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CAMH Stories Centre for Addiction
and Mental Health

CAMH nurses drive change to meet evolving client needs

As client care becomes more complex and special issues continue to emerge, CAMH nurses are there to respond to these trends -- and drive change.

“As a leader in mental health and addictions, CAMH has an increased accountability,” says Rani Srivastava, Chief of Nursing and Professional Practice. “We are delivering care to our clients based on the best evidence, and advancing knowledge that is informed by our practice. This is a global mandate.”

Trends don’t always go in a straight line, Rani says. Her objective is to foster “flexibility and a learning mindset in our nursing community at CAMH. We are giving nurses the opportunity to discover their passion, learn, grow and find a special place in our field. My role is to continue to expand both formal and informal leadership in nursing at CAMH.” Strong leadership makes CAMH a destination for hundreds of student nurses each year who will consider a career in mental health and addiction. “We are also growing our relationships with health, education and research partners outside CAMH to advocate for mental health care and bring expertise to the broader community.”

Dr. Rani Srivastava
Dr. Rani Srivastava, Chief of Nursing and Professional Practice

We asked six experts in CAMH’s nursing and treatment disciplines to share their insights on trends in nursing, and how CAMH is staying ahead of the curve.  They spoke about an evolving approach to engaging clients – one that provides the foundation for recovery. They are going beyond direct care to support clients in other aspects of their lives such as work and school. And they are mentoring the next generation of nurses and building on their strengths.

How does CAMH support that journey? Through more sophisticated technology, a richer learning environment, and greater opportunities to expand the scope of nursing practice.

Diana Sebera
Perspective: Diana Sebera, Nurse Educator, Ambulatory Care and Structured Treatments Program

Nursing trend: Evolving our relationship with clients

Mental health and addiction nursing is possibly the hardest but also the most creative specialty of nursing.

We use ourselves to engage and work with the client. The client has to trust you to feel safe before any meaningful work can be done. We need to be aware of what we are bringing to the therapeutic relationship, knowing what our own issues are, and not putting them on the client.

We need to have in-depth knowledge of the client’s history and care plan and be flexible with the care we deliver -- some clients may want to talk, some may want to go for a walk, some may need attention to their meds.

Today, we are more open and more vocal about our vulnerability, less of the authority figures, less of the polarized view of “staff or patient” from the past.  As part of the education program, we role-model how to engage clients. We have a positive regard for the client – they are a good person even if their behavior may be difficult.

At the same time we want to help clinicians develop knowledge and skills – hopefully we light a spark of curiosity that the clinicians can use to make their practice unique and rewarding.

Trauma is a huge issue for our clients – 90 per cent of them are affected. As well, addiction and mental illness can go hand in hand. There are physical risks, like injuries related to falls. We always have to be mindful of these underlying or co-existing issues, and that’s a big part of our education program.

As nurses, we wear street clothes to normalize the client experience. When I graduated I had the white cap and I hated it. All people saw was a generic nurse. Today, the client is relating to a person instead of an authority. Our client-centred approach is supported by our new physical site and spaces which are evolving to be more open and integrated.

Historically, nurses came from religious orders and the military and there was that sense of rigidness and authority. Today, universities and colleges motivate student nurses to explore and grow.

We are seeing challenges around the acuity of client situations, and with underserved populations like youth and older adults. As a mentor, I notice that young nurses more proactive and vocal today. They want to be here in mental health nursing – that’s a really hopeful sign as we move forward.

Patricia Merka
Perspective: Patricia Merka, Registered Nurse, Child, Youth and Family Services

Nursing trend: Creating a circle of care

Families and children will often walk by and look at the collection of stuffed animals in my office window, which faces outside near the entrance to our centre.

I believe a welcoming environment is part of a circle of care that goes beyond a client’s diagnoses. Kids who are here to get care will grab the toy Ferrari or one of the stuffed animals in my office. Then you realize that they will open up to you much more easily when they are playing with a toy.

First impressions are important, and as part of the Best Practice Spotlight Organization (BPSO) initiative we’ve done some surveys of our space to ensure it really is welcoming. That goes for simple things like the entrance, signage, food options, and outdoor spaces. Clients who feel welcome want to come back

A teenaged boy who I’ve been helping to address anxiety confided to me recently: ‘I haven’t been able to talk to anyone about this.’  Instead of asking him about mental health, I had started with other things in his life: video games, food, what he wanted to do for his career. You need to see where the client wants to take the conversation. That opened up into talking about his relationships.  He was 16 and thought things would never get better with his parents. We talked about ways to build that relationship.

He was dealing with some learning issues at school, and anxiety and pressures at school. His parents brought him here initially, but he came back on his own to work through those issues.

Our clients have a right to be successful, and to be accommodated in some situations. They need someone to have their back. So my work takes me beyond discussions with the individual client. In many cases I can reach out to the school to be an advocate. Guidance departments are usually quite open to accommodating kids. Also student services in colleges and universities can provide support. You can help a young person make that transition. In many cases we will deal with Children’s Aid when that agency is involved.

