Mental health - nursing exam

Phil Maude and Alistair Ross

Question 1. (6 marks)

Search for the Victorian MH Act on the web and define the following terms

1.1. Approved Mental Health Service

The Mental Health Act (1986) defined an approved mental health service as a service or premises which either proclaimed to be an approved mental health service under section 94 or declared to be one under section 94A as a place where treatment can be provided to patients under the Act. For example, the psychiatric in-patient units of public hospitals are typically proclaimed as approved mental health services.

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1.2. Community Treatment Order

Community treatment order (CTO) is an order made by an authorised psychiatrist for a person having mental illness and under involuntary treatment order while not detained in an approved mental health services. However, this order does not affect patients in approved mental health services or a prisoner having mental illness (Mental Health Act, 1986).

1.3. Community Visitor

The Mental Health Act of 1986 stated that community visitors of each region are whom appointed by council’s governor under recommendation directly from the minister.

1.4. Involuntary Patient

Mental Health Act (1986) specified a patient being subject to an involuntary, community or hospital transfer treatment order as an involuntary patient. This particular patient is also influenced by some conditions under section 12 and section 93 of the Act.

1.5. Mental Illness

Mental illness refers to a person who is medically and mentally ill with significant disturbance of thought, perception, cognition, mood or memory (Mental Health Act, 1986).

1.6 Mental Health Review Board

Mental Health Review Board is the Board established under theMental Health Act to conduct reviews of, and hear appeals by, involuntarily treated psychiatric patients either as inpatients or on community treatment orders (Mental Health At, 1986).

Question 2. (5 marks)

Using your reading of the Victorian MH Act explain the involuntary admission process for a person who is suspected to have a mental illness. Ensure you mention the correct forms that will be required

The involuntary admission process for a person suspected having a mental illness is detailed with the following steps:

Admission and detention for an involuntary patient can only occur in a public funded approved psychiatric hospital. This patient may be admitted or detained according to the Mental Health Act only if he or she presents or appears with psychological illness and need immediate treatment that can be achieved by admission to and detention in an approved mental health service. Additionally, in order to improve or prevent a deterioration in physical or medical conditions of that patient and protect the public members, the patient may be admitted to an approved mental health service to receive adequate and appropriate treatment rather than stay in less restrictive of that person’s freedom and action.

The person needs to be referred to a registered medical practitioner by himself or herself, family, relatives, health professional officers, police personnel or others related to the referral.

Medical practitioner satisfies that person meets the criteria for involuntary treatment which is under section 8(1) of the Mental Health Act 1986. Otherwise, he will either provide the service or refer the examined patient to other mental health or health services.

A request form must be completed by the person, who is over the ages of 18 years, making request for the admission and a recommendation signed by registered medical practitioner following patient’s examination made not more than three days prior to the admission of that patient. The request and recommendation cannot be signed by the same person making the recommendation.

Consequently, the patient who is subject to an involuntary treatment order is taken to an approved mental health service by police officers, ambulance, any person authorised by the person making the request or arrangement admission made by that approved mental health services.

At the approved mental health service, the registered medical practitioner who is employed by this health service or mental health practitioner must make an involuntary treatment order under section 12AA(2) and necessarily detain patient for his or her own safety according to section 12AA(4) of the Victorian Mental Health Act 1986. The registered medical practitioner can possibly release the person from detention to await examination by the authorised psychiatric if they suspected the criteria in section 8(1) of the Act and consulted with the authorised psychiatric involving section 12AA(5). Then, authorised psychiatrist will examine the person as soon as after the registrar making the involuntary treatment order or within 24 hours following the order to confirm the involuntary admission (Mental Health Act, 1986, s. 12AC). If the consultant is whether satisfied with the criteria under section 8(1) or not, he or she will either discharge the person from the order or confirm the involuntary treatment order. In addition, the authorised psychiatrist confirm the involuntary treatment order under subsection 2(b), the CTO can be placed on the person under section 14 (Mental Health Act, 1986, s. 12AC).

