My final week with the Community Mental Health Team

Tomorrow will be my last day with the Community Mental Health Team, as my four week placement has now reached its end.   This learning curve has been fabulous, but it is now time to return to my studies at university. 

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This week I attended the Clozaril Clinic, in which clients who are taking the anti-psychotic drug, Clozapine, regularly have their blood taken for monitoring of their white blood cell count.  As a result of taking the drug, clients are at risk of developing neutropenia or agranulocytosis.  This is when the white blood cell count gets low, and the person’s immune system consequently becomes compromised.   In order for clients to remain healthy, it is therefore essential that those taking Clozapine regularly attend for testing. 

In the first 18 weeks of starting Clozapine, clients should be tested every week, and then every fortnight for up to a year.  Afterwards a monthly test is the usual requirement.  The results of the blood tests are carefully scrutinised, and are awarded a rating of green, amber or red.  A green result is absolutely fine, whereas a red result means that the medication should be stopped with immediate effect.  An amber result will require another blood sample to be taken, and depending on the result, a decision will be made to either stop or continue with the medication. 

Clients on Clozapine have to tolerate regular blood monitoring, because of the strong possibility of undesirable side-effects being present.  These clients will be taking Clozapine specifically because other anti-psychotics have not suited them.  Clozapine is one of the old atypical drugs, but it is still the best choice for a significant number of clients.  The drug, Lithium, as commonly taken by clients who are bi-polar or manic depressive, is another medication where regular blood monitoring is an essential requirement.  Regular Lithium clinics are also therefore held at the Community Mental Health Centre.

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On another day this week, I went with the Occupational Therapist to take a lady shopping.  The client has learning disabilities and is currently being assessed to determine her levels of independence and need.  The shopping trip was to the local supermarket, which also has a clothes section.  The client, the OT and my-self walked from the client’s place of residence to the shop.  Along the way, the client was regularly observed to see how she coped with using the pedestrian crossings and negotiated general road-crossings. 

At the shop, the client found that she had forgotten to bring her shopping list, but she was still fortunately able to remember what she needed to buy.  The client chose some items of clothing and was aware of her size requirements.  I helped her to find the correct sizes and she was reminded to keep her receipt, just in case later, they are found not to fit properly.  The client also bought a few essential toiletries and then made her way to the till point, in order to pay.  The OT carefully observed to see how she managed her handling of cash, and she did fairly well, except for not checking her change. 

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It was lovely to walk back with the lady and help her to negotiate the road-crossings once again.  I was rather touched that she chose to link my arm and chatted to me a little as we made our way back to her home.  Upon arriving, the OT reminded her to hold on to her receipt for the clothes items, just in case they needed to be changed.  It was lovely to have done something useful, in order to have helped a person in need of some assistance.  Upon arriving back at the office, the OT and my-self filled in the assessment form of how the client had coped with different aspects of the shopping trip and traffic awareness.  On the whole, she had done rather well.

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My third week working with the Community Mental Health Team

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I have now completed the third week of my placement with the Community Mental Health Team, and I am pleased to report that it has been another fantastic week of learning.  Of all the different things that I have experienced this week, there were two things in particular that I really enjoyed.

One day I accompanied a client to have a look around a local arts project scheme which helps people who have had various health problems.  This particular client has been suffering with poor mental health for many years, and is now at the stage where she is ready to move on independently and further develop her confidence.  The client expressed a wish to engage in some activities outside her home, and so getting out a couple of times each week, to a suitable group, is probably exactly what this client needs.  The lady in question is very artistic, and paints and draws in her spare time, and so the arts project seemed perfect for her.

Looking around the arts project we were shown a variety of different activity rooms.  The centre caters for pottery, painting and drawing, textiles, woodwork, photography and music.  The facilities there are absolutely brilliant, and I was really excited for the client.  The client was asked which groups she would like to join, and she happily signed up for the painting and drawing, and the pottery class.  The client is able to start with immediate effect, so I was so very happy for her.  I feel sure that the groups will be of such great benefit to her, as well as being personally enjoyable and satisfying too.

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It is great that projects such as this exist, and there should be more of these types of opportunities in various parts of the country.  Stimulating the mind is of benefit to us all, and moreover, is especially important when recovering from mental illness.  An active mind that is engaged in enjoyable pursuit is incredibly therapeutic.  Suitable physical activity is also really good for helping with conditions such as anxiety and depression, as the release of endorphins is good for the brain.  Gardening, for example, would be a great activity for this purpose.        

Another day I was involved in a training day for risk assessment.  My mentor was actually teaching part of the session, so this is how I came to get a place on the course.  Risk assessments are a central part of being a mental health nurse, and when anything changes for a client, we always need to update the assessment.  Many of my recent patients have just had annual reviews, and so I have been involved in carrying out new risk assessments alongside the client; like a care plan, the client should be involved in the risk assessment too.  When working on risk assessments, I often found them quite difficult, and it is so important to look at possible risks from all possible angles.  Therefore, as I was struggling a little, the training day was incredibly useful.

The teaching explained how risk needs to be considered from three main views: current, historic and future.  Historic risk is not always relevant, and the main focus should be on the ‘here and now’.  Risk assessments also need to look at the risk to self (i.e. the client), the risk to others, vulnerability and exploitation, self-neglect, as well as safeguarding of children. 

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When thinking about risk in more detail, consideration of the following is also relevant: nature, severity, frequency, imminence, likelihood, risk reducing and risk enhancing.  When applied to a fictitious risk scenario, for example, the nature of the risk may be an overdose by paracetamol.  The severity may be that in 1994, the client made a serious attempt on their life.  The frequency is that it was a single attempt.  Given that it was 20 years ago, it therefore seems unlikely that the client may make a similar attempt at present.  For the risk to be reduced, the client needs to take their medication and to engage with their CBT treatment.  For the risk to be enhanced, the client would need to stop taking their medication, there would be increased mental stresses and a failure to engage with the CBT support.  Finally, any strong protective factors, such as a supportive family network, should be identified, along with any early warning signs of deterioration, such as the client withdrawing in isolation.

