Mental health articles

A nursing home director contacts you about a resident at her facility who has become more withdrawn and resistant. At your initial meeting with the director, the resident is described as an 80-year-old woman, Ruby, who has been at the nursing home for 2 years. She was previously more involved with others and had a close relationship with her roommate. The director indicates that since Ruby’s roommate moved out to live with her family several months ago, she has been more argumentative with staff and often refuses her medication. As you learn more about the nursing home program, you discover that there has been much staff turnover in the past year. The day charge nurse has been there 5 years and is primarily responsible for all the individuals during the day. This is the staff member who has shared the majority of the complaints regarding the client and requested that the administration assist her in coping with Ruby’s situation. You schedule an appointment to meet with the charge nurse on the following day to gather more specific information about the presenting issues. After the initial meeting, you review the information that you have gathered and contemplate how to proceed. You can already identify that there may be some issues to address with the overall nursing home program and consider taking a programcentered approach in which you could work with the director to look at more organizational
changes and solutions to developing more effective programming for the patients.
However, more information is needed to determine the role of the charge nurse and the uniqueness of Ruby’s situation compared with other residents.
On meeting the charge nurse, you discover that she is initially somewhat defensive at the idea of talking with an outside consultant. She is made to feel at ease as you explain
that the director felt the issue that was raised was important, beyond his ability to solve, and that the whole program could benefit from an outside consultation. As the
charge nurse begins to share her concerns regarding Ruby, you note that she appears extremely frustrated and is negative about the other staff ’s actions. Ruby is described
as a problem because she does not cooperate with the schedule, requires extra staff time to coax her to take medication, and affects the morale of the other residents when
she refuses to eat with the group or attend activities. You inquire about the roommate loss and any other factors that the charge nurse thinks may be contributing to the situation.
The nurse has questioned depression, health concerns, and new staff who are not yet fully trained as potential contributing issues.
As the consultant, you contemplate using a client-centered approach at this point.
You certainly have indicators that depressive concerns or staffing issues may be contributing.
However, these concerns do not sound particularly unusual for nursing home
patients, and the nurse has already identified potential causal factors. There may be some reason why the nurse, who has years of experience in this facility, is not able to
handle this situation or make necessary referrals on her own. Therefore, a consulteecentered
approach is felt to be the best starting point to support the nurse in developing a plan to address the concerns.
During subsequent meetings with the charge nurse, you discover that she has assumed
much personal responsibility for Ruby’s difficulties. Several times, the nurse
had voiced her concerns to the director that with all the new hires and scheduling
changes, there were not enough fully trained staff members available to deal with patient
issues. In the past, the director had not been able to offer any further administrative
support and tended to reassure the nurse that she could handle the concern at hand.
As the charge nurse, she has the responsibility for the staff and the residents and feels
overwhelmed by the heightened demands of meeting Ruby’s needs.
The goals of the intervention are developed by the charge nurse and the consultant.
They identify together that the nurse has not been able to be objective because of the
impact of Ruby’s behaviors on others’ potential views of her work performance. Feeling
incompetent to address all the problems in the facility at once, the focus became shifted onto Ruby. The consultant and the nurse as consultee discuss possible strategies
that could assist in supporting Ruby as well as elicit environmental changes for coping with staffing issues. New information regarding addressing depression in the
elderly was obtained for the charge nurse who then trained her staff. Ruby was referred
for a physical by the charge nurse and assigned an individual staff member with more experience. The client was identified by her physician as having worsening
arthritis in her back and prescribed new medication. The staff was educated about the
apparent signs of Ruby’s depressive reaction to the loss of her roommate and recommended
supports to offer her. The charge nurse developed a mentoring training method with senior staff training the newer staff with excellent results; administrative pay
incentives supported this approach and the increased scheduling demands. The consultant’s
follow-up at 2 and 4 weeks later indicated that Ruby had shown significant improvement, and the charge nurse had continued to implement new staff training and mentoring programs.
Use of this model was effective because the consultee was empowered by the consultant’s
nonjudgmental support in seeking staff training information and implementing
problem-solving skills (Conoley & Conoley, 1992). Through the facilitation of the consultant, the charge nurse was able to identify the interference of poor objectivity
and esteem issues in meeting the client’s needs. Her gain of new information, increased
confidence, and problem-solving skills will benefit other clients in the nursing
home now and in the future. The client was also able to improve as a result of the consultation
efforts although there was little or no direct client contact (Brown et al.,
2001). This was Caplan’s original intent of the consultee-centered mental health consultation
model, to improve the lives of clients through indirect assistance to a caregiver.
Long-term gains of the consultee should also ensure that skills gleaned from the experience will continue to benefit others without further dependence on a consultative relationship.

Tags: Mental health