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A day in the life of ... a practice mental health nurse

A practice mental health nurse
I am attached to four practices at three different sites. These are all in the Easter Ross area, a 30-minute drive from Inverness. It is a rural environment, and my time is split between Tain, Dingwall and Strathpeffer. If my job was ever less than enjoyable and challenging then at least I would still have the benefit of working in a beautiful part of Scotland, although having lived beside the Moray Firth for 21 years I have yet to see a dolphin or porpoise!

I commenced RGN training back in 1982 at Raigmore Hospital in Inverness (I had worked in a shipyard previously). From there I went into RMN training at Craig Dunain Hospital in Inverness, where I worked for 10 years in rehabilitation, day hospital and acute admission. The next six years were spent in Elgin, mostly working in rehabilitation. During this time I obtained my specialist practitioner qualification in mental health rehabilitation and resettlement. Before starting in my present position I worked with the drug and alcohol team covering Morayshire in Grampian.

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In some respects my current role is similar to that of a counsellor, and I describe it as involving a large degree of counselling as well as other activities. I consider my model of working to be closest to what is known as the consultation- liaison model.(1) This "places greatest emphasis on developing close links within a practice between the primary care team and psychiatric staff". The major aim is to retain care of patients with "neurotic illness" within primary care.

I work with patients who have what can be described, somewhat simplistically, as mild mental health problems. My contact with them is expected to be short-term. Before I began accepting referrals it was anticipated that anxiety- and depression-type problems would predominate. While this has certainly been the case, the referrals to date indicate a wide range of problems, including people with recent bereavement, relationships ending and interpersonal difficulties.

I usually adopt a cognitive-based approach. I discuss the "exercises" that will need to be carried out with the patient. These might involve, for example, graded exposure to certain situations that cause anxiety. Diaries can be kept and relaxation techniques explored. Progress is discussed and monitored at subsequent visits.

My hours are Monday to Friday, 9am to 5pm, although this can change for various reasons and depending on where I am working on a particular day. For example, two practices have me on their computer systems, ensuring that patients can "book in" for appointments and that the casenotes will be available for me. In the other practices I have to organise appointments myself and ask for casenotes to be extracted, but this is not really a major problem.

If I am seeing someone for an initial appointment I will set aside at least an hour. This allows time to explore the patient's problems and to discuss possible approaches to deal with these problems.

If the patient wishes to return, an appropriate time can be arranged. Subsequent appointments tend to happen weekly or fortnightly, and 30 minutes are allocated for these. When it is felt that the patient's situation is improving then contact can be less frequent. Generally, contact should be "short term". Before I started, the steering group behind the post felt that six to eight sessions would be adequate.

Feedback from patients indicates the benefits from talking to someone who is "not involved" and who will "not pass judgement". Other comments include that involvement has "put things in perspective" and "made me feel better about myself".

Following a meeting with a patient I complete their documentation. I do not have my own "unique" casenotes - all documentation is held within the medical casenotes. If a patient needs to meet with their GP while they are seeing me, then their progress (or otherwise) will have been documented and put in their casenotes to be read. In effect, I have regular contact with the patient's GP. At two of the practices there are regular team meetings attended by other members of the primary care team. In this way, information can be disseminated as appropriate. I also meet with the referring GP on an "ad-hoc" basis and discuss progress or issues such as possible changes in medication or alteration in dosage, this having first been discussed with the patient.

During my working day any available time is used to liaise with other referrers, such as health visitors, community midwives, practice nurses and the community mental health team.

If at the end of contact, or following the initial assessment, it is clear that the presenting problems have not improved, or are not within my remit, then referral to a more appropriate service provider is made. My role involves acting like a "filter". Referral, normally carried out by myself, is usually to secondary mental health services, although it has sometimes involved tertiary providers. Of almost 170 referrals, fewer than 10 have been referred on to other services - referrals tend to be to a consultant psychiatrist, the community mental health team or an addictions CPN.

As the post is still "under the spotlight", auditing will soon be taking place. An external organisation has applied for funding to undertake research into my position and two other similar services elsewhere in Scotland. Being provided with a laptop by my employers has been extremely useful. From my first day of contact with patients I have been collecting quantitative data. These include information on gender, age and occupation, and also frequency and duration of contacts. Interestingly, it confirms what is already known about certain professions being stressful.

Using The hospital anxiety and depression scale with patients on a regular basis ensures that an "objective" and well-validated monitoring tool is utilised.(2)

I enjoy meeting with people, patients and colleagues, and hope that my involvement makes a difference. I can see the varying degrees of change that take place with those referred. Research and audit will hopefully lead to my post being expanded. It is clear that my time in each locality could be increased.

I think the best way to describe how I feel about my job is to use a quote from the novelist and poet Andrew Greig, which I find has resonance in my daily activity, both in and away from work - this is "the perpetual adventure of passionate engagement with another human being".(3)

If you would like more information on Alex's role, you can email him at alex.hamilton@hpct.scot.nhs.uk

References

  1. Gask L, et al. Evaluating models of working at the interface between mental health services and primary care. Br J Psychiatry 1997;170(1):6-11.
  2. Snaith R, Zigmond A. The hospital ­anxiety and depression scale. Windsor: NFER-Nelson; 1994.
  3. Greig A. When they lay bare. London: Faber; 1999.