I now feel much more capable in carrying out risk assessments, and my mentor has already noticed that they have markedly improved.  Next week will be my last chance to practise my newly acquired skills for a while, as my placement is due to finish next Friday.   I will provide a final update on the community next week, and then it is back to university again.

Working with the Community Mental Health Team

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My second week in the community is now complete, and I am now half way through this short placement of just four weeks.  It is a great shame that this placement is not actually the longer one of ten weeks, which is later in the year, as I absolutely love it and the time is going far too quick.

As being a community mental health nurse is rather like being a social worker too, the role is sufficiently varied to keep it interesting and challenging.  Part of the time is spent in client’s homes, maybe delivering a specific talking intervention over a cup of coffee, giving them their two-weekly depot injection, or just making sure that everything is generally okay with them. 

Another part of the time is spent seeing clients at the mental health centre.  Clients may be visiting to have their depot injection or to get their bloods checked, or they may be attending for a six or twelve monthly review of their treatment.  If it is the latter, the resulting paperwork is extensive.  The review has to be written up, and copies are sent to the client and their GP.  The client’s risk assessment and care plan are updated, and an essential care cluster review and a SALT are carried out.  I can’t remember what SALT stands for, but I know it is not the acronym that I am usually familiar with – speech and language therapist – and is instead something to do with the social work side of assessments.  Of course, if clients have got better and have stabilised, reviews sometimes end in them being discharged from the service.  It must be so rewarding for the staff to see a previously poorly client regain good mental health once more.  It can often be a long journey, and this is what must make it all the more worthwhile.

As inferred above, another part of the time is spent in the community mental health office, catching up with all the paperwork.  After a couple of client visits, this does tend to pile up rather quickly, and I can see that if you are not very careful, paperwork could potentially take over from actual client contact.  It is therefore essential to be organised and to get ahead as much as you can.

Yet another portion of the time is spent being on duty triage.  Unwell clients or concerned family members phone up for advice, and if a person is deemed to be in need of further help, they may be asked to visit the community mental health centre, in order to have an assessment.  The assessment may be booked for a future date, but if really urgent, will be carried out that day.  Assessments are a hugely time consuming exercise, but are essential for nurses to get to know their clients, what might be wrong with them, and how they can be helped.

I took the notes during an assessment last week, and it took about two hours in total.  Information needed to be gathered under various headings, such as presenting problem, past psychiatric and physical health history, medication, family history, personal and social history, appearance and behaviour, speech, mood, and so forth.  The resulting array of information was massive, and of course, all had to be typed up once the exercise was completed. 

The process that I witnessed was not just an information gathering procedure.  The community psychiatric nurse, that conducted the assessment, spent time to build a good rapport with the client, and used appropriate opportunities to teach the client about the identified problem, and to persuade them to see how the likely diagnosis was justifiably applicable.  The nurse was extremely skilful and managed to normalise some of the client’s concerns by sharing a little about her own personal life experiences.  This shared human element was extremely effective, and helped to put the client at ease, and to help the client to address the next stage of her treatment journey.

The experience with the community team is proving to be both enjoyable and educational.  I can hardly wait for week three to begin, but for now I will enjoy what is left of the weekend.         

Community Mental Health Nurse, or Care Co-ordinator?

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This week I have started my first placement as a second year mental health nurse, and this time it is in the community working alongside the Community Mental Health Nurse (CMHN).  When I initially found out that I had been assigned to the community I was really pleased, as up until now, I have always spent time on the wards.  I thought that it would be fun to be out and about visiting people in their homes, and so far on the placement, it is proving really enjoyable.

Before starting, I had read a few articles on the role of the CMHN, as I wanted to learn more about what the role entailed.  In fact, one of my learning objectives was to obtain a good general overview of what the job involved.  I was therefore really surprised when my mentor explained to me, that CMHNs do not really exist anymore.  CMHNs are nowadays known more commonly as CPNs – Community Psychiatric Nurses – but this title, and role, has been replaced in many areas by the more general term of Care Co-ordinator.

A Care Co-ordinator’s job can be fulfilled by a Mental Health Nurse, a Social Worker or an Occupational Therapist.  The three professions, in many districts, are becoming as one.  I can understand in many ways how this has come about, because already I can see how many duties overlap, such as visiting people in their homes to offer general support.  On a basic level, all of these professionals are intent upon helping people to manage their lives, whether it is on an emotional or a practical level.

Within the Community Mental Health Team where I am working at present, I am working alongside the CPN, and she has encouraged me to spend a day working alongside the Social Worker and Occupational Therapist, in order for me to judge how the roles differ, if at all.  To this end, I have made arrangements to spend a day with each of these professionals, and am greatly looking forward to finding out what each of these days will bring.

From what I have seen of the CPN’s or Care Co-ordinator’s role this week, it is a fast-paced assortment of many tasks.  My mentor and I have visited many clients to provide emotional support and practical advice in their homes; we have taken clients on specific visits and have assisted them with phone calls.  At the health centre, we have administered medication to visiting clients.  In the office, we have completed paperwork, made lots of phone calls to clients and other professionals, and have liaised with other team members during face-to-face meetings.  The CPN’s role is undoubtedly busy and varied.  Each CPN has a caseload of clients that they are responsible for, and it has been wonderful for me to witness first-hand, the trust, care and positivity that is invested into these relationships.  Take it from me, whatever the Community Mental Health Nurses are called; they are definitely doing an absolutely fantastic job, and also one that is very important.