The circle of care also extends to more fun things – we’ve taken young clients on sailing trips to the Toronto harbour sponsored by the Broad Reach Foundation.  Also to Raptors’ basketball games when we have received donations to support that. The kids return with big smiles.

My day involves a variety of individual therapy, new client assessments, and teen group sessions for mood and anxiety. I’m also the nurse for our CATCH classroom serving youth with ADHD and behavioural issues. We’re seeing increasingly acute needs among our young clients. We help them directly but also need to look at the big picture of their lives and how we can reach out to support that.

Anita Martin
Perspective: Anita Martin, Nurse Educator, Dual Diagnosis and Underserved Populations

Nursing Trend: Mentoring for a stronger voice

One of my favourite concepts of teaching and learning is from the poet William Yeats. He wrote that “education is not the filling of a pail but the lighting of a fire”.

As a nurse educator, I value the opportunity to help staff connect to information in ways that ignite flames and transform practice.  To do this, I ground my work in the principles of transformative and adult learning theory. That means ‘learning alongside’ and constructing knowledge with the teams that I support.

In education sessions, I spend most of the time talking with nurses about their perspective s on the issue at hand -- and how the information that I’ve shared fits with what they know about it. Sharing new information is only the beginning. To be effective, I need to accompany them as they walk the information out into their practice. I help them to draw on their strengths and experience to problem-solve its application.

Most recently, I have been supporting teams to integrate the use of IPOC (Interdisciplinary Plan of Care). I’ve found that when nurses are given the time and supported in their efforts to arrive at a shared understanding of the client, their eyes light up and they begin to appreciate the utility of the technology. 

I’ve seen nurses gain a stronger voice over the years at CAMH. A good example is the evolution of the Nursing Practice Council (NPC).  Over the years, the council has become a responsive and dynamic go-to source for the perspective of CAMH nurses.  NPC representatives meet for a full day every other month to raise and discuss issues impacting practice and to hear about and give feedback on current and planned initiatives such as I-CARE.  The council also provides nurses with a chance to connect with colleagues from across the organization in different areas of practice and to nurture their nursing spirit. 

It was not so very long ago that I thought of the nursing community at CAMH as a sleeping giant.  I believe that that is no longer the case.  As opportunities for mentorship and supports for practice have increased, nurses are finding and owning their collective voice. Nurses are the backbone of our hospital, providing 24/7 care. Our nursing leadership is growing with more Advanced Practice Nurses, Nurse Educators and the professional practice office. This can only mean good things for the quality of care of the people we serve.

It’s especially rewarding to support a nurse who is new to CAMH, to find out what makes them tick, what brought them to mental health nursing, to watch them grow. I want to support them, to provide mentorship, to help them make a difference.

Kwasi Adu-Basowah
Perspective: Kwasi Adu-Basowah, Registered Nurse, Acute Care Unit

Nursing trend: Managing staff and patient safety

One of the most important tools our team uses to manage staff and patient safety is communication. There are patient trigger identifiers that we monitor through things like the DASA risk assessment tool and the care plan.

All of these factors need to be communicated amongst staff, volunteers, family, and anyone on the unit. Communication is key.

 It is important we work collaboratively to deal with issues that present themselves. We need to do the best we can to prevent these safety issues from happening. At the end of the day, staff safety translates into better client care.

We are here to care for clients. That is our main job. We need to keep ourselves safe.  Reducing safety-related incidents leads to a higher continuity of care.

Kama Kalia
Perspective: Kama Kalia, Discipline Chief Nursing, Professional Practice Office

Nursing trend: Leveraging technology

Nursing is becoming more complex, and great client care means increasing our communications with other disciplines, with the laboratory department, the pharmacy, and creating more detailed client records. Over the past few years, we’ve introduced several technologies to support our nurses during this evolution.

The new I-CARE system captures the complexity of nursing in an integrated system for client records.  It’s a new way of thinking about documentation, with distinct segments such as assessment, medication and therapy notes. We’re continuing to fine-tune our nursing workflow and the system – for example, with the goal of capturing additional details of a client’s story. I-CARE also gives us a great opportunity to mine data and analyze it for trends over time -- for better client care.

On our inpatient units, 70 new mobile nursing workstations are helping us to be more mobile to meet the clients where they’re at. The workstations include a barcode scanner to confirm identity via a client’s wristband, a computer and screen for access to information and documentation, and a medication drawer.

As well, our nursing leadership group, including Nurse Educators, now has laptops and cell phones to increase our accessibility and mobility at CAMH.

We’ve seen the continuing shift from institutionalization to a community model that also addresses social determinants of health such as housing and employment. At the same time we have a fundamental therapeutic model that asks the client: What are your goals? How can I support you to live a meaningful life, despite your illness.” We continue to focus and update our technologies to meet evolving trends and to fulfill our commitments to clients.

