PROMOTING / DEVELOPING RECOVERY IN MENTAL HEALTH
Introduction
The clinical area where I am working is the neuropsychiatry department, specifically working on brain injury patients. This is the department of the hospital wherein patients with mental disorders that are somewhat related to nervous system diseases are being treated. From the fact alone, that nurses deal with patients that have mental disturbances or disorders, the nurse deals with a very difficult role. Issues such as asking for consent and the confidentiality of patient records is of particular importance.
As a newly qualified nurse on my first job, a preceptorship experience is needed. In my preceptorship experience in the area of mental health, I have learned a lot of things. Specifically, I was dealing with patients recovering from brain injuries. The reason why I chose this topic for preceptorship experience is that injuries to the brain can create very unpleasant experience for both the patients and their families and presents a challenge to nurses. Nurses can help the patients and families through providing care. Survivors of brain injuries face many challenges as they recover from their initial injuries and strive to regain function. At the same time, the family members of the patient face challenges as they adjust to permanent changes in their family roles and functions. It is therefore a challenge for the nurses and other members of the healthcare team to work together to effectively meet both the needs of patients and their families.
My experience in the preceptorship focused more on involving the family in the rehabilitation process. Family support is defined as assistance provided by nurses to patient and family. Family support is an intervention that assists the family in realistically assessing the impact of the head injury event on the patient and family. In providing family support, the critical care nurse engages the family so it can expand, contract or stabilize (1996).
The diagnostic and treatment procedures experienced by brain injury patients during life-threatening illness are major sources of distress for the patient and the family. Procedural distress may be defined as unpleasant physical sensations and negative psychological states associated with specific diagnostic or treatment procedures. Physically invasive procedures involve objects such as needles, catheters or probes entering the body. It is believed that procedures that are physically invasive cause more distress than do procedures that do not penetrate the skin or a body orifice (1996). Using a structured critical pathway that addresses the common needs of patients and family members can assist in organizing care and ensuring that important issues are not overlooked (2006).
Main Body
The importance of this chosen theme RECOVERY in the context of national and local mental health policies
Nurses who care for patients with brain injuries face unique challenges, especially when it comes to caring for the patient during recovery. Patient care can be time consuming and complex, with appropriate treatment and rehabilitation varying from patient to patient. Interactions with patients’ families place further demands on nurses’ time and energy. Ineffective communication between anxious family members and healthcare providers has been identified as a major source of stress for both nurses and families ( 2003), as well as a factor in the success or failure of a patient’s recovery.
Contemporary changes in the healthcare setting have created further challenges not only for the nurses but also for the patient recovering from the brain injury. Nursing shortages have led to increased patient care loads, and managed care has led to shorter hospitalizations. The result is that less time is available for healthcare providers to anticipate and meet the needs of those family members assuming caregiver responsibilities. Nurses require specialized training and resources to help families cope with the effects of brain injury upon recovery.
Neuroscience nurses practicing in the community or within rehabilitation programs are well-positioned to assess and comprehensively refer and manage the brain injury survivor upon recovery. It is important to note that there are some negative effects on the patient after the brain injury. Physical changes may include sensory deficits (e.g., visual or heating impairment), diminished coordination and muscle control, fatigue, seizure disorders, and headaches. The physical changes are generally the most easily recognized by others. In addition, typical emotional changes include emotional lability, decreased inhibition, increased anger, depression, frustration, and anxiety.
These post- brain injury alterations become most apparent to family members or co-workers. Cognitive changes post- brain injury may create additional rehabilitation needs and include decreased short-term memory, inability to maintain attention/concentration, difficulty with receptive and/or expressive communication, and poor organization/planning. These changes once again are most noticeable to those who have close contact with persons who have brain injury (1990).
Pharmacotherapies may be indicated, yet there is no substantive evidence on the most effective drugs. Because primary depression is best treated when pharmacotherapies are combined with strengthening interpersonal relationships, similar strategies should be employed with this population (2000).
(1990) described cognitive changes with greater specificity by discussing the pervasive limitations that impaired executive functioning may present. Diminished executive functioning is connected to frontal lobe damage, and simply put, is “an organically based inability to plan, put into action, and carry through with an appropriate course of action.”
