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Assessing clients' mental well-being: an experienced mental health nurse reflects on her practice and the wider context within which she works, including the social issues now causing more stress and anxiety for people.

Tracey Forward trained as a psychopaedic nurse in 1992 and subsequently as a mental health nurse in the United Kingdom (UK), and came to New Zealand in 2003. She had a friend working here and her gut told her it was the right move. It's one she's not regretted.

She'd lined up a job at Auckland District Health Board before setting off. A phone interview had secured the role--half crisis team, half community mental health nursing, based at the Taylor Centre in central Auckland. While some drug names differed and legislation, such as the Mental Health Act, was different, "the basic nursing functions were the same".

A significant difference was the more holistic approach to care. She puts this down to the influence of Maori culture and, to a lesser extent, other cultural traditions. "People are considered a whole; spirituality and faith are seen as part of who we are; mana is recognised, as is the importance of whakapapa--these concepts are acknowledged and accepted far more here than in the UK. These are really refreshing and positive differences."

She was no stranger to nursing people from a vast range of cultures--South London was her working milieu. "It was very multicultural but I was working with more African, West Indian and Asian people there. My working environment here is still multicultural but I've had to learn to work with new cultural traditions, notably Maori and Pacific. I'm not an expert but I know who to ask if I don't know."

Another significant difference from the UK is that methamphetamine use is much more prevalent in New Zealand. It brings in its wake a range of psychiatric problems for some users. "Paranoia and anger feature and, anecdotally, it appears that some long-term users are subject to delusional disorders. There seems to be difficulty in treating those disorders related to neuro-chemical changes within the brain from the long-term meth use," Forward explained.

Despite the differences in aspects of practice, Forward says her mental health nurse training in the UK fitted her well for work here. "Our training was strengths-based and that fits well with the recovery model here."

She explains the recovery model as one which "makes the client the case manager of their own care. Decisions are made collaboratively. Clients are in charge and we are the coaches, helping them work out their choices, the different paths they can take, and recognising the strengths they may not realise they have. It doesn't always fit with the medical model. Nurses are always trying to bridge that gap--to make the medical model more user friendly. The more people on the same page--remembering the client has helped write the page--in terms of care, the greater the success for the client."

Crisis mental health nursing spurred Forward to embark on the nurse practitioner (NP) pathway. She is one of 23 nurses on the funded pilot NP training programme run by Auckland and Massey Universities, which started early this year. The trainee NPs will face a Nursing Council NP endorsement panel in March 2017.

"When I was doing crisis work, we would often have new clients with major assessments who had to wait some time for a doctor to prescribe and that was unfair on the client, as was having to tell their distressing story over and over again. And sometimes there's 'the white coat syndrome' with mental health clients - they find it easier to talk to a nurse rather than a doctor. Nurses are a bit more informal, a bit more relaxed and clients feel more able to disclose to them. This is no disrespect to medical colleagues, but the syndrome is real. So I wanted to be able to provide a one-stop shop for clients to minimise their distress as much as possible."

Becoming an NP was the way to do that. But Forward is no longer working in crisis nursing and is sorry there are no NPs in that practice area. She is now working at Manaaki House in Panmure as a nurse specialist, providing comprehensive assessments and some brief interventions. Those she sees are mostly referred by GPs, but can be referred by others in the multidisciplinary team at Manaaki House--there are close to 40 staff at the community mental health centre. Clients also self refer.

Forward assesses these clients - "they see me rather than a psychiatrist". Following a comprehensive assessment, which includes the presenting complaint, recent stressors, psychological, medical, personal and family histories, any physical concerns, medications and a risk assessment, Forward then arrives at a working diagnosis and treatment plan. She also makes medication recommendations to the client's GP. Brief interventions can include strategies for anxiety management and distress tolerance.

"I have had to stretch myself differently, both professionally and personally, in this role. Following the assessment, I am solely responsible for coming up with treatment recommendations and talking with GPs about what I would like, treatment efficacy and medication side effects. I am the driver of care provision in collaboration with the client. It was a bit scary to begin with."

But she has a psychiatrist, who is her clinical supervisor, with whom she brainstorms ideas and treatment suggestions. "I wouldn't be able to do this role without the support of people here."

Her major challenge at present is the workload of the NP training programme. Forward completed her masters in 2013, but is still required to do some postgraduate papers; she is completing her prescribing practicum with her clinical supervisor; meeting with a pharmacist and a nurse educator every second week to learn as much as she can about the medications she will be prescribing; and attending the course at university--all on top of a full-time workload. "It is self-directed and requires a lot of devotion--it's an enormous commitment - and involves the complete absence of an outside life. Nursing Council don't want to make it easy to prescribe," she laughs ruefully.


