Nursing - Mental Health

So, here it is 0815 hours and the day begins. I unlock the door to the poor dilapidated house that we work out of. The house looks as forgotten as our service.

It is a grubby post-war affair that has seen better times but it’s all we have and our service is essential to mothers and babies who are experiencing significant post-natal difficulties.

3 Clinical Nurse Specialists (CNS’s) run the Family Care Centre. This is the one place that families can go and get free help for unsettled babies, postnatal depression and anxiety, feeding problems and parenting difficulties.

The first thing I do is go to the intake desk and check the diary. I see I have 3 home visits – 1 new client, 2 reviews and my usual space left at the end of the day for emergency clients. It’s a real bonus if this space isn’t filled, but it usually is.

This is a  usual day for me. I know 3 clients doesn’t sound like much, but in reality it’s 3 – 4 families we work with. So it may be 3 or 4 clients per visit. Do your maths that’s 9 -12 clients per day. But we only count the children in our stats!

I check the phone messages and see I have several from clients wanting me to call back. I make my phone calls first. My clients — all mums with babies and preschoolers all need my reassurance. Jane has called to tell me that last night she was so upset with her baby, she has bitten her! I ring her first. We discuss what happened and I reluctantly tell her I have to make a notification to the Department of Communit Services. She cries and I tell her I will come over and see her today so we can talk about why this happened. I put her into the emergency time slot.

The first task is then to call the DoCS Helpline and make my notification. I have no choice and I wish it could be different. I know Jane didn’t mean to hurt her baby – but I also know that she has such ambivalent feelings about her that I can’t risk ignoring the dangers.

The DoCS notification and writing up the notes take 40 minutes so by the time I’m finished I only have time to acknowledge the other CNS’s with a wave and a quick explanation, grab my notes, home visiting bag, car keys to our one and only allocated car and rush out the door to get to my first home visit at 9.30 am.

I have to check the road directory for my first visit, and once I’ve figured out where I’m going, I go! When I get there I’m greeted at the screen door by a sleek cat. I knock and call and finally I’m greeted by a forlorn young woman in a halter-neck dress. She can only whisper hello and I can see straight away that she is very unwell. I look for her baby and ask where he is.

Karen, the mum, waves her hand towards a little bundle on the floor in a corner and I see a little thing in a bouncy chair facing the wall all on his own. It’s not looking good and I sigh within myself. I can see there is a lot of work to be done here. Karen invites me to sit down and I suggest we bring baby Timmy over with us.

Karen is more interested in having the cat with us and so our meeting begins. Karen sobs softly and the 4-month old baby looks blank. These two sad people haven’t been able to form a relationship yet and I can see that we have no time to lose. I do my first mental health assessment of Karen and her relationship with Timmy. I carefully observe their interactions and determine my plan with this mother-infant dyad. They will need lots of interventions and I will need to get the ball rolling today.

Referrals to GP and psychiatrist for meds, psychologist for CBT and weekly visits from myself for mother-infant therapy. We will be working together for at least a year, probably more. After 2 hours I have finished my first assessment and take my leave.

Karen clings to my hand and I see in her eyes and face a look I’ve come to know so well. It’s heart-rending, because it’s such a mixture of despair, hope and lost loneliness. I promise her I will be back next week and will ring her to confirm a time. I leave her my details so she can contact me and then climb her garden stairs, very aware that her eyes are following me with hope.

I did see this young woman for a long time and she formed a very strong relationship with me. I had to be very careful as she wanted to idealise me and that’s always a danger sign! When you’re idealised it’s not very long before you can become a villain when you don’t live up to the unreal ideas that a client has about you. I had to work closely with the other members of the health team and let Karen know we were all working together.

In the beginning Karen wrote me lots of poems about me being an angel and saviour etc. but as she got better these stopped. When you work in mental health you have to have a really clear understanding of how people think when they are unwell and not get drawn into their often skewed internal worlds.

My next two visits were reviews — both mums had chronic depression and anxiety and having  children had exacerbated their conditions significantly to the detriment of their forming good relationships with their children.

One of these mums had a 3-year old boy who was so naughty and defiant, and a 6-month old girl with a genetic illness that needed frequent hospitalisations. This young woman had chronic depression and no energy to mother her children. I had known her since the birth of her fist child and we had worked on and off for 3 years.

This mum has had a troubled and abusive childhood and didn’t have the capacity to undergo psychotherapy (some people don’t). My work with her focused on ensuring she kept on with her meds, understood what the doctor was advising her to do, encouraging her in social activities and working on parenting skills which was mostly about increasing her ability to be show empathy to her children.

I was essentially her children’s interpreter because she had no idea why her children were behaving like children and she got so frustrated and angry with them! Every visit we would observe the children’s behaviour and we would ‘wonder together’ why they were doing this thing or that. It was an uphill battle, but she slowly got better with her parenting skills and her second child got a much better deal from her than the first one!

At 2.30pm, before my last visit I stopped at a shop, grabbed a sandwich and a juice and ate them in the car while I scribbled some of my notes. I phoned into the Centre to let them know where I was, that I was okay and my ETA back at the Centre.

At 3pm I arrived at my last visit. Jane was waiting for me with her husband, John. I was glad John had stayed home from his busy job to support her. He was looking grave and confused. He was trying to understand Jane, but he was having difficulty with knowing what to do. Thankfully we had built a good enough relationship over the last 10 months for me to be able to tell Jane and John that I had made a notification to DoCS and what this would now mean to the family and they could still welcome me at the door.

The baby was fine, she did have a bite mark on her arm, but I was more concerned about the psychological damage that a mother biting her child causes. Jane, John and I talked together for an hour. I did a risk assessment and we formulated a plan for how she could manage when she felt like this again.  I had to ensure the children’s safety and John had to be a big part of this.

In a way, this crisis was a positive event. Up until this point Jane had refused all meds and psychotherapy as she could not accept that she needed them. In Jane’s world anti-depressant medication meant personal failure. Now she had shocked herself into action and she now believed she did need medication. I called her psychiatrist while I was with the family and explained what had happened. An emergency appointment was made and we discussed medication. I was relieved at last we could make some positive progress.

I arrived back at the Car Cottage at 4.30pm. First stop….the ladies room! Then I greeted my just as busy colleagues and went to my desk to check phone messages. My first phone call was a return call to Jane’s allocated DoCS caseworker. Babies under 12 months are a high priority. After that I began the writing of my copious notes, chatting and joking with the other CNS’s and eating an apple.

By 5.45pm I was alone and pretty much finished my notes. I put them all away, locked the filing cabinets and shut up the dilapidated little house. I was tired, but okay. My work is worthwhile, I do this because all women and their children deserve to enjoy their lives together.

You know – almost all women want to be good mother’s to their kids, it’s just that some mothers just don’t know how to do it without some help and that’s what I’m there for.

And that’s the day of a Specialist Child & Family Health Nurse.

What about you? What’s your day like?

Note: All clients in this piece have been de-indentified.

Images courtesy of Photobucket and Photoxpress