graduate diploma in mental health nursing

Graduate Diploma in Mental Health Nursing

Overview of Course &

Role of PreceptorsBarry Tolchard

Course Coordinator/Senior Lecturer

©B.Tolchard (2003)

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

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ASSESS PLAN IMPLEMENT EVALUATE

Primary Health Care

Mental Health Nursing Practice 1

Client-Focussed AssessmentMental Status Examination

Risk AssessmentMausdley/Psychosocial

AssessmentCultural Awareness

Problems & GoalsValidated Measures

Therapeutic InterventionsMedication Management

PortfolioClient Feedback Sheets

Student Outcomes of Learning

Problem-Based LearningAnxiety/Psychosis/Depression/Co-Morbidity/Personality Disorders

Reflective Practice/Clinical Supervision/Preceptor Feedback

Clinical Assignments

Mental Health Assessment or Mental Health Nursing

Assessment?Client-Focussed Assessment

Referral Letter Duty of Care and Legal ResponsibilitiesMedications and their Use-Therapeutic or Not?Ethical Considerations and Other Legal Issues

Reflective Practice

Clinical Case Management

Mental Health Nursing Practice 2

Client-Focussed Assessment Therapeutic Workshops PortfolioClient Feedback Sheets

Student Outcomes of LearningProblem-Based Learning

Elderly/Homelessness/Adolescence/Population Health

Reflective Practice/Clinical Supervision/Preceptor Feedback

Clinical Assignments

Leadership Family TherapyGroup Therapy

Advanced Therapeutic InterventionIndigenous Issues

Evidence Based mental Health Nursing

Independent Study/OptionAOD/CBT/Forensic/Child & Adolescence

Client-Focussed Assessment

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The Assessment

The 5 W’sWhat is the distressing experience?Where does the distressing experience occur/where not?When does the distressing experience occur/when not?Why does the distressing experience happen?With whom is the distressing experience better or worse?

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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.

• This happens in a number of situations such as going to the shops, watching TV and in busy public places.

• The problem occurs 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.

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F.I.N.D

F.I.N.DThe frequency of the distressing experienceThe intensity of the distressing experience when it occursThe number of times the distressing experience may occurThe duration of time the client has the experience

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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.

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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.

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Typical situationFunctional analysis—Jason Grantley Jason described an incident where he believed a car parked outside his house was flashing its lights which was a sign for the Italian boys to kill him. Prior to seeing the car, he was looking out of his window and listening to music. He felt fairly relaxed but had tension in his back. He was thinking about the lyrics of the song. On seeing the car, he became very anxious where his breathing increased and his heart began to pound. He closed the curtains and hid behind his bed. During this time he thought the Italian boys were after him and that he needed to stay low. Throughout he felt very scared. After a while when he heard the car drive away be began to feel better. He checked the window by peeking through the curtain to make sure they had gone. He then played his music even louder and thought he had been lucky this time and remained alert for possible situations.

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emotions thoughts behaviour feelings

before calm I wonder what these lyrics mean.

looking out of the window

slightly tense

during terror I am going to be killed by the Italian boys

closed curtains and hid behind bed

hyperventilating, heart pounding

after worried I have been lucky this time, but I must stay alert

peeked through curtain, played music louder

as above but lessening

Functional Analysis

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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?

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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.

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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)

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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.

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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

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GAF

Code Description of Functioning

91 - 100

Person has no problems OR has superior functioning in several areas OR is admired and sought after by others due to positive qualities.

81 - 90

Person has few or no symptoms. Good functioning in several areas. No more than "everyday" problems or concerns.

71 - 80

Person has symptoms/problems, but they are temporary, expectable reactions to stressors. There is no more than slight impairment in any area of psychological functioning.

61 - 70

Mild symptoms in one area OR difficulty in one of the following: social, occupational, or school functioning. BUT, the person is generally functioning pretty well and has some meaningful interpersonal relationships.

51 - 60

Moderate symptoms OR moderate difficulty in one of the following: social, occupational, or school functioning.

41 - 50

Serious symptoms OR serious impairment in one of the following: social, occupational, or school functioning.

31 - 40 Some impairment in reality testing OR impairment in speech and communication OR serious impairment in several of the following: occupational or school functioning, interpersonal relationships, judgement, thinking, or mood.