Question 3. (5 marks)

Thinking about the forms and roles and responsibilities of people who may be associated with an involuntary admission of a person under the MH Act, what roles could the following people have and what forms would they be able to complete

3.1. Carer of a family member who has a mental illness

The Mental Health Act (1986) suggested that a carer has the authority to make a request to a registered medical practitioner for admitting an involuntary patient. He or she has the responsibility to take or authorizes any person, for example a community nurse, either taking the person to an approved mental health service or arranging for one to admit the person. The carer is able to complete the “Request for Person to Receive Involuntary Treatment from an Approved Mental Health Service” form under schedule 1prespribed by the Mental Health Regulations 1998 to the registered medical practitioner employed by an approved mental health service or a mental health practitioner.

3.2. Community Mental Health Nurse

In case of the registered medical practitioner is unavailable for a reasonable period of time for making the recommendation, the person may be taken to an approved mental health service for examination after being assessed by an mental health nurse who must complete an “Authority to transport without recommendation” form under schedule 3 of the Mental Health Regulations 1998 (Mental Health Act, 1986).

3.3. General Practitioner

The general practitioner has the responsibility to make a recommendation in a prescribe form which is “Recommendation for a person to receive involuntary treatment form a approved mental health services” form following a the person’s examination (Mental health Act, 1986, s. 9) (Victoria Government, 2009)

3.4. Registrar

Registrar who is a medical practitioner employed by an approved mental health service is responsible for assessing the person according to the request and recommendation. He or she has to make the involuntary treatment order under section 12AA(2) and detain patient for safetry issue according to section 12AA(4) of the Victorian Mental Health Act 1986. The registrar may release that person to await for the psychiatrist’s examination if they suspect the criteria in section 8(1) of the Act applying to the person and consulted with the authorised psychiatrist involving section 12AA(5) (Mental Health Act, 1986, s. 12). The registrar has the authority o complete the following forms:

Schedule 4 Form 1 – Restraint for the purposes of safely transporting a person to an approved mental health service”

Schedule 4 Form 2 – Sedation for the purposes of safely transporting a person to an approved mental health service

Schedule 6 – Involuntary treatment order. (Victoria Government, 2009, Schedules section)

3.5. Consultant

A consultant means a authorised psychiatrist who should examine the person as soon as after the registrar making the involuntary treatment order or within 24 hours following the order to confirm the involuntary admission (Mental Health Act, 1986, s. 12AC). If the consultant is whether satisfied with the criteria under section 8(1) or not, he or she will either discharge the person from the order or confirm the involuntary treatment order. In addition, the authorised psychiatrist confirm the involuntary treatment order under subsection 2(b), the CTO can be placed on the person under section 14 (Mental Health Act, 1986, s. 12AC).

Under the power of the Mental Health Act 1986 section 12AD, the authorised psychiatrist may give written consent on behalf of the involuntary patient if this patient refuses to necessary treatment or unable to consent to the treatment for his or her mental disorders. The authorised psychiatrist has the authority o complete the following forms:

MHA1 – Examination of involuntary patient by authorised psychiatrist

MHA3 – Examination of security / involuntary / forensic patient by authorised psychiatrist

MHA4 – Treatment plan

MHA6 – Community treatment order

MHA16 – Discharge from involuntary patient status. (Victoria Government, 2009, Mental Health Act Forms section).

Question 4. (4 marks)

Once a person has been received under the MH Act under what circumstances can an emergency registrar administer sedation?

If the emergency registrar believe that it is essential to sedate the person in order to take him or her to the approved mental health service safely. The emergency registrar is also able to direct an authorised person to administer sedative medications to the patient. In addition, they must specify the particulars required by the prescribed form and deal with this form according to the regulations (Mental Health Act, 1986, s.10).

Question 5. (2 marks)

A patient must be seen by a Psychiatrist to confirm admission as an involuntary patient. Once a patient is received what time frame must be observed for the Psychiatric review?

