Birthday Reflections on a Nursing Career

Today is the occasion of my 49^th birthday and therefore it is a good day to reflect on many things. One of those is that I am nearer to retirement – six years to go as I am one of a dwindling number of colleagues who have mental health officer status, enabling us to retire at 55.

In two and a half weeks time I will have worked consistently, and full time, for 30 years in the NHS as a mental health nurse. This causes me to reflect on the people I have met along the way and from whom I have learnt so many things. Having a birthday right at the end of August meant that I was one of those children who were up to a year younger than their classmates at school. Therefore, I started my nurse training at just 18, it was tough and I very nearly didn’t make it through to the second year. In my final year I met one of my oldest friends, also a student nurse, and now a very skilled Advanced Practitioner in dementia care. One of the most interesting conversations that I had with her recently was about the the idea of recovery for those with dementia. Nearly thirty years on we continue to have wonderful, exciting conversations about nursing and both of us are still passionate about working with those with mental health problems, probably more so now than we were when we first started as nurses.

Learning from others

For much of my career I have watched other clinicians practise and I have consciously taken on the methods and approaches that I like, and disregarded those I don’t agree with or don’t think will work for me. I wonder if this attempting to emulate others is how others have learnt many of their nursing skills, and also I am reminded of the work of Pat Benner (1984) and how it is still applicable today. I have often admired colleagues who can truly listen, who are calm under pressure, able to smooth situations rather than rustle feathers, are respectful of others but still strong in their own values and ideas. These are the people I have taken inspiration from. One of my current role models, has been my clinical supervisor for 5 years and is now about to move posts and organisations. She is probably one of the best clinicians that I have ever come across, and despite being in a very senior position she remains grounded as a nurse. When I come across a difficult situation, am tempted to cut corners or ignore something, I often think about my supervisor and ask myself what she would do. I always come up quickly with an answer, it is never the easiest method of dealing with the issue, but inevitably it is the right one.

I have worked with some amazing people over the years. Some colleagues have had their own mental health problems that they have worked hard to manage. I have witnessed the excruciating difficulties that they have had when they have become unwell, feeling doubly stigmatised; firstly, as people with a mental health problem and secondly, as a workers in mental health and with illnesses themselves.

The service users that I have worked with over the years have probably taught me the most about myself and about being a nurse. I have learnt to listen to them, to really listen. I have learnt to not be afraid of feelings, to be intuitive in asking questions and not to worry if they get upset. I learnt about substance misuse as a new ward manager, not just from the very experienced staff on my ward, but more so from the service users who could not sleep during the long nights of detoxes and spent the time telling me their life stories. As a CPN, I have been honoured to see people in their own homes, for them to open their doors and their hearts to me at such difficult times of their lives. Much of my community work has been in rural areas, and coming from country background myself, I felt most comfortable in this setting. I could understand the difficulties of rural life, the hidden poverty, others in small communities knowing your business and the importance of landscape and animals to health and to illness, but how to nurse in this setting was something I had to learn.

I have been fortunate to have been given so many training and development opportunities by the organisations for which I have worked. I have completed supervision courses, a CPN certificate requiring a year in University with community placements, a THORN course (psychosocial interventions for psychosis), a BSc, PGCHE and most recently an MSc in Advanced Practice. All of this learning has transferred in some way to practice and has allowed me to develop as a practitioner and as a person. Many that have taught me, especially fellow clinicians on the THORN course, have inspired me to undertake teaching myself. These THORN trainers gave knowledge and information freely, with such an altruistic delight in developing others that has become a value that I work to replicate.

In my current teaching role I often work with younger, newer staff, many of whom amaze me with their skilfulness, their kindness and their enthusiasm for the work they do. I see so many young mental health nurses and practitioners from other disciplines who do not realise just how good they are as clinicians. Nursing is having a difficult time at the moment and a bad press, but these young practitioners give me hope for the future of nursing and for mental health care. They will hopefully still going long after I am retired and probably after I have shuffled off this mortal coil.

So, today, as I reflect on my career, as I look back at a 30 year journey and forward for the next six years of my career I want to focus on how I can keep going with the same passion and drive that I have right now – I want to retire with a bang, not a whimper. In the meantime, the one thing that I am clear about is that, I wouldn’t have any other job than being a mental health nurse.

Benner, P. (1984). From novice to expert: Excellence and power in clinical nursing practice. California: Addison-Wesley.