21 - 30

Presence of hallucinations or delusions which influence behavior OR serious impairment in ability to communicate with others OR serious impairment in judgement OR inability to function in almost all areas.

11 - 20

There is some danger of harm to self or others OR occasional failure to maintain personal hygiene OR the person is virtually unable to communicate with others due to being incoherent or mute.

1 - 10 Persistent danger of harming self or others OR persistent inability to maintain personal hygiene OR person has made a serious attempt at suicide.

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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.

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Mental status examination—main areas examined

Appearance and behaviour Speech Mood Depersonalisation, derealisation Obsessional phenomena Delusions Hallucinations and illusions Orientation Attention and concentration Memory Insight

Mental Status Examination

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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

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Maudsley or Psychosocial Assessment

• Medical

• Living circumstances

• Forensic

• Family

• Childhood/Development

• Employment

• Sexual history

Measurement

Problems & Goals

Validated Measures

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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

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Problems and Goals

• 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”

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Validated Measures

• General morbidity scales

• Diagnostic Schedules

• Specific measures for particular disorders

• Nurse-Rated Measures

• Work & Social Adjustment Scale

• Brief Psychiatric Rating Scale

• Kessler 10

• HoNOS

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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

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Brief Psychiatric Rating Scale (BPRS)

– 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

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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.

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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?

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The Kessler Psychological Distress Scale (K10)

• The response categories for each of the 10-items are:

1. All of the time

2. Most of the time

3. Some of the time

4. A little of the time

5. 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

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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’

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HoNOS versions

• HoNOS: – for services for working age adults HoNOS65+: 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

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HoNOS

• 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

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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

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Name Post code Age Gender M'F Therapist ReferrerReferral received Assessment date Attended Y/N Suitable Y/N Accepted treatment Y/N Assessed for in-patient Y/N In-patient Y/NDiagnosis 1 (DSM-IV) Diagnosis 2 (DSM-IV) Diagnosis 3 (DSM-IV)Treatment 1 screening ass mid post 1MFU 3MFU 6MFU 1YFUTreatment 2 dateProblem A Self

Therapist

Goal A1 Self

Therapist

Goal A2 Self

Therapist

Problem B Self

Therapist

Goal B1 Self

Therapist

Goal B2 Self

Therapist

Onset problem A (yrs) FQ Main phobiaOnset problem B (yrs) FQ Fear Questionnaire:

SC –BI- AGFQ Anxiety/DepressionWSAS WorkWSAS Home Management

Total sessions:Missed sessions:Total therapist Hours:Total assisted hours: WSAS Social Leisure

WSAS Private LeisureWSAS RelationshipsBeck Depression InventoryBeck Anxiety Inventory

Outcome1=Completed treatment2=Dropout before ses. 23=Dropout between ses. 3-84=Other Y-BOCS

Other professional involved Y/N Other (specify)Other (specify)Professional name

Other (specify)

Data Summary Sheet

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Fear Questionnaire (FQ)

Name: Ms Brenda Pollack Date: 23 January 2001 A/M/D/1/3/6/12

Choose a number from the scale below to show how much you would avoid each of the situations listed because of fear orother unpleasant feelings. Then write the number you choose in the box opposite each situation.

0----------- 1---------2------------- 3---------4------------- 5---------- 6---------7------------- 8Would not Slightly Definitely Markedly Alwaysavoid it avoid it avoid it avoid it avoid it

1 Main problem you want treated (describe in your own words)

2 Injections or minor surgery 83 Eating or drinking with other people 14 Hospitals 85 Travelling alone by bus or coach 16 Walking alone in busy streets 07 Being watched or stared at 08 Going into crowded shops 09 Talking to people in authority 110 Sight of blood 811 Being criticised 112 Going alone far from home 113 Thought of injury or illness 814 Speaking or acting to an audience 115 Large open spaces 016 Going to the dentist 817 Other situations (describe)Sporti n g even ts, vi olen t movi es/tv, i l l

people i n c. school chi ld ren

Ag + B1 + Soc = Total (2-16)Now choose a number from the scale below to show how much you are troubled by each problem listed, and write thenumber in the box opposite.