An unemployed person manifesting executive dysfunction may claim he/she wants to go to work, but has no idea how to initiate, plan, or complete a job search. Additional behaviors related to executive dysfunction include difficulty sequencing events, loss of self-monitoring ability, and inability to analyze social situations and self adjust. When a person demonstrates such behaviors, he/she may have difficulty interacting with others and may be identified as cognitively impaired, unmotivated, and disinterested. Such residuals from diminished executive functioning create pervasive social and vocational problems that the nurse should help address. Once professionals have identified common residuals, brain injury professionals can design services to meet these specialized needs.
Critical evaluation of the rationale for introducing this development and the theoretical framework used
It is well established that irreversible tissue damage following brain trauma is a result of primary and secondary processes. The primary injury occurs at the time of the traumatic event and encompasses mechanical processes such as neuronal shearing, transection and axonal injury. Obviously, these primary events cannot be prevented once the trauma has occurred. However, secondary injury develops over time following the primary traumatic insult. Recent evidence suggests that much of the irreversible damage after brain injury is actually caused by these secondary events initiated at the time of trauma but taking hours to days after the insult to resolve. The time factor involved in the secondary injury process suggests that irreversible brain injury may be prevented or at least attenuated. As such, understanding the role of these secondary mechanisms in the injury process permits the implementation of nursing care practices that may potentially minimize irreversible tissue damage (1999).
Training and inclusion of the family in patient care is a concept that most nurses felt would lessen negative encounters. Approaching care from the perspective of the nurse-family team helped instill a sense of control in family members. It should be pointed out, however, that “not all families want to be involved in care. Some are scared, and some think that the nurses are not doing their job if they ask the family to help. Although family involvement in care is needed, the critical care environment can be intimidating during the early phases of care, so family members must be approached cautiously and individual circumstances carefully assessed when involving them in physical care of the patient.
We nurses also encountered some barriers to effective implementation of the pathway. The shortage of registered nurses necessitates increased patient loads and the use of temporary nursing staff, which could disrupt the continuity of care. To be most effective, the role of coordinator should be assigned to the patient and family educator or someone not involved in direct patient care. There is also emphasis on the need for consistent staff or someone to guide existing staff (2006).
The nurses also recommended that training be provided for all staff members involved in implementation of the critical pathway because it is difficult to maintain continuity of information with staff who had not been involved in the orientation phase of implementation. Because the pathway is an interdisciplinary tool, it has been suggested that all staff, from nursing assistants to physicians, be trained and roles clarified before pathway implementation. When there are multiple physicians, including subspecialists and residents, interacting with the families, information consistency is difficult to maintain. It is also recommended that weekly interdisciplinary team meetings including the families be instituted. These suggestions have been implemented as the program has grown and evolved.
The reason for incorporation of the family in the recovery process is that many family members do not understand the whole situation. In their recent investigation of common misconceptions held by family members of individuals with brain injury, (1997) found that most family members did not really understand altered states of consciousness. Further, family members believed that personal motivation and hard work were the primary determinants of recovery of function, as opposed to extent and severity of the injury. Such misconceptions can be detrimental to the rehabilitation process and highlight the need for family education.
The family needs to be approached as an integral part of the team in rehabilitation. For this reason, they need to be well informed about all aspects of the patient’s program of care. They also need to be able to share their knowledge of the patient with the professional staff. Within the first week of a patient’s arrival at the facility, the family is scheduled to attend an introductory class that includes an overview of brain injury as well as an overview of the program. Any person identified as assuming a caregiver role with the patient receives a “learning needs and barriers to learning” assessment before attending the class.
More specifically, the integration of the family within the treatment can help a lot in the improvement. Sometimes strong families can provide a solid infrastructure to support and facilitate recovery of the person with brain injury (2002). Normally, the family initially is of minimal help as it manifested shock, disbelief, and are devastated by this event. Consequently, in my experience, the family appeared to be of little help to a brain injury patient’s recovery. However, we the interdisciplinary team educated the family on brain injury, described how daily functioning may be impaired, and learned how to implement simple strategies to enhance his time management skills, memory, spatial orientation, and social interactions.