The authorised psychiatrist should examine the patient as soon as the involuntary treatment order is made by a medical practitioner employed by the approved mental health service or within 24 hours following the order (Mental Health Act, 1986, s.12AC). Therefore, the patient should be observed in that time frame until he or she being seen by the authorised psychiatrist.

Question 6. (4 marks) (section 15 )

If a person is discharged from the inpatient unit on a Community Treatment Order, what restrictions can be placed on the patient?

If the authorised psychiatrist considers that it is appropriate and for the good and wellness of patient, the psychiatrist can discharge him or her from the approved mental health service on CTO. The person who had the community treatment order upon is influenced during the duration of the order which is not over 12 months. The person has to stay where it is specified by the order for the treatment.

The order sets out the term that a person must accept therapy and medication, conselling, management, rehabilitation and other related health services while living in the coummity. The person is provided compulsory care authorised by the CTO. In case of the person breaches the CTO by not complying with the conditions, the person may be taken to a mental health service and given appropriate treatment and care (New South Wales Government, 2007, what is a community treatment order (CTO)? section).

Question 7. (4 marks)

How often must a Community Treatment Order be reviewed and what is the maximum length of time a Community Treatment Order can be imposed?

At least once a month, the supervising psychiatrist or a medical practitioner such as general practitioner will visit you to decide whether the order should continue or not. If the psychiatrist, at the end of three months period, can extend the order for another three months (Government of Western Australia, 2005, what will happen while I am on the order? section).

A CTO can be made for period of up to 12 months and ends on the date stated on the order and if no date is stated, it will expire 12 months after the order was made (New South Wales Government, 2007, when does a CTO come to an end?).

Question 8. (5 marks)

What is a Special Warrant and what powers does this provide?

Special Warrant apply where a member of the police force or any other person has reasonable ground to believe a person who appears mentally ill is unable to care for him or herself due to mental illness. In this case, “the member of police force or that other person may give information oath to a magistrate” (Mental Health Act, 1986, 11, para. 5) and seek a special warrant.

Under section 12 of The Mental Act (1986), a police force’s member who accompanied by a registered medical practitioner is authorised and directed by the magistrate in the form of a special warrant in the prescribed form to visit and examine the person. Additionally, police personnel who act under special warrant with assistance as required have authority to legally enter any premise and use such force as necessary so that the registered medical practitioner can examine that person (Mental Heal Act, 1986, 12).

Question 9. (5 marks) (No need to cite references for these answers)

True or False

• 9.1. A patient can be detained in a Private Psychiatric Hospital bed as an involuntary patient
• False. A patient who is under involuntary treatment order can only be detained in a public funded approved psychiatric hospital.
• 9.2. The Victorian Mental Health Act makes provision for voluntary patients
• False. Admission of voluntary patients has been deleted by the amendment of 1995. As a result, they are treated as other voluntary patients and need consent to all treatments provided.
• 9.3. Any patients can be given Electro Convulsive Therapy against their consent.
• False.Written consent needed from the patients to perform electro convulsive therapy.
• 9.4. Any one who commits violent acts in the Emergency Room can be restrained
• True. A person doing harm to him or herself ,patients, staffs other surrounding people in the emergency room will be restrained for safety issue.
• 9.5. An involuntary patient who refuses required surgical treatment can have this imposed upon them by the Psychiatrist
• False. For major medical or surgical procedures, the psychiatrist needs consent from the Guardian and Administration Board.
• 9.6. Lobotomy is legal in Victoria.
• True. In Australia, psychosurgery is performed by a select group of neurosurgeons. In Victoria, each individual operation must receive the consent of a Review Board before it may proceed.
• 9.7. Patients who have difficulty with budgeting can have their accounts taken over by the Guardianship board
• False. The Guardianship board appoint another person who is managing patient’s account.
• 9.8. Patients can not be kept in seclusion for more than 15 minutes
• False. For the purpose of safety and treatment, the patient can be restrained until he or she settle down.
• 9.9. The Psychiatrist must send a report of all seclusion that has occurred within a 12 month period to the Chief Psychiatrists Office.
• False.The psychiatrist has to send a report each month.
• 9.10. Electroconvulsive therapy is to a course of not more than 6 treatments given over a period with not more than 7 days elapsing between any 2 treatments
• True. It is what described in electroconvulsive therapy.

