Funder by the Department of Human Services Auspiced by Our Community

A CONSUMER'S GUIDE TO PSYCHIATRIC NURSES

Psychiatric or mental health nurses are the lifeblood of the mental health system.

They are registered nurses who hold a recognised specialist qualification in mental health nursing.

They work in a huge variety of roles and in a range of primary, secondary and tertiary mental health settings, including (but not restricted to) community mental health services, acute units, public and private hospitals, and as case managers, as part of crisis teams and in specialist mental health services, working with youth and aged care, for example.

To become a psychiatric nurse, you must first become a registered nurse (three years), and then you must get a post-graduate degree or post-graduate diploma in mental health nursing (one year).

The psychiatric nursing profession is served by the Australian College of Mental health Nurses (ACMHN), which provides courses, information and credentialing for members. The ACMHN represents mental health nurses and the profession as a whole; in such a way, it's also a bit like a union.

Registration of the profession is carried out by the Australian Health Practitioners Regulation Agency (AHPRA). Consumers can check a nurse's qualifications and make complaints about a psychiatric nurse to AHPRA.

All nurses must register for an Annual Practicing Certificate and provide evidence of a minimum 20 hours clinical study each year.


Hierarchies of power

Psychiatric nurses are the group in mental health with the greatest numbers and the least status.

There are some exceptions to this rule, however. As in physical health, many psychiatric nurses aspire to and gain senior positions in management - head nurse or unit manager, for example - giving them considerably more power within the service.

Going even further afield, there are psychiatrically trained nurses who gain positions of considerable esteem and power in more general public hospital positions or in the state bureaucracy which run mental health services in Victoria.

Having said this, however, the general premise remains true. Nurses in most positions in private and public services are seen by some patients and some other staff as relatively low in the pecking order. This underlies their practice and influences their relationships with us and with the service in general.


Nurse practitioners - mental health

Nurse practitioners are senior, experienced nurses who have opted to gain promotion whilst staying as hands-on nurses. Their introduction was, in part, to try and offer promotion opportunities for outstanding clinicians who did not want to go into a managerial stream in order to enhance their career. Nurse practitioner position were created across all health areas including mental health.

Nurse practitioners, as senior clinicians, may have responsibility for a number of tasks that had previously been the responsibility of doctors. This frees up medical practitioners, particularly in the public sector, to see more people and spend more time with people in need. Two of the tasks nurse Practitioners may now do is prescribe pharmeceuticals (in a restricted way) and complete some reports and paperwork, tasks which have historically weighed down clinical time.


Care and treatment plan

As a mental health 'patient' in an acute setting, our care plan (or treatment plan) will outline what nurses (mainly) have to do to look after us in the most timely and professional way.

It may contain information from us about the most appropriate way to care for us, including information from our Advance Directive if we have one, but more importantly (from most clinicians' standpoints), it includes summary statements from registrars, consultants or private psychiatrists, as well as information about medication and what groups we must attend.

Most consumers believe we would do much better if our care and treatment plans were made in an authentically collaborative way. A lot of what is said to be collaborative decision making is a bizarre farce. Many of us answer what we know nurses, representing the system, want us to say. Sometimes this is imperative (we want our children back, for example) and sometimes actual collaboration isn't an option.

Nurses are expected to formally admit us to a unit, orientate us and introduce us to other inmates. Often this doesn't happen or is not done well and we get left alone and scared in an environment that is completely foreign to us. Nurses are expected to write a treatment plan with us on admission. Often this doesn't happen either and the 'collaboration' is merely a signature on a document already written within the safe glass walls of the nurses' station. Unfortunately these practices smudge in our minds the genuinely dedicated practice of the nurses that Isabell Collins evocatively calls, 'Light a Beacon Nurses' who practice what she describes as 'Beauty of Care'.


Confidentiality

Your medical information will be treated confidentially, right? Well, there's confidentiality and then there's confidentiality.

Case histories

The term 'case history' refers to our history as seen through clinicians' eyes. It's our story but it is not something we write or can control. It's sometimes helpful to just think the psychiatric unit has borrowed our story for a while.

Our case history may include our schooling history, illness and mental health history, family history, current health and support status, as well as our financial and housing situations.

All of this information may be available to the clinicians tasked with providing our 'care'.

Psychiatric nurses may add to our case history as a result of one-on-one conversations with us and 'observations' of our 'behaviour'. They may include notes on what we have said, as well as commentary on whether we are attending the groups we are expected to attend (and whether we're doing so graciously), and comments on our demeanour (aggressive, passively aggressive, quiet, contemplative …). Unfortunately we have no say over what is included.

Consumers all over Australia have complained bitterly about both what is recorded about them in an acute setting and also how it is recorded. Private phone calls have turned up verbatim in a medical history accessed through Freedom of Information, as have private conversations with other patients, family and friends. The ethical problems this presents are mind boggling, as is the consequent lack of action by other clinicians to correct the file.

