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Author Psychiatric/mental health nursing

Canadian RPN

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Canadian RPN

  • Joined: Jan 2007
  • Location: Surrey, BC, Canada
  • Posts: 5

Fri Jan 19, 2007 8:01 am

Hello everyone!

I am a nursing instructor in Canada and just wanted to say that we still have psychiatric nursing education programs here and also a number of degrees, such as the Bachelor of Psychiatric Nursing. Years ago, Australia did away with this separate stream of education and I have been to conferences in the last couple of years where the Australians have begun to suggest this was not really as wise as they thought. I understand you have a shortage of nurses just as we do, including a shortage of nurses with psychiatric nursing skills and competencies.

The posting from the members interested in careers in psychiatric nursing in Australia on this forum inspired me to write. It seems that even from their perspective it is hard to get into the career speciality and/or find out about it. I am very keen to learn more about the situation in Australia. Would anyone like to fill me in? Love to hear about it.

Melodie in Canada

Shaun

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  • Joined: Apr 2006
  • Location: Wallaroo
  • Posts: 2

Feb 20, 2007, 11:23 pm Last edited Feb 20, 2007, 11:23 pm update #1

Hello Melodie,

This may or may not be relevant but I am a third year nursing student currently studying as an external student at a rural South Australian campus and as part of my degree I am required, this year, to complete a course in Mental Health. The course is a full subject of 9.5 units with three assignments and a four week mental health clinical placement. The course is not designed to have us qualified as experts in this field but to equip us with the skills required to deal with mental health issues if confronted with them in a rural nursing practice, as specialised services are not always available in remote locations. The students who are completeing this same degree in the city locations are not required to complete this subject but are offered a smaller version of the subject as an elective specialty course, one of many to choose from so how many people would take this subject up is unknown.

Leaving this subject as just a specialty programme or post graduate course may not assist in finding willing nurses to work in this field. So prehaps an exposure to this nursing field as part of a general nursing degree is probably a good idea as it will at least give us a taste of what it is all about, who knows some of us may even enjoy the experience and decide to follow it through and seek employment in this field. As I have not yet completed my degree and started nursing I have not looked into further study options but I would believe that Psychiatric Nursing would be offered somewhere as a post grad course. As for other Universities I'm not sure if mental health nursing is offered as a part of their degree course, it would be interesting to hear from some others.

I hope this may have helped or be of interest to you, the course materials have arrived and they look very interesting I'm sure it will be a subject that will create alot of debate and discussion in our workshop and will be a challenge for us that we can sink our teeth into.

Regards
Shaun

modified: Tuesday 20 February 2007 11:24:55 pm - Shaun

PrincessDemonik

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  • Joined: Mar 2007
  • Location: Sydney
  • Posts: 16

Mar 29, 2007, 08:44 pm

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.

Senior RN

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  • Joined: Dec 2008
  • Location:
  • Posts: 24

Dec 27, 2008, 12:28 pm

I like working in Psych that much, that for about ten years, I never set foot on a 'medical' ward ( to work as a floor staff member ).

Psych. ( Mental Health Nursing ) is just so much easier than Med / Surg.

Staff : Patient ratios are much higher. Eg. eight day shift staff for 20 - 30 patients ( in a 'General' psych. ward )

I once worked on a Medical ward, where on nights, I had 15 acute patients to manage myself..... as a first year RN. I had no support from Nursing Education, because ( wait for it ..... ) I was an AGENCY NURSE, and agency staff don't get support on the wards. Whereas, my peers who graduated with me, and got into a ' New Grad. Program ' had no more than four patients each, and had a Nurse Educator come in to check on them every second hour.

Anyway, back to psych....

One of my best jobs ever ( and this would make a good thread topic ), was as an 'assessment nurse' in a community forensic program.

Basically, the system identified a number of 'high risk' prisoners in jail, who were about to be released, and put them through a three month psych assessment program in a 'community' setting. Eg. special purpose housing.

The staff got to take the 'patients' / 'clients' out on picnics; to the beach; to the movies; on shopping trips, etc. etc.

and our rate of pay was at 'private' agency rates, plus 25% for 'environmental allowance'.

So, imagine a job, where on a Public holiday, you are paid $93. an hour, to go swimming at the beach; then have two ( 2 ) beers at the local club; see a latest release movie ( free of charge ), and then have a picnic dinner of KFC ( on the Program account as well ).....

I used to do about three ( 3 ) double shifts every week. 0700 - 2300hrs. So, on the Public Holidays, over Christmas, in one year, I earned $1,488.00 a day to have fun !!!

