Transcript Overview of Course & Role of Preceptors

Graduate Diploma in Mental
Health Nursing
Overview of Course &
Role of Preceptors
Barry Tolchard
Course Coordinator/Senior Lecturer
Course Outline
• Semester 1
– Primary Health Care
– Mental Health Nursing Practice 1
6units
12units
• Semester 2
– Mental Health Nursing Practice 2
– Evidence-Based Mental Health Nursing
– Independent Study/Option Topic
©B.Tolchard (2003)
6units
6units
6units
ASSESS
PLAN
IMPLEMENT
EVALUATE
Primary Health Care
Mental Health Nursing Practice 1
Client-Focussed Assessment
Mental Status Examination
Risk Assessment
Mausdley/Psychosocial
Assessment
Cultural Awareness
Problems & Goals
Validated Measures
Therapeutic Interventions
Medication Management
Portfolio
Client Feedback Sheets
Student Outcomes of Learning
Problem-Based Learning
Anxiety/Psychosis/Depression/Co-Morbidity/Personality Disorders
Reflective Practice/Clinical Supervision/Preceptor Feedback
Clinical Assignments
Mental Health Assessment or
Mental Health Nursing
Assessment?
Client-Focussed Assessment
Referral Letter
Duty of Care and Legal Responsibilities
Medications and their Use-Therapeutic or Not?
Ethical Considerations and Other Legal Issues
Reflective Practice
Clinical Case Management
Mental Health Nursing Practice 2
Client-Focussed Assessment
Therapeutic Workshops
Problem-Based Learning
Elderly/Homelessness/Adolescence/Population Health
Reflective Practice/Clinical Supervision/Preceptor Feedback
Clinical Assignments
Leadership
©B.Tolchard (2003)
Family Therapy
Group Therapy
Advanced Therapeutic Intervention
Indigenous Issues
Evidence Based mental Health Nursing
Independent Study/Option
AOD/CBT/Forensic/Child & Adolescence
Portfolio
Client Feedback Sheets
Student Outcomes of Learning
Client-Focussed Assessment
The Assessment
The 5 W’s
What is the distressing experience?
Where does the distressing experience occur/where not?
When does the distressing experience occur/when not?
Why does the distressing experience happen?
With whom is the distressing experience better or worse?
©B.Tolchard (2003)
Jason Grantley—5W’s
• Jason states that his main fear is that the Italian boys from
school are following him and he reports hearing a man and
a woman talking, even when he is alone. They give a
commentary of his actions, sometimes telling him that he
is bad and today he admits they told him to take his life.
• This happens in a number of situations such as going to the
shops, watching TV and in busy public places.
• The problem occurs at any time of day, but mainly happens
in the evenings.
• Jason experiences this problem mostly when he is alone or
with strangers. Having his family around also makes the
problem worse.
• He fears he may be killed by the Italian boys.
©B.Tolchard (2003)
F.I.N.D
F.I.N.D
The frequency of the distressing experience
The intensity of the distressing experience when it occurs
The number of times the distressing experience may occur
The duration of time the client has the experience
©B.Tolchard (2003)
Jason Grantley—FIND
• Jason has had many similar episodes over the last
12 months.
• Overall, he has experienced varying degrees of
concern/anxiety ranging from 4-8 out of 8.
• The concerns/anxiety occur at least once per day
and last for up to 2 hours or until he is able to
distract himself in some way.
• The number of voices is 2—always the same man
and woman.
©B.Tolchard (2003)
Functional Analysis
• The functional analysis aims at describing a
typical situation where the client has the
experience.
• The aim is to determine the possible
triggers, what the person does in response to
those triggers and how that response affects
them afterwards.
©B.Tolchard (2003)
Typical situation
Functional analysis—Jason Grantley
Jason described an incident where he believed a car parked outside his house was
flashing its lights which was a sign for the Italian boys to kill him.
Prior to seeing the car, he was looking out of his window and listening to music.
He felt fairly relaxed but had tension in his back. He was thinking about the lyrics
of the song.
On seeing the car, he became very anxious where his breathing increased and his
heart began to pound. He closed the curtains and hid behind his bed. During this
time he thought the Italian boys were after him and that he needed to stay low.
