Not criminally responsible

I haven't updated this for a long time, but Allison suggested, so here it is.

Rob Ford and Don Cherry suggested that the man who killed he police officer when he was psychotic was playing at being mentally ill and should not have been found not criminally responsible.

Though I think the man should be treated and be certified until he is once again clear from his psychosis, and ensure that he is continuing to be treated, the idea that someone would be able to fake illness is kind of far fetched. There are people who do try to fake illness but I highly doubt in this case that this man was doing it-he had been in hospital after all. I am not sure what kind of psychosis he had, but he was examined by doctors who found him ill.

I guess the issue is whether he knew what he was doing was wrong-and also did he really understand the extent of it?

Working with people who have an illness similar to this guy, I would say that untreated mental illness should not be criminalized. Treatment itself is no fun time-being kept in a facility with no ability to choose treatment, and I would suspect, fairly significant restrictions on day to day activities is not a walk in the park. Mental health icu's are not places where people have 'fun'.

I don't think people have any really clear understanding of either what mental illness looks like, or the treatment itself. The media portrayals are terribly inaccurate. One Flew Over the Cuckoo's Nest and Girl Interrupted do not explain mental illness or effective treatments.

No one chooses to have mental illness, at least anyone I have come in contact with, nor have I heard anyone who works in mental illness health care suggest that it would be a good way to get out of jail. Sure, I would bet there are some anti-social types out there who might try it, but really you would be trading in one set of restrictions in jail, for another set in a secure mental health facility. Neither would be at all appealing to anyone looking at them.

At least when you get out of jail, you are done. I would think that if you had killed someone as a result of your illness, you would be on a community treatment order for the rest of your life-meaning that you have to be under psychiatric treatment forever-taking medication, seeing your mental health team etc. The drugs are not a walk in the park. And treatment for mental illness is difficult-medication is part, but so is healthy lifestyle, understanding the illness, etc etc. And treatments still are not totally effective, a person could be doing everything 'right' and still get ill. Much like someone could do everything right for their heart condition, and still have a heart attack.

I know this isn't an exact analogy, but if someone had been driving a car, had a heart attack and lost consciousness and killed that police officer, would we find the driver guilty?

So much for posting monthly

But since September is almost here, with the feeling of renewal, I will post again!

I have been thinking about how though making change to improve things is at times extraordinarily painful, that there are great pay offs. There have been multiple changes at work, significant ones, and I can see results that are so very positive. Such as family members saying how much they appreciate care, and thinking back to what we used to do, and now have changed things dramatically.

Like no visiting hours-with no problems. Like avoiding blanket rules and instead focusing on what specific patients need.

It is so easy to get caught up in the negative and lose sight of what we're doing, but looking at our care-I think we do a great job. And I didn't think I'd say that 5 years ago.

Really

So this course I am taking ia all about relational ethics, which I would think I would be all over.
But I'm not.
I get that nurses need to be aware and willing to relate to their patients and always open to considering the effect of their care and interactions. It certainly makes sense to me.
Where I struggle is with the constant navel gazing (As Mom would put it) on how important this relationship to people getting better.
Naturally, if you are having care from a nurse, and you get good, competent, interested, engaged nursing care-that is what should happen.
But is some of this focus on the importance of nursing care, based on our own self interest?
I was looking up environment and effect of it on care and how nurses manage.
All the articles were written by nurses. well, given that it is central to what nursing does, ok I get it. But does every interaction with a nurse have to be a long relationship, or can we have small, kind interactions that do the job just as well?
I keep hearing about how as nurses we don't have enough time. But perhaps we are looking to the past too much, when people were in the hospital for a week or 2 after having a baby with no complications. Sure, there was lots of time for nurses to interact, but it wasn't needed. And though I do believe that as nurses we have an important role in people getting better-are we overestimating this role to make ourselves feel more valued? Would people get better anyway, and how much is about our needs, not the patients.

art and science

It has been a long time since I've posted, but my goal is to update this at least once per month. My other goal for the new year is to exercise and I have been doing that with success, so I will accomplish this!