Dr. Kristin Cleverley
Perspective: Dr. Kristin Cleverley, Director, Practice Research and Innovation, Professional Practice Office

Nursing trend: Driving innovation and inquiry

My role is to support innovation and inquiry among professional practices staff. In supporting them, we continue to increase breadth and opportunities across the organization for the nursing discipline, including front-line nurses. Our nursing staff at CAMH are seeking opportunities to pursue continuing education and new horizons.

Inquiry starts with inter-professional teamwork. A great example is our best practice initiative, known as BPSO (Best Practice Spotlight Organization). It’s a program sponsored by the Registered Nurses’ Association of Ontario (RNAO). In April 2015, we celebrated the accomplishments of seven BPSO initiatives at CAMH, ranging from pain management to smoking cessation to developing cultural competency.

For the past three years, these initiatives have been led by CAMH Advanced Practice Nurses, clinicians and other leaders with the intent to drive practice change and improve client care through recommendations from the Best Practice Guidelines (BPG). Nurses, along with their interprofessional colleagues, have embraced this opportunity to bring a mental health specialty focus to the guidelines. The tools that have been developed continue to put CAMH in leadership position in the health care sector.

The assessment and management of pain was the first BPG guideline to be implemented at CAMH as part of the BPSO Initiative. It included new education modules, tools, resources, and requirements for our I-CARE client records system. As with all BPGs implemented at CAMH, feedback from clients and families in the process was a critical component.

Inquiry and innovation also mean inter-hospital collaboration. We are a part of the Toronto Academic Health Science Network (TAHSN), comprising the University of Toronto and 13 affiliated academic hospitals. The TAHSN group launched the TAHSNp (practice) Fellowship this year, and CAMH had a nurse and behavioural therapist complete a quality improvement project on the assessment and management of aggression. The project used the DASA-IV risk assessment tool within the Complex Mental Illness program. This project was an excellent example of how we can leverage our specialized knowledge to benefit other hospitals on a topic like managing aggression. Likewise, we benefit from the skills and experience of our partner hospitals.

We are always looking for innovative ways to support continuing education, leadership and practice development. The Barford Scholarship Program provides financial support for three nurses at CAMH each year to resume their graduate education and receive mentorship. Nurses can also apply for a paid six-month advanced practice internship with a mentorship component. These opportunities are funded by a generous donation from the Barford family.

As part of individual planning, many CAMH nurses complete the Canadian Nurses Association (CNA) Psychiatric Mental Health Nurse certification reflecting specialized knowledge in our field.

Being selected as the CAMH Chair in Mental Health Nursing Research is an important catalyst for increasing awareness, dialogue and research in mental health nursing with the goal of improving patient outcomes. CAMH and the University of Toronto recognize the important role nurses have in this process, and part of my focus as the Chair will be to mentor a cadre of nurses and graduate students to become leaders in mental health nursing research.

I’m excited about contributing to the richness of nursing at CAMH through innovation and inquiry. Ultimately that continues to drive a sound, evidence-based approach to client care. 

Dr. Peter Voore
Perspective: Dr. Peter Voore, Medical Director, Ambulatory Care and Structured Treatments

Nursing trend: Enhancing the scope of practice

What I continue to see is how CAMH nurses are enhancing the scope of practice here. That includes embracing new skills and advancing knowledge.

Nurses are acquiring new therapeutic skills such as Cognitive Enhancement Therapy (CET) for schizophrenia. We know that this illness affects cognitive and social functions; CET helps to counteract those effects and improve function for our clients. Another example is Dialectical Behaviour Therapy (DBT). The mindfulness component of this treatment is helping tremendously in the area of self-harm. Clients get a broader perspective on their thoughts, the role of self-harm, and their behaviours.

CAMH nurses have been working collaboratively to advance knowledge and expertise in areas such as pain management, suicide assessment, and tobacco cessation. These are three examples of projects in the Best Practice Spotlight Initiative (BPSO). CAMH nurses are co-leading these initiatives.

If we look at tobacco cessation and its potential to help clients, our nurses are playing a key role in education and cessation strategies such as nicotine replacement. Many years ago, smoking was pervasive on client inpatient units, and cigarettes were used as a reward for patients. And yes, I had an ashtray in my office for clients. That was a different time and our culture has moved on. Today, we recognize that the heavy smoking of a client with schizophrenia can cut 25 years off his or her life. We can be worried about things like suicide risk, but death from smoking-related cardiac and lung illness is an even greater risk. We are taking a very active approach to smoking cessation for our clients.

When I entered the mental health profession, I was fascinated by the people and the human mind.  How can we help people live and function as best they can? Our treatments are often not cures. For some with mental illness, it’s about how far we can go to support their recovery and quality of life.

Among mental health and addictions professionals, there’s a saying that ‘We are the tool.’ That principle is demonstrated each day by CAMH nurses as they use interpersonal skills to engage clients, employ new treatment strategies, and advance their scope of practice.

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