Saturday 14 February 2015

About beating the stigma's on mental illness at the workplace

Last week I read a tweet about a BBC article on prosthetic Hollywood masks being used to educate trainee mental health nurses. The writer of the article seemed enthusiastic about the idea and so were the people in the attached video. 

What surprised me most was that they seemed to be unaware of the stigma attached to using those masks. To me they seemed to portray people with mental illness as weird Hollywood movie characters.  They didn't look at all like the people I have been supporting in my 25 years of mental health nursing. 

This article shows again that there is still a lot of stigma's to beat within the profession. Besides: what about non-verbal communication, the most important thing to learn about because most people put their 'mask' on pretending they are fine. As very often, do we all. But maybe more when we are anxious or paranoid and don't feel safe enough to express ourselves. 

"I am fine" is the most commonly told lie. When you use masks you can't see the look in someone's eyes or their facial expressions. 

This idea isn't helping trainee mental health nurses and as a result of that its not helping the people who have mental health problems. Its  counter-productive. A much better idea would the use of trained actors as we had when I was at nursing school. 

We all stigmatise and probably much more than we think.  The stigma attached to mental illness is a major obstacle to our patients and to better care. Lives will be improved if we keep ourselves and each other aware of that.

The stigma within the profession leads to a lot of unwanted and serious effects. A few examples: 
It makes people feel unwanted; 
I'm not understood and;
I'm uncared for. 

Apart from that it's a great danger to their physical health because it leads to not being taken seriously when having a physical health problem. I have seen people die from stigma, from not being believed, from assuming it was "psychosomatic"or "attention-seeking" It's that serious. 

I once supported a patient to ER after she suddenly lost the sight in one eye. She talked very slowly, a reason for the triage nurse to think that it was psychosomatic and if I had not been there to urge her to contact an ophthalmologist that patient would have been blind now. 

The stigma within the profession discourages our patients to dare to take chances in life, to improve their future. It prevents family members from being important team members. It leads to people feeling labelled instead of being a person with many strengths and skills, someone who is more than just a diagnosis. It prevents us from really listening to someone. 

I have a patient who was put in an isolation room for throwing a glass on the floor because a voice told her so. She wasn't hurting anyone. Later she said : "if only someone had asked me why I did that they would have known I had voices. And I would have cleaned it up and paid for a new glass if they had asked me ".

I used to get annoyed about stigma's but nowadays I find beating them a challenge instead of a problem. The stigma on mental illness is an important reason why people don't understand and why those who with  mental health problems often don't dare to seek help in time.
I hope this mask issue will lead to better awareness of the stigma within ourselves and our colleagues.And to improved support of people with mental illness so they feel listened to ,accepted and cared for.

Friday 15 November 2013

A smoking ban for mental health workers at the workplace

To force a breakthrough in the smoking culture in psychiatry it should be prohibited for mental health staff to smoke in the work place. There I said it! (and yes I agree it should be like that everywhere in health care but in this blog I will focus on psychiatry).
Last time I said I would like to see a smoking ban for all mental health staff within hospital grounds and during home visits was when I arranged a meeting for mental health workers about psychiatry, health and sports. Many smokers weren’t pleased and that’s an understatement. Some were very annoyed and kind of hostile as if this was denying them a civil right. Many many health workers that smoke with patients say its good for bonding but its just an excuse to maintain the smoking culture.
It’s a challenge for patients to quit smoking in psychiatry where a lot of people smoke. They get discouraged. Mental health workers may often tell the patient that it’s too hard to quit with mental illness, that it stresses them out too much. And of course it’s quite an effort for them but I have seen enough to prove that it is not impossible. Sometimes I wonder if staff who smoke feel threatened by the brave attempts of patients who want to quit when they can’t manage to quit themselves.
Addiction to nicotine is the most common form of substance abuse in people with schizophrenia, who are more than three times more likely to be addicted to nicotine than the general population. The relationship between smoking and schizophrenia is complex. People with schizophrenia perceive certain benefits from smoking but at the same time it’s threatening their health and wellbeing in a serious way and can make antipsychotic drugs less effective. Heavy smokers often need higher doses of medication.
People with schizophrenia have a shorter life expectancy (up to 15-20 years shorter) than the average population and the main cause is smoking.

