Workload Management / Transition to Practice (Mental Health)

Prescribed Evidence

General Introduction

The clinical setting I have chosen for the workload management is Connolly Norman House Mental Health Clinic. For my seven week placement in this clinic I was working with the CMHNs from the Mater Sector Community Services. The aims of the Mater Sector Team continuously focused on providing the highest standard of care to each patient while working in partnership with the service user and its family and respect the person’s individuality.

The Mater Sector Team consisted of two consultant psychiatrists, two medical registrars, five CMHNs, one social worker, one clinical psychologist and one administrative secretary. Other services which were linked to the clinic included the main hospital, the day hospital, day centres and numerous other support services. Each CMHN had assigned a number of service users for which she has designated responsibility. Each patient’s care was planned in collaboration with them and the amount of input provided to each patient depended on how unwell somebody was and how much input was necessary was decided by the CMHN.

In order to identify the care needs of service users, the Bio-Psycho-Social Nursing Assessment is used in the particular clinical setting chosen for this assignment. This model is recovery oriented and involves service user’s opinions on what is needed in order to improve their recovery journey. The main goal of this assessment framework is to empower the service user re-gaining a life, which includes responsibility, choice, risk taking, hope and social inclusion.

The Quality Framework for Mental Health Services in Ireland (Mental Health Commission 2007) was the philosophical framework which guided my delivery of nursing care. The framework promotes a user centred, recovery focused approach. It aims to empower users of the service while also emphasising the person’s journey towards recovery. This framework is very broad and enabling as it applies to all services equally regardless whether care is being delivered in an in-patient setting, in the community or in the home.

Client Work

For the duration of my seven week placement in this clinic I was delegated a caseload of five patients but for this assignment I will focus only on three patients because of the word count limit. The patients to be taken onto my caseload were selected by my preceptor and the other CMHNs.

John is a 76 year old man with a history of depressive disorder and anxiety. John lives alone and socially isolates himself. He is divorced for many years. He has two sons but has contact with only one of them who visits him regularly. His physical health is not very good as he has a history of diverticular disease which causes him abdominal and stomach pain. At the moment, objectively John does not display any symptoms of depression or anxiety and subjectively John reported “I am feeling ok now.” John’s main issue at the moment is that he continues to be socially isolated and remains unmotivated to go out for walks or to attend any of the groups in the Day Care Centres. When I met John for the first time I informed him what my role is and together we devised a care plan for him in order to reduce his social isolation and to remain well in mental and physical health. The first plan devised was in relation with his daily routine. I explained to him that incorporating short walks in his daily routine will benefit his physical and mental health. I also explained to John that social interaction is very important in reducing and preventing the symptoms of depression. John also agreed for me to refer him to “Befriending” services with a view to reduce his social isolation as they can make available one-to-one companionship once a week. John also agreed for me to visit him once a week and to go out for short walks. For the first two weeks John denied going out for walks together with me as we planned previously. He was displaying lack of motivation and he would find different reasons to avoid going out. As a former psychiatric nurse, John would always like to talk to me about his career and the hospital he was working with. As he was still living nearby his previous workplace, on my third visit I asked John if he would like to show me around the grounds next to the hospital where he used to work. John was very happy about this and agreed to go for a walk. For the next few weeks John appeared to be more motivated to go out for walks while me accompanying him and reported that he really enjoys the walks. Because John has a history of non-compliance with medication, on each of my home visits to him I ensured that he was taking his medication as prescribed and checked his dosset box. At the end of my placement John informed me that he is socialising more with his friends and agreed to continue to go out for walks few times a week.

Sarah is a 44 year old lady with a diagnosis of chronic paranoid schizophrenia with prominent negative symptoms. Sarah has two sisters and one brother who died two years ago. She is living with her parents and they look after her at home. Sarah has major difficulties in attending self-care and ADL’s in general. She has a lack of daily routine spending much of her time in bed. She has isolated herself from the outside world since her early teenage years. Sarah has also difficulty in retaining information and is unable to travel on her own around town because of her lack of awareness regarding directions and safety. Because of this, her parents fear of her welfare or becoming lost. Since Sarah’s medication was changed to Clozapine, she has been more interactive with others and increasingly initiating conversation. She has also expressed an interest to attend the art and music therapy group in a Day Centre. I worked closely with Sarah and together we devised a care plan with a view to improve her self-care and to have more structure throughout the day. She also agreed for me to accompany her to the Day Centre in order to attend the art and music groups. This would improve her social activity outside of home and her independence by improving her directions skills to and from the Day Centre. Next, we formulated a plan to be followed every day and that consist of her to have a shower in the morning, helping her mum to prepare the meals for the day and going out for walks daily accompanied by one of her parents. While I accompanied Sarah to the Day Centre I used picture and monument identification folder to identify what bus to get and what stop to wait at. I also allowed Sarah to lead the way with minimal assistance. At the end of my placement Sarah had more structure to her day and her mum informed me that she could see a real improvement in Sarah’s behaviour while attending her activities of daily living. Sarah’s interaction with other people in the day centre also improved and she reported that she really enjoys the groups. She was still unsure of bus route numbers but she was able to lead the way from the bus stop to her house. Sarah and her family were delighted of her improvements.

