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Multi-tasking on road to recovery

Michael Robertson discusses the provision of acute care for those with mental health problems and what is lacking for such patients.

Nursing professionals working in acute care settings frequently provide the only clinical contact such patients receive. Acute care teams in mental health services encounter clinical problems including adjustment reactions, episodes or deteriorations in established severe mental illnesses, and problems arising from the abuse of illicit drugs and alcohol.

The challenges faced by those clinicians include the assessment and initial engagement of the patient or "client", formulation of the risks posed by these problems, provision of psychological interventions and the co-ordination of medical care.

A typical day for a nurse clinician working on an acute care mental health service may involve:

• assessments of "walk-in presentations", referrals from other health services, government agencies or police
• provision of education, counselling, clinical review and psychological therapies to patients
• home visits, medication supervision and clinical review of patients in their homes
• transporting patients to medical appointments, liaising with psychiatrists or GPs and the implementation and supervision of medications
• participation in care planning or multidisciplinary meetings with other mental health clinicians
• counselling and supporting carers and families.

Nursing clinicians are part of the patient journey for a patient with an acute mental health problem at every point.

Consider the example of a young man with an adjustment disorder who has expressed suicidal ideas to his GP. The GP contacts the acute care service and the patient is assessed by a nurse clinician including details of symptoms, life stressors, personal background, current lifestyle choices and previous history.

The nurse clinician then formulates an initial management plan focused on risk, and the patient's clinical team is tasked with this care. Nurse clinicians will then engage the patient in a care program, regularly assessing the patient's progress and modifying the management plan in response to this.

The patient may require advocacy to different government agencies, clinical services or interventions aimed at resolving the crisis that brought the patient to the point of distress. Once the crisis resolves, the nurse clinicians participate in discharge planning, referral to further medical care and provision of follow-up. The process of appropriate continuity of care requires close attention to clinical handover and the provision of a comprehensive account of the patient's care.

Like many people with mental health difficulties, the primary challenges faced by people in acute distress arise from the lack of resources needed to provide adequate services. Mental health services have been consistently under-resourced and politically attractive funding programs are usually "one-off" and tended to flow towards the well-advocated needs of the youth mental health sector.

The kind of mental health services needed to contain patients with severe disturbances are state-funded, meaning that any funds directed towards them tend to disappear into the quagmire of state treasuries.

Nurses working in acute care mental health settings face increasing burdens of administrative duties, and work in institutions with low-tolerance of risk. They are tasked with multiple responsibilities in the face of an ever-diminishing pot of resources. Despite this, their professionalism, dedication and the high standards of care they provide to those in distress is an inspiration to work beside.

Michael Robertson is a clinical associate professor of psychiatric ethics at the Centre for Values, Ethics and the Law in Medicine at the University of Sydney. He has worked in community mental health for well over a decade and works as a psychiatrist in the Marrickville Community Mental Health Service.

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