Over the years I have seen many people with mental illness die young because of smoking related diseases like heart failure, different forms of cancer, strokes, COPD. People in psychiatry can get help with quitting drinking, quitting street drugs, quitting benzo’s, quitting gambling… but there’s usually no specialised help for quitting or reducing smoking for people with mental health problems. Smoking doesn’t seem to have priority in the smoking culture of this specific field of health care with mental health staff having the highest percentage of smokers of all healthcare staff.
But with worrying statistics on physical health problems among people with mental illness we need clear measures. And mental health workers who are addicted to smoking should get over themselves and only practise their addiction outside the hospital gates and out of sight of patients, including in outpatients and in community settings. After all our goal is to improve and encourage health from a holistic point of view. Staff who smoke give the wrong message. Smoking should be banned and it should be the responsibility of managers in mental health care to enforce those bans.
I have been giving a “decrease-smoking-course” for people with mental illness for a few years now. The course is free. Most of the attendees have schizophrenia. There is always one chair for a mental health worker who wants to quit. They can attend the course during work hours. Thanks to the course we have a smoke free team now.
First it was called a “quit-smoking course” but we got very few subscribers. Quitting seemed a step too far for many. So we changed it to “decrease-smoking-course” which consisted of 10 sessions including a smoke break of 5 minutes. Soon we had a waiting list.
The first session was about smoking habits and keeping a smoking diary to get insight in smoking habits and coping. Many people started to smoke when they were admitted to a mental hospital for the first time. One of the patients started smoking when she was admitted with psychosis at age 27. She told us:
“Everyone, patients and nurses, seemed to smoke so I thought it might be helping and some nurses even promoted smoking by giving me a cigarette even though I didn’t smoke. And they took out the patients who smoked more often than the ones who didn’t smoke. So some started smoking to be with the others.”
Now at age 45 her GP told her she had to quit smoking because she had COPD. She joined the course and eventually managed to quit.
Most people who attend the course don’t quit but decrease a lot. That’s important improvement too. People who go from 60 to 10 cigarettes are not unusual. We involve psychiatrists, family, GP’s and mental health workers as supporters to make their resolution a success.
We notify and work closely with all people involved in their treatment and give information on how to offer support. The psychiatrist monitors blood levels especially when patients are taking Clozapine and sees the patient more frequently to adjust medication doses when needed. Smoking cessation can lead to higher plasma concentrations and potentially more side-effects. With Clozapine their levels can raise in a dangerous way.
Quitting smoking with this group should be monitored closely whether there is any exacerbation of symptoms or medication side effects, so possibly the dose of neuroleptic medication needs to be adjusted. Since quitting smoking is a challenge we make sure that the patients get extra support. Nicotine replacement methods may benefit their effort to quit.
Every mental health trust should offer specialised quit or reduce smoking support for patients and mental health workers.
I’m not promoting a smoking ban for patients. I’m very much against that. In the hardest times we shouldn’t force patients to quit. But I strongly believe that a healthier and more encouraging environment will help people to find the motivation to reduce or quit smoking and improve their wellbeing.
And that’s our job as mental health workers.

Monday 31 December 2012

Sexual side effects of medication

A shockwave went through my family the day my cousin Anna opened a chic erotic shop in town. Some people, like my aunt, tried to cover it up by saying Anna and her husband had " become franchisers ". That wasn't a lie but not exactly the whole truth either. It all became clear to everyone the day the invitations for the opening hit the doormats with a figurative loud bang.
I was pleasantly surprised, I often like it when things are a bit "different". So I took some friends and colleagues to the opening festivities and met quite a few family members there. Some shy , giggly or clearly uncomfortable. Others unexpectedly interested and curious and going through the shelving as if it were an exclusive exhibition in a trendy museum.
I observed Anna selling her products and listened to her talking in detail about sex and erotic equipment with ease as if she was Nigella Lawson in person promoting her cooking and favorite kitchen utensils.
Lots could be learned for  mental health care from the openness of my cousin. She inspired me to get the topic of sexual side effects of medication higher on the agenda.
Back at work my colleagues and I made a checklist for physical health to be used at care evaluations. Sexual side effects of medication was one of the topics and now much harder to neglect . And we encouraged colleagues to talk about it more.