Question 10. (10 marks)

List 10 of the reasons why a person is not to be considered to have a mental illness and write a brief paragraph explaining why this is for each of these 10 reasons

As stated in the Victorian Mental Health Act 1986 under section 8(2), a person is not considered to have mental illness due to the following reasons:

“The person expresses or refuses or fails to express a particular political opinion or belief” (Section 8(2)).

In Victoria, the law inhibits discrimination against people because of their actual or assumed political beliefs. (Victorian Equal Opportunity & Human Rights Commission, 2007, para. 1)

“The person expresses or refuses or fails to express a particular religious opinion or belief” (Section 8(2)).

Freedom of religion and belief is a basic human rights which is protected by a number of international treaties and declarations that include article 18(1) of the International Covenant on Civil and Political Rights (Australian Human Rights Comission, What is the freedom of religion and belief? section, para. 1)

“The person expresses or refuses or fails to express a particular sexual reference or sexual orientation” (Section 8(2)).

In 1973, because the influence of empirical data and changes in social norms along with the development of a political active gay community in the United States, the Board of Directors of the American Psychiatric Association removed homosexuality form the Diagnostic and Statistical Manual of Mental Disorders (DSM). The empirical evidence and professionals norm do not support that homosexuality is a form of mental illness. (Gregory, 2009, Removal from the DSM section, para. 1)

“The person engages in or refuses or fails to engage in a particular political activity” (Section 8(2)).

Political activity refer to a whether a person participate or refuse to take part in a lawful political activity (Victorian Equal Opportunity & Human Rights Commission, 2007, What does ‘political beliefs and activities’ mean? section, para. 1).

“The person engages in or refuses or fails to engage in a particular religious activity” (Section 8(2)).

In a major research of Cruz et al. (2010), in the United States, many people use activity as a form of coping with life stresses. Over half of American population ranked the religion’s importance very high in their lives, attent religious activities regularly and pray daily.

“The person engages in immoral conduct” (Section 8(2)).

As an example, incest is defined as any sexuality between closely related people usually within an immediate family, which is either illegal or social taboo (Incest, 2009, Definition section, para. 1)

“The person engages in illegal conduct” (Section 8(2)).

Criminality is “specifically not a medical or psychiatric term, diagnosis, illness, or syndrome. The term refers to a pattern of human behavior or a specific act violating a law” (Menaster, 2008, introduction section, para. 1).

“The person is intellectual disable” (Section 8(2)).

Intellectual disability is a developmental disorder which affect almost one per cent of the population, where people have significantly more difficulty than others in understanding concepts and solving problems. It is not a mental illness (Government of South Australia, p.1)

“The person takes drugs or alcohol” (Section 8(2)).

Alcohol usually refers to drinks such as beer, wine, or spirits containing ethyl alcohol – a substance that can cause drunkenness and changes in consciousness, mood, and emotions. Its effects lead to so many accidents, injuries, diseases, and disruptions in the family life of everyday Australians (Australia Government, para. 1). However, alcohol abuse should be consider mental illness.

“The person has an antisocial personality” (Section 8(2)).

The person expresses anti-social behaviour includes abusive or noisy neighbors, littering and graffiti (Directgov, para. 1)

Question 11. (10 marks)

An involuntary patient is found dead in a seclusion room by you? What is a reportable death and what are the responsibilities of the registered nurse?

Coroners Act (2008) defined reportable death is a particular category of death which is investigated by a coroner according to the Act and it is considered reportable if it meets one the following criteria:

The body, the death or the cause of death of the person is founded in Victoria.

The person ordinarily stayed in Victoria when death occurs with unnatural, unexpected and resulted from a direct or indirect injury or accident.

