Mental health practice learning

4 Mental health practice learning

• To gain an understanding of the nature of various mental health practice areas

• To identify the possible learning opportunities which will enable you to optimise your placement experience and meet your Nursing and Midwifery Council competencies and essential skills clusters

• To consider the views of students and mentors who have experience of working within the practice area

• To develop skills in action planning for placements in order to direct your experience in line with your learning needs

Introduction

This chapter will introduce a variety of mental health placements which you may be given the opportunity to experience as a pre-registration student. The chapter is made up of contributions from students and mentors who have practised in the various clinical areas. The specific name of a service or the way it is structured may vary in your area, however the insights offered by students and practitioners will be helpful in preparing for your placement and getting the most of the learning experience.

Practice learning (placements) may be organised slightly differently depending on the university that you are studying at. These might be in placement blocks of so many weeks in which you rotate around different practice areas with time spent in university during these placements or in between (e.g. one placement in services working with older people, one in a community mental health team and one in an acute in-patient service). Practice learning may have also been organised so that you have a caseload of service users who you follow throughout your training. The changing nature of health care is also facilitating the increasing use of a different structure of practice learning.

The NHS next-stage review outlined a new direction for the configuration of health and social care services promoting increased integration and partnership, requiring health professionals to work across service boundaries (Darzi 2008). In the future, healthcare services will be required to meet a number of challenges including an ageing population, the delivery of care in different environments and rapidly changing technology (Longley et al 2007). In order to help nurses of the

Have a look through your student handbook alongside your course information and read the sections on practice learning.

1. Identify what approach to practice learning is used in your university.

2. Identify what ‘type’ of practice settings you might be going to on your course.

3. Consider what you already know about these settings and what you might need to know to help you plan your learning for these areas (Ch. 5 will help you with this).

4. Check the chapter aims and outcomes for Section 2 and highlight the chapters you feel will be most relevant.

5. Write an action plan for how you will find out any further information you need about the practice areas where you will be on placement.

future meet some of the challenges, the Nursing and Midwifery Council (NMC) stipulates that practice learning for students undertaking pre-registration education must reflect the service users’ journey in order to support the practitioners of the future to work in reconfigured service structures (NMC 2010).

This means that rather than blocks of placements, universities and the care providers they work in partnership with are increasingly moving towards structuring placements to more closely follow a pathway that a service user may take through services. This might mean that, as a student, you spend longer time working with one mentor, service user or service. One of the important implications of this is identifying how the skills that you are learning can be used effectively in different settings (some of which you might not get the opportunity to spend lots of time in during your education). This emphasis on how skills can be used in working with individuals in different settings is reflected in the structure of this book, through its focus on approaches and skills important for mental health nursing across service boundaries.

In some courses this pathways approach will mean you are based in one practice area for longer, spending a few weeks during this time in practice areas that link with this service. This might also include shorter insight visits where you may have the opportunity to spend time with different professionals or in settings outside health care (such as the coroner’s court). Figure 4.1 shows what this might look like. The centre box represents the main placement area, the lightly shaded boxes may be the practice areas where you could spend a few weeks and the unshaded boxes may be where you link with for insight visits. Depending on your course, this could be arranged for you, or it may be something that you have the opportunity to get involved in arranging yourself following discussion with your mentor.

Fig 4.1 Example of a pathway learning experience in mental health

Routes into mental health services

Mental health support is provided to individuals across the age span in a variety of settings within healthcare services. The manner in which individuals gain access to this support is to a certain extent defined by the nature and priority of their need (in a similar way to access to all health services). However, given some of the tensions that may be associated with mental health care, including care delivered to individuals detained under the Mental Health Act, the means through which initial contact is established could have major implications for the development of the therapeutic relationship and the delivery of the required support.

GPs remain one of the main gatekeepers to mental health services and, in many respects, GP surgeries are a major provider of mental health support. However, GPs refer to both primary and secondary mental health services (there will be some local variations in the design of these services). Counselling and psychotherapy services are delivered by mental health nurses and specially trained mental health workers in GP surgeries. These practitioners provide support for individuals with common mental health problems or who may be experiencing trauma and can gain psychological input for their experiences on a short-term basis. GPs will refer directly to these practitioners. They may also refer people on to community mental health teams of which there are a number of different types (see Ch. 6). The circumstances and diagnosis of each individual may define where they are referred. Here, professionals working in the community (commonly mental health nurses) will conduct an assessment to decide whether they are the appropriate people to provide support. For people who are highly distressed and in immediate need, GPs can also refer directly to a crisis and home treatment team. This service can provide short-term and intensive support to the individual in his or her own home until the crisis period is over. They can also work towards securing an admission to hospital for the individual if this is required.