There are many different types of psychotropic medications and they may cause a range of sexual side effects like decreased libido, erectile- or ejaculation dysfunction for men and decreased lubrication for women. For both men and women, the quality  of sensation may be less and the time it takes to reach an orgasm can be prolonged or completely impossible . Some medications are less likely to cause trouble. And some people may not experience any of the sexual side effects at all..
Sexual side effects can have a negative impact on lives and relationships. That makes it important to encourage and enable patients to speak about it.

People who are well informed about these side effects are often better prepared and more likely to comply with treatment. They know that side effects often decrease in time. But if not , a medication change,adjustment or additional medication can help to overcome these troubles. 

It's important that mental health professionals learn to discuss this subject more. It may take courage to overcome our own shyness. But there are many cases in which a solution can be found and lives  can be improved. That’s definitely worth the effort .

Wednesday 29 August 2012

How to improve dental care in psychiatry

Dental care is poor and a disregarded health issue among people with serious mental illness. They are on a higher risk than average for tooth decay,inflamed gums and denture problems. Medication combined with reduced self care is an important cause. 
Poor dental health can increase the risk for social stigmatization / isolation and serious physical health problems. 
There is a causal link between poor oral health and cardiovascular disease and even stroke.Considering that people with serious mental illness like schizophrenia die 15-20 years earlier on average than the general population we have have enough reasons to take dental health seriously.

According to Danish research only 31% of schizophrenia patients complied with a regular annual dental check-up visit , compared to 68% in the general adult Danish population. 
Huge risks for poor dental care are: substance abuse diagnosis ,living in an institution or admission to a psychiatric facility for a minimum of 30 days  and male sex.
However Clozapine treatment, at least monthly outpatient visits , and age 50+ were associated with a lower risk for inappropriate dental care.


 Psychotropic meds can cause shortage or too much saliva or a change in acidity. Combined with poor oral health  this can make tooth decay occur faster. 
Many patients smoke. This increases the risk for gum disease : one of the leading causes of tooth loss in adults.
Smoking also slows down healing after oral surgery. It can damage gum tissue and receding gums leaving the roots of the teeth exposed. This can increase the risk of tooth decay and cause hot/cold sensitivity.

To improve the level of dental health we can help patients to

- Use less sugar and acidic products like carbonated drinks
- brush 2x a day preferably with an electrical toothbrush , they are much more efficient than ordinary brushes
- use fluoride toothpaste
- use floss or interdental cleaning brushes twice a day
- visit a dentist and support the visit if needed. We may ask the dentist about screening for the rate of salivation to see if the amount and acidity of the saliva is within limits.
- decrease smoking 
- Use 4 - 7 xylitol chewing gums or lozenges devided over the day. It needs to be 100% xylitol, no other sugar substitutes.This reduces dental    plaque. It stimulates the production of anti-bacterial saliva and remineralization of the teeth. And it partially replaces sugars in the diet (satisfies the ‘sweet tooth’) Using Xylitol chewing gum or rinse can decrease tooth decay with 60 %. For those who cant use gum or lozenges xylitol mouth water may be an option.
 In high amounts xylitol can have a laxative effect and cause flatulence.
- Inform patients that they should avoid to consume acidic products one hour before brushing  teeth. The surface of teeth is softened by the acid and can be damaged.

Let's make dental care a priority in psychiatry. After all it is basic care, not luxury .

Saturday 21 April 2012

The importance of family support

Fourteen years ago, after working  11 years at mental hospital wards  I started working as a community psychiatric nurse. A month later I had to take my partner to a psychiatrist because he was psychotic. An unexpected  experience.

It started on a Saturday. We decided to wait till tuesday  so we could see the GP we knew. Monday was a bank holiday.Things got worse over the  weekend  and I had no idea where it would end. Although I was familiar with psychosis it was like getting hit by an avalanche in mid summer. We only just met a year and a half earlier.

On tuesday the GP referred us to an office for mental health that same day. We were welcomed very friendly by a  CPN who knew I was a colleague from another hospital. He took us to an office. A few minutes later he introduced us to the psychiatrist who seemed  unpleasantly surprised . His words: “ It is not usual that family comes along unannounced” . Then he shook my hand reluctantly.
That is not the best way to introduce yourself  to a highly stressed person with an adrenaline level way beyond that of the average marathon runner. I can’t imagine a doctor of an emergency room would have said the same if my partner would have had a heart problem or an accident. This was an emergency  as well. A psychiatric one. 