Mary is a 77 year old lady with a long history of paranoid schizophrenia. Mary has one daughter and after the separation from her husband, she lived with her mother who would look after her and her daughter. Since her mother died twenty years ago Mary lives on her own but her daughter and her sister visit her regularly. At the moment Mary’s mental state is stable and she complies with the medication prescribed. However, Mary feels that her memory is poor and she is worried about not being able to manage paying the bills. After I had been introduced to Mary, together we devised a care plan in order to reduce her anxiety in relation of not being able to remember things and to reduce her worries regarding bills. Mary agreed to use a notebook to write down what she needs to remember. I also encouraged her to attend for an assessment with psychiatry of old age and she agreed for me to talk with one of the doctors in the clinic about this. Mary also agreed for me to complete a budget plan form for her and to send it to….I also encouraged her to pay the bills weekly until this would come into effect. Furthermore, I advised Mary to have more social outlets by attending day services or community social services. Mary agreed with this and asked me to refer her to one of the day centres. At the end of my work with Mary she informed me that using the notebook helped her significantly about recalling things she has to do and that she is using it very often. I also informed Mary that I was in contact with one of the charity organisations and they agreed to help her pay the bills until she could use the budget plan and she was very happy with this. Mary continues to attend a day centre once a week and she finds it very enjoyable. Mary was pleased with the help she received from me as she informed me and I advised her to contact the CMHN if she has concerns regarding her mental health and for support.

Management Tasks

During my placement, I carried out numerous administrative and management tasks, including: answering the phone and taking messages for other members of the team, carrying forward patient’s appointments for their depot injections and ordering from the pharmacy if necessary. I would also take part in organising and filing medical and nursing notes. Seeing that there was an administrative secretary in the clinic she carried out many of the administrative tasks.

Workload Management

For this assignment I am going to describe a typical working day within Mater Services Team in the clinic of Connolly Norman House. The day usually commences at 9:00hrs and ends at 17:00hrs. After arriving I informed my preceptor that I have to carry out two home visits to two of the patients in the morning. At 9:30hrs I left the clinic to visit one of my patients. I arrived at my patient’s house at 9:45. I accompanied my patient for a walk and to the local coffee shop for a cup of tea. After we returned to my patient’s house I completed a nursing assessment with him. I left the patient’s house at 11:00hrs. I walked to visit my next patient. I arrived at her house at 11:15. After I have talked with my patient about how she feels and about her concerns I went back to the clinic. I arrived at the clinic at 12:15hrs. I recorded in the patients nursing notes regarding the home visits. I also did a handover to my preceptor about the two patients. While in the office, I had to answer the phone and record a few messages in the message book. I also had to make a referral for one of the patients to one of the support services for people with mental illness. After I completed the referral, I went for my lunch break from 13:00hr to 13:45hrs. In the afternoon from 14:00hrs to 17:00hrs patients are expected to attend the clinic in order to receive their depot injection and to attend their appointment with the doctor. At 1:45 I went to the clinical room to prepare the trolley for the depot injections. The clinic lasted from 14:00hrs until 16:30hrs. During this time I had to administer depot injections under the supervision of staff nurse and afterwards I sign the patient’s kardex and get it co-signed by the nurse who supervised me. I then ensured to follow up the depot book and document when his/her depot is next due and I informed the patient when they are due to return again and provide them with an appointment card. I also had to check each patient’s vital signs and weight as part of a physical screening evaluation programme. At one point I had to link with the secretary as I couldn’t find one of the patient’s kardex but she couldn’t find it either. Therefore I had to ask the doctor to re-write a new kardex in order for the patient to receive her depot injection. While in the clinic I also had to take two phone messages and pass them on to one of the CMHN. At 16:30hrs I went for a hand over from the doctors working within our catchment area. The handover was regarding new referred patients to the services and lasted for 30 minutes. I had to record all the information from the doctors with regards new patients referred to the services. I finished work at 17:00hrs.

Conclusion

After completing this placement I feel I have gained a lot of experience in working in the community. By having my own caseload it encouraged me to use my own initiative and whenever I felt in a challenging position I always asked for guidance from my preceptor or other staff nurse. My preceptor and the other CMHNs supported and guided me throughout my seven weeks placement.