The important notion that nurses are collecting highly sensitive information to put in a document that can never be changed seems to have got lost in the translation to nurses undergoing clinical training.

Handover

The way that nursing staff communicate from the morning shift (usually starting at 7am/7.30am) to the afternoon shift (usually starting at 3pm/3.30pm) and from afternoon shift to the night shift (usually starting at 10pm/10.30pm) is through an oral report about everyone in the unit/ward handed from the nurses finishing their shift to those starting their shift.

The nurses will have also have written notes about us which the next shift reads but at handover the nurses will provide more detail about what they had experienced and found out during the previous shift. All staff on the next shift, regardless of whether they are our designated contact staff, will be privy to this information.

Seasoned consumers know the '20 minutes to go' handover drill, where nurses suddenly appear and ask us a barrage of questions in front of anyone who happens to be around. They demonstrate little interest in our answers before darting back to write their notes that will be read to everyone in the handover room regardless of whether they have any legitimate interest in our particular 'case'.

This is no different from the model used throughout medicine. However the content in psychiatry is entirely different. No one is writing about sugar levels here. It's about us - our person, our self, our reputation, our honour, our intimate relationships, our trauma and our abuse. Consumers argue there is a case for psychiatry to do things very differently.

Multi-disciplinary teams

In many settings psychiatric nurses work in multi-disciplinary teams - your team may consist of a registrar, a nurse and an occupational therapist, for example. These teams occur both in acute inpatient units and in the many teams that operate out of the Area Mental Health Services.

Organising staff in this way is an attempt to bring the expertise of the different clinical groups together to enable us to receive the 'best possible' practice.

However, perhaps the most important thing to remember is that teams can expand and contract - this affects who is given intimate information about you.

Confidentiality considerations

In the context of case histories, multi-disciplinary teams and the tradition of handover, we must be careful about what we say and to whom. Every nurse in a multi-disciplinary team, regardless of whether they are working in 'the community' or in hospital, is required to report back to 'The Team' everything they judge to be important.

Many consumers misunderstand the way the word 'confidentiality' is used in these circumstances. 'Confidentiality' always means 'confidential to the team', not confidential to the particular staff member we are speaking to at the time.

There are some fantastic nurses who draw us in by their competence and caring and we may start talking to them about things that are so personal that we have never spoken about them to anyone. It is incumbent upon the nurse in this context to let us know that this information will be passed on to The Team and may be shared at handover. They don't always do so.


Contact nurses

Generally in Victoria, patients admitted to a psychiatric unit are designated a particular 'contact nurse' (or 'primary nurse') for each shift, except for the night shift when the ratio of nurses to patients is much lower.

Almost always there is a list of nurses and designated patients for that shift clearly displayed for all to see in the ward or unit. It can be terribly embarrassing to see your name on a list like this; while those working in this environment day after day seem to simply lose sensitivity to these things, many consumers find it shaming.

Each contact nurse has responsibility for roughly eight to 15 patients. In many units an effort is made to have the same contact nurse come back to the same group when they are next on duty.

As a patient, we are expected to pose all our questions to our assigned contact nurse and leave the other nurses alone. This is great when s/he is competent, enthusiastic and available (i.e. not on a lunchbreak), but not so great when they are not.


Charge nurse or head nurse

If you are admitted to a psychiatric unit, whether it be private or public, it's a good idea to find out who the charge nurse is. They run the unit. They have a lot of authority, even over doctors. It's the place to go if you have a complaint.


Quality of practice

Many psychiatric nurses work incredibly debilitating shift work (though some like the shifts). Even though they almost never get the press (nor the money) of psychiatrists, and rarely get the overt thanks and appreciation that they might get in a maternity unit (say), some act with such skill, grace and kindness they should be better acknowledged.

There are unfortunately also a number of psychiatric nurses who do the wrong thing. These might be big things which are inexcusable; however much of the behaviour that upsets us happens within the culture of the institutions of psychiatry. Many of us have felt these institutions have robbed us of our self confidence, figuratively undressed us, disempowered and infantilised us. We may feel unable to speak and scared to be angry.

In such a context, let's pretend a nurse is really off-hand and rude to one of us in a hospital setting. Under the conditions above and depending on our personality and world view, we might react in one of the following ways:

Unfortunately, such actions tend to leave us frustrated (as in the case of complaints that go unanswered or unacknowledged), and can often lead to more guilt, more shame, more judgement, and more trouble for us - even though it was not us that was rude in the first place!


Good practice/brave practice

What is experienced as good nursing practice is different from nurse to nurse and consumer to consumer.

Some things that we have experienced as excellent practice might be questionable to some nurses. Many of us believe that the number one characteristic of good nursing is bravery: bravery to take on a bad practitioner, bravery to act on our behalf, bravery to push the boundaries of professionalism and bravery to be whistleblower if an extreme circumstance calls for it.