During the visit my partner only told about 40 %  of what had happened - being distracted and paranoid. After some time I added a few things to the conversation but I was being ignored  by the psychiatrist.  And when he finally asked me: “Do you have any idea what psychosis is?“ I was so mad that I answered very calm : “ I have read some about it a while ago”   
He wrote a prescription for an anti-psychotic  and handed us the piece of paper. I asked him to add Biperiden in case of side effects.  I guess he had not expected that because he looked a bit confused. He wrote it down and wanted to say something but I felt too reared for further conversations. I felt like yelling  , throwing things around or burst into tears and I didn’t want to do either one of them. If you come for help the last thing  you need is people who make you feel  worse. A few minutes after we got home the phone rang: the  psychiatrist. He asked me if I could come long next time.  I asked him if he would  have called if I had not been a CPN. Later on we talked and things went better. He learned from the experience. 
And so did I. Although I always had a focus on family support : really knowing the despair, fear and frustration helps to keep it on top of the “to do”- list and encourage others to do so. This was just a bad experience, educational though. Many psychiatrists do an excellent job.

Family support is an important thing in mental health care. Ifcourse there are very dysfunctional families  and some people have caused problems our clients are facing now. No need to deny that and very important to take that into account. But most of them have good intentions and are willing to learn and help.And they usually know their ill family member better than we health professionals do. We shouldn't consider ourselves too important but see family members as team members. 

Psycho-educational family interventions and family support can reduce relapses, readmissions and suicide risk. An important part of our work because it benefits to the welbeing of our patients and a better future for them.

Many family members have felt left alone by mental health care in the past on more than one occasion.Imagine yourself in their shoes and do the best you can to make their next experience a better one.
If family  is visiting a hospital ward make them feel welcome and comfortable. That will make it easier for them to visit more often. For mental health workers a mental hospital ward might be an everyday thing but for visitors it’s often a very  unusual scary place to go , especially the inpredictable crisis wards. If possible give them a quiet place to talk and relax. Encourage family and friends to stay in touch. 
Loneliness is a huge problem for people with mental illness. And it is important to prevent that as much as we can.Giving good information and support to friends and family can make an important difference here.


Sunday 8 April 2012

20 Commandments for Mental Health workers

  1. Thou shalt respect your patient and not judge
  2. Thou shalt increase the well-being, opportunities and happiness of your patient
  3. Thou shalt be in time for appointments and phone calls. It will show your patients that they matter
  4. Thou shalt have a well-chosen and well-timed sense of humour
  5. Thou shalt reconsider your ‘professional distance’ if it makes your patient feel he stands alone; show that you are a person too
  6. Thou shalt not let your bad mood or personal issues influence your professional attitude
  7. Thou shalt have an open conversation if your patient is suicidal and give good support and protection if necessary
  8. Thou shalt not hide behind a newspaper or smartphone on the ward or make any other unapproachable impression otherwise
  9. Thou shalt not hide and chat in the nurses’ offices but be with your patients as much as possible to create a safe and friendly environment
  10. Thou shalt consider family and good friends of your patient as team players (unless it’s impossible) and support them well in the interests of your patient
  11. Thou shalt inspire and support your colleagues to make mental healthcare as good and friendly as possible and ask and give feedback on a regular basis to become a ‘winning team’
  12. Thou shalt inform your patient well about side effects of medication, observe well and help to find solutions if needed
  13. Thou shalt not avoid the subject ‘sexual side effects of medication’
  14. Thou shalt help your patient to get good dental and physical care and support them on doctor and dentist visits if needed
  15. Thou shalt help and support your patient to exercise on a regular basis to increase their health and give support to decrease smoking.
  16. Thou shalt support your patient to overcome financial or housing problems and fight bureaucracy
  17. Thou shalt listen well to the patients' aspirations for their life and give support to achieve them
  18. Thou shalt stand up for the rights of your patient
  19. Thou shalt fight the stigma of mental illness at every opportunity
  20. Thou shalt help your patient to keep up hope

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