0----------- 1---------2------------- 3---------4------------- 5----------- 6---------7------------- 8hardly slightly definitely markedly very severelyat all troublesome troublesome troublesome troublesome

18 Feeling miserable or depressed 219 Feeling irritable or angry 020 Feeling tense for no reason 121 Upsetting thoughts coming into your mind 622 Feeling you or your surroundings are strange or unreal 123 Sudden panic for no reason 124 Other feelings (describe)

TOTAL

How would you rate the present state of your main problem on the scale below?

0----------- 1---------2------------- 3---------4------------- 5--------- 6---------7-------------8phobias slightly definitely markedly very severelyabsent disturbing/ disturbing/ disturbing/ disturbing/

not really disabling disabling disablingdisabling

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SELF-DIRECTED TREATMENT DIARY

Name: Week Commencing:

Please record all daily progress made against your weekly targets, and any other progress made

0---------1---------2----------3------------4-----------5---------6----------7-----------8No anxiety Moderate anxiety Panic

Date Time Target Anxiety Ratings Remarks/commentsStart/Finish

Nos Before During After

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Work & Social Adjustment Scale

NAME: DATE: A/M/D/1/3/6/12

Some peoples problems affect their ability to do certain tasks. On the scales below rate how much yourproblem affects the following tasks.

SCR PRE MID POST 1MFU 3MFU 6MFU

Date: .......... .......... .......... .......... .......... .......... ............

1 WORK/STUDYSelf

Therapist NA

0 1 2 3 4 5 6 7 8Not at all Slightly Definitely Markedly Very Severely

2 HOME MANAGEMENTCleaning, tidying, shopping, cooking, looking afterhome/children, paying bills

Self

Therapist NA


3 SOCIAL LEISURE ACTIVITIESWith other people eg parties, pubs, outings,entertaining, etc

Self

Therapist NA


4 PRIVATE LEISURE ACTIVITIESThings done alone eg reading, gardening, sewing,hobbies, walking, etc

Self

Therapist NA


5 FAMILY & RELATIONSHIPSForming and maintaining close relationships with othersincluding the people you live with

Self

Therapist NA


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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.

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The three components of PBL

• The PBL case (the task(s) of PBL)

• The small group—process of PBL

• Independent learning—self directed learning

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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

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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…..

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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

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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 …..

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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

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The three components

• The PBL case “task of PBL”

• The small group “process of PBL”

• Independent learning “self direction”

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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

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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)

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The three components

• The PBL case “task of PBL”

• The small group “process of PBL”

• Independent learning “self direction”

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Self directed learning ...

• shifts responsibility for learning to students• shifts curriculum emphasis from teaching to learning• alters student & “teacher” roles; students are central• the tutor’s role is to facilitate and provide opportunities

for learning• students have high autonomy to select learning goals &

methods that suit them best• guided by learning objectives, students set own goals

and learn at their own pace, help each other

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Evidence: PBL outcomes

• increased retention of knowledge over periods of several years

• learning in context facilitates later recall in context• high self directed learning skills• enhances integration of diverse areas of knowledge• better team skills• more likely to be up to date (life long learning attitude)• higher student and faculty satisfaction• little evidence relating to improved clinical skills

• (NB: PBL teaching of clinical skills has not been tried)

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Jason Grantley

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PATIENT PRESENTATION • Jason Grantley comes to see Dr Smith with his

mother. He is a 17 year old unemployed man, who lives with his parents and younger sister.

• His mother tells Dr Smith that Jason has been

spending most of his days alone in his bedroom listening to music for the last 9 months since leaving Year 11 high school. He rarely sees his friends, and there have been fights with his father because of the untidiness of his bedroom, and his reluctance to shower.

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PATIENT PRESENTATION • On questioning from Dr Smith, Jason says he likes to listen to music and

smoke cigarettes and dope. He does not think it is important that he no longer sees his friends. He denies he is depressed, and says he is sleeping and eating well, and has had no changes in his energy or concentration.

• He smokes 40 cigarettes per day, and regularly uses marijuana. He tried amphetamines 6 months ago, and LSD once 18 months before. He does not drink alcohol.

• As the interview with Dr Smith progresses, Jason states that his main fear in life is that the Italian boys from school are following him. They park outside his house. He believes his phone is tapped, and that they have put listening devices in the ceiling.

