Dec 09, 2019, By: Michelle Danda
Take away messages:
- Through deliberate efforts to embrace and embody best practices, it is possible to make change in addictions and substance abuse services.
- Specific focus on the clinician-patient relationship with fundamental principles like compassion, trauma-informed practice, person-centred care and recovery-oriented practice can be a solid foundation for building a values-based program.
- Engaging and encouraging input and participation of staff in open and honest dialogue about struggles and challenges can be transformative in workplace satisfaction.
Mental health and addiction issues have been receiving increased media attention, especially with respect to those touched by the pain and loss arising from the opioid crisis. The focus on death and destruction, and the resulting trauma to nurses—especially those who work in the emergency room, acute inpatient mental health, and community addiction and mental health programs—can result in moral distress and burnout. Some nurses may even leave the profession for good.
During this challenging time I think that more than ever, we need to focus on the good work that is being done by nurses in meeting this crisis. Indeed, shifting my own focus to the good saved my nursing career.
My story involves the success of a carefully designed and well-delivered, youth-focused, collaborative mental health and substance use program. In sharing it, I seek to inspire hope that systemic change is possible when the care and expertise of nurses as holistic health care practitioners are recognized and valued within an interdisciplinary health care team.
Making the change
I live and nurse in the Lower Mainland, BC. I have been working in mental health since the beginning of my 10-year nursing career. In that time I have seen many changes in mental health care, not always for the better.
About three years ago, I found I was becoming disillusioned and frustrated by the disconnection between mental health and addictions services, and the fracture between inpatient and community providers. I wanted to grow professionally, but realized that I was leaving work each day feeling angry, misunderstood in my nurse role, devalued, and disempowered. I needed a change.
Then, in 2017, I had the opportunity to join an interdisciplinary, collaborative, and innovative adolescent concurrent disorder inpatient program in North Vancouver. The program serves youth aged 13 to 18 living with complex mental health and substance use issues. I had always considered this a challenging field, but I jumped at the chance. The goal was ambitious: to help youth facing multiple barriers, kids who had not previously succeeded in other community-based treatment programs. This program’s goal differed from the traditional, one-size-fits-all model of mental health care. Instead, it took a collaborative, strengths-based approach focused on holistic, individualized recovery care planning based on the young patients’ needs and goals.
A shift in focus: Embodying mental health best practice
The model is refreshing, especially in contrast to what I was used to in adult inpatient mental health settings, where the nurse’s role seemed more about minimizing risk, increasing observation, and maximizing safety. Working in different adult care areas, I began to see a marked shift away from person-centred, relational models of care, toward risk aversion under the guise of “safety” at seemingly all costs, including patient dignity and autonomy. I needed more; I needed better. I needed an opportunity to work within a model of care that used recovery-oriented, strengths-based best practice care models.
On the adolescent inpatient concurrent disorder team, I felt I was truly surrounded by other clinical staff who shared my beliefs about trauma-informed practice. For the first time in my career, I experienced open and honest, team-based conversations about delivering trauma-informed practice within a system largely based on involuntary treatment. I felt that I now had the time, space, and support to provide the best interventions for patients who were often ambivalent about their admission.
This work environment is open and welcoming, rather than gloomy and professionally stifling. I witness at first hand the impact that both environment and staff approach can have on patient outcomes. For example, focus on creating open-unit design with plenty of natural light and spaces where private conversation can be held between patients and clinicians, but also where social interaction is encouraged. Trauma-informed practice has become more than simply buzzwords. Clinical staff regularly engage in discussion about the impact of care. There is deliberate and concerted effort to minimize the potential iatrogenic trauma of inpatient mental health care.
I am proud to say that now I work on a team that empowers and encourages staff to contribute new ideas rather than simply maintain the status quo. I feel pleasure when I reflect on the work we do and the efforts that we make to learn each youth’s unique life story, even in tough circumstances such as involuntary admission.
Recognizing the difference
I recognize that mental health nurses often become burnt out and disconnected from their work because of moral distress, vicarious trauma, and desperation from such workplace challenges as short staffing, poor environmental design, and deficits in training. The result is job dissatisfaction and high staff turnover.
More energy and ideas must be focused on creating and fostering workplaces that keep nurses engaged, excited, and enthusiastic about their job and the possibilities that each day brings. Each day we can use our genuine curiosity, compassion, and care to change a patient’s life for the better.
In part, this is also a result of strong leadership from staff who emphasize and uphold individualized patient care collaboratively, including the patient’s own care decisions. For example, sitting down with each patient to discuss their personal recovery goals, and bringing this information to Care Team Rounds. Care improves when each patient is viewed as a deserving human being regardless of diagnosis, life circumstance, or number of times they have previously accessed care.
I also recognize that challenges remain, as with any new team of interdisciplinary care providers, both regulated and unregulated: occasional role confusion, lapses in communication, and knowledge gaps (especially for clinicians new to the hospital setting). However, reframing each challenge as an opportunity to provide education and ongoing support to members of the interdisciplinary team enables a positive shift to a better, shared understanding of the full scope of the nurse’s role.
The interaction among team members offers opportunities to share in a way that is impossible on teams where members work in isolation in discipline-based silos. Leadership support and meaningful inclusion of direct care staff in decision-making about practice are also paramount in empowering and engaging clinical staff.
Yet, moral judgments and stigma surrounding both mental health and substance use issues still overshadow the need of persons living with mental health issues to receive help. In the midst of the overdose crisis, we can too easily lose sight of the potential for good when we witness patients’ self-destructive behaviours and experience moral distress.
To save my own career and reignite my passion for nursing, I made a deliberate shift to a care team aligned with my own values and beliefs, and this has helped me to see the good in our work even when we are surrounded by great suffering.
Michelle Danda, RN, MN, MPN, CPMHN(C), graduated from the Bachelor of Nursing Accelerated Track program at the University of Calgary in 2008. She currently lives and practises mental health nursing at Lion’s Gate Hospital in North Vancouver, BC. She has four beautiful children with her partner, who is also a mental health nurse. She is also a fulltime doctoral student in the PhD Nursing program at the University of Alberta.