For access to mental health services, support or hospital admission out of hours, the accident and emergency department might be a first port of call which can result in an assessment by a psychiatrist, referral to a crisis team or, in some areas, short-term input from a specialist accident and emergency liaison team.

People can also come into contact with mental health services via the police and the criminal justice system. Mental health services have received criticism due to the inequalities in access among different ethnic groups, as Afro-Caribbean men are more likely to come into contact with mental health services via the police. Rates of mental health problems are high among prisoners and this group is at particularly high risk in relation to suicide. Prison in-reach teams may take on referrals from people in prison experiencing mental distress. At times this can result in individuals who require support being moved to forensic secure units or hospitals. If an individual is arrested and there is concern they may have mental health problems, forensic or court liaison teams may conduct assessments to identify whether the person requires the input of specialist mental health services.

Care delivery environments

The environment in which a service is delivered will have a significant impact on the learning opportunities available. Each environment offers unique experiences and can also present specific challenges. This section will highlight some of these points by considering the impact of community and in-patient environments on student learning.

Community placements

The key advantage of many community placements is that they offer you the opportunity to visit people in their own homes. This helps you to gain an insight into how the person’s mental health problems are influenced by their environment and social circumstances. It can often provide pieces to the jigsaw puzzle which you would never have known if assessment and contact with the person only happened in an office or a ward environment. Therefore, a more holistic picture is gained of the person by paying attention not only to what they say, but also to your observations of their surroundings and how they interact within their community.

This does, however, have an influence on the dynamics of the relationship you build with the person and how you communicate with them. Most significantly the person is inviting you into their home and, therefore, it is important to respect their rules and routines. In an in-patient setting, the organisation sets the rules and the person who is using the service is expected to adhere to them. In the community, the person is setting the rules and, therefore, you have the opportunity to begin an interaction based on a more equal footing. For example, is there a particular chair that they would rather you sat in? Would they prefer it if you took your shoes off? These simple acts have significant implications for the nature of the relationship you begin to build.

It is also important to remember that the person may not wish to see you that day and, provided that you are not concerned about their safety, they have every right not to allow you into their home. This also reinforces the person’s position of choice and emphasises the importance of investing time to engage with the person rather than taking for granted your right to be invited into their personal space.

A further benefit of community placements is the opportunity for you to engage in one-to-one time with the service user without the interruptions or distractions associated with in-patient settings. This can offer you the opportunity to build significant relationships with people and advance your communication skills. You may be encouraged by your mentor to visit someone independently or lead the interaction. This will allow you to take a more active role and move beyond chit-chat to more autonomous and focused interactions. Many students say this opportunity is very beneficial for the development of their confidence as they begin to think of themselves more as a responsible practitioner.

The nature of the one-to-one time you spend with a person can vary widely depending on their current needs and care plan. Students often take advantage of having more time to engage in supporting a person to achieve a specific goal. Some interventions you may be involved in will take place in the community and will be focused on supporting the person to develop independence and confidence or to combat social anxiety. At times, some students find it challenging to see the purpose of their involvement with the person in terms of their learning and feel that they are fulfilling the role of a support worker. It is, therefore, important to be clear about the rationale for the contact you are having with the person so you can ensure you are working within the overall plan of care rather than creating a more socially supportive relationship, which cannot be sustained due to the length of your placement.

The nature of community placements sometimes means that you are not spending as much time in direct contact with service users. This could be because your mentor is completing paperwork, the service user is reluctant for you to visit them or your mentor does not feel it is appropriate for you to be present. During these periods, some students find it difficult to know how to use this time effectively. In order to combat this, we suggest taking a more self-directed and proactive approach to this placement. Once you have identified the times when you will not be working directly with your mentor, you are then able to approach other members of the team for additional opportunities. Many members of the multidisciplinary team will be very happy to spend time with you or take you with them on visits. You can also use your time to develop your skills in record keeping, becoming familiar with documentation or liaising with other members of the care team. You may also want to organise to visit a service which is linked to the placement area you are in. Whatever you choose, with a little planning you can utilise this time effectively.