I have been reflecting upon what is the art and what is the science of nursing. When I was taking my undergrad, instructors would refer to this and though I acknowledged that there was both within nursing, I don't know if I considered how this looks in mental health.

One of the reasons that some in nursing don't like mental health is because there are not a lot of physical skills, like inserting a catheter, starting an IV etc. Most of our time is spent talking, listening, and intervening in those fashions.

I think I kept trying to quantify the communication as science, and I think many in psychiatry do this want to make mental health a 'real nursing' job, with quantifiable measures and recognized by the dominant medical discourse. Hence the overreliance on medications as a 'cure'-it meets scientific/biomedical standards-medications are studied extensively and the medical community can measure side effects, efficacy etc. Not to mention our society's determination to find cures through pharmaceuticals, but that's a whole different topic.
Really, I think within mental health, the art piece is foremost, and how do we measure that?
Specifically, I was thinking of how I intervene with a patient who is angry, distressed etc. Sure, I can set out some guidelines on how to speak, what my body language should look like, but how do you scientifically quantify empathy, understanding, and gentleness?

I had a situation with a patient, who was angry and suggested to the nurse that since I had a fairly good rapport with the patient, perhaps I could try intervening. It all turned out well and the patient resettled, but when thinking about what I did, versus what could have happened, I don't know if I could quantify what I did. Obviously, I made eye contact, had open body language, listened, but how do you exactly replicate caring, and isn't that caring and empathy, the art of nursing? Now if I had jumped in and had a more intrusive intervention, such as calling a code white and giving a medication intramuscularly, perhaps it would look like I was doing more-that kind of thing lends itself to measuring much easier, held patient this long, gave this medication in this spot with this dose, this many people present. Perhaps that is part of the reason people want to jump in and deal with the situation physically and quickly-it seems like a more societally valid form of intervention? Follows the biomedical discourse?

I think within mental health, it is the artful ability to listen so that the patient knows you hear them, and the genuine connection between nurse and patient, it is not the science of 'maintain a leg's length distance while keeping direct but not intense eye contact'

Within nursing there is a difficult balance between keeping scientific rigour in our practice, while recognizing that it is the art of nursing that differentiates this branch of health from medicine. We need to balance evidence based practice with the artful interactions and human compassion. If we nurse while only using the scientific background, the empathy, caring and humanness is lost. If we only use the art of caring, it can degenerate into doing things because we've always done it this way, leading to care and interventions that may or may not work.

Interesting stuff, maybe next time I'll reflect on the biomedical reliance on medication to cure.

Questioning status quo in mental health

There are many things in nursing and health care that seem to happen because 'we have always done it that way'
Sometimes that's good-after all Florence Nightingale said that having a clean hospital would keep people healthier-it turns out that handwashing works.
Sometimes I don't know the purpose of it. Why do psychiatric patients sometimes have to wear pyjamas? After all the nurses are wearing street clothes-why don't the patients?
Not all psychiatric patients do, but some have to, and I actually don't know the reason why.
I suppose it is because of the risk of people running off-part of some illnesses includes lack of insight-meaning people don't realize that they have a mental illness-so people would rather not be in hospital because they don't see the need for it. Another part would be safety-having people in pyjamas gives an opportunity to examine clothes and make sure there is nothing harmful in pockets etc. And I would think another advantage would be that if someone has been neglecting their hygiene due to another sign of illness-lack of self care-clean pyjamas is an improvement.
So, there are some good reasons for it. But there are also some problems with it. Wearing pyjamas singles you out as a psych patient-not just another patient in the hospital-but the only patients who wear the pj's.
Another issue is that it is not good to wear pj's all day. 'Normal' people don't do that-and a sign of getting better when you are sick is wearing clothes.
A large issue is that people feel embarrassed wearing them-no underwear, just pj's, for women this is quite embarrassing-no bra, especially when you consider that substantial numbers of women in in patient settings have had violence -up to 70% have experienced physical and sexual abuse. Having to wear clothes that leave people feeling vulnerable and exposed could create harm.
Which is the better way?
I need to do research on this...

