Birthing a Collaborative Approach: Mental Health & Addiction, Maternal Child

Nursing and the Woman with a Trauma History

2015

Lisebeth Gatkowski, RN BScN, CPMHN (C)Julie Pace,  RN, BScN, MSc HSEd (C)Sarah Simpson, RSW

5FACTS

Mental Illness:• affects 1:5 Canadians• affects people of all ages, income levels, cultures & educational • often occurs during adolescence & young adulthood

Health Canada, 2010; WHO, 2008

6PREVALENCE OF ABUSE

• 1 of 3 women is beaten, coerced into sex

• 33.5% of murders (women) & 4% murders (men) attributed to intimate partner

• 1.5 million women & 834,732 men raped or physically assaulted by partner (Carretta, 2008)

• 8% women & 7% men experienced intimate partner violence (Stats Canada, 2000)

7PREVALENCE

• Canadian Women with Severe Mental Illness:

83% experienced severe physical & sexual abuse as children & as adult (Morrow, 2004; Firsten, 1991)

• Partner abuse: is a contributing source of psychiatric

disorders among women of childbearing age

• Intimate partner violence: is associated with high rates of

depression, substance misuse & anxiety disorders

(Ehrensaft et al. 2006)

(RNAO BPG, Woman Abuse: Screening, Identification & Initial Response, 2005)

8TRAUMA & SUBSTANCE ABUSE

• “Co-occurring disorders are so common among trauma survivors that they should be considered the expected rather than an exception”

• Substance use is very common amongst

trauma survivors…a way to numb feeling & avoid emotional pain

Trauma Informed: The Trauma Toolkit, 2008

Trauma

Shame

Housing

Relationships

Legal concerns

Concurrent Disorders

Financial Concerns

Isolation

Addiction(s)

UnemploymentParenting

Loneliness

Abuse Loss

Bereavement Eating Disorders

Physical Health

Leisure

10MENTAL HEALTH & ABUSE

Persons with mental illness and/or addiction are vulnerable to all forms of abuse…

&this may have a significant impact on their

diagnosis, treatment & recovery.

11

Mental Illness

Trauma Historie

s

Addiction

WORKSHOP

12BEGININGS

We realized that the needs of individuals who have or are experiencing mental illness,

addiction and trauma are not being adequately served by our system….

We want to do better!

13BACKGROUND: INTEGRATED NURSING CLINICAL SKILLS

Project:• stems from the vision of the Mental Health

Integration Task Force• several key areas identified to facilitate and

advance integrated clinical care at St. Joes

• this project addressed ~ developing and enhancing shared core nursing competencies amongst nurses

14FACTS

“A more integrated approach to clinical care

will be an important contribution to our strategic directions by breaking down

barriers and transforming the way we work” 

Acute Care Clinical Areas focus:• Mental Health & the

Law• Mental Status

Examination & Risk Assessment

• Therapeutic Relationships & Communication

• Addiction

SHARED CORE NURSING COMPETENCIES FOR INTEGRATED CARE

Mental Health & Addiction focus:• Assessment & Early

Interventions in: – cardiac– neurologic– respiratory– gastro-intestinal &– endocrine systems

16ST. JOSEPH’S HEALTHCARE HAMILTON

Demographics• Hamilton population

500,000+

• 3rd largest immigrant population in Ontario

• 2010 code red series highlighted areas of poverty, low birth weight babies, mental health & addiction concerns

• 4 methadone clinics- 3,500 people serviced

HAMILTON’S CODE RED DISTRICTS

18ST. JOSEPH’S HEALTHCARE HAMILTON

St. Joseph's Healthcare Hamilton:• 3 campuses- acute, mental health & addiction,

ambulatory care

• Affiliated with McMaster University

• Centre of excellence: Mental Health and Addiction, Respiratory Care, Kidney Renal Program

19ST. JOSEPH’S HEALTHCARE HAMILTON

St. Joseph's Healthcare Hamilton: Charlton

• Located in downtown core• Centre of Excellence: caring for expectant mom

& baby suffering with addiction

• Babies delivered yearly- 3,600

• Special Care Nursery: 500 babies/yr.

• Babies suffering with neonatal abstinence syndrome (NAS): 50/yr.