In-patient placements

The term ‘in-patient area’, when used in the context of mental health services, can be taken to mean a setting for mental health care that involves a level of service delivery that is of higher intensity than in a community context. The intensity is heightened in terms of the following aspects:

• Service users are perceived as needing assessment and treatment in a contained setting rather than the service user’s home environment.

• The Mental Health Act (1983) may be used at some point during the service user’s assessment and treatment.

• Interaction with, and interventions by, a range of mental health professionals is a given.

• The potential for disturbance, annoyance, irritation and aggression from other service users is ever present.

• Opportunities for copycat behaviour and infection by other service users’ pathologies are increased.

• Lack of continuity and consistency is an inevitable consequence of the shift systems used in many institutional care settings.

• Activities of daily living such as sleeping, eating, activity and so on may be compromised for most service users in some way.

The student nurse may at first see the above list as intimidating and disadvantageous for their learning opportunities as compared with the more autonomous work setting of the community practitioner. However, you will find that many of your mentors may hold the view that the institutional setting, despite its many disadvantages and discomforts for service users and professional carers, can be a source of similarly intense learning experiences for students. If that idea is applied to the seven areas above, the opportunities for students can be as follows:

• The contained environment is needed to facilitate, primarily, safety and security for the service user. In most instances the reason to assess and treat someone in a hospital environment rather than in their own home means that they are too distressed or disturbed at the time of assessment to be helped in their own home. It is likely, therefore, that the student will see service users being admitted and treated who are often clearly more distressed or disturbed than can be seen in community settings.

• The use of the Mental Health Act (1983) inevitably produces tension between healthcare workers and service users who are being subjected to detention or treatment orders. The ways that experienced and effective professionals strive to maintain therapeutic relationships with service users, despite often being the implementers of the law, can provide rich learning opportunities.

• Institutional healthcare settings, by definition, are sustained by other institutional systems. For example, a typical mental health ward will be serviced by social workers, psychiatrists, occupational therapists, psychologists, phlebotomists, pharmacists, clerks, domestics and so on. The effective mental health nurse must sustain a constructive working relationship with all of these different visitors, in order to provide the best possible service to the client group. As the nurse does this, she provides a role model for the observant student, as well as evidence that the job of a qualified mental health nurse involves skills such as diplomacy, assertiveness and so on, as much as knowledge of medications and Mental Health Act Sections.

Mental health placement learning areas

Adult community mental health care services

In 1999 the Department of Health published the National Service Framework for Mental Health which outlined a new structure for community mental health services. Traditionally community teams worked within a location (often called a catchment area) to provide support to people with a vast variety of problems and at different points in their experiences of distress. In order to promote a recovery approach to delivering community services, a new structure was defined which involved a number of more specialised teams who would focus on specific client groups and provide interventions during defined periods of their distress.

The following section will provide information from students and mentors on these services with a focus on what you should know before commencing the placement, a description of what you might experience and hints and tips on how to make the most of the learning opportunities. Further descriptions of services can be found at the Mind Website (http://www.mind.org.uk).

Placement 1: Crisis intervention and home treatment team: a student experience

Denise Sproat, second-year mental health branch student nurse

The service offers 24-hour crisis intervention and home treatment for people experiencing a severe mental health crisis. People are referred by other services such as their GP and the team are known as the ‘gatekeepers’ to other services. If the referral meets the criteria initially, the team have to respond within 4 hours and carry out an assessment of the person’s mental health. On the whole I found that people presented with thoughts of suicide, or had made an attempt to end their life, and so were high risk. The service is an alternative to hospital and where a person is taken on by the team they are usually assessed daily over a 72-hour period. Assessments are carried out by two nurses so, as a student, you will be the second person. People are treated at home from anywhere between 2 weeks and 2 months and supported holistically to recovery from their crisis. However, sometimes people can deteriorate and be admitted to hospital.

Melissa Wheeler, second-year mental health branch student nurse

My time as a student nurse with the crisis team was one of the most intense periods of my training within practice. Having the opportunity to work alongside such experienced nurses and multidisciplinary team members on a one-to-one basis was invaluable and made me appreciate the versatility and skills of the team when adapting care to an individual client.