• On further questioning 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 “do it” - the ‘it’ being to take his life.

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PATIENT PRESENTATION • Dr Smith performs a Mental State Examination (MSE), a summary of which is

given below:• Jason presented as a pale young man with shoulder length black unwashed

hair, he wore a black T shirt and jeans. He looked worried and his eyes constantly scanned the roof and walls of the room and he continuously tapped his right foot on the floor. His conversation was tangential, but without looseness of associations, or other thought disorder. It contained delusional content. For example “I saw a white car flash its headlights passing by my house last week, and I knew that was a signal to the other Italian boys that I had to be killed.” He also described auditory hallucinations of a running commentary and commands instructing him to take his life.

• He was oriented in person, place and time. He was only able to register a name and address after 3 attempts, and could only recall half of the address at 5 minutes. He started serial 7s, but then stopped and discussed the threat from the Italian boys.

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PATIENT PRESENTATION • At this point Jason asks to leave as he wants to go home to watch some videos.

Dr Smith advises him that she would recommend that he spend some time in the psychiatry ward of the local general hospital. He refuses and attempts by both Dr Smith and his parents to persuade him to be admitted to hospital are ineffective.

• Dr Smith advises Jason that she will detain him to the local hospital. She organises transport via ambulance with a police escort (one police officer in the ambulance and the other following behind in a patrol car). She informs Jason of his legal rights under the Mental Health Act.

• Transport arrives but Jason becomes agitated because he believes that one of the ambulance officers (who is of Italian background) is part of the plot. He attempts to flee but is restrained by the ambulance officers, police, and Dr Smith in the waiting room of the surgery.

• He becomes more settled and stops struggling; no sedating medication is administered at this point.

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Two-plus-one approach

• A basic model of treatment that:– uses a comprehensive client-focussed assessment,

– identifies the areas of change using client specific and standardised measures,

– applies a process of therapy which is carried out by the client between session 1 and 2 and then for 3 months afterwards and,

– is done in liaison with future case manager.

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• Session 1– client-focussed assessment– problem and goals– measures– coping strategies identified– coping strategy enhancement model used– homework set

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• Session 2– previous homework reviewed– changes made where appropriate– new coping strategies identified for a range of

situations– coping strategies practiced in session– continued use of strategies established and set

as homework

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• Session 3– previous homework discussed– new areas identified from discussion– new tasks set– repeat measures– discharged to case manager

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Coping-Strategy Enhancement (vulnerability reviewed)

• information is received by the senses and processed whereby understanding is made of it in the brain (information processing)

• the autonomic nervous system (which controls bodily responses to stress) are important in mental health problems

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Defined

• “As long as the stress induced by challenging events stays below the threshold of vulnerability, the individual remains well within the limits of normality…

• …when the stress exceeds the threshold, the person is likely to develop a psychopathological episode of some sort…

• ...when the stress abates and sinks below the threshold, the episode ends” (Zubin & Spring, 1977)

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Rationale

1. Continua of functioningmental health symptoms merge with normal

behaviour

positive symptoms are points on a functioning continuum

symptoms are different in degree or are exaggerations of normal responses to stress

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Rationale

2. Normal experiencesimilar symptoms and signs occur in all people

3. Cultural beliefsa number of irrational/abnormal beliefs have

cultural equivalentsno evidence scientifically for such occurrencesfrank “scientific” discussion

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Rationale

4. Normal thoughtsfleeting grandiose ideas, ideas of reference and

paranoid or overtly negative thoughts can be described as very common in the general population

5. Differences between thoughts and actionsexplain that thoughts do not necessarily lead to

the subsequent action

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Rationale

6. Vulnerability and Stress“Stress seems to affect people in different ways,

depending on their makeup. This includes any family susceptibility, personality and possibly even brain structure. The same sort of stressful events may make some people depressed or anxious, but they may not affect others at all. In your case you have begun to…”

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Process of therapy

B oos te r s ess ion s

R e lap se p reven tion

Tac k lin g n eg a tive s ym p tom s

Tac k lin g en tren c h ed p syc h o tic sym p tom s

R ea lity tes tin g

Trea tin g an y co -exis t in g d ep ress ion o r an xie ty

E xam in in g th e an teced en ts o f p sych o tis b reak d ow n

E xp la in in g p s ych os is u s in g n orm a lis is n g ra tion a le

E n g ag in g an d rap p ort b u ild in g

Deal with current problems. Aim for accuracy and consistency. Avoid humouring.