Forward admits she drives herself hard. Meeting the pharmacist and nurse educator is not a requirement; rather she is doing it to enhance her understanding. March next year, when she hopes to be endorsed as an NP, can't come soon enough. She loves her work but says she'll love it an awful lot more after March.

Talking about the wider context of mental health nursing, Forward says the practice specialty seems to be "way down the pecking order" in terms of the profession as a whole. She's disappointed only seven of the country's 164 practising NPs are in mental health. But she hopes the recent announcement that the NP training programme will be funded next year will enable more nurses to train as NPs, including some from mental health.

Over the last year, the pressure of social issues had led to increased levels of anxiety and stress. "Flousing issues cause so much stress for clients, as does having to repeatedly front up at WINZ [Work and Income] and repeatedly feel they are not being heard. We are seeing people now we ordinarily would never have seen. The working poor are being hit really hard. They are in full-time jobs but are on low wages and can't afford the rent. They have a home but they are eating baked beans on toast every day. These situations cause people enormous stress and it is very difficult to try and help them improve their lives," Forward said.

"Poor housing, low incomes, cheap food, because that's all they can afford--these issues can drag people into a horrible cycle which can be very hard to pull out of."

In the last year, she's seen more people in these sorts of situations than previously. Her workplace has shifted from central Auckland, with its many affluent suburbs, to Panmure, which services more socially diverse areas. The shift may be a factor in the higher prevalence of people in difficult situations seeking help.

Forward says she can't let the impact of the wider social environment get to her. "We have to help people find hope wherever they can. We have to connect them to free resources. We have to write letters and advocate for them. We have to help them maximise the skills they have to manage their stress. We can't fix everything, but we can still help."

To continue being able to help, maintaining her own emotional well-being is paramount. A key way she does this is through regular meditation. "I've done it for decades. I also have very good friends, I'm active--I love walking--and I have holidays to look forward to."

A part of being human

Forward sees mental health issues as part of being human. "Anybody can experience them, it doesn't make them bad people. It just means they are having a particular difficulty at that particular time. It is a tiny part of somebody's being and can be treated as much as we treat those with diabetes."

She acknowledges that, for some people, their mental illness is a major part of their life. "But even those who have difficult episodes because of schizophrenia, for example, can be well managed. They can function as a member of their family and society, and have enjoyment and a purpose in their lives. They should not be stigmatised because they have a mental illness."

The rewards of mental health nursing are manifold for Forward. "I like seeing people get better. I love getting insights into people's humanity and coaching them to become better self managers. I like helping people recognise how improving little things in their life can help them live a better, healthier life."

And it is "a privilege and an honour" when people trust her enough to disclose their "deepest, darkest secrets".

Work frustrations

There are frustrations but these are not related to the clients--"dealing with clients is the easiest part of our job. Obviously we deal with difficult and complex situations, but they are very much the minority".

The paperwork, the bureaucracy, some processes, and the lack of resources cause frustration. "The context within which we work can be frustrating, not the clients with whom we work."

What are the characteristics of a good mental health nurse? "They have to be good listeners and ask the right questions to clarify information. They have to be inquisitive and patient--getting well doesn't always happen quickly. They have to be able to recognise small improvements in a person's mental health and to look for these incremental improvements. They have to have a sense of humour, to be able to laugh. They have to be a team player and respect their colleagues' strengths and weaknesses."

Reflecting on the wider profession, Forward is concerned about many nurses' seeming inability to value their own abilities and competence. "Nurses are very, very capable. We need to understand that nursing is a vital profession that needs to be encouraged, and we need to recognise how competent and capable we are."

Nurses' lack of confidence is multifactorial, she says. She has had some nurses ask her, when she has told them of her NP journey, "Why don't you become a doctor then?"

"I don't want to become a doctor. I think the question itself reflects a lack of confidence in nursing and nurses' abilities, and a sense that aspiring NPs might have ideas above their station. I don't have ideas above my station. I'm doing what I'm doing because I love it. We must champion nursing as a discipline and nurses' abilities, so all nurses can reach their potential."

* Disclaimer from Auckland District Health Board: The opinions expressed here are Tracey Forward's, not Auckland DHB's.

By co-editor Teresa O'Connor
COPYRIGHT 2016 New Zealand Nurses' Organisation
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 2016 Gale, Cengage Learning. All rights reserved.

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Title Annotation:profile; Tracey Forward on her practice as a mental health nurse in New Zealand
Author:O'Connor, Teresa
Publication:Kai Tiaki: Nursing New Zealand
Geographic Code:8NEWZ
Date:Sep 1, 2016
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