At crisis point

Without improved communication between health professionals, mental health outcomes will remain less than perfect. Annie May reports.

Sometimes homeless, at times experiencing problems with drugs or alcohol or simply suffering a mental health episode - people with a mental illness come to crisis point in the community every day.

And responses and support for the mentally ill when they are in crisis and when they seek assistance can be less than perfect.

In an ongoing bid to address these issues across the community, SA Health's 'Acute Unit Matters' and UniSA's Mental Health Research Group recently held a nurse-led symposium to bring together a broad section of professionals to share insights and strategies for dealing with risk associated with mental illness and mental health-related crises in the community and hospitals.

It is the second of a series examining risk assessment and management, with participants looking at shared learning and practice in mental health.

Country Health SA Mental Health nursing director Phillip Galley and UniSA Chair in Mental Health Nursing, Professor Nicholas Procter led the symposium, which covered a wide range of mental health scenarios from mental health in the rural and regional context, cultural issues in relation to mental health management and practice, acute inpatient care for older people, rehabilitation, suicide and suicide attempt responses, and learning from the example of positive practice outcomes.

It was, says Galley, an opportunity for people not just to engage with a new tool or a new project but to actually spend the day listening to clinical champions, people who engage with the issues of risk assessment and risk management. This is something, he says, that needs to happen on a regular basis.

"When you look at any given critical incident surrounding mental illness in the community, it doesn't take too long to understand the complexity of managing these issues," Galley says.

"A range of mental health services come into play, each with a different perspective on the situation. We want to learn from each other and from case studies about what can improve consumer outcomes and favourably shift the risk.

"The symposium is designed to share new thinking on when things go well in practice and by working together and sharing those perspectives and the knowledge we have as a professional community, find a deeper understanding about dealing with critical incidents involving people with a mental illness."

Procter says mental health is one of the nation's critical community issues, and that every four hours somebody completes suicide in Australia. "Studies have consistently demonstrated that people with mental illnesses are over-represented in prisons and that rates of mental illness in the criminal justice system are substantially higher than those found in the general population," Procter says.

He says a range of other key factors put people with a mental illness at risk.

"People who are dependent on alcohol and other drugs are up to 50 per cent more likely to have a co-morbid psychiatric condition and people with a diagnosis of serious mental illness are four times more likely to abuse alcohol and six times more likely to have some other substance abuse problem," Procter says.

"This starts to paint a picture of the layered challenges people with a mental illness struggle with and the difficulty in isolating one aspect of their situation for treatment and support."

As important as early intervention is in mental health, there is also a need for urgent assistance when people are in crisis and require an urgent mental health response.

Good risk assessment and good risk management, said one presenter on the day, is fundamentally about diagnosing a person's condition appropriately and thoroughly and then initiating a treatment pathway for that condition in an appropriate and timely fashion.

"The core business of mental health services - and by implication mental health nurses - is enabling people to understand what is wrong and receive a comprehensive approach to treatment, and then risk management," says Galley.

As well as clinicians, also attending the event was two users of mental health services.

"Consumer perspective is often lost when clinicians talk about their practice. But it is incredibly important to get their input - they have experienced what clinical assessment feels like, what it doesn't and what it ought to," says Galley.

Procter says the symposium resulted in a number of ideas to build a better and deeper understanding of evidence-based responses that are safe for individuals with mental health problems and the wider community.

One of the recommendations to come out of the day was that mental health nurses must scrutinize their work. This came from the South Australian Deputy Coroner, who said nurses and other health professionals should adopt a 'Triple S' policy - scrutinize, scrutinize, scrutinize.

"When the Deputy Corner gave his very powerful keynote address you could have heard a pin drop. It is uncommon for clinicians to come face-to-face with the person in that position, unless it is in court. And while it may take time to do, that time spent scrutinizing the information helps you know not only your current action but also your next steps," says Procter.

Other recommendations revolved around increasing the value of networks for information and truth-telling.

"What I mean by this is we need to work closely with the NGO sector and between acute services and rehabilitation services. We have to be truth telling in the way in which we convey risk management strategies or risk management information. And sometimes it is really hard for people to do that because, as one presenter titled his presentation 'this is how I sleep better at night'. There is a lot of stress and anxiety associated with managing a person with mental health issues."

Increasing reflective practice and case reviews in the workplace was another recommendation. In other words - writing down what you are doing and why. "This comes back to scrutinizing. Someone might be assessing a person and they may say that person isn't suicidal. This person should then write in their notes what they are thinking at that particular time," says Procter.

"The reason for this is that it gives others information that can be shared and has value. But it also means that if there is medical misadventure and in two or three year's time that person is called to give evidence at an inquiry they have that information."

The aim of the event wasn't about criticism, but about finding improvements.

"It is critical to take the time to talk about practice. Unfortunately, this doesn't happen often," says Procter.

"The importance of sharing knowledge can't be underestimated for those working in the mental health sector - or any health sector for that matter.."

"Our aim is to develop the kind of clinical care that will inform strategies, not only to meet crises with better outcomes, but to avoid them in the first instance."

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