However, the effectiveness of psychotherapies and support groups has been understudied. Studies indicate tremendous problems with social support, social isolation, and belonging. Strengthening social support and assisting the survivor to feel valued and connected to a group or person is imperative in rehabilitation. Educating support persons about the importance of their role in assisting the survivor maintain interpersonal relationships and appreciate the changes in ability and temperament is truly a challenge and not to be accomplished in a single session. Long-term follow-up for comprehensive management of the survivors and their support system is required (2000).
Implementation process, highlighting issues encountered and their resolution
The goal of a clinical pathway is to create a user-friendly tool for nurses that would meet both their needs and those of families. Neuroscience nurses involved in the trial implementation of the pathway can offer insights into the complexities of delivering holistic, structured care to patients and families. The opportunity to approach family care from a structured perspective can offer the nurses insights about their past feelings toward family care.
A critical pathway designed and implemented to help nurses identify family needs during the acute and postacute phases of brain injury and to provide a structured approach to applying nursing interventions to address family needs was used during my preceptorship. The critical pathway presents a structured approach to family care from admission through discharge. Specific interventions, developed from the professional literature (2002), are indicated throughout phases of care: Phase 1 – admission, Phase 2 – acute critical care and hemodynamic stabilization, Phase 3 – acute critical care/mobility and weaning, and Phase 4 – postacute care/prerehabilitation or predischarge.
The critical pathway addresses six aspects of family care adapted from the Brain Injury Family Intervention (BIFI) program ( 2002). Although the BIFI program was designed to focus primarily on rehabilitative care, the six interventions were constructed to meet the needs identified most frequently in Kreutzer, et al., by brain injury families across the continuum of care.
Typical brain injury rehabilitation phases include acute medical services, acute rehabilitation services, and post-acute rehabilitation services. These phases target preserving life, increasing post- brain injury physical and daily functioning, and facilitating successful community reintegration, respectively. The ideal goal has been to provide necessary comprehensive rehabilitation services to assist with the successful reintegration of each person with brain injury into all areas of life. The increasing numbers of persons surviving brain injury have stimulated rehabilitation professionals (neuropsychologists, psychologists, and rehabilitation counselors) to more closely examine this population and deliver more comprehensive rehabilitation services. Physical, cognitive and emotional deficits serve as obstacles to community integration and vocational success for adults with brain injury (2001).
Post acute rehabilitation services may be appropriate and may be provided in many ways. The person may be afforded to continue with multidisciplinary rehabilitation services on an outpatient basis. This is desirable when the person is medically stable, is making progress, and the team collectively agrees more progress can be made. Also, referral to the state/federal mental support system to facilitate successful return to work or independent living services may be appropriate. Perhaps referral to innovative community based rehabilitation programs within many parts of the UK designed to facilitate community reintegration of persons with brain injury (2001) are possibilities. It should be emphasized that emergency medical treatment and the state/federal support system are accessible to most persons in the UK.
The bulk of acute and post acute brain injury rehabilitation services are available on a limited basis, depending on one’s financial resources. Services are provided to achieve an overriding goal of functional independence. More specifically, comprehensive service provision is directed toward productive employment and independent living outcomes (2002).
Chronological rehabilitation for recovery milestones important to the person’s overall recovery are noted. In one patient, one month after rehabilitation started, the patient gained and reported slight cognitive awareness of his current situation, diminished his aggressiveness, and expressed his needs verbally. This cognitive awareness was the beginning of ongoing improvements. Six weeks into rehabilitation this person is able to successfully participate in a family outing further encouraging the family to stay involved with his rehabilitation. However, at this time he was still under 24 hour supervision.
After two months in the recovery process, the patient’s daily supervision was reduced to 16 hours (no supervision while sleeping). Furthermore, three months into his rehabilitation he only requires eight hours. During these times he is making small gains in his memory, daily routines, and social interactions from a combination of his therapeutic meetings (averaging three days a week) and family assistance. The therapeutic meetings focus on cognitive rehabilitation strategy to enhance his attention, memory, language skills, and personal awareness.