Throughout he felt very scared.
After a while when he heard the car drive away be began to feel better. He
checked the window by peeking through the curtain to make sure they had gone.
He then played his music even louder and thought he had been lucky this time and
remained alert for possible situations.
©B.Tolchard (2003)
Functional Analysis
emotions
thoughts
behaviour
feelings
before
calm
I wonder what these
lyrics mean.
looking out of the
window
slightly tense
during
terror
I am going to be
killed by the Italian
boys
closed curtains and
hid behind bed
hyperventilating,
heart pounding
after
worried
I have been lucky
this time, but I must
stay alert
peeked through
curtain, played
music louder
as above but
lessening
©B.Tolchard (2003)
Other Questions/Prompts
• When did these experiences first begin?
• Is the client doing anything specifically to
cope with the distress?
– is the coping helpful/unhelpful
– are they using modifiers
• What impact is this having on work, family,
friends etc?
• Does the client do anything to excess or not
do things to deal with the experience?
©B.Tolchard (2003)
©B.Tolchard (2003)
Formulation
• Simply summarises the experience that the
client has described.
• The nurse may also suggest a possible
diagnosis if this is felt necessary including
all 5 axis on the DSM IV.
• A prognosis and future management plan is
given.
©B.Tolchard (2003)
DSM-IV
• Axis I
– Clinical Syndromes
• Axis II
– Personality disorders
• Axis III
– Physical disorders and Conditions
• Axis IV
– Severity of Psychosocial Stressors
• Axis V
– Highest level of adaptive functioning in the past year (GAF score)
©B.Tolchard (2003)
Jason Grantley—Formulation
• Jason Grantley, a 17-year-old unemployed
young adult, lives at home with his parents
and sister. He presents with a 1 year history
of psychotic features with increased
avoidance leading to social isolation and
drug use.
©B.Tolchard (2003)
Jason Grantley-DSM-IV
• Axis I
– Schizophrenia
• Axis II
– none
• Axis III
– none
• Axis IV
– Extremely isolated from family and friends. Unemployed.
• Axis IV
– 21
©B.Tolchard (2003)
Code
Description of Functioning
91 - 100
Person has no problems OR has superior functioning in several areas OR is admired and sought after by
others due to positive qualities.
81 - 90
Person has few or no symptoms. Good functioning in several areas. No more than "everyday" problems
or concerns.
71 - 80
Person has symptoms/problems, but they are temporary, expectable reactions to stressors. There is no
more than slight impairment in any area of psychological functioning.
61 - 70
Mild symptoms in one area OR difficulty in one of the following: social, occupational, or school
functioning. BUT, the person is generally functioning pretty well and has some meaningful interpersonal
relationships.
51 - 60
Moderate symptoms OR moderate difficulty in one of the following: social, occupational, or school
functioning.
41 - 50
Serious symptoms OR serious impairment in one of the following: social, occupational, or school
functioning.
31 - 40
Some impairment in reality testing OR impairment in speech and communication OR serious impairment
in several of the following: occupational or school functioning, interpersonal relationships, judgement,
thinking, or mood.
Presence of hallucinations or delusions which influence behavior OR serious impairment in ability to
communicate with others OR serious impairment in judgement OR inability to function in almost all
areas.
There is some danger of harm to self or others OR occasional failure to maintain personal hygiene OR
the person is virtually unable to communicate with others due to being incoherent or mute.
21 - 30
11 - 20
GAF
Persistent danger of harming self or others OR persistent inability to maintain personal hygiene OR
1 - 10
©B.Tolchard
(2003)
person has made a serious attempt at suicide.
Jason Grantley—Management Plan
• Jason presents with psychotic symptoms that may
result from an early onset Schizophrenia. He is
suitable for treatment using a two-plus-one
approach of Cognitive-Behaviour Therapy with
medication management and will lead in planning
his own programme of treatment involving coping
strategy enhancement with assertive case
management. It is anticipated he will be in
treatment for 6-8 months and his overall prognosis
is unclear.