Oh, yes, there were a few little problems that popped up from time to time..... like absconding clients; clients running toward children in the park, to steal their ice creams; clients 'acting out' in Public; clients hailing taxis / buses, when they were not going anywhere ( in staff custody ), etc. etc. etc.

But hey !!! It was the most 'fun' I ever had in a paid position. I have stories that would 'freak' some nurses out, but when you have a certain level of confidence & training, and a repetoire of skills & tactics, such a 'risky' psych job can be as much fun as you will ever have in a paid job.

regards,

Canadian RPN

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Canadian RPN
  • Joined: Jan 2007
  • Location: Surrey, BC, Canada
  • Posts: 5

Dec 28, 2008, 06:11 am

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

Senior RN

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  • Joined: Dec 2008
  • Location:
  • Posts: 24

Dec 30, 2008, 10:19 am

Melodie,

Yes, sorry you took 'offense' at my post. I'll explain a bit more:

The situation I spoke of, was a pilot project. It was almost a unique situation.

The project was called, The Integrated Services Project ( ISP ), and was headed by NSW DADHC ( our State Govt. disability service ). Others involved were, NSW Corrective Services ( Justice Health ); NSW Police; NSW Health, and NSW Dept. of Housing.

The ISP Director identified 126 prisoners in the system, who had multiple diagnoses, and were of greater than usual risk of assault insitu, and, had serial reoffending behaviours ( along with high grade 'challenging' behaviours in general ).

The Psych. Assessment unit housed no more than six ( 6 ) clients a any one time. This project actually had a budget of $26 million...... for just six people !!!

The nurses involved were sources from an 'agency', including the NUM. Nobody was anything more than 'an agency nurse'. We had no specific rights, other than to be paid for hours worked.

That meant, we had no reponsibility, other that to carry out allocated tasks diligently.

We did not have Case Work responsibility. DADHC managers did. We did not plan a course of activities or any other forms of treatment or rehabilitation. The DADHC managers did all that.

We were nothing but 'baby sitters'. We did what we were told to do..... exactly.

That meant, when the DADHC manager said, " I want the guys to go out today - do a picnic ". That's what they got. ( now "picnic" also meant a few little side trips as well, eg. shopping for food, car trip, and we threw in the 'beach' on most occasions as well )

So, in this particular case, 'other' professsionals actually ran the Project, not the nurses.

If any 'nurse' objected to certain activities, or the 'style' of management.... you didn't get any more shifts. Simple as that. I lasted eight ( 8 ) whole months.... pretty good really, since we went through about ten staff who got 'rotated out' of the Project for critical comments about the DADHC staff.

Let me tell you about the 'get out of jail free' card these guys had....

The NSW ISP had an MOU with NSW Police.

The subject clients were not to be charged with new offenses.

Thus, due to their inherent challenging behaviours, they 'broke out' of the Unit several times each, absconded, and committed various crimes, caught by police, and returned to the Unit, all without charge.

At times, the police were not able to go chasing these guys, so we were DIRECTED ( remember that ), to go and find them ourselves. That meant, we got into our unmarked service vehicles, and drove around looking for our absconded clients. After a while, we knew where to find them, on most occasions. We must have looked like 'agents' of some type.... plain clothes, bundling people into vans, and driving off quickly !!!

As nurses of the NSW ISP, we were directed to do many things, that are not apart of 'usual' nursing practise. We did not have control, as in other practise environments.

So, I hope you will appreciate the unusual circumstances here.

I also hope, that as a 'senior practitioner' at your level, that you can have some "fun" along the way as well.....

regards,

GORDON

Canadian RPN

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Canadian RPN
  • Joined: Jan 2007
  • Location: Surrey, BC, Canada
  • Posts: 5

Dec 30, 2008, 12:17 pm

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

Senior RN

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  • Joined: Dec 2008
  • Location:
  • Posts: 24

Dec 30, 2008, 07:59 pm

Thanks for your reply there Melodie.

I agree, I would like to be in a position of some power, in order to dictate my own 'professional' terms and conditions. but in the previous scenario, as I said, this State Govt. Dept. held ALL the power. They were paying well, and it was for a reason.... to do as you are told, not do what YOU think you should do.

In other States of Australia, like Victoria, there are some very refined community programs for the rehabilitation of forensic patients from jail. I believe, from attending a few conferences of the Australian & NZ College of Mental Health Nurses, that many new ideas are introduced into Australia from other countries. Prominent nurses travel around the world, researching ideas, techniques, and practise models for solutions to our problems with 'dual diagnosis' and other issues in forensic nursing. International conferences are a great way of being introduced to what the rest of the world is doing.

All the best to you for 2009.

regards,

GORDO

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