Photo by Sherria Hind

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The Place of Animals in Mental Health Recovery

The following is an article published in the Care Programme Approach Association journal, The Approach. It is reproduced here, with kind permission from the CPAA, in a slightly shorter form.

The Place of Animals in Recovery

Half of UK households own a pet (Reynolds, 2006), therefore many people experiencing mental health problems will have companion animals and their relationships with these are often significant and important.  Owners will each have a different level of attachment to their animals and where several are owned it is likely that the individual will have a different connection with each one (Peacock, Chur-Hanson and Winefield, 2012).  However, mental health services very rarely consider the significance of animals in people’s lives, their role in recovery or how they impact on risks.  Understanding an individual’s relationship and attachment to animals could be a significant element in recovery that is being missed.  Whilst animal assisted therapy for mental health, as well as other health problems, has been fairly well researched, examination of the significance of actual animal ownership and effect on mental health has had little consideration (Walsh, 2009; Peacock, Chur-Hanson and Winefield, 2012).

Owning a companion animal can allow us to have an important relationship, one that is safe, trusting and uncomplicated.  It brings responsibility and a role, as well as an opportunity to focus on another living being.   Animals provide unconditional love and affection which, for those who are isolated and stigmatised due to mental health problems, can be highly important and affirming and can also provide physical contact and reassurance.  For many, companion animals are considered to be a member of the family, may be included in celebrations and given presents (Walsh, 2009).

Mental health workers are required to collate a great deal of information about service users, starting at the first assessment, but individuals’ relationships with their animals are rarely asked about, or considered to be important, therefore they are unlikely to feature in care plans or reviews.  If workers do not understand, or even acknowledge a service user’s animals in assessments, in conversations and in care plans there can be a significant gap in holistic care.  Peacock, Chur-Hanson and Winefield (2012) identified that any psychological assessment should include information about attachment and relationships with animals.  At the very least talking about a person’s animals is a good method of building rapport and engagement, often helping someone to start to talk about them self.

Recovery based care is an important and recognised approach but when services do not consider a person’s animals and their significance, care cannot be truly individualised and recovery focused.  Animals can be helpful in building resilience to mental illness and can provide a routine that supports important coping strategies.  If we are to use a truly holistic approach which considers every aspect of peoples’ lives, their animals should feature.  For many, both those who are experiencing mental health problems, and for those who are not, animals can give meaning to their lives.  Therefore care plans need to take in to account the part played by any animals in service users’ lives.

For many, animals can reduce risks, as they can be protective factors for those who self harm or are suicidal.  The thought of leaving their animal behind has been shown to prevent individuals from harming themselves, can give them a focus (Walsh, 2009) and animals can be a comfort which provide solace and affection.  In these situations a companion animal can offer hope and help a service user develop a belief that they can cope with life and Walsh (2009) identified that animals can support individuals through difficult events and transitions.

For many, animals provide a purpose and a structure to the day by giving them a sense of worth and control over part of their life (Slatter, Lloyd and Kind, 2012).  Those with poor motivation may find that they will get up and out for their animals when they would not do so for themselves.  Routines based around animals can support the development of coping strategies for difficult times.

Where animals provide livelihoods there will be different attachments to them by their owners but these are no less important than those with companion animals.  Farmed animals are often given names (Brown, 2006) and the impact on mental wellbeing for farmers and others when they lose their stock can be profound as demonstrated in the last foot and mouth epidemic, the ongoing tuberculosis infections of cattle and the recent losses of stock in the severe weather of spring 2013.

For some individuals the owning of animals can increase risk.  As circumstances change, due to factors such as illness and reduced finances, owners can become overwhelmed with the care that their animals require.  Physical risks in the form of trips and falls can be a problem with those who are physically infirm; however owners with dogs and who walk them have been shown to be physically fitter (Smith, 2012).  Owning an animal can expose previously unidentified issues.  When they first own an animal the nurturing that it requires can be overwhelming for some individuals due to their own experiences of poor nurturing or neglect by their families.

For some, the thought of being separated from their animals will lead them to delay treatment (Peacock, Chur-Hanson and Winefield, 2012) or prevent them from moving to appropriate accommodation (Morley and Fook, 2005).  This has been the case for older people needing a care setting and also for homeless individuals who will not take up accommodation if their animal is unable to go with them (Slatter, Lloyd and King, 2012).  Concern about one’s home, including pets, has been identified as a factor in absconding from hospital (City University, 2003).