• LOS for NAS babies: 2-12 weeks; average 6-8 weeks

Patient

Nursing

Social work

Addiction counsellor

Leadership

COLLABORATIVE APPROACH

21STIGMA

Literature on community attitudes

suggest that individuals with mental illness and/or addiction are viewed by

others with distaste and fear

23WORKSHOP OBJECTIVES

1. To understand mental illness, addiction and trauma in the women we serve looking at

a) prevalenceb) health consequences

2. To share:c) strategies to improve services to those

living with mental illness, addiction & trauma

25WORKSHOP

Topics included:1) Mental Illness• Overview of schizophrenia,

mood disorders, concurrent disorders • Stigma • Resources available to staff: consultation

liaison team

2) Trauma informed approach to care• Definition of trauma• Prevalence• Health consequences of abuse• Cultural considerations• Effects of trauma

26WORKSHOP

Topics included:3)Addiction:• Definitions• Psychological addiction• Stages of change• Strength based approaches

4)Therapeutic Communication:• Elements of therapeutic

communication• Verbal & non-verbal communication• Biases & prejudices• Screening

5) Case scenarios• Skills development

28TRAUMA INFORMED CARE

Screening: Know when & how to screen for abuse history (starting in L&D)

Acknowledge the person’s history

Offer support

Assess for safety

Referrals as requested

Trust = Influence

29WHAT MIGHT IT LOOK LIKE

Because abuse is so common in women’s lives, I now ask all my patients about it. May I ask you?

Or

Many women are dealing with abuse in their relationships. Some are too afraid or embarrassed to bring it up themselves, so now I routinely ask about abuse. May I ask you?

Trust = Influence

30WHAT MIGHT IT LOOK LIKE

Have you ever been threatened or hurt by someone? Are you or have you ever been in a relationship where you have been physically hurt, threatened or made to feel afraid?

If “Yes” to disclosure, then

No one deserves to be hurt or to live in fear. You are a very strong woman to talk about this.

Trust = Influence

31WHAT MIGHT IT LOOK LIKE

Are you currently getting help with this situation?

Can I refer you to someone who can help you?

Can I offer you some information onresources available to you? Trust =

Influence

32CAUTION

Always interview the woman in private

Disclosure may be difficult if there is no

therapeutic relationship

Pelvic examinations may cause distress

Be discreet when offering information

If abuse is current in person’s life, then

consult, refer & ensure that person has a

safety plan

LET’S PRACTICE

A woman you are caring for in L&D is 39 weeks pregnant. Her partner is present. He seems to hover over her and often interrupts you when you are speaking to her. You have a gut feeling that she may be in an abusive relationship.

What tactics would you use to get her partner out of the room?

SCENARIO #1

When the partner leaves the room and you find yourself alone with her, what would you say to her?

SCENARIO #1

You are working in the Special Care Nursery with a baby with Neonatal Abstinence Syndrome who was admitted 3 weeks ago. This baby is receiving morphine and is scoring high on the Finnegans (scoring tool for infant withdrawal). The baby is really hard to settle and cries most of the shift. Mom says she would like to come in and feed baby daily at 2:30pm. The nurse is becoming frustrated when she notices that mom is often late for feeds or doesn’t show up at all.

How would you engage this mom and address the concern?

SCENARIO #2

You later find out from Social Work that this mom takes 2 buses every day to go to the Methadone clinic for her treatment dose. She also has 2 other children at home.

Please pick the best response you could use with this mom when she comes in late next time.

SCENARIO #2

SCENARIO #2

A woman comes into L&D for a Non Stress Test. She is 35 weeks pregnant with a history of anxiety, depression and panic. She seems overwhelmed and distracted. She tells you that she is having horrible flashbacks of her childhood and abuse. She has missed work, is crying a lot. She also has a history of self-harm.

Please pick the best response you could use with this mom.

SCENARIO #3

SCENARIO #3

SCENARIO #

You are taking care of an 18 year old on mother-baby unit who has just delivered her first baby yesterday. She is often texting when you are in the room doing health teaching. You are bothered by her lack of interest toward you as the nurse, and the baby.

Take 5 minutes to work with a partner or small group. Please discuss what you would say to this mom or how you would respond.

WORKSHOP EVALUATIONS

Mental Health Knowledge

Addiction Knowldege

Trauma Knowledge

Communication0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

BeforeAfter

STAFF TESTIMONIALS

“Don’t judge a book by

its cover…I am more

compassionate and

open minded about the

path that brought

them here”

“I now recognize that addiction is

an illness rather than a behaviour”

“I am more aware of my body language and the way I say things”

“The workshop helped me develop strategies to talk to the

woman alone”

“I feel more comfortable

now in asking rather than

always sending social

work in”

45CONTACT INFORMATION

Lisebeth Gatkowski: lgatkows@stjoes.ca

Julie Pace: jpace@stjoes.ca

Sarah Simpson: ssimpson@stjoes.ca