©B.Tolchard (2003)
Mental Status Examination
Mental status examination—main areas examined
Appearance and behaviour
Speech
Mood
Depersonalisation, derealisation
Obsessional phenomena
Delusions
Hallucinations and illusions
Orientation
Attention and concentration
Memory
Insight
©B.Tolchard (2003)
Risk Assessment (Suicide)
•
•
•
•
•
whether the client is thinking about suicide
whether they have a plan
whether they have a history of suicide attempts
their levels of alcohol and drug use;
the number and quality of their social supports
• their reasons for hope
©B.Tolchard (2003)
Maudsley or Psychosocial Assessment
•
•
•
•
•
•
•
Medical
Living circumstances
Forensic
Family
Childhood/Development
Employment
Sexual history
©B.Tolchard (2003)
Measurement
Problems & Goals
Validated Measures
Case Specific Measures
• Problem and Goal methodology
– identifies the persons own problem using their own
words and expressions and is written clearly and
precisely by them
– measurement is made using scale
– goals are devised to reflect the problem
– they are observable, achievable and measurable and
directly related to the problem
– they are also rated using a similar scale
©B.Tolchard (2003)
Problems and Goals
• Problem statement
–
–
–
–
–
•
• Goal statement
–
–
–
–
The problem
The feared consequence
The antecedent
The behaviour
The consequence
“Anxiety whenever I believe the
Italian boys are out to kill me
leading me to become isolated at
home for fear of the this happening
and thus restricting my daily life”
©B.Tolchard (2003)
•
The behaviour
The conditions
The frequency
The duration
“To arrange to go out with one of
my friends for the day to the local
sports centre”
Validated Measures
• General morbidity
scales
• Diagnostic Schedules
• Specific measures for
particular disorders
• Nurse-Rated Measures
©B.Tolchard (2003)
• Work & Social
Adjustment Scale
• Brief Psychiatric Rating
Scale
• Kessler 10
• HoNOS
Work & Social Adjustment Scale (WSAS)
• Simple measure of disability
– 5 items rated from 0 (no difficulty) to 8 (severe
impairment)
–
–
–
–
–
©B.Tolchard (2003)
Work
Social Leisure
Private Leisure
Relationships
Home Management
Brief Psychiatric Rating Scale (BPRS)
–
–
–
–
–
–
–
–
–
–
–
Somatic concern
Anxiety
Depression
Suicidality
Guilt
Hostility
Elated Mood
Grandiosity
Suspiciousness
Hallucinations
Unusual thought content
©B.Tolchard (2003)
–
–
–
–
–
–
–
–
–
–
–
–
–
Bizarre behaviour
Self-neglect
Disorientation
Conceptual disorganisation
Blunted affect
Emotional withdrawal
Motor retardation
Tension
Uncooperativeness
Excitement
Distractibility
Motor hyperactivity
Mannerisms and posturing
Brief Psychiatric Rating Scale (BPRS)
• 24 symptom constructs
• each to be rated in a 7-point scale of severity
ranging from 'not present' to 'extremely severe'
• if a specific symptom is not rated, mark 'NA' (not
assessed)
• circle the number headed by the term that best
describes the patient's present condition.
©B.Tolchard (2003)
The Kessler Psychological Distress Scale (K10)
• consists of 10 questions, which all have the same
response categories
– In the last four weeks, about how often?
•
•
•
•
•
•
•
•
•
•
Did you feel tired out for no good reasons?
Did you feel nervous?
Did you feel so nervous that nothing could calm you down?
Did you feel hopeless?
Did you feel restless or fidgety?
Did you feel so restless that you could not sit still?
Did you feel depressed?
Did you feel that everything was an effort?
Did you feel so sad that nothing could cheer you up?
Did you feel worthless?
©B.Tolchard (2003)
The Kessler Psychological Distress Scale (K10)
•
The response categories
for each of the 10-items
are:
1. All of the time
2. Most of the time
3. Some of the time
4. A little of the time
5. None of the time
©B.Tolchard (2003)
• K10 score Level of anxiety or
depressive disorder
• 10 to 15 Low or no risk
• 16 to 29 Medium risk
• 30 to 50 High risk
HoNOS
Health of the Nation Outcome Scales
•
1993—developed to measure
the health and social
functioning of people with
severe mental illness
•
aim to provide a means of
recording progress towards
the Health of the Nation target
‘to improve significantly the
health and social functioning
of mentally ill people’
©B.Tolchard (2003)
HoNOS versions
• HoNOS:
– for services for working age adults HoNOS65+: for
services for older adults
• HoNOSCA:
– for services for children and adolescents
• HoNOS-LD:
– for services for people with learning disabilities
• HoNOS-MDO:
– for services for mentally disordered offenders
• HoNOS-ABI:
– for services for people with acquired brain injury
©B.Tolchard (2003)
HoNOS
• 12 scales that rate mental health
service users of working age.
