Psychiatric/mental health nursing

Hello

I did my nursing degree through the University of Technology, Sydney. In third year we were offered a submajor in medical/surgical, mental health, or peadiatrics. I was one of the few who selected mental health.

As far as I know, UTS is the only uni in australia to offer such a thing, and I am very thankful for it. I work in aged care, and it has given me the skills to deal with not only the complex chronic illnesses this population have, but also the mental disturbances that occur such as delirium.

On a whole, I feel that psychiatric nursing skills are undervalued in this country.

Dear Senior RN.

While I can appreciate that you thought your job with Forensic patients in the community was 'fun' and profitable, as a senior psychiatric nurse with years of experience in forensic psychiatry, I must say I am offended by your nonchalance. There is a great deal of literature availabe regarding this advanced specialty in psychiatric nursing. Indeed, I have written and presented on the subject internationally and in a moment I will paste a bit of that in this message. In Canada, the job you had would be assigned to a Mental Health Worker employed in community forensic psychiatric, who would respond much as you have. However, a professional would see there was much more to learn, know and be responsible for in the care AND custody of forensic psychiatric patients.

It is offensive to many, many psychiatric nurses worldwide that general duty nurses think psychiatry is EASY and FUN and therefore choose to transfer off medical, pediatric or obstectric units because they are 'tired' of the work and think we have it 'easy'. To fully understand psychiatric nursing any nurse transferring in to such a job would be professionaly responsible and accountable for LEARNING the job. Yes, part of this would be the responsiblity of the employer, but a professional nurse is required to work within the scope of skills and competencies if his/her licence. If you do not understand the field in which you are working ESPECIALLY as an agency nurse, it your professional duty and obligation to research it and learn it! When you talk about your trips to the beach, I wonder what psychiatric nursing assessment you were doing there (i.e: assessing the client's safety and ability to function appropriately in the community) and to whom and how you reported this. Just these 2 criteria alone speak pbulic safety and to the reason the patient is in forensic psychiatry and NOT general psychiatry. Huge implications here.

I have just returned from a week long conference on psychiatric nursing in Malta put on the Horatio: the European Association of Psychiatric Nurses. This incredible organization is leading the way for best practices in psychiatric/mental health nursing. They, as we here in Canada and the USA understand that the field is a specialty. At the World Congress of Psychiatric Nursing held in Canada in the spring of this same year, very similar themes were presented. Yes, I spoke at both of these. And one of the other major themes arising at both conferences is this stigmatization of being a psychiatric nurse ( by other nurses) and being considered somehow 'less than' equal to other nurses or their work or their competencies. This is very disturbing to all of us.

In closing, I want to offer you the benefit of a doubt and believe that you actually are more interested in patient care and best practices in mental health rather than 'fun' and 'money'. However, I am going to add some information from my last forensic psychiatric presentation here just in case:

"A forensic psychiatric nurse workswith a very special population: the mentally disordered offender. He/she makes first contact with this client when a crime is alleged to have occurred. Shives (2005, p57) points out that ‘evaluation of an individual’s competency and mental condition at the time of the alleged crime constitutes the specialized area of mental health referred to as forensic psychiatry. “ While caring for this particular client the offence, too becomes a major focus of care, custody and the nurse-patient relationship. Scope of practice includes but is not limited to assessment of the offender’s state of mind now and at the time of the crime and collection of data for competency evaluations for Court. These iinclude re-evaluation for mental competence and/or mental status at routine intervals while the client is under the Courts and forensic psychiatric jurisdiction, whether in custody or in community care (Shives, 2005). Post-offence, the forensic psychiatric nurse has a duty to care for individuals with mental health challenges who are either held in secure forensic psychiatric facilities or through outreach in community mental health centres. Mental health concerns are paramount. Treatment revolves around this. On-going assessment of the mentally disordered offender includes risk assessment for not only danger to self, but danger to the public.
The forensic psychiatric nurse also carries a huge responsibility related to custody and providing a safe, secure environment for the client. Adhering to the scope of practice of Registered Psychiatric Nurses or Registered Nurses, the forensic psychiatric nurse engages the client in assessment, treatment and evaluation of mental status and mental health care. Establishment of the interpersonal relationship is crucial to this role. Forensic psychiatric nurses must also address the crime and integrate custody with caring. Johnson (2003, p192) points to the dual obligation of this work: “social necessity and social good”, as well as “custody and caring”. Beyond responsibility to mental health assessment for treatment, the forensic psychiatric nurse must assess for competency to stand trial, client’s ability to formulate intent to commit a crime, current mental status, potential for violence or re-offending, documents in relation to mental health and criminal activity, and he/she collaborates with the care team related to countermeasure to violence, substance abuse, etc. The FPN in the role of Case Manager writes formal reports to court which may include preparing release/disposition recommendations and provides consultation to the Courts or forensic psychiatric outreach nurses for discharge planning. Working within both the health care and criminal justice systems, scope of practice evolves to include a familiarity with legal proceedings, legal status and legal terminology. Kneisl et al (2004, p833) believe the forensic psychiatric nurse must have the “ability to apply clinical skills to complex legal problems”.Martin (2001, p 30) believes “it is a responsibility of forensic psychiatric nurses to create conditions for patients to promote health and protect them from the consequences of their actions.” The forensic psychiatric nurse must be aware of how mental disability or mental illness may influence or cause the crime so that appropriate treatment, prevention, and disposition can occur.
Love and Morrison( 2002, p7) succinctly identify a number of criteria for advanced practice in forensic psychiatric nursing: “finely honed communication skills, advanced preparation in psychodynamic theory…”, and study of “extreme character pathology, life long patterns of exploitation and perversion of interpersonal relations, deviant violent impulses and intractable .
psychotic symptoms.” Indeed, these competencies speak to advanced education and a much more significant involvement with the mentally disordered offender than the entry-level forensic psychiatric nurse. Advanced practice education would also include exploration and skill building in expert witness testimony, summaries for court or review boards impacting disposition: Shives (2005, p59) sees forensic psychiatric nursing practice developing to “combine empathy with a willingness to translate complex, scientific, and psychiatric findings into clear and pertinent meaning . With advanced education, the forensic psychiatric nurse can provide intensive individual and group counselling. This nurse can also function as a case manager, supervisor or director of out-patient clinics. He/she may becomes a consultant in criminal justice and health care. Consultants may also conduct evaluations of hospital policies, procedures and provide testimony to courts (Shives, 2005). "

Respectfully submitted,
Melodie Hull, RPN, MSC, MED

Hey, Gordon:

Fantastic letter of reply. Thank you for taking the time to clarify the situation you were in. I still do not believe you should have been in that position, because no matter what, if you have a nursing licence you are still accountable as a nurse no matter what the employer says. Also, if because of ethical reasons nurses refused this type of assignment, then the program managers/directors would need to revisit its purpose and staffing. When nurses simply 'comply' with work demanded by employers they breach professional accountability. But that is just my opinion.

On the other hand, I totally, totally agree that having fun at work is a GREAT thing!! I am ALL for that! I believe it makes my own work and the team's so much better. Its healthy. I also am keenly aware of the therapeutic value of fun for clients and staff.

In Canada, we have some forensic psychiatric outreach programs similar to the one you are talking about but under no circumstances would the clients be allowed to get out of hand, abscond, etc. To do so would mean immediate discharge from this type of program and placement back in a higher level of security. Immediately. No discussion. This has worked as a wonderful deterent because generally, no one wants to go back into the institution and onto a secure unit. The program you are talking about in NSW doesn't sound well thought out and I wonder whose idea this was and how much experience they have with psychiatric patients let alone forensic psychiatric patients?

I'd like to share a similar kind of program in forensic psychiatry - similar in that those who designed it really had little comprehension about the target group. At a large forensic psychiatric facility, the Occupatonal Therapy Dept. had an excellent idea to get some of the fellows job training and jobs at local businesses. Only clients on Minimum Security (who could have day passes or escorted day passes) could attend. However, in this iparticular institution it seemed to me the OT people knew very, very little about psychiatry overall. They took into account that the clients were male and set about finding work experiences & training in the community that they thought would appeal to men. This meant they found positions for the clients driving forklifts, working on scaffolding, and roofing! The staff was oh-so-happy to present this at an inservice following 8 or 9 months of what they perceived to be a successful program. Well, perhaps it was but I could not help but point out at the end of that meeting, that these same clients were on heavy doses of psychiatric medications . This led me to ask what precautions were/are being taken to protect the clients when they are using heavy equipment, machinery or standing high in the air somewhere . These medications clearly caution against such activities. OT, of course was stunned. It hadn't occurred to them. Tsk.

So, Gordon, in conclusion, whether in your country or mine... it really behooves us as nurses to advocate for the safety and the health and wellness of our clients no matter what the employer says and no matter how difficult this is. And sometimes it means refusing to do the work or refusing to refer a client to a program. Very uncomfortable but it is the right and proper thing for a nurse to do.

Respectfully,

Melodie