Joe is a 55-year-old man who has recently been made redundant; he has yet to find another job. Joe has a history of depressive episodes and during these episodes Joe has been treated with antidepressant medication. On assessment by mental health crisis services Joe mentioned that he was not coping and that he felt "worthless", he also described feeling "low in mood".
On further exploration Joe talked about not being able to sleep properly due to worrying about money; he was finding it difficult to fall asleep and when he did he was waking up early in the morning. He felt tired all the time and had little energy. He mentioned that he had stopped going out even to fetch a paper and he was at the point where he was struggling to get washed and dressed. Though he felt his family was supportive he found it difficult to interact with them and at times he noticed he was becoming "snappy" with family members.
Joe disclosed that more and more he is having thoughts of "not wanting to be here", and increasingly he is thinking about "ending it all". Due to these thoughts Joe felt scared and confided in his wife who persuaded him to see his GP.
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(a) To support Joe at a vulnerable time in his life what values and behaviours would the nurse utilise when communicating with Joe?
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Correct answer: It is essential in this situation that the mental health nurse shows empathy through a genuine understanding of Joe's experiences. To ensure this in-depth understanding of Joe's experiences the nurse would use good communication skills, which are underpinned by such values and behaviours as:
- Care
- Compassion
- Competence
- Communication
- Courage
- Commitment
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(b) How would the nurse demonstrate that they are listening?
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Correct answer: Responding appropriately is a key part of active listening, and to respond appropriately the mental health nurse needs to concentrate on what Joe is saying. During this process the nurse needs to control any potential distractions, giving Joe time and space to talk.
At the right time the nurse will demonstrate they are listening by responding in a way that is appropriate to what is being said. This can be achieved through the nurse nodding their head – a non-verbal sign that they are listening.
The nurse can also summarise what Joe has said and then check or clarify with Joe that their understanding of what has been said is correct. Questioning is also a key part of understanding Joe's narrative; this can be achieved by asking open questions – "describe what you mean by 'low in mood'" – and also by asking probing questions – "what time of day do you feel most sad?"
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(c) Joe has been diagnosed with "severe" depression; what "risk factor" may have increased Joe's vulnerability towards being depressed?
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Correct answer: A psychosocial factor such as loss of employment may increase an individual's vulnerability, though other factors need to be considered such as:
- family history of depression;
- psychosocial factors such parental loss, lack of a confiding relationship;
- severe physical illness;
- childbirth;
- genetic predisposition (theory)
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(d) What types of treatments may be used to treat Joe's condition and also what types of psychological interventions would the nurse potentially deliver?
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Correct answer: Depending on the nature of the condition, treatment guidelines recommend:
- cognitive behavioural therapy;
- interpersonal therapy;
- guided self-help;
- self-help groups;
- structured physical activity;
- behavioural activation;
- antidepressants;
- ECT in severe cases.
When delivering psychological interventions the nurse would follow a stepped care model that is designed to indicate the choice of intervention by the severity of the depressive episode. Before the nurse delivers any specific psychological interventions they will need to ensure that they have built an effective therapeutic relationship; they will also need to manage any identified risk and/or any comorbid conditions. Depending on the skill of the nurse the types of interventions they may deliver are:
- cognitive restructuring;
- behavioural activation;
- problem solving;
- relapse prevention;
- psychosocial interventions;
- motivational interviewing;
- guided self-help.
Consider Chapters 1 and 16.
Joe has now been referred to his local community mental health team. He was initially visited once a week and he is now being visited once a month.
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(a) What kind of organisational approach will the community mental health nurse use to manage Joe's care?
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Correct answer: The nurse would use a case management approach to care delivery that is typically used within the community mental health team settings. It is a multidisciplinary team approach where a number of professional groups are both involved in the decision-making process and the delivery of care, though in terms of overall responsibility one member of team is allocated to be the case manager.
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(b) Joe's community mental health nurse is also Joe's case manager. What leaderships skills would the nurse utilise in this role?
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Correct answer:
The nurse would demonstrate such behaviours and values as:
- being able to communicate effectively;
- dealing constructively with setbacks;
- taking on board others' viewpoints;
- being clear about the way forwards;
- engendering trust.
and cultivate the following qualities:
- effective self-management;
- having integrity;
- a focus on quality;
- motivation;
- influencing others;
- being adaptable and astute;
- change agent;
- being authentic;
- being a coach.
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(c) To support their leadership development what activities should the nurse engage in?
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Correct answer: The mental health nurse as a practitioner and as a leader should actively engage in:
- lifelong learning;
- expert skill development;
- critical reflection.
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(d) What nursing interventions should the nurse deliver to help manage Alex's incontinence?
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Correct answer: The nurse may need to consider when managing Alex's incontinence that it may be the case that if Alex could reach the toilet in time he may no longer be incontinent. While undertaking bowel and bladder care the nurse must remember to:
- wear disposable gloves and wash your hands even when wearing gloves;
- wash the person and keep the skin clean;
- use a barrier cream sparingly and preferably a cream that has a pH near to that of normal skin;
- do not use solutions with alcohol or disinfectant.
Consider Chapters 31 and 32.
