Determinant Of Health Case Study

Progress

I believe that personal health practices and coping skills have been a very evident determinant of health on unit 56B. Many of these patients are admitted with a major depression, suicide attempt, schizophrenia, or psychosis. I believe that in order to overcome and manage these diagnoses, coping strategies must be in place for this to come together. On my first day in psychiatric emergency, I worked with a young girl who was admitted with suicidal gestures, as she threatened to jump out of her window, not to kill herself but instead to prove a point to her parents. Upon further exploration, I found out that this young girl appeared to come from a very dysfunctional family, where the parents rarely engaged their children in social

and family outings. There was constant fighting in the home between the mom and the dad, physical violence between family members, and poor emotional regulation amongst all. After working with the psychiatrist, medical and mental health nurse, and social worker, it become clear that coping strategies were lacking in this girls life, which led to behaviours that spiralled out of control. Admitting this girl to the mental health unit and working with her to build coping mechanisms appeared to be a very valuable decision in improving her mental health. In addition, when a patient comes in to the hospital attempting suicide because “they just can’t take it any longer,” I truly believe they lack the coping mechanisms and perhaps the resources to deal with these thoughts and actions.

In addition to coping skills, I believe that social support networks are also very influential to these patients. It is clear that social support/family systems do not always help a person’s situation, but actually exacerbates their feelings of depression or psychosis even more. For example, if a patient was brought in on a Form 8 because a family member filed for this warrant, it may cause tension in the family dynamics and may negatively affect the healing process for this patient at that particular time. I worked with a young girl who was admitted to the hospital on a Form 10. After she came to the hospital and was assessed, she expressed anger towards her father due to alleged physical violence. Due this this allegation, the nurse got social work involved and social work contacted child and family services, whom would later get into contact with the family. This is an example of a situation that could bring tension to the home when the parents find out that they are being investigated.

On the other hand, I do believe the support networks are very important because they may positively affect the patient’s healing process (being there for them, taking an interest in their mental health) and also provide health care providers additional information about the patient that the patient may not necessarily disclose himself or herself.

Socioeconomic status often has a significant impact on an individual’s mental health. It is evident on our unit that there are patients who are homeless, involved in a foreclosure of their home, or in a mental state that does not allow them to appropriately handle their finances. Financial struggles may become a barrier in getting better and back on their feet.

Progress

I believe that developing a mutual therapeutic relationship with a patient, one that encompasses trust and transparency of care, is essential. I believe it is important to display a sense of openness, so that patients feel comfortable approaching you. I also believe it is important to accept and remain non-judgmental even when you experience a situation that is hard to comprehend. As part of a collaborative partnership, where the patients plays a key role in their recovery, I believe sharing power is important. For example, asking the patient what time of the day works for them to have a conversation or where they would prefer their injection. Giving them options allows them to play a role in their care and feel mutually respected. These are examples of ways that I try and share power and engage my patient in their care.

Providing the patient with a sense of autonomy, by allowing them to choose what time we sit down and have a conversation, seemed to be very therapeutic in the relationship I had with them over the course of the semester. I would often ask what time would work best or I would suggest a time during the shift so they can plan out their day.

I believe that communication is essential in building a plan of care that best works for the patient, their family, and their health challenges. For example, frequent communication with my primary nurse allows me to ask questions and let them know about things that I have learnt that day about our patient. Conference allows all members of the health care team to engage in care and work together to optimize the patient’s health outcomes (psychiatry for medications, psychologist for therapy, transition services, etc.). Groups allow for expression of ones self and psychoeducational opportunities, with the hope that the patients feel empowered and ready to take on the day.

One thing that stood out to me this block was the connectedness between the multidisciplinary team. Each nurse knew so much about each patient, which is something that isn’t as common on a medical unit. Furthermore, the psychiatrists, psychologists, occupational therapists, social workers, and pharmacist all work so closely with one another in providing care for the patients. Not only are they present on the unit most of the day, but they communicate well with the nurses as well.

Although I haven’t had any opportunities working with families, I feel as though engaging with family would be a great experience as well, as you’re discussing very sensitive topics re: patient’s mental health states, challenges, etc.

Progress

Each clinical day I complete an initial entry, a behavior multidisciplinary report, a mental status examination, a final entry, and a KARDEX comment on SCM. I find that keeping up with my documentation allows me to stay focused on my patient, how they are doing, what they are doing, etc. I have become very comfortable performing an MSE and I am surprised how much information you gather from your patient by just sitting down and having a conversation. Before I started clinical, I was worried that an MSE would seem too much like an interview, but it is completely far from that. I have really enjoyed these last few weeks building a relationship with my patients and seeing their fluctuations over the weeks. I have become comfortable with the mental health terminology and being able to identify bizarre behavior or thought content. For example, I am able to see first hand what loose associations appear like in conversation or what it is like for a person to experience a hallucination. I have witnessed several de-escalation techniques and how registered nurses handle these particular situations. Disorganized thinking and tangential conversations were very prevalent on the unit, which made working with these individuals very interesting. Their thought process was very unique and often difficult to follow at times, but it was also very eye opening to the fact that this type of illness exists.