• Rate various aspects of mental
and social health, each on a
scale of 0-4.
• Designed to be used by
clinicians before and after
interventions so that changes
attributable to the interventions
(outcomes) can be measured.
©B.Tolchard (2003)
• The scales are as follows:
– Overactive, aggressive, disruptive or
agitated behaviour
– Non-accidental self-injury
– Problem drinking or drug-taking
– Cognitive problems
– Physical illness or disability problems
– Problems associated with hallucinations
and delusions
– Problems with depressed mood
– Other mental and behavioural problems
– Problems with relationships
– Problems with activities of daily living
– Problems with living conditions
– Problems with occupation and activities
HoNOS - Rating
• Each scale is rated as follows:
– No problem
– Minor problem requiring no action
– Mild problem but definitely present
– Moderately severe problem
– Severe to very severe problem
©B.Tolchard (2003)
Data Summary Sheet
Name
Referral received
Diagnosis 1 (DSM-IV)
Treatment 1
Treatment 2
Post code
Assessment date
Age
Gender M'F
Attended Y/N
Suitable Y/N
Diagnosis 2 (DSM-IV)
Therapist
Accepted treatment Y/N
screening
date
Self
Problem A
Therapist
Self
Goal A1
Therapist
Self
Goal A2
Therapist
Self
Problem B
Therapist
Self
Goal B1
Therapist
Self
Goal B2
Therapist
Onset problem A (yrs)
Onset problem B (yrs)
Total sessions:
Missed sessions:
Total therapist Hours:
Total assisted hours:
Outcome
1=Completed treatment
2=Dropout before ses. 2
3=Dropout between ses. 3-8
4=Other
Other professional involved Y/N
Professional name
©B.Tolchard (2003)
FQ Main phobia
FQ Fear Questionnaire:
SC –BI- AG
FQ Anxiety/Depression
WSAS Work
WSAS Home Management
WSAS Social Leisure
WSAS Private Leisure
WSAS Relationships
Beck Depression Inventory
Beck Anxiety Inventory
Y-BOCS
Other (specify)
Other (specify)
Other (specify)
ass
Referrer
Assessed for in-patient Y/N
In-patient Y/N
Diagnosis 3 (DSM-IV)
mid
post
1MFU
3MFU
6MFU
1YFU
Fear Questionnaire (FQ)
Name:
Ms Brenda Pollack
Date:
23 January 2001 A/M/D/1/3/6/12
Choose a number from the scale below to show how much you would avoid each of the situations listed because of fear or
other unpleasant feelings. Then write the number you choose in the box opposite each situation.
0----------- 1---------2------------Would not
Slightly
avoid it
avoid it
3---------4------------Definitely
avoid it
5---------- 6---------7------------- 8
Markedly
Always
avoid it
avoid it
1
Main problem you want treated (describe in your own words)
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
Injections or minor surgery
Eating or drinking with other people
Hospitals
Travelling alone by bus or coach
Walking alone in busy streets
Being watched or stared at
Going into crowded shops
Talking to people in authority
Sight of blood
Being criticised
Going alone far from home
Thought of injury or illness
Speaking or acting to an audience
Large open spaces
Going to the dentist
Other situations (describe)Sporting events, violent movies/tv, ill
people inc. school children
8
1
8
1
0
0
0
1
8
1
1
8
1
0
8
Ag + B1 + Soc = Total (2-16)
Now choose a number from the scale below to show how much you are troubled by each problem listed, and write the
number in the box opposite.