For many owners the loss or death of a companion animal will cause a grief reaction that is often experienced similarly to the death of a loved person (Brown, 2006; Walsh, 2009).  The level of grief experienced will be related to the level of attachment to the animal (Donohue, 2005).  This is normal especially as companion animals are generally considered to be family by owners.  What often causes problems are the responses from others, including health workers, who give trite reassurances such as pointing out that it was only an animal or that another can be obtained.  Responses such as these further compound the individual’s grief and sense of loneliness (Brown, 2006).  Sometimes the death of an animal has a wider significance when it is a last link to a human that they have lost.

Women in abusive relationships have delayed or not left the situation due to either, not being able to take their animals or their children’s animals with them, or due to threats of harm to the animals from the abuser (Krienert ,et al 2012; Allen, Gallagher and Jones, 2006).  The abuse of animals has been identified as a possible indicator for domestic and child abuse (Blewett, 2008) with agencies in some USA states routinely sharing information where animal abuse has been identified (Patronek and HARC, 2001).

The responsibility, time and cost of caring for a companion animal will increase risks for some individuals but will reduce them for others.  Caring for an animal can become overwhelming and can be costly which may result in a service user ‘going without’ to provide for their animal.  For some individuals caring for animals runs out of control, in worst cases producing animal hoarding situations (Williams, B. 2014).  Here numbers of animals are kept in conditions that not only do not meet their needs, but significant cruelty, suffering and death are caused.  The impact on humans in animals hoarding situations is also enormous as children and vulnerable adults can be living in the household.  Animal hoarding situations are often driven by changes in circumstances including physical illness, but it is very likely that there will be comorbid mental health problems (Patronek, Loar and Nathanson, 2006).  Animal hoarding is more common than many think but is often ignored by agencies as it is seen as a ‘lifestyle choice’ (Reinisch, 2008).

It is important to consider if there is an impact on carers when those they support have animals.  Carers can experience an increased burden by having to take responsibility for animals when a service user is unable to do so.  For some this may be something that they are willing and able to do, but services should not just assume that a carer is able to meet the welfare needs of someone else’s animals, including the financial implications.  The role of the care coordinator and good care planning is essential to identify what is the best for a service user, carers and the animals should there be a crisis or if circumstances change.

In the current times of economic austerity some may feel that taking the time to understand and support service users’ relationships with their animals is inappropriate, but if we are to work in a truly recovery based way we need to understand what is important to service users.  Those with mental health problems are stigmatised enough without services ignoring or dismissing an element of their lives, which may be immensely important and helpful to them.

Workers, services and others may believe that those they work with do not have the ability or resources to care for a pet.  As long as the animals’ welfare needs are sufficiently met as required by law (Animal Welfare Act, 2006, see box 1), there is a positive impact for the service user and the responsibility is manageable for them, why would there be a problem?  We can work with service users to ensure they chose appropriate animals for them and their circumstances.  We can care plan with crisis and contingency plans including details of how their animals can help or increase symptoms and risk when they are becoming unwell.  We can also support the drawing up of clear plans for where animals should go should the service user become unwell.

Box     1 An animal’s needs shall be taken to  include; (a)     its need for a suitable environment, (b)     its need for a suitable diet, (c)     its need to be able to exhibit normal behaviour patterns, (d)     any need it has to be housed with, or apart from, other animals, and (e)     its need to be protected from pain, suffering, injury and disease. (The Animal Welfare Act, 2006, section 9)

Mental health workers are already pressured for time and may consider discussing a service user’s animals as a waste of time or unnecessary, however this then misses an opportunity for aiding engagement, for understanding what is really important for the individual and their life. It also can mean that certain risks and protective factors are missed.  Many mental health workers own animals that are hugely important to them, so why should our service users be treated any differently?  For many their relationships to animals are important, life affirming and profound. Recovery approaches cannot be authentic if workers and services chose to ignore this significant aspect of service users’ lives.

In summary, there is a significant part of people’s lives that is often missed by services and if we are to really deliver supportive, meaningful and individualised care we need to consider the role of animals in peoples’ lives.

 References

Allen, M., Gallagher, B. & Jones, B. (2006) Domestic Violence and the Abuse of Pets: Researching the Link and Its Implications in Ireland. Practice. 18,3, 167-181.