The death happen during or after following a medical procedure and this was not expected by the registered medical practitioner before the procedure’s operation.

The identity of the death person is not known.

The medical practitioner himself or herself has not signed or not likely to sign a death certificate.

Death occurred outsite Victoria and the cause is not certified.

The death of a person influenced under the Mental Health Act 1986 or under controlled, cared or custody of the Secretary to the Deparment of Justice or a member of the police force.

Death of person who is subject to non-custodial supervision order under section 26 of the Crimes (Mental Impairment and unfitness to be Tried) Act 1997 (Coroners Act, 2008).

In the context of a patient found is death in a seclusion room, registered nurses division 1 or division 3 (Division 2 nurses are excluded) can ‘verify death’ since the law do not inhibit them for taking this role. ‘Verify death’ means competently undertake a clinical assessment of the death body to establish death has occurred (Victoria Government, 2009, p. 1).

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As guideline in Victoria Government (2004), the dead body should be disturbed as little as possible and the nurse is to inform the authorised psychiatrist and next of kin or carer of the death. The State’s Coroner’s Office is mean to be contacted for all reportable deaths occurred under the Coroner Act 1985. After copying the clinical record, the registered nurse is able to send the original or any other materials requested to the Coroner. The nursing staffs involved should provide appropriate and adequate support and debriefing to people affected by the death such as family, friends, staffs and those who have witnessed the death (Victoria Government, 2004, procedure to be followed in the event of a reportable death, para. 5). In case of patient died because of violence or suicide, chef psychiatrist needs to be notified on the day of the death and staff involve in the death should conduct a clinical review of the person’s treatment and management (Victoria Government, 2004, procedure to be followed in the event of a reportable death, para. 6-9).

Question 12. (10 marks)

List the Axis contained within the DSM-IV (TR) and provide details of the focus of each including an example of a diagnosis that might be found on each of the Axis.

Axis I Clinical Disorders

Other Conditions That May Be a Focus of clinical Attention

American Psychiatric Association (APA) of 2000 stated that Axis I focus on all the conditions and various disorders included in the Classification except for mental retardation and personality disorders. An example of this is schizophrenia.

Axis II Personality Disorders

Mental Retardation

In a study by APA (2000), Axis II reports personality disorders and mental health retardation and also used for noting prominent maladaptive personality features and defense mechanisms. Personality disorders and mental retardation are listed in separated axis to ensure consider given to the presence of these two that might otherwise be overlooked when attention is directed to the more usual axis. For instance, borderline personality disorder is included in axis II.

Axis III General Medical Conditions

This one describes general current medical conditions which are potentially related to the understanding or management of individual’s mental disorders (American Psychiatric Association, 2000).

Axis IV Psychological and Environmental Problems

In a major study (APA, 2000), Axis IV is identified for reporting psychosocial and environmental problems that are likely to affect the diagnosis, treatment and prognosis of mental disorders classified within Axis I and Axis II. A psychosocial and environmental problem is possibly a negative life event, a familiar or other interpersonal stress, lack or inadequate of social assistance pr personal resources or other problem related to the context where a person’s difficulties have developed. In addition, psychosocial is possibly developed as a result of a person’s psychopathology or may constitute problems that are considered in the overall management plan (APA, 2010). For instance, problems with primary support group.

Axis V Global Assessment of Functioning

APA (2010) suggested that Axis V is used for reporting the clinician’s judgment regarding a person’s overall function level. This is helpful for planning treatment and measuring its impacts, also predicting the outcomes. The Global Assessment of Functioning (GAF) Scale is used as an appropriated choice in order to report the overall functioning of Axis V. In a research by APA (2010), this scale is rated respectably among psychological, social, occupational functioning and is not applied to impairment in functioning because of physical or environmental limitations.

For example, GAF = 12 indicate some dangers of hurting self or others (e.g. frequently violent.) or occasional fails to maintain personal hygiene (e.g. smear faeces.) or gross impairment in communication (e.g. largely incoherent or mute) (APA, 2010).