0----------- 1---------2------------hardly
slightly
at all
troublesome
18
19
20
21
22
23
24
3---------4------------definitely
troublesome
5----------- 6---------7------------- 8
markedly
very severely
troublesome
troublesome
Feeling miserable or depressed
Feeling irritable or angry
Feeling tense for no reason
Upsetting thoughts coming into your mind
Feeling you or your surroundings are strange or unreal
Sudden panic for no reason
Other feelings (describe)
2
0
1
6
1
1
TOTAL
How would you rate the present state of your main problem on the scale below?
0----------- 1---------2------------phobias
slightly
absent
disturbing/
not really
disabling
©B.Tolchard (2003)
3---------4------------definitely
disturbing/
disabling
5--------- 6---------7-------------8
markedly
very severely
disturbing/
disturbing/
disabling
disabling
SELF-DIRECTED TREATMENT DIARY
Name:
Week Commencing:
Please record all daily progress made against your weekly targets, and any other progress made
0---------1---------2----------3------------4-----------5---------6----------7-----------8
No anxiety
Moderate anxiety
Panic
Date
©B.Tolchard (2003)
Time
Target
Start/
Finish
Nos
Anxiety Ratings
Before
During
After
Remarks/comments
Work & Social Adjustment Scale
NAME:
DATE:
A/M/D/1/3/6/12
Some peoples problems affect their ability to do certain tasks. On the scales below rate how much your
problem affects the following tasks.
Date:
1
0
1
Not at all
2
3
Slightly
0
1
2
3
Slightly
SOCIAL LEISURE ACTIVITIES
With other people eg parties,
entertaining, etc
0
1
Not at all
1MFU
3MFU
6MFU
..........
..........
............
2
1
2
pubs,
3
3
0
©B.Tolchard (2003)
1
2
Slightly
5
8
Very Severely
6
7
Markedly
8
Very Severely
NA
4
5
4
7
8
Very Severely
NA
4
Definitely
6
Markedly
5
Definitely
3
7
NA
Definitely
Slightly
6
Markedly
outings,
FAMILY & RELATIONSHIPS
Forming and maintaining close relationships with others
including the people you live with
Self
Therapist
Not at all
5
4
PRIVATE LEISURE ACTIVITIES
Things done alone eg reading, gardening, sewing,
hobbies, walking, etc
Self
Therapist
0
NA
Definitely
Slightly
Not at all
5
POST
..........
4
Self
Therapist
4
MID
..........
Definitely
HOME MANAGEMENT
Cleaning, tidying, shopping, cooking, looking after
home/children, paying bills
Self
Therapist
Not at all
3
PRE
..........
WORK/STUDY
Self
Therapist
2
SCR
..........
6
7
Markedly
8
Very Severely
NA
5
6
Markedly
7
8
Very Severely
Problem-Based Learning
• PBL is the learning that
results from the process of
understanding and
resolving a real life
problem.
• The problem comes first
in the learning process.
©B.Tolchard (2003)
The three components of PBL
• The PBL case (the task(s) of PBL)
• The small group—process of PBL
• Independent learning—self directed
learning
©B.Tolchard (2003)
In Mental Health Nursing
• health care problem
presented stepwise
aka “the PBL case”
• students work in small
groups
• students identify
important issues in the
problem
• students set their own
learning goals
©B.Tolchard (2003)
Between tutorials
• independent study of resources
• in ‘hybrid’ curriculum additional resources
provided eg lectures pracs, seminars CAL,
accessing ‘resource persons’
• return to discuss new information (report back)
• apply new knowledge to understanding and
explaining the underlying presentation
• continue further problem pages…..
©B.Tolchard (2003)
Key steps
• identify important information in the ‘case’
– key information & presenting problem
• generate ideas about what is happening
– hypotheses
• attempt to explain problem with what already know
– mechanisms
• decide what is not known
– learning issues
• study and return with new knowledge to group for
discussion
– report back
• continue the case—progressive disclosure model
– new learning issues
©B.Tolchard (2003)
Next...
• learning issues are worked on by students
between tutorials
• report back of learning issues at next
tutorial
• new knowledge is critically appraised
• new knowledge is applied to case
• then the case progresses page by page …..