Animal Welfare Act (2006) HMSO

http://www.legislation.gov.uk/ukpga/2006/45/contents (Last accessed: April 22 2013).

Blewett, J. (2008) The link between animal cruelty and child protection. Community Care. 1745, 26-27.

Brown, K. (2006) Pastoral concern in relation to psychological stress caused by the death of a companion animal. Mental Health, Religion and Culture. 9, 5, 411-422.

City University Department of Mental Health and Learning Disability (2003) Anti-Absconding self-training package for ward staff. http://www.citypsych.com/index.html

(Last accessed: April 15 2013).

Donohue, D. (2005) Pet Loss: Implications for Social Work Practice. Social Work. 50,2, 187-190.

Krienert, J., Walsh, J. & Mathews, K. et al (2012)  Examining the Nexus Between Domestic Violence and Animal Abuse in a National Sample of Service Providers. Violence and Victims. 27, 2, 280-295.

Morley, C. & Fook, J. (2005) The importance of pet loss and some implications for services. Mortality. 10, 2, 127 -143.

Patronek, G. & HARC (2001) The Problem of Animal Hoarding. Municipal Lawyer. 19, 6-9.

Patronek, G., Loar, L. & Nathanson, J. (Eds) (2006) Animal Hoarding: structuring interdisciplinary responses to help people, animals and communities at risk. http://vet.tufts.edu/hoarding/pubs/AngellReport.pdf (Last accessed February 15 2013).

Peacock, J., Chur-Hansen, A. & Winefield, H. (2012)  Mental Health Implications of Human Attachment to Companion Animals. Journal of Clinical Psychology. 68, 3, 292-303.

Reinisch, A. (2008) Understanding the Human Aspects of Animal Hoarding. The Canadian Veterinary Journal. 49, 12, 1211–1214.

Reynolds, A. (2006) The therapeutic potential of companion animals. Nursing and Residential Care. 8, 11, 504 – 507.

Slatter, J., Lloyd, C. & King, R. (2012) Homelessness and companion animals: more than just a pet. British Journal of Occupational Therapy. 75, 8, 377-383.

Smith, B. (2012) The ‘pet effect’. Health related aspects of companion animal ownership. Australian Family Physician. 41,6, 439-442.

Walsh, F.  (2009) Human-Animal Bonds 1: The Relational Significance of Companion Animals. Family Process. 48,4, 462-480.

Williams, B. (2014) Animal Hoarding: devastating, complex and everyone’s concern. Mental Health Practice. 17, 6, 35-39

First Steps

A Toe in the Water
This is my first blog. I have been working, for the past year, on writing articles for publication in professional journals. Starting a blog is the next stage of an exploration of writing in my nurse and educator roles and also as an individual. Many of the methods that I have found helpful to support my writing have come from the book How to Write a Lot (Silvia,P. 2007) in which ways of starting writing and sustaining production are described. Silvia’s ideas are all underpinned by his work and knowledge as a psychologist and even though the book is mainly targeting academics it has much that is useful to those who are nurses and other health professionals.
Why write? – A professional responsibility?
I firmly believe that mental health nurses and other practitioners should write in order to share great practice and to develop others’ knowledge, and in these unprecedented times of difficulty in health and social care, professionals should be making their voices heard. Most mental health workers have strong views on how life is for service users, carers and staff. We all have a responsibility to speak up about health and social care but, “many clinicians underestimate the relevance and importance of what they can contribute” (Happell, 2012). Rather than just moaning, we need to articulate our concerns in professional and coherent ways. The Francis report, Berwick report and the 6Cs of nursing all call for transparency, for individuals to speak up and writing is a way to do this. When there is so much reporting of poor and negligent care it is important that the day to day good practice is described and discussed, not lost. The act of writing about professional concerns and practice can take many forms. It may be simply putting concerns in an email to a line manager, writing a short piece about positive practice for a Trust in-house magazine, or it might be writing a letter, an opinion piece or an article describing clinical practice and developments for a professional journal.
Personal experience
One other strong motivator for writing, for me, was the experience of supporting an in-law who recently became a mental health service user. At times the difficulties that I encountered as a relative, combined with what I knew should be happening from my experience as a clinician, generated so much anger in me that it had a significant impact. Writing about the experience helped alleviate the feelings of powerlessness, the periods of all consuming fury and probably reduced my blood pressure.
In my next blog I will start to explore how we can start to write, how to generate ideas, start writing and keep going.