Question 13. (30 marks)

Search the world wide web for Hildergaurd Peplau and do a search for her publication. Write at least 4 pages about her life, her theoretical frameworks, her publications and her major contributions to Mental Health Nursing.

Life

Hildergaurd Peplau was born in Reading, Pennsylvania , and in the year of 1909. She is the second child and middle daughter of immigrant parents who are an authoritarian father and a dedicated but emotionally remote mother preserving in a difficult marriage with the comfort of music and religion, and more acceptable in her time and place by immersing herself in baking and meticulous home making (Callaway, 2002). During childhood, Peplau was a child with intellectual curiosity, but stifled and physically abused by her domineering mother. The occur of World War I made her family even more difficult along with persecution form their neighbous due to their German immigrant roots …Cite.

Her chosen nursing career had little to do with the idea of providing care for sick people. In Reading, she had worked as a bookkeeper, store clerk and payroll clerk while finishing courses at a business school and graduating as class valedictorian in 1928. Hildergard Peplau herself did not work in hospital or as private-nursing duty after successfully completing her nursing training. On the other hand, she found and a job as a staff nurse at Vermont’s new elite but progressively to Bennington College. Callaway (2002) stated that because of her great impressive work, the college president decided to suspend admission requirement and admit Peplau for a degree course major in psychology.

During World War II, Peplau enlisted into the U.S Army Nurse Corps and was posted to a psychiatric hospital in England with the purpose of treating scarred the soldiers and those with battle-fatigue sent back from the front lines (Callaway, 2002). She was always at the center of conflict and usually endured great personal hardship. She earned the nursing diploma, baccalaureate, master’s and doctoral degrees and ultimately rose to the top of her profession. Unfortunate y, she was disappointed by the lack of vision among co-workers and repeatedly betrayed by professional friends and sabotaged by the nursing leaders. Consequently, she decided to retired in 1974 from the faculty Rudgers University and sadden that all her years effort had seemingly come to naught.

During the 25 years between the retirement from Rudgers University and her death in 1999, “She was awarded no less than nine honorary doctorates and was honored by the American Nurses Association with the establishment of the Peplau Hildegard Award, recognizing continuous contribution to the nursing profession” (Callaway, 2002, p. 2). In addition, she received both the nursing highest honors that are the Christiane Reimann Prize and the only nurse so recognised within “Fifty Great Americans” designated by Marquis’ Who’s Who in 1997. Within her lifetime, she also earned the celebrity of being acknowledged by the American Academy of Nursing as a “Living Legend’ and an unofficial designation recognised by the University of California at Los Angeles as “Psychiatric Nurse of the Century”. However, her life’s story is not well known in nursing professional.

Hildegard Peplau’s professional life included:

6 years of general and private-duty nursing, 7 years as a student and the nurse in charge at the health service at Bennington College, 3 years in the Army Nurse Corps, 5 years at Teachers College of Columbia University, 1 year as a practicing therapist, 20 years as a professor at Rudgers University, and 1 year as Execituve Director and 2 years as President of the American Nurses Association – the only person ever to serve in both positions. (Callaway, 2004, p. 6)

Theoretical Frameworks

Peplau had shown her theoretical framework for psychodynamic nursing in a manuscripts entitled Interpersonal Relations in Nursing which is published in 1952. It defined elements that are person, environment, health and nursing, and discussed about phases of the interpersonal process between nurse and patient. She also revealed variety in nurses’ role during the course of contact (Landry, 2009).

In a recent studies of Alice Landry (2009), phases of the interpersonal process according to Peplau’s theory consist of four sequential phase that are orientation, identification, exploitation, and resolution. There are related factors influence the orientation component of the experience such as personal values, cultures, beliefs, expectations and past related incidents.

Role of nurses as described theatrically by Peplau are stranger, teacher, resourse person, counselor, surrogate and leader. Secondary roles play included technical expert, mediatoe, safety agent, researcher, tutor, and manager of environment.

Publicati