©B.Tolchard (2003)
Problems are multi dimensional
• creates a knowledge base
rich in connections
• integrates important
knowledge in a
professional context
close to actual conditions
for use
• encourages elaboration
of prior knowledge base
©B.Tolchard (2003)
The three components
• The PBL case “task of PBL”
• The small group “process of PBL”
• Independent learning “self direction”
©B.Tolchard (2003)
Small group learning:
student issues
•
•
•
•
•
high level faculty/student interaction
question, explain, challenge, appraise
learn for understanding
examine own values and attitudes with peers
gain high level skills in communication, time
management, group skills and team work
• feedback skills practice & development
©B.Tolchard (2003)
Small group learning: tutor
• process of small group learning is important
to effectiveness and efficiency of learning
• tutor must have highly developed process
skills
• student will develop high level process &
group management skills
• tutors lose authoritative role (+ & - aspects)
©B.Tolchard (2003)
The three components
• The PBL case “task of PBL”
• The small group “process of PBL”
• Independent learning “self direction”
©B.Tolchard (2003)
Self directed learning ...
•
•
•
•
shifts responsibility for learning to students
shifts curriculum emphasis from teaching to learning
alters student & “teacher” roles; students are central
the tutor’s role is to facilitate and provide opportunities
for learning
• students have high autonomy to select learning goals &
methods that suit them best
• guided by learning objectives, students set own goals
and learn at their own pace, help each other
©B.Tolchard (2003)
Evidence: PBL outcomes
• increased retention of knowledge over periods of several
years
• learning in context facilitates later recall in context
• high self directed learning skills
• enhances integration of diverse areas of knowledge
• better team skills
• more likely to be up to date (life long learning attitude)
• higher student and faculty satisfaction
• little evidence relating to improved clinical skills
• (NB: PBL teaching of clinical skills has not been tried)
©B.Tolchard (2003)
Jason Grantley
©B.Tolchard (2003)
PATIENT PRESENTATION
• Jason Grantley comes to see Dr Smith with his
mother. He is a 17 year old unemployed man,
who lives with his parents and younger sister.
• His mother tells Dr Smith that Jason has been
spending most of his days alone in his bedroom
listening to music for the last 9 months since
leaving Year 11 high school. He rarely sees his
friends, and there have been fights with his father
because of the untidiness of his bedroom, and his
reluctance to shower.
©B.Tolchard (2003)
PATIENT PRESENTATION
•
•
•
•
On questioning from Dr Smith, Jason says he likes to listen to music and
smoke cigarettes and dope. He does not think it is important that he no longer
sees his friends. He denies he is depressed, and says he is sleeping and eating
well, and has had no changes in his energy or concentration.
He smokes 40 cigarettes per day, and regularly uses marijuana. He tried
amphetamines 6 months ago, and LSD once 18 months before. He does not
drink alcohol.
As the interview with Dr Smith progresses, Jason states that his main fear in
life is that the Italian boys from school are following him. They park outside
his house. He believes his phone is tapped, and that they have put listening
devices in the ceiling.
On further questioning he reports hearing a man and a woman talking, even
when he is alone. They give a commentary of his actions, sometimes telling
him that he is bad, and today he admits they told him to “do it” - the ‘it’ being
to take his life.
©B.Tolchard (2003)
PATIENT PRESENTATION
•
•
•
Dr Smith performs a Mental State Examination (MSE), a summary of which is
given below:
Jason presented as a pale young man with shoulder length black unwashed
hair, he wore a black T shirt and jeans. He looked worried and his eyes
constantly scanned the roof and walls of the room and he continuously tapped
his right foot on the floor. His conversation was tangential, but without
looseness of associations, or other thought disorder. It contained delusional
content. For example “I saw a white car flash its headlights passing by my
house last week, and I knew that was a signal to the other Italian boys that I
had to be killed.” He also described auditory hallucinations of a running
commentary and commands instructing him to take his life.
He was oriented in person, place and time. He was only able to register a
name and address after 3 attempts, and could only recall half of the address at
5 minutes. He started serial 7s, but then stopped and discussed the threat from
the Italian boys.
©B.Tolchard (2003)
PATIENT PRESENTATION
•
•
•
•
At this point Jason asks to leave as he wants to go home to watch some videos.
