the patient regarding the world. This approach focuses on present life situations, changeovers, dilemmas and relationships. This approach assumes that every person possesses a unique potential for development and under this approach, the psychotherapist attempts to simplify the realisation of the human potential (U.S. Department of Health & Human Services, 2011). The humanistic approach is also classified into two types of therapies which are ‘person centred therapy’ and ‘gestalt therapy’. The person centred therapy attempts to put great emphasis on individual experiences of the patients. This approach focuses on establishing relationship by compassion, respect and friendliness. Alternatively, gestalt therapy focuses on increasing patients’ consciousness and liveliness through awareness techniques and experiments (Jones, 2010). Cognitive Behavioural Approach: The cognitive behavioural approach evaluates the behaviour and opinions of patients. Every person has certain opinions regarding themselves which can also possess an impact on the relationship and behaviour deciphered by the patients. For instance, negative opinion can result in maladaptive behaviour (Cully & Teten, 2008). Thus, evaluation of these beliefs can help to change the behaviour of patients and also assist them in developing more adaptive behaviours amid the patient. This approach is particularly useful for changing bad practices, behavioural patterns and several forms of despair (Enrichment Counseling and Assessment, 2012). Postmodern Approach: The postmodern approach uses social constructivist perspective by assuming the process of creating information. It is in this context that postmodernism approach concentrates on the past in order to serve the present. Thus, in order to recognise the present psychological, physical and social requirements, cognitive behavioural approach has been followed. The rationale for using cognitive behavioural approach is that it can assist patients who are experiencing ranges of medical difficulties. Hence, this method can effectively address the behaviour of patients and their feelings (Kinsella & Garland, 2008). Psychological Needs According to the record, it has been observed that Mrs. N was diagnosed with schizophrenia since she was ten years old. The reason for her psychological stress has been majorly due to isolation from friends, being unemployed and passing through several broken relationships. These aspects resulted in loss of support on which she was dependent in the past. In order to deal with the problems, Mrs. N started became addicted to alcohol and to smoke Caribbean. She has also isolated herself which has worsened her mental conditions. The report stated that she would feel much better if she could shift to Africa with her family. Thus, considering these aspects, it can be stated that gaining friendly support is the most vital psychological need for Mrs. N in her present situation (Hewitt & Coffey, 2005). Physical Needs Weak physical condition can negatively impact the stability of mental health. Furthermore, patients with weak health also pose the risk of early death. The mental stress of Mrs. N caused by isolation, low level of socialisation and other relationship related matters has made her to use alcohol and drugs as a mechanism to cope with her negative thoughts and depression. She was also reported of hearing voices and facing difficulties with respect to attentiveness, thoughtfulness and motivation. These aspects resulted in weak social and professional functioning (Cormac & et. al., 2002). Furthermore, due to continuously deteriorating mental and physical health, combined with alcohol abuse made her quite vulnerable to other physical health related aspects, such as lever problem. Besides, because of her lowering degree of self-confidence and lack of motivation towards personal hygiene, Mrs. N faced difficulties to conduct regular activities for living. Therefore, Mrs. N needs routine and structured activities to maintain strong health and also avoid consuming unhealthy diet (Gournay, 1996). Social Needs From the information gathered reviewing her personal and family history, it can be observed that Mrs. N spent her entire educational life in Africa. Thus, shifting from Africa to UK made her isolated from friends and relatives. In London, she currently stays at a seven bedroom house with her family. Her life revolves around the house with only few friends in the new place. After numerous broken relationships, the father of her youngest son has been her major support in the current days. All these aspects leave her helpless towards self-neglect, having lower degree of self-confidence and social separation. She reports being overly dependent on her husband for house hold activities such as taking care of children and housekeeping. Furthermore, joblessness has also changed the social role from being independent to depending on welfare benefits. The constant stress and social isolation associated with family conditions can therefore result in depressive signs (Williams & Garland, 2002). Thus, she requires socialisation with friends in order to stay energetic and mentally fit. Identification of Aims & Goals The Cognitive Behaviour Therapy (CBT) can assist psychotherapists to practice healthcare services more effectively by recognising stressors and problems of patients that is useful for identification of aims and goals. With respect to the cognitive behavioural approach, the three major objectives of the treatment of paranoid schizophrenia and co-morbid poly-substance misuse are as follows. Reduction of Physical Vulnerability From the report it has been observed that Mrs. N is a victim of substance abuse. Thus, the therapy will intend to control the consumption of alcohol, to diminish the consumption of Caribbean and to manage the medications regularly (Bradley & Westen, 2005). Minimisation of Stress The medical record of Mrs. N depicts that she was suffering with stress due to loss of job and detachment with friends. She was even found to be less motivated to attend her personal hygiene. Thus, the therapy would also aim to assist her to maintain good self-hygiene and healthy activities, to encourage maintenance of balanced diet through healthy eating and drinking, to enhance her capability to consider self-safety by demonstrating the importance of her surroundings and to involve with her welfare and to assist in earning income (Sandyford Wellness Centre, 2010). Effective Stress Management Mrs. N has been observed to have low capability to deal with the stress in life. She has low level of self-confidence and does not prefer to interact with anyone including her children. She has also experienced several broken relationships and used to isolate herself which in turn reduced her capability to deal with the mental stress. Hence, the therapy will be aimed to upraise the mood of patient along with her self-confidence, to inspire higher social attachment and to attend the professional treatment, to seek supportive relationships with family and therapists and to encourage optimistic opinion and conversation (Pilling & et. al., 2002). Therapeutic Nursing Intervention Therapeutic nursing intervention can only be effective when there is an environment of faith and cooperation. Contextually, the interpersonal relationship between patient and therapist is believed as the major tool for change in behaviour of patient. In case of mental health issue, relationship plays a vital part in order to achieve a positive therapeutic result. It is also worth mentioning in this regard that positive relationship between patient and therapist can generate trust which shall be helpful for any kind of medication. If, in any circumstance, patient does not trust the therapist, he/she will hardly take any assistance. Besides, without any trust it will be impossible for the therapist to be frank with the patient and therefore identify the problems. As a result, the patient will be unable to cope up with the mental worries (Norman & Ryrie, 2009). With respect to the condition of Mrs. N, it is vital for the therapist to develop trust. Hence, meeting and speaking with her on a regular basis will help the health service professional to examine her feelings. Furthermore, speaking will also act as a form of therapy that can assist Mrs. N to feel valuable as a human being. Regular conversation of patient can also help to convey the feel of friendship which is important for Mrs. N to regain her self-confidence (The Centre for Cognitive-Behavioural Therapy, n.d.). Besides, friendship can also result in developing healthy relationship with the therapist, helping better recovery of the patient. Throughout the home visits, the therapists can continuously assess the progress of the patient and thus can provide accurate medication requirements (Jones & et. al., 2010). Maintaining positive relationship with Mrs. N can also help to share her experiences and ideas. As a result, she will be capable to deal with the present despair situation. Furthermore, relationship building with Mrs. N will also help her to distract herself from harmful negative thoughts such as suicidal tendencies, killing attempts, dullness and lack of socialisation which can generate feelings of loneliness and depression (Pinto & et. al., 1999). In order to assist Mrs. N for minimisation of natural vulnerability, it is necessary for the therapist to provide proper medication to her. Medication can assist to cure the negative health conditions which have occurred due to the consumption of alcohol and drugs. Medications are effective methods which can help to diminish as well as eradicate the symptom of poor mental conditions and to prevent further health deteriorations (Azhar, 2007). However, for effective medical treatment, the patient must be well educated with respect to management of medication being acknowledged with the probable pros and cons. In this context, it can be stated that providing specific and useful information to the patient i.e. Mrs. N, regarding her medication requirements can help to generate a positive outcome. Furthermore, education can also generate awareness of Mrs. N about the negative consequences of taking alcohol and drugs, therefore the process can be able to enhance the impact of medication by a greater extent (Garety & et. al., 2011). Maintaining routine is a vital part of life. Therefore, in order to overcome the problem of regular routine activities, such as hygiene activities, Mrs. N must be stimulated to stick to a specific daily routine. With this concern, a nursing chart comprising all important routine activities can be introduced to her in order to observe and assess the effectiveness of the medical intervention (Turkington, 2006). With respect to the problem of unhealthy eating and drinking, it is vital to monitor her food and liquid consumption regularly. It can help to prevent deterioration of heath and risk of life loss. By positioning Mrs. N on food observation diagram, the nursing team will be capable of monitoring her eating habits in comparison to her health requirements and likewise direct her towards better health. Thus, it will help to identify any essential supplements for the improvement of her health. Mrs. N must be encouraged to take at least three meals in a day. Since she was reported having issues with respect to household capabilities such as taking care of children and avoiding violent activities, it is beneficial for her to communicate about development of life skills (Bowlby, 2012). Clinical Reviews Clinical review is a periodic evaluation of health intervention program used for aiding quick recovery of patients. It is in this context that clinical review helps to make rational decision as to whether the medical intervention activities have effectively resolved the problem of the patient and successfully satisfy her psychological, physical and social requirements. Thus, in order to make an appropriate clinical review of Mrs. N, it shall be useful to arrange a meeting by the Multi-Disciplinary Team (MDT) once in every two weeks. It will also help to detect any kind of changes in the behaviour of Mrs. N. The report reveals that Mrs. N has several social and psychological difficulties. With the help to clinical review, therapists can effectively mark her improvement with respect to health and mental stability (Vetter, 2003). Therapeutic Efficacy Providing therapeutic support in a homely atmosphere can provide more personalised approach to a patient rather than transferring under medical service facility. The CBT approach in such an ambience will also help to provide support to Mrs. N in a minimum restrictive atmosphere and with negligible interruption in her personal life. CBT approach also delivers flexibility in conducting regular routine activities. Providing medical therapy at a homely atmosphere, rather than practicing in a hospital atmosphere, can render more comfort, relaxation and confidence to the patient. Conversely, providing therapeutic support in hospital environment could be obstructive for Mrs. N to recover as there are several rules and restrictions that must be followed by both the patient and her therapist (National Institute for Health Research, 2009). However, it is worth mentioning that if the therapeutic intervention in home environment does not produce positive outcome, it can enhance the security risk of patients in terms of self-harm. In such circumstances, it would be beneficial for therapist to transfer Mrs. N to any medical facility where she could be monitored by professionals and capable healthcare workers (Egan, 2009). Conclusion The evaluation of patient’s (Mrs. N) medical record provided significant understanding about the method of mental health nursing. There are several approaches a therapist can utilise in order to serve a metal patient. However, considering the condition of Mrs. N, it can be stated that the use of CBT approach would be most effective for the patient. It would help to recognise the major problems of Mrs. N and accordingly provide solution to her. CBT approach can thereby enable an organised consultation with patients. Thus, it provides therapists with ranges of techniques which can assist them to address the present situation faced by the patient and to practice effective solutions to cure the identified problems. CBT approach has also been proved beneficial for numerous patients with schizophrenia. Although CBT approach is quite difficult to implement in the practical scenario, as it is an individually customised approach, it can provide long lasting advantages to patients (Scottish Intercollegiate Guidelines Network, 1998). References Azhar, M. Z., 2007. Cognitive Behaviour Therapy for Schizophrenia. Malaysian Journal of Psychiatry, Vol. 16, No. 1, pp. 1-2. American Psychological Association, 2013. Ethical Principles of Psychologists and Code of Conduct. Ethics Office. [Online] Available at: http://www.apa.org/ethics/code/index.aspx [Accessed January 03, 2013]. Bowlby, J., 2012. A Secure Base: Clinical Applications of Attachment. Routledge. Bradley, R. & Westen, D., 2005. 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