Caring

We had a 1 day education inservice (thank you big pharmaceutical for providing unrestricted educational grant) and one of the topics was on caring.

We spent a lot of time on this topic when I was in school-what exactly is it, how do nurses do it, and what happens when it is not being done?

It is central to nursing-and I find it a fascinating topic. The presentation was based on the presenter's research on how nurses care while in stressful situations. Her research showed that caring is a choice that people consciously choose and that though environment plays a part, that it does come down to the individual's decision. Her thought and I would agree, is that nurses who are able to engage in this are happier and can provide quality care despite various circumstances.

I was discussion this a colleague, who is a social worker, he said that though he enjoyed the presentation, that his perspective tended to be more on the environment and how that impacted care. Makes sense when you also consider that nursing tends towards individualized interactions, whereas social work tends towards looking more at systems. Both of course frequently move in and out of those frames of reference.

Naturally both play a role, but I do think that it does come down to more of a conscious choice in the particular workplace I am in. It is easy to get caught up in the idea that we don't have enough money, there is not enough time, there are too many patients. But when compared to most health care systems in the rest of the world, we are far and away able to offer superior care. So why does it seem that it is not enough?

What would be enough?

Yes, I would like to be able to ensure that more people with mental illness have access to timely, prevention focused care, and I agree that we are often stretched to do this, but I can't say that I go home at night feeling that people have not received good care-and honestly when I do, it is more likely to be as a result of what I see as uncaring nursing. On an individual basis.

I never really thought of myself as being someone who sees things as more individual responsibility, with my patients, I encourage people to act within their ability to change, but also strongly believe that societal systems have hugely impacted the onset of mental illness and ability to manage mental illness.

But it seems with nurses working, that I do see their behaviour and actions in terms of individual choice. What is the difference for me then?

I suppose because though nurses have in the past (before the 1980's?) been a devalued group, now they are not. They wield a great deal of power within the healthcare system-without nursing, healthcare does not function. we are paid well-I would venture to say, very well. We are professionals-well educated, and self regulating. Generally we are well respected-depending upon which study you look at, nursing is at the top or near the top of the lists ranking professionals who are trusted.

Why are we still acting in ways that seem to take the stance that the system works against us, that we don't have control, that we are not respected then? I think that this sometimes victim focused mentality leads to uncaring nursing. Because if I am a victim too, why should I have to put so much effort into doing a caring act? How can I gather enough energy to care for others if I am being trampled on?

I think that we need to recognize and acknowledge that we have power within the health care system and that we need to be using that power respectfully-whether interacting with the health authority, each other, and above all with patients. Would that help?

Medicare

The idea of extraordinary drug coverage seemed like a good one to me when the Romanow Report came out, but didn't really think about it as I haven't known anyone personally or professionally needing that kind of coverage as BC has pretty good pharmacare.

As with most things, once you know someone affected, this changes perspective. As in a family member needing a super expensive medication costing about $20,000-$24,000/year and the province they are in has a terrible pharmaceutical program.

How this can be when it makes so much money off of industry is beyond me-but I guess they don't have a debt do they? As if that matters when you are sick.

The arbitrariness of this kills me. For a related disease, drug is covered, though I noted when looking through the special coverage form that you pretty much have to be at the end of the line treatment wise before they will consider covering. This seems to be true of most of the drugs I saw on the document.

Yes, because multiple hospital stays are so much cheaper aren't they?

In relation to psychiatry, I saw that a drug we pretty much routinely give here, is not covered there, unless you get special authority, and that is after you have developed nasty side effects from older drugs.

This is not to say that I think newer drugs necessarily are the cat's meow-after all pharmaceutical companies like to make a lot of money and new drugs do this for them. But if we know that a drug is effective, why wouldn't we cover it (as in we-the government and taxpayers) rather than spend the money on repeated hospitalizations, ineffective medications, and the like?