Dr Smith advises him that she would recommend that he spend some time in
the psychiatry ward of the local general hospital. He refuses and attempts by
both Dr Smith and his parents to persuade him to be admitted to hospital are
ineffective.
Dr Smith advises Jason that she will detain him to the local hospital. She
organises transport via ambulance with a police escort (one police officer in
the ambulance and the other following behind in a patrol car). She informs
Jason of his legal rights under the Mental Health Act.
Transport arrives but Jason becomes agitated because he believes that one of
the ambulance officers (who is of Italian background) is part of the plot. He
attempts to flee but is restrained by the ambulance officers, police, and Dr
Smith in the waiting room of the surgery.
He becomes more settled and stops struggling; no sedating medication is
administered at this point.
©B.Tolchard (2003)
Two-plus-one approach
• A basic model of treatment that:
– uses a comprehensive client-focussed assessment,
– identifies the areas of change using client specific
and standardised measures,
– applies a process of therapy which is carried out by
the client between session 1 and 2 and then for 3
months afterwards and,
– is done in liaison with future case manager.
©B.Tolchard (2003)
Two-plus-one approach
• Session 1
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client-focussed assessment
problem and goals
measures
coping strategies identified
coping strategy enhancement model used
homework set
©B.Tolchard (2003)
Two-plus-one approach
• Session 2
– previous homework reviewed
– changes made where appropriate
– new coping strategies identified for a range of
situations
– coping strategies practiced in session
– continued use of strategies established and set
as homework
©B.Tolchard (2003)
Two-plus-one approach
• Session 3
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previous homework discussed
new areas identified from discussion
new tasks set
repeat measures
discharged to case manager
©B.Tolchard (2003)
Coping-Strategy Enhancement
(vulnerability reviewed)
• information is received by the senses and
processed whereby understanding is made
of it in the brain (information processing)
• the autonomic nervous system (which
controls bodily responses to stress) are
important in mental health problems
©B.Tolchard (2003)
Defined
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•
“As long as the stress induced by challenging
events stays below the threshold of vulnerability,
the individual remains well within the limits of
normality…
…when the stress exceeds the threshold, the person
is likely to develop a psychopathological episode of
some sort…
...when the stress abates and sinks below the
threshold, the episode ends” (Zubin & Spring,
1977)
©B.Tolchard (2003)
Rationale
1. Continua of functioning
mental health symptoms merge with normal
behaviour
positive symptoms are points on a functioning
continuum
symptoms are different in degree or are
exaggerations of normal responses to stress
©B.Tolchard (2003)
Rationale
2. Normal experience
similar symptoms and signs occur in all people
3. Cultural beliefs
a number of irrational/abnormal beliefs have
cultural equivalents
no evidence scientifically for such occurrences
frank “scientific” discussion
©B.Tolchard (2003)
Rationale
4. Normal thoughts
fleeting grandiose ideas, ideas of reference and
paranoid or overtly negative thoughts can be
described as very common in the general
population
5. Differences between thoughts and actions
explain that thoughts do not necessarily lead to
the subsequent action
©B.Tolchard (2003)
Rationale
6. Vulnerability and Stress
“Stress seems to affect people in different ways,
depending on their makeup. This includes any
family susceptibility, personality and possibly
even brain structure. The same sort of stressful
events may make some people depressed or
anxious, but they may not affect others at all.
In your case you have begun to…”
©B.Tolchard (2003)
Rationale is based on stressvulnerability model.
Decatastrophise referring to
sleep/sensory deprivation.
Reinforce medication
compliance.
Process of therapy
Deal with current
problems. Aim for
accuracy and consistency.
Avoid humouring.
Engaging and rapport building
Explain typical symptoms and
neurophysiology of anxiety. Rx
with muscular relaxation and
CBT.
Hallucinations
Explaining psychosis using normalisisng rationale
Examining the antecedents of psychotis breakdown
Treating any co-existing depression or anxiety
Cover in detail. Elicit life events, identify
automatic thoughts using inductive
questioning. Identify maladaptive
assumptions.
Reality testing
Set realistic goals. Teach
appropriate avoidance. Make use of
paradox, activity scheduling and
mastery and pleasure forms.