By the end of the semester, I was working with two patients on every shift. These patients stayed relatively consistent and the only time I was assigned a different patient was if there was a discharge. I really enjoyed working with 2 patients as it allowed me the opportunity to time manage and prioritize my days. It was also a challenge as I was dealing with two very unique people who were managing very unique mental health illnesses.

Progress

Something I really enjoy doing is linking symptoms to a condition and seeing how these symptoms present in a patient and how they are treated.

I find that organizing complex illnesses in such way allows me to grasp the bigger picture and see things from a more broad perspective. A basic example of this could be…my patient has a diagnosis of schizophrenia, she experiences tardive dyskinesia, but this is well managed by Vitamin E. From this, I know that if she is not compliant with her medications, these symptoms may arise, which in that case would require me to problem solve and collaborate with my patient on ways that we can alleviate her symptoms (ie. Talking with the doctor… Because we do a lot of that). Since we are on a mental health unit and most of these patients are mentally ill rather than physically ill, critical thinking goes beyond the pathological conditions but rather ways to personally manage symptoms. For example, if a patient is diagnosed with generalized anxiety disorder and based on their personality, perhaps cognitive behavioral therapy would positively impact the patient. However the decision to use this as a form of therapy requires critical thinking and consideration of the various factors that affect this person’s life. If a patient has a strong language barrier, perhaps putting them in a room full of people may do more harm than good (overwhelming, difficult to understand, misunderstandings, ect.). We had a patient on the unit who spoke only Vietnamese. Not only was it hard for the nurses to engage in conversation and work with this person therapeutically, but it appeared difficult for this person to engage in social situations/groups, etc. Thankfully this individual has a family member who spoke English and could translate, however it still appeared very challenging for everyone involved in the

care.

As mentioned above, one of my patients suffers from tardive dyskinesia secondary to her schizophrenia. I noticed my patient was receiving Vitamin E to help manage this symptom. After researching this online and finding minimal results relating to the pharmacokinetics and how it actually improves symptoms, I spoke with the unit pharmacist and she was able to clarify this information for me.

During the down times on the unit, I often research the various mental health medications (anti-depressants, anti-psychotics, etc.) or look up policies related to restraints, forms, suicide assessments, and de-escalation information. There is an abundance of information that AHS provides on their website so I find looking this information up is very useful.

I would communicate frequently with my primary nurse so that they are aware of what I have been doing and there is transparency between the two of us. The nurses all brought forth a different approach to their nursing practice, which was very insightful to observe and work with as a student.
Progress

I feel as though I am always on alert while working on unit 56B. Not just because it's a mental health unit, but because of the unpredictability of the patients. Considering these individuals may have a history of aggression or time incarcerated, I believe a way that I display good clinical judgment is through adequate space between me and the patients who I do not comfortable around. For example, the patient that I am currently working with has experienced no homicidal ideations or history of violence; therefore, I am able to make that judgment call about how close I sit beside her. On the other hand, I find myself keeping my distance with patients who experience extreme delusions, whose behavior is sporadic, those with a violent history, etc.

I worked with another patient who came across very confrontational and disorganized. She often appeared very irritable and frustrated, which made me feel unsure of my safety while working with her alone. After our initial meeting and myself cutting the meeting short due to what seemed like a potential escalation, I decided that it would be best to continue to provide care either with my nurse or in an open area.

I enjoy seeking out educational opportunities, such as shadowing a nurse while they complete a mental status exam or while they fill out discharge documentation, or perhaps going down with a patient to ECT. I really enjoy learning about resources and treatments that are available to patients so that in a time where I am asked a question regarding such, I am able to discuss it comfortably.

I have gotten more comfortable with my circular questioning, and I am feeling much more comfortable with it since the midterm evaluations, however I still feel like I need to work on this. Working with my current patient, who is much quieter, I feel it is a challenge to ask circular questions, as this person is not as open to discuss things in great detail. I find myself prompting the conversation often, as my patient is less likely to start up a conversation or bring up a specific topic. On the other hand, I worked with someone who had pressured speech and flight of ideas. This made it difficult for me to come up with the questions quick enough due to how quickly they spoke and started new conversation. I believe developing this skill will come from experience.

On my second last week of clinical, one of my patients were attending their review panel, as they had appealed their Form 10 certificate. Prior to the meeting, I researched the patient and the review panel documents. Although I did not sit in on the interview, I worked with the nurse afterwards and had a one on one with the patient. In this case, due to the patient’s high speech volume and pressured speech, I felt much more comfortable working along side the nurse with this particular patient, rather than alone. Recognizing the uncertainty of this patients actions and how they may express themselves after loosing their review panel, I had made my clinical judgment to have my nurse join me in the interaction.
Progress

The Mental Health Act is a very important document that I have had the opportunity to explore throughout this block. It has given me a better understanding of the various forms a patient may be certified under as well as when they have a right to refuse treatment or not.

I had the opportunity to administer rispiradone depot IM to my patient, as I looked up this medication and spoke with my clinical instructor, it become aware to me that one injection can cost up to $500.00. Because pharmaceutical companies charge such mass amounts for certain medications, such as an anti-psychotic medication like rispiradone, it may hinder someone’s ability to receive this medication in the community if they do not have adequate health coverage. Since many patients who suffer who psychosis are often unable to hold a job, especially a job that provides them with hefty health benefits, these people are deprived of treatment that may possible put them into recovery, relieve their symptoms, and improve their quality of life.