While there I gained a greater understanding of assessments, including mental health examinations, risk assessment and written documentation, and became familiar with a variety of therapeutic approaches and interventions. Time spent with the consultant psychiatrist was extremely rewarding as was attending home visits: both offered opportunities for learning, developed my knowledge base and strengthened my skills of care delivery within changing environments.

I found that many of the crisis team members proved to be supportive role models who were able to facilitate my personal learning and, on reflection, provided me with a greater self-awareness and understanding of others. Although often challenging and hard work, I felt privileged to have been given such a valuable learning opportunity.

Placement 2: Adult community mental health teams (CMHTs)

Rosie Robinson, third-year mental health branch student nurse

In my second year I did two community placements. There are many learning opportunities in a community setting such as working in a team which involves other

Melissa and Denise identify a number of learning opportunities which they encountered while working with the crisis team. Identify up to three of these learning opportunities which you would prioritise for your placement and consider what prior reading may be helpful in enabling you to achieve these.

Within Melissa and Denise’s narratives there may be some roles, definitions or language that you have not heard before. Use the jargon and acronyms buster in Appendices 1 and 2 to identify what these terms mean in a mental health context.

professions such as psychologists, occupational therapists, social workers and psychiatrists. This includes multidisciplinary meetings in which you can participate. I had the opportunity to develop my confidence in administering depot medication. The key learning opportunity for me was that you have the chance to visit people in their own homes and support their carers. I also got much more comfortable with using the Care Programme Approach paperwork, including notes, assessment documentation and care plans along with participating in initial assessments.

I hope you enjoy your community time as much as I did and have a great experience!

Rosie describes the benefits of working with the various professionals who work within the CMHT. Before starting your community placement, identify the role of each of these professions and consider how you might benefit from working with them on your placement and what learning outcomes you might achieve.

Placement 3: Early intervention team

Gabriella Maria Burton, second-year mental health branch student nurse

During my second year as a student nurse I got the opportunity to go on placement with an Early Interventions in Psychosis Team. They predominantly work with 15–35-year-olds, suffering with their first untreated psychotic episode. They work to detect early, and intervene to prevent further, damage to the service user’s life. This involves intensive work with the service user, families and carers.

Many service users in the service can have a dual diagnosis or no diagnosis at all. This can be many people’s first involvement with mental health services and often a very confusing time for them. Due to this, some service users may present angry, scared or confused about the current situation they find themselves in, which is understandable, so you need to educate, support and empathise with them. Although saying this, many service users have been with the team for some time and have built a therapeutic relationship with their care coordinator and there will be various people that you can work closely with and build your own therapeutic relationship with.

There are many learning opportunities as there are so many different professionals in the team such as family therapists and cognitive behavioural therapists. Opportunities I came across incorporated initial assessments, depots, social groups, care plan reviews, social circumstance reports and many more interventions.

Reflection point

Gabriella describes how a person might feel who is experiencing psychosis for the first time and the importance of empathising with their experience.

1. How might you feel if you were in the service user’s position?

2. How might this influence how you work with the person?

Placement 4: Assertive outreach team

Amy Ramful, third-year mental health branch student nurse

During my second year of training I had a placement with the Assertive Outreach Community Team. Assertive Outreach work with service users with severe and enduring mental illness who have difficulties engaging with services. Some service users may also have a forensic background or dual diagnosis. The team tends to have smaller case loads compared to a CMHT, which allows for more intensive treatment which helps with engagement issues.

As a student, don’t be surprised if some service users aren’t keen on having you involved in their care. This is the nature of the client group. When I first started the placement my mentor told me to expect a lot of unanswered doors and running around trying to get hold of people. However, don’t let this put you off because, of the work the team does with clients, many have built very good therapeutic relationships with the team, and there will be plenty of opportunities for you to work closely with some of them, and you may even have the chance to have your own mini caseload.

Other learning opportunities I came across included depot administration, Care Programme Approach reviews, risk assessments, Mental Health Act assessments, care planning and doing individual work with service users.

Reflection point

Amy describes the challenges of working with people who are reluctant to have students involved in their care.

1. Why do you think this might be the case?

2. Think about how you would make the most of your time on placement during periods when you are not having contact with service users.

3. What type of approach might help people feel comfortable with having you involved in their care?

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Tags: Placement Learning in Mental Health Nursing A guide for students

Feb 25, 2017 | Posted by admin in NURSING | Comments Off

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