Tackling entrenched psychotic symptoms
Tackling negative symptoms
Relapse prevention
Booster sessions
©B.Tolchard (2003)
Use inference chaining to find underlying
irrational belief. Work through emotional
investment. Promote active coping
strategies.
Explain role and need for
medication, identify
triggers. Decatastrophise
Coping Strategy Enhancement
(Tarrier)
• psychoeducation approach to explaining
illness
• builds on coping methods already used by
client
• uses simulated/imaginal situations
• homework in real life situations
©B.Tolchard (2003)
Overview
• Begin with careful client-focussed
assessment of the clients symptoms
including the antecedents and
consequences.
“I have no money”
©B.Tolchard (2003)
• if lack of insight—focus on alleviating distress
caused by symptoms
• one symptom is targeted and a strategy to cope
with it selected
• strategy is then practiced under increasingly
difficult conditions in session and then as
homework
• cognitive strategies are demonstrated overtly
by the therapist, then overtly and finally
covertly by the client
©B.Tolchard (2003)
• behavioural strategy is taught through
role-playing or guided practice
• if strategy successful another symptom
is chosen
• if unsuccessful then client trained in a
further strategy and so on
©B.Tolchard (2003)
• the nature of the symptoms
• elicit the accompanying emotional
reactions
• elicit antecedents
• elicit consequences
• elicit active coping
• effectiveness of coping
©B.Tolchard (2003)
Preceptor Role
• welcome, orient & guide student clinical
learning according to employer expectations
• be familiar with Flinders GDMHN expectations
of student learning
• liaise with clinical lecturer/facilitator
• deal with student/employment concerns
©B.Tolchard (2003)
Clinical Concerns/
Employment Concerns
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•
Clinical Concerns
Either the student or clinical or
academic staff can initiate this process.
In the first instance discuss the issue
with:
clinical preceptor or assessing nurse
if not resolved consult
clinical lecturer/facilitator who will
liaise with appropriate local division
management
if not resolved consult
Professor of Nursing (Mental Health)
if not resolved consult
Associate Dean or Dean
if not resolved a request may be made
for discussion of the issue at Faculty
Board meeting.
©B.Tolchard (2003)
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•
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•
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•
Employment concerns
Either the student, clinician or
employer staff can initiate this process.
In the first instance discuss the issue
with:
CNC/team leader
if not resolved consult
student co-ordinator or human
resources consultant who can advise on
the correct course of action within the
employing organisation
if not resolved consult
Mental Health Service Division
Nursing Director.
Preceptor Tools
• individual Student Learning Contract
• clinical Assessment Record for Clinical
Placement
• guide or provide input into Clinical
Assignments
• Clinical Contact Sheets
©B.Tolchard (2003)
Example of an Individual Student Learning Contract
Students Name: Ann Nurse
Clinical Placement: Acute Inpatient Unit
Dates: from __23__/___03_/__02__to___13_/___07_/_02___
Learning Objectives
What would I like to
develop competence
with?
Learning Strategies
How will I do this?
Who will be involved?
What resources?
Evidence of Accomplishment
How will I know I have achieved my
goals?
How will I show that I have?
Target
Dates
When
will I do
this by?
No 1. To apply
knowledge of
psychopharmacology to
individual cases.
Know the drug regime for my
caseload.
Participate in regular medication
administration to a level of safe and
independent practice.
Test my knowledge with other MHN
and preceptor. Be observed
undertaking drug rounds.
Identify and be familiar with the
patient drug information leaflets.
1/05/02
No 2. Develop skills in
assessing the need for
prn medication.
Observe and discuss with other nurses.
Undertake a critical incident analysis
where prn utilisation is involved.
Complete medications and their use
clinical study sheet. Individual case
note documentation of rationale and
effect. Demonstrate knowledge of
nursing interventions for side effects
and drug protocols.
11/06/02
©B.Tolchard (2003)
©B.Tolchard (2003)
Clinical Contact Sheets
©B.Tolchard (2003)
Student Tools
• Preceptor tools plus:
– Client feedback sheets
– Portfolio
©B.Tolchard (2003)
Client Feedback Sheets
©B.Tolchard (2003)
Student Portfolio
©B.Tolchard (2003)
Where next
http://www.mhnflinders.com