Fourth months into his rehabilitation and many changes have occured. Continued progress from the complementary professional and family involvement is observed. During the fifth month, the professionals work on preparing this person and his family for termination of the recovery program. Preparation for termination was completed and rehabilitaion interventions for this brain injury patient ended after six months. Many gains were made including the eradication of behavioral problems, but slight amnesia, impaired executive functioning, and limitations with independent completion of Activities of Daily Living. At termination, this person was referred to a protected education facility where he continued working on his social skills and independence.
When a patient does not show improvement that warrants continued inpatient rehabilitation, a family may decide to care for the injured family member at home. Even with the education they have received, the family takes on an overwhelming, 24-hour-a-day job that is both physically and emotionally draining (1999). Some temporary home health services may be available, but previous experience suggests that these services often do not have the expertise needed to work with this special population. Also, without a way to monitor and evaluate the ongoing status of the patient, family members may attach significant meaning to a patient response that is not truly indicative of a change in the patient’s neurological status. Moreover, important changes may go unnoticed and rehabilitation opportunities may be delayed or never recognized (2002).
Additionally, an educational module can also be developed to train the nursing staff members participating in the implementation of the critical pathway. This approach was chosen because of the number of individuals who needed training and the difficulty of bringing them together. Each participant could complete the module individually at his or her own convenience. In addition the module served as a resource for information throughout the implementation period. The module included topics derived from the literature review, such as the concept of family-centered care, typical emotional responses of families following severe brain injury, research findings related to family needs, and use of the critical pathway to meet family needs. These topics were the most pertinent to families and those trying to address their needs (2006).
Evaluation of own role in the process of managing this development, lessons learned and areas for further development
I have learned from my preceptorship that nursing strategies to structure the patient and family’s environment consist of organizing the patient’s immediate environment and providing for the physical comfort of the family. Critical care or trauma units are crowded with unfamiliar noise and technology. Resources provided in the critical care environment are a clear benefit to the patient. However, the environment may place additional demands on the family of a head injury patient. For example, equipment sense of crowding for the patient and family. People providing care and physically close to critically ill patients are usually strangers while those who are emotionally closest are kept physically distant by restricted visiting hours and the assembly of bedside equipment, tubes, wires, catheters and lines (1996).
As nurses, the nursing strategies are to structure the patient’s environment minimizing the amount of equipment. Interventions include those actions that enhance and respect the patient’s and family’s personal space and need to control the immediate environment. The family doesn’t know what to expect from the critical care environment. To facilitate environmental structuring, discuss items such as equipment and scheduling with the family.
Comfort measures that optimize family member’s participation in the care of the critically ill patient are found in an environment that is as pleasurable and attractive as possible. Comfort measures include couches large enough for a family member to recline and telephones near critical care. The family can designate a family member as the primary person responsible for communicating information about the patient’s condition to other family members. This will alleviate the nurse receiving telephone calls from other family members (1996).
Nurses can expand their concept of the patient with brain injury as an individual in a bed to that of a member of a family. It is important for the nurse to assess the needs of families of head injury patients during the crisis period. It is during the early phase of the crisis that the family can experience feelings of hopelessness. The ultimate outcome of a family’s attained and maintained hope is dependent upon the nurse developing successful hopeful interventions. By applying hopeful strategies to families, the nurse increases the family’s sense of hope in the present and the future.
The nurse obtains information about the family’s past experience with critical illness, the family’s need for information and family readiness and/or ability to cognitively process information. Once this information has been obtained, the nurse can develop informational strategies. Informational strategies include providing information about the family’s loved one, explaining procedural distress from invasive procedures and/or treatments, providing instructional materials and establishing family meetings or rounds.
Conclusion
Nurses working with brain injured patients at the neuropsychiatry department face varied challenges from other nurses working with people who are mentally stable. For one, care for brain injured patients is very different and requires great effort and dedication. The care should include not only health care professionals but most especially the family of the brain injured patient. There are many ways by which the nurse can include the family in the care of the brain injured patient and the nurse should see to it that she performs these duties and not miss one of them for no matter how small it could be, such negligence can have a profound effect on the brain injured patient. Not only that, this could also affect the credibility of the nurse.
Credit:ivythesis.typepad.com
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