Rationale is based on stress-vulnerability model. Decatastrophise referring to sleep/sensory deprivation. Reinforce medication compliance.

Cover in detail. Elicit life events, identify automatic thoughts using inductive questioning. Identify maladaptive assumptions.

Explain typical symptoms and neurophysiology of anxiety. Rx with muscular relaxation and CBT.

Hallucinations

Use inference chaining to find underlying irrational belief. Work through emotional investment. Promote active coping strategies.

Set realistic goals. Teach appropriate avoidance. Make use of paradox, activity scheduling and mastery and pleasure forms.

Explain role and need for medication, identify triggers. Decatastrophise

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Coping Strategy Enhancement (Tarrier)

• psychoeducation approach to explaining illness

• builds on coping methods already used by client

• uses simulated/imaginal situations

• homework in real life situations

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Overview

• Begin with careful client-focussed assessment of the clients symptoms including the antecedents and consequences.

“I have no money”

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• if lack of insight—focus on alleviating distress caused by symptoms

• one symptom is targeted and a strategy to cope with it selected

• strategy is then practiced under increasingly difficult conditions in session and then as homework

• cognitive strategies are demonstrated overtly by the therapist, then overtly and finally covertly by the client

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• behavioural strategy is taught through role-playing or guided practice

• if strategy successful another symptom is chosen

• if unsuccessful then client trained in a further strategy and so on

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• the nature of the symptoms

• elicit the accompanying emotional reactions

• elicit antecedents

• elicit consequences

• elicit active coping

• effectiveness of coping

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Preceptor Role• welcome, orient & guide student clinical

learning according to employer expectations

• be familiar with Flinders GDMHN expectations of student learning

• liaise with clinical lecturer/facilitator

• deal with student/employment concerns

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Clinical Concerns/Employment Concerns

• Clinical Concerns• Either the student or clinical or

academic staff can initiate this process.• In the first instance discuss the issue

with:• clinical preceptor or assessing nurse• if not resolved consult• clinical lecturer/facilitator who will

liaise with appropriate local division management

• if not resolved consult• Professor of Nursing (Mental Health)• if not resolved consult• Associate Dean or Dean• if not resolved a request may be made

for discussion of the issue at Faculty Board meeting.

• Employment concerns• Either the student, clinician or employer

staff can initiate this process.• In the first instance discuss the issue

with:• CNC/team leader• if not resolved consult• student co-ordinator or human resources

consultant who can advise on the correct course of action within the employing organisation

• if not resolved consult• Mental Health Service Division Nursing

Director.

©B.Tolchard (2003)

Preceptor Tools

• individual Student Learning Contract

• clinical Assessment Record for Clinical Placement

• guide or provide input into Clinical Assignments

• Clinical Contact Sheets

©B.Tolchard (2003)

Example of an Individual Student Learning ContractStudents Name: Ann Nurse Clinical Placement: Acute Inpatient Unit

Dates: from __23__/___03_/__02__to___13_/___07_/_02___

Learning ObjectivesWhat would I like to develop competence with?

Learning StrategiesHow will I do this?Who will be involved?What resources?

Evidence of AccomplishmentHow will I know I have achieved my goals?How will I show that I have?

Target DatesWhen will I do this by?

No 1. To apply knowledge of psychopharmacology to individual cases.

Know the drug regime for my caseload. Participate in regular medication administration to a level of safe and independent practice.

Test my knowledge with other MHN and preceptor. Be observed undertaking drug rounds. Identify and be familiar with the patient drug information leaflets.

1/05/02

No 2. Develop skills in assessing the need for prn medication.

Observe and discuss with other nurses. Undertake a critical incident analysis where prn utilisation is involved.

Complete medications and their use clinical study sheet. Individual case note documentation of rationale and effect. Demonstrate knowledge of nursing interventions for side effects and drug protocols.

11/06/02

Where next

http://www.mhnflinders.com

graduate diploma in mental health nursing

Documents

italian boys

mental health nursingoverview

time of day

duration of time

